2019 Perinatal Health Annual Report
In 2018, Arkansas ranked 8th worst in the nation for the percentage of low weight births: the state reported 9.4% compared to 8.3% nationally (National Vital Statistics Reports, Vol. 68, No. 13, November 27, 2019). In 2018, Arkansas had the 5th highest percentage of preterm births in the nation (CDC) and in 2019, 11.9% of babies born in Arkansas were preterm (Arkansas Department of Health (ADH), Health Statistics Branch). In addition, only 71.5% of mothers received first trimester prenatal care in 2019. More White women received early prenatal care (75.4%) than Black women (66.5%) or Hispanic women (62.8%).
The top three causes of neonatal death in the state in 2019 were:
- Preterm birth and low birth weight
- Birth defects
- Maternal pregnancy complications
The top three causes of post-neonatal death in 2019 were:
- Sudden infant death syndrome
- Birth defects
- Accidents
In an effort to address the state’s high infant mortality rates, Title V efforts are focused on increasing the percent of hospitals with nurseries that are participating in the Perinatal Regionalization Network; increasing the percent of infants ever breastfed and exclusively breastfed for six months; and increasing the percent of infants placed to sleep on their backs, on a separate approved sleep surface, and without soft objects or loose bedding.
Priority Need: Persistently High Infant Mortality Rate
NPM 3: Percent of very low birth weight infants born in a hospital with a Level III+ Neonatal Intensive Care Unit.
Strategy 3.1: Encourage hospitals to voluntarily participate in surveys to determine the level of nursery/neonatal intensive care unit they provide.
In 2014, the ADH Maternal and Child Health program worked with stakeholders to establish a voluntary Perinatal Regionalization System. To guide this system and to establish risk-appropriate levels of maternal and neonatal care, the ADH established the Perinatal Regionalization Committee, which includes representatives from the University of Arkansas for Medical Sciences, Arkansas Children’s Hospital, the Arkansas Hospital Association, the Arkansas Center for Health Improvement, the Arkansas Foundation for Medical Care, as well as representatives from many of the State’s 39 birthing hospitals.
The Perinatal Regionalization Committee developed the following Arkansas Perinatal Levels of Care Recommendations, which were approved by the Arkansas Board of Health in 2016:
Level I
- Facilities provide the most basic level of community-based maternal newborn service, caring for low risk mothers and infants at 35 weeks gestation or greater.
Level II
- Specialty facilities have a special care nursery and are able to care for infants greater than 32 weeks’ gestation and weigh more than 1,500 grams. They can care for select high-risk pregnancies greater than 32 weeks judged unlikely to deliver before 33 weeks and with a low risk of neonatal or maternal morbidity.
Level III
- III-A represents subspecialty facilities with a perinatal care center and neonatal intensive care unit. They can provide care for infants at 26 weeks’ gestation or greater and weighing more than 750 grams. They can care for pregnancies greater than 25 weeks in women without significant comorbidities. All high- risk deliveries should occur at Level III+ facilities.
- III-B represents subspecialty facilities with a perinatal care center and neonatal intensive care unit with neonatal subspecialty service. Level III-B hospitals can care for infants less than 26 weeks’ gestation, weigh less than 750 grams, or who have severe or complex illnesses but do not need services provided by a Level IV facility. These hospitals are also able to care for pregnancies of all gestational ages and maternal conditions, even those with severe maternal complex illness. All high-risk deliveries should occur at Level III+ facilities.
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Level IV
- The only hospital with this designation is Arkansas Children’s Hospital, which is able to provide subspecialty care for all neonates who have severe or complex illnesses, offering the most advanced level of care, including extracorporeal membrane oxygenation.
Arkansas currently has 17 Level I hospitals, 14 Level II hospitals, 5 Level III-A hospitals, 2 Level III-B hospitals, and 1 Level IV hospital.
After the levels of care were approved a process was developed for all hospitals to voluntarily verify their maternal and neonatal levels of care annually. In addition to the annual verification survey, site visits were to be conducted every three years for level III-A, III-B, and IV hospitals. It was intended for site visits to be conducted in 2019 to verify the level III+ hospitals, but transformation efforts within ADH, the Committee, and the Perinatal Regionalization System delayed progress with this effort.
In 2018 the Perinatal Regionalization Committee began its transformation under new leadership and 2019 brought about more change with two key pieces of legislation signed by Governor Asa Hutchinson in April 2019. Act 829 gave the ADH authority to establish the Arkansas Maternal Mortality Review Committee (AMMRC) to review maternal deaths and develop prevention strategies, Act 1032 gave ADH authority to establish a Maternal and Perinatal Outcomes Quality Review Committee to review data on births and to develop strategies to improve birth outcomes. Both Acts require their committees to submit annual reports to the Arkansas Legislature, and the information will be shared with policy makers, health care providers, health care facilities, and the general public.
Once Act 1032 was signed, the Perinatal Regionalization Committee assumed responsibility for the mandates set forth by the legislation and was renamed the Arkansas Maternal and Perinatal Outcomes Quality Review Committee (AMPOQRC).
The AMPOQRC began reviewing the state’s Perinatal Levels of Care Recommendations and comparing it to the most recent Perinatal Care Guidelines developed by the American Academy of Pediatrics, American College of Obstetricians and Gynecologists, and Society of Maternal Fetal Medicine in 2019. The AMPOQRC voted to adopt a new process to assess the hospitals’ perinatal levels of care using the CDC’s levels of care assessment tool (LOCATe). Although LOCATe is not intended to assign or verify levels of care, and does not replace the State’s levels of care designation process, it will be a useful tool in assessing the state of perinatal care in Arkansas. LOCATe will guide efforts to improve the state’s perinatal care system and help align the state’s recommendations with the most recent national standards.
The ADH was not granted access to the LOCATe tool until the end of 2019 because the CDC updated it to align with the 2019 release of the American College of Obstetricians and Gynecologists/Society of Maternal Fetal Medicine levels of maternal care. Arkansas will continue to build and improve its risk-appropriate levels of perinatal care system. Currently, 38 of the state’s 39 birthing hospitals and the state’s only pediatric specialty hospital are participating.
Strategy 3.2: Encourage hospitals to voluntarily develop agreements for transfer of high- risk patients to hospitals with the proper level of care to give birth.
The voluntary system designating risk-appropriate perinatal levels of care in Arkansas is currently in a state of transformation and efforts to address this strategy have been postponed. While hospitals are encouraged to develop transfer agreements, this strategy is designed for more mature, established systems. The AMPOQRC is not only responsible for designating perinatal levels of care, but also for implementing quality improvement projects, so the Committee can likely address this strategy through a future quality improvement project. Birthing hospitals will continue to be encouraged to develop agreements with other hospitals to facilitate transfer of expectant mothers to facilities that best meet the needs of the mother and unborn child prior to delivery.
Priority Need: Breastfeeding
NPM 4: Percent of infants who are ever breastfed and percent of infants who are exclusively breastfed for 6 months.
Breastfeeding rates in Arkansas consistently lag behind national averages and Healthy People 2020 expectations (Table 1).
Table 1
Comparison of Arkansas’s 2016-2017 Breastfeeding Rates with United States Rates and Healthy People 2020 Objectives
|
Ever Breastfed |
Exclusive Breastfeeding at Six Months |
Arkansas |
73.8% |
20.4% |
United States |
83.2% |
24.9% |
Healthy People 2020 |
81.9% |
25.5% |
The ADH’s strategies to improve breastfeeding rates include 1) increasing the percentage of birthing hospitals that have policies requiring staff to encourage new mothers to breastfeed their infants and 2) increasing the percentage of infants who are ever breastfed and who are breastfed exclusively through six months of age.
Strategy 4.1: Develop breastfeeding toolkit for hospitals to use. The toolkit will have sample policies and educational material for staff and patients.
The Baby Friendly Arkansas Toolkit was developed in partnership with the Arkansas Breastfeeding Coalition, the Arkansas Hospital Association, the Arkansas Foundation for Medical Care, and the University of Arkansas for Medical Sciences. The toolkit includes educational materials for staff and patients as well as sample policies and research studies that support early initiation of breastfeeding.
The toolkit was distributed to 29 of the state’s 39 birthing hospitals at the first Baby Friendly Arkansas Summit in 2018. All birthing hospitals attending the Summit pledged their commitment to become a Baby Friendly Hospital, and to date, eight are Baby-Friendly hospitals and have breastfeeding/infant feeding policies that support breastfeeding as the normal method of infant feeding and address all of Baby Friendly USA’s Ten Steps to Successful Breastfeeding (https://www.babyfriendlyusa.org/get-started/d2-development).
Strategy 4.2: Provide training for hospital staff on breastfeeding and how to encourage breastfeeding by their patients. Training will include on-site training and telemedicine (video conference).
In 2019, 100 representatives from 29 of the Arkansas’s 39 birthing hospitals, which represent approximately 90% of the state’s annual births, attended the 2nd annual Baby Friendly Arkansas Summit. The Summit provided education, support, and mentoring opportunities for hospitals interested in becoming Baby Friendly (https://www.babyfriendlyusa.org/about/), which is a two to four-year process.
In 2019, 75 newly certified lactation counselors served rural and low-income areas of the State, where lactation counseling is not easily accessed. Hospitals on the path to becoming Baby Friendly continued to receive mentoring and support through monthly coaching calls and webinars.
The state has many activities that support the objective to increase the percentage of infants who are ever breastfed and who are breastfed exclusively through six months of age.
- The ADH continues to facilitate a monthly meeting of the Breastfeeding Promotion Taskforce. The Taskforce brings together stakeholders from the Family Health Branch; Women, Infants and Children (WIC) Program; Office of Health Equity; and Child and Adolescent Health Section as well as representatives from the Arkansas Breastfeeding Coalition, Arkansas Injury Prevention Center, Arkansas Children’s Hospital, and the Baptist Health System.
- Arkansas’s Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program also has focused efforts to support breastfeeding. The program has a benchmark measure about breastfeeding (Percent of infants (among mothers who enrolled in home visiting prenatally) who were breastfed any amount at 6 months of age). Four of the five MIECHV-funded programs (the fifth program works with children ages 3-5 years) ask mothers about this measure. In addition, the Following Baby Back Home, Healthy Families America, and Parents as Teachers home visiting programs use the Family Map Inventories (http://www.thefamilymap.org/), which asks “How old was your child when you stopped breastfeeding?” Answer options are: not applicable, until two months, 2-5 months, and six or more months. The Nurse-Family Partnership home visiting program asks mothers about initiation of breastfeeding and follows up at six and 12 months.
Arkansas’s MIECHV Training Institute developed instructor-led and online courses to educate home visitors about breastfeeding. The instructor-led training is available to all home visitors in the state regardless of funding stream (http://www.arhomevisiting.org/Training_Institute/modules). The online training is accessible to anyone with an internet connection (http://www.arhomevisiting.org/Training_Institute/online-training).
All of the Nurse-Family Partnership’s Programs’ nurse home visitors and the ADH’s Section Chief for Home Visiting completed and passed the exam for the Academy of Lactation Policy and Practice’s Certified Lactation Counselor course in 2016. These certifications were valid through December 31, 2019. WIC funding for certifications has ended. Alternative funding source through Home Visiting is being reviewed for re-certifications. The Nurse-Family Partnership Program continues to work on continuous quality improvement initiatives focused on improving breastfeeding initiation rates.
- The Arkansas WIC Program offers breastfeeding information and education to all WIC participants online through the WICSmart (http://www.wicsmart.com/) website, the USDA’s WIC Breastfeeding Support website (https://wicbreastfeeding.fns.usda.gov/), the WICSmart mobile phone app, and in-person through nutritional kiosks that have been placed in all 96 of the state’s local health units.
In addition, WIC clients who are breastfeeding or intend to breastfeed have access to WIC breastfeeding peer counselors who provide education and support. Breastfeeding peer counselors who work for Arkansas’s WIC program must have breastfed for at least six months and have received WIC services. These mothers must love breastfeeding and be willing to share that love with other mothers.
The Breastfeeding Peer Counselor Program currently serves 18 Arkansas counties, and peer counselors provide support in a variety of ways including through hospital visits, home visits, by text, email, phone, or through support group meetings. WIC clients who live in areas not served by a peer counselor still can receive support by calling the WIC Breastfeeding Helpline, which is available Monday through Friday from 8:00 am to 4:30 pm (https://www.healthy.arkansas.gov/programs-services/topics/meet-our-breastfeeding-peer-counselors). On nights and weekends the WIC Breastfeeding Helpline rolls over to Baptist Health’s Breastfeeding Helpline.
- The ADH Sisters United program is a culturally sensitive, community-based initiative designed to increase public awareness about the burden of infant mortality among African-Americans. The initiative is a partnership among members of the Alpha Kappa Alpha, Delta Sigma Theta, Zeta Phi Beta, and Sigma Gamma Rho sororities. This campaign is the first time the four African-American sororities of the National Pan-Hellenic Council have taken up an issue collectively. The Sisters United campaign focuses on the four areas: folic acid before pregnancy, flu shots during pregnancy, breastfeeding, and safe sleep. Research has shown that these four areas are effective ways to decrease infant mortality rates. The model for this program is Train-the-Trainer, which enhances the skills and knowledge of the trainers. By utilizing this method of training, the trainers master the curriculum and are able to transfer knowledge to community members.
- The ADH Brothers United program is a companion program to Sisters United and is also focused on increasing public awareness and promoting healthy behaviors that are known to reduce infant mortality. The initiative is a partnership among members of Alpha Phi Alpha, Kappa Alpha Psi, Omega Psi Phi, Phi Beta Sigma and Iota Phi Theta fraternities. The Brothers United program hosts “Tailgate Parties” during fraternity chapter meetings. The purpose of the Tailgate Parties is to provide education to expectant and new dads with the goals of 1) increasing the number of expectant and new dads with an awareness of infant mortality and 2) increasing the percent of expectant and new dads with knowledge of safe sleep and breastfeeding.
- The ADH Office of Health Equity collaborates with Brothers United, Sisters United, and the state’s WIC program to host Mocha Café Live, a culturally sensitive, social media initiative designed to increase public awareness and promote healthy behaviors that support breastfeeding in the Black community. The Mocha Café is the first breastfeeding support group specifically designed for Black mothers.
Originally the group met monthly at 11 am to noon and 6 pm to 7 pm in a local library; however, after receiving feedback from moms that could not attend due to work or other commitments, the group facilitator decided to try a live support through the Sisters United Facebook page, thus creating Mocha Live. Each meeting has a monthly topic, guest speaker(s), and is facilitated by a panel of certified lactation counselors.
Through Mocha Live mothers are more likely to participate and receive the same benefits of an in-person support group. All of the mothers who started with the program are still breastfeeding and have exceeded the World Health Organization recommendation of at least six months of breastfeeding. These mothers have formed a close-knit community resulting in the creation of Arkansas’s first black breastfeeding photo. Based on these results, we can conclude that online support groups provide live problem solving & empathy, education, and support for Black breastfeeding mothers.
- The ADH continues to support the Baptist Health Breastfeeding Helpline with funding from the Preventive Health and Health Services Block Grant and Title V MCH Block Grant. The helpline operates 24 hours a day, seven days a week and is in its fourth year of operation. The helpline is a tool to increase adoption and duration of breastfeeding by providing support from an International Board Certified Lactation Consultant or Certified Lactation Counselor.
The Breastfeeding Helpline receives calls via a toll-free phone number (https://www.baptist-health.com/womens/breastfeeding-education-products). Call volume continues to be measured in the following ways:
- Calls between the hours of 8:30 AM – 5:00 PM
- Calls between the hours of 5:00 PM – 8:30 AM
- Calls from WIC participants
- Resident of Pulaski County or outside of Pulaski County
During the 2019 federal fiscal year, the helpline received a total of 4,590 calls. The number of calls reported during this period increased by approximately 17% when compared to the number of calls received during the previous federal fiscal year.
- In 2016, Governor Asa Hutchinson launched Healthy Active Arkansas, a platform for improving the health of the citizens of Arkansas. Breastfeeding is one of the nine priority areas addressed through this initiative. The Arkansas Breastfeeding Helpline is a key component to the breastfeeding priority area. One of the main goals of the breastfeeding priority area is to assist hospitals statewide in obtaining the Baby Friendly Hospital designation. The Baby Friendly designation is based on the World Health Organization’s 10 Steps to Successful Breastfeeding to help hospitals improve maternity care and increase breastfeeding rates (https://www.babyfriendlyusa.org/for-facilities/practice-guidelines/10-steps-and-international-code/). The Breastfeeding Helpline is an essential piece of the community resources needed to obtain the Baby Friendly designation.
- The ADH Breastfeeding Promotion Task Force, established in 2013, is a collaborative workgroup including the Family Health Branch, WIC breastfeeding and peer counseling programs, Office of Health Equity, Hometown Health Coalition Initiative, Office of Health Communications, and School Health Services. Members also include representatives from partner organizations including Baptist Hospital, Arkansas Foundation for Medical Care, the University of Arkansas for Medical Sciences, and the Baby Friendly Hospital initiative. Although the Task Force’s focus has shifted over time in response to changing priorities, it has always provided a forum for private and public partners to convene, share information, and strategize ways to promote and increase breastfeeding in Arkansas. Current focus areas include: 1) using community-based organizations to promote and support breastfeeding and 2) strengthening programs that provide breastfeeding support and breastfeeding counseling.
In 2018, it became clear that many members of the Task Force were also members of the Arkansas Breastfeeding Coalition and each group was working on the many of the same issues. An informal comparison of members, mission, vision, objectives, projects, accomplishments, attributes, and areas needing improvement revealed that both groups possessed attributes that could enhance joint efforts. For example, the Coalition included a larger, more diverse group of members, while the Task Force included members with decision-making authority within the agency. The Task Force receives technical and administrative support from ADH while the Coalition receives support and recognition from the U.S. Breastfeeding Committee.
Each group wanted to maintain its unique identity but acknowledged that greater coordination and streamlining of efforts could be beneficial for both. In order to glean these benefits yet maintain the identity of each group, they began aligning their meetings in February 2019. The groups hold meetings on the same day in the same location with the Task Force meeting first and the Coalition meeting immediately following. This allows partners to attend one or both meetings, allows for sharing of networking equipment and administrative assistance, and establishes a system that allows improved flow of communication and partnership. Ultimately, the goal is for the Task Force to help set evidence-based project objectives and the Coalition to implement and oversee projects through its’ members and use of the ABC’s 501(c)(3) status. Examples of current coordinated projects include an initiative to create breastfeeding nooks in worksites and early childcare centers, an annual Lactation Symposium, collaboration to ensure consistency of messaging, and education for the Baby Friendly Hospital initiative and EMPOWER efforts in Arkansas.
Priority Need: Safe Sleep
NPM 5: 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.
The ADH has many efforts focused on improving infant safe sleep practices in the state, including 1) increasing number of women who report placing their infant to sleep on their back and 2) increasing the number of hospitals with safe sleep policies.
Strategy 5.1: Expand the efforts of the Sisters United and Brothers United campaigns and replicate the programs with other minority groups in the state.
The individual responsible for the coordination of Sisters United and Brothers United activities works in the ADH Office of Health Equity and is a member of the Arkansas Safe Sleep Collaborative Improvement and Innovation Network (CoIIN) team. In 2019 the Sisters and Brothers United programs shifted their focus to maternal mortality among Black women and breastfeeding. The programs also provided safe sleep education at two events during the year, including hosting a table at the Kappa Alpha Psi Southwestern Province Leadership Conference in Little Rock in September 2019. Table top education kits were used to provide a hands-on learning experience using the teach-back method.
The ADH Office of Health Equity, the Arkansas Safe Sleep CoIIN, and Sisters and Brothers United programs were working together to plan an in-person Day 366 celebration for September 2020. Due to COVID-19, however, planning is now focused on hosting a virtual event instead. The partners have developed a Governor’s proclamation to declare September 2020 as Infant Safe Sleep Awareness month in Arkansas.
Strategy 5.2: Provide training for hospital staff on safe sleep and how to encourage safe sleep by their patients. Training will include on-site training and telemedicine (video conference).
The Safe Sleep CoIIN team provided training and technical assistance to all birthing hospitals in 2019.
In November 2019, the Arkansas Nursery Alliance unveiled its Safe Sleep Pathway screening tool during the 2nd annual Nursery Alliance Leadership Conference. The Nursery Alliance includes five Level I and II hospitals as well as Arkansas Children’s Hospital, which is the only Level IV hospital according to the state’s perinatal levels of care guidelines. Representatives from all six member hospitals participated in a conference breakout session designed to engage hospital representatives in strategy discussions on how to ensure successful implementation of the Safe Sleep Pathway. The discussions became the basis of the Safe Sleep Pathway’s key driver diagram. The project goal is to screen 100% of babies born or cared for at Nursery Alliance partner sites for a safe sleep environment using the Nursery Alliance Safe Sleep Pathway prior to discharge. Success will be measured by the number of times activation of the Safe Sleep Pathway resulted in supplying families with a pack-n-play or resource referral.
Strategy 5.3: Develop a safe sleep toolkit for hospitals to use. The toolkit will have sample policies and educational material for staff and patients.
Only one hospital was safe sleep certified prior to CoIIN implementation in 2015. To date, all 40 hospitals have received the safe sleep toolkit. Currently, 37 of Arkansas’s 39 birthing hospitals and Arkansas Children’s Hospital are safe sleep certified and one hospital is in the process of applying for certification by Cribs for Kids (https://cribsforkids.org/). This national organization requires all certified hospitals to educate their health care staff, families, and caregivers about safe sleep practices. Five of the birthing hospitals are Gold certified, 20 are Silver certified, and 12 are Bronze certified. Arkansas Children’s Hospital is Gold certified. Prior to the CoIIN efforts only seven hospitals had written safe sleep policies. Due to the CoIIN team’s efforts, all 40 hospitals now have written safe sleep policies.
In addition to the strategies noted above, there are many activities that support safe sleep in the state, including:
- In 2017, after receiving a three-year grant from HRSA, the National Institute of Children’s Health Quality invited Arkansas, along with three other states (Mississippi, New York, Tennessee), to participate in a second-generation Safe Sleep CoIIN. The Safe Sleep CoIIN continues efforts that began in 2015, and has broadened its scope to not only provide technical assistance to birthing hospitals wanting to be Cribs for Kids certified, but also to recruit community-based partners (e.g. childcare centers and first responders) and clinics to provide safe sleep education and direct patients and clients to safe sleep resources in their communities.
The Safe Sleep CoIIN team includes partners representing: the ADHs Family Health Branch, Office of Health Equity, WIC Nutrition Program, Emergency Medical Services for Children (EMS-C), and Nurse-Family Partnership home visiting program as well as Arkansas’s Infant and Child Death Review Program, Arkansas Nursery Alliance, Arkansas Children’s Hospital’s Injury Prevention Center, Arkansas Hospital Association, Arkansas Foundation for Medical Care, Arkansas Department of Human Services’ Division of Child Care and Early Childhood Education, Arkansas Center for Health Improvement, University of Arkansas for Medical Sciences, Baptist Health Community Outreach, March of Dimes, and the Zeta Dove Foundation.
In 2018, the CoIIN team modified a patient education tool originally created by the Tennessee Department of Health and distributed over 200 tools throughout the state. In 2019, after discussions with several health care providers, it was found that the modified patient education tool (flip book) was too long and there was a need for a way to educate patients quickly. A brief version of the tool was developed, then reviewed and edited for health literacy and readability by the Center for Health Literacy at the University of Arkansas for Medical Sciences.
- The Safe Sleep CoIIN team is working with first responders to implement the Cribs for Kids® National Public Safety Initiative program to prevent sleep-related infant deaths in Arkansas communities. This project launched as a partnership between the ADH Family Health Branch, the Injury Prevention Center at Arkansas Children’s Hospital, and the ADH Emergency Medical Services for Children program, which receives funding through the Health Resources and Services Administration’s Emergency Medical Services for Children State Partnership Grant. First responder agencies are invited to join the program by their region’s pediatric emergency care coordinator facilitator. There are seven regional facilitators throughout the state and the program’s goal is to recruit three first responder agencies in each of the state’s seven regions.
When a first responder agency joins the program, the agency is given safe sleep supplies and materials and the first responders are trained. Once trained and the program is implemented, the first responders follow the procedures listed below if they encounter a baby under the age of one in what appears to be an unsafe infant sleep environment while on a non-emergent call:
- Ask if the baby has a safe place to sleep.
- Ask the caregiver(s) to show them where the baby sleeps and provide hands-on education (removing blankets, pillows, etc. from the crib) if necessary. Review safe sleep toolkit packet materials with the family. If the family does not have a safe place for the baby to sleep, the first responders inform the family that they can provide a safe sleep environment.
- Take the blue card from the packet. The family completes the front of the blue card, which collects unidentifiable demographic information, asks about any safe sleep education they have received, and about their infant sleep practices. First responders then complete the back of the card, giving information about the encounter, the education provided, and what safe sleep products they gave to the family.
- If the family needs a portable crib, the first responders bring one back to the home and helps set it up.
Upon return to the station or agency, the first responder returns the blue card to the designated safe sleep champion, who then returns the completed cards to the Safe Sleep CoIIN team.
To date, first responders at 63 locations have completed training on safe sleep. The training sites are listed below and Figure 1 shows the areas of the state where trainings have taken place.
Figure 1
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Arkansas Valley
- Fort Smith Fire Department: 11 stations
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Central Arkansas
- Conway Fire Department: 7 stations
- Jacksonville Fire Department: 4 stations
- Little Rock Fire Department: 20 stations
- Wooster Volunteer Fire Department: 1 station
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North Central Arkansas
- Floyd-Romance Volunteer Fire Department: 4 stations
- Searcy Fire Department: 3 stations
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Northeast Arkansas
- Barton-Lexa Volunteer Fire Department: 2 stations
- Helena-West Helena: 2 stations
- Marvel Police Department: 1 station
- Newport Fire Department: 2 stations
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Southeast Arkansas
- McGehee Fire Department: 2 stations
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Southwest Arkansas
- El Dorado Fire Department: 4 stations
- The Arkansas Safe Sleep CoIIN team, in partnership with the Arkansas Single Parent Scholarship Fund, provides infant safe sleep education and safe sleep products to scholarship recipients. The Arkansas Single Parent Scholarship Fund started as a grassroots effort in Northwest Arkansas in 1984 and was available statewide in 1990. The organization has nine regions that encompass all 75 counties and awards more than $1.5 million dollars in scholarships to low-income single parents each year. The Fund provides recipients with more than educational funding: it also provides mentoring, developmental life skills workshops, and career coaching. Over 80% of the program’s recipients either remain in school or complete their educational programs each year. Scholarship recipients all meet or exceed the 100-200% poverty level requirements and are all single parents or single, soon-to-be parents.
To be eligible to receive safe sleep products, parents are required to attend a one-hour in-person workshop during the regional semester interviews, and to complete an online educational module developed by the American Academy of Pediatrics. After completion of the online-training and final test, the parents receive a certificate to give to their regional program manager. Parents receive their play yard and safe sleep products at the scholarship award ceremony, where a final “safe sleep refresher training” is provided to all ceremony attendees, including the students’ family members, friends, and supporters.
CoIIN funds are used to provide Cribette play yards, wearable blankets, and safe sleep board books to parents so they can keep their baby safe while sleeping. The pilot program began in September 2019 in two of the organization’s nine regions. Twelve single parents participated in the program pilot. In February 2020 an award program was held at Arkansas State University in Heber Springs for Cleburne County’s scholarship recipients. Approximately 75 were in attendance including several local dignitaries and business owners. As part of the program, the Safe Sleep refresher was provided, and two single parents were presented with Cribette play yards and safe sleep supplies for completion of the Safe Sleep program. The extended family members and friends of both recipients participated in the refresher training, and their grandparents commented on how they felt they also learned and benefited from the refresher program. Following the awards program several members of the audience commented on how beneficial this program was and they appreciated attending and learning with the families. The Safe Sleep program was also presented at the Spring Award Program in Stone County (15 attendees) and Independence County (40 attendees) as community awareness presentations.
- The WIC Baby and Me parenting program was implemented in selected WIC clinics across the state. The parenting program focuses on strengthening the parent/child relationship, promoting healthy child development, and connecting parents to community resources in WIC clinics selected by the WIC Baby and Me Advisory Board. Parent support mentors meet with interested families during WIC clinic certification visits. The visits include one prenatal learning session on safe infant sleep practices and six brief post-birth learning sessions that include facilitated mother-child interaction time that is focused on enhancing secure attachment and reinforcing education provided by the hospital where the mother gave birth and her pediatric/primary care physician.
The Safe Sleep CoIIN team provided consultation on the safe sleep education module for the Baby and Me program, ensuring the content and images were consistent with the 2016 American Academy of Pediatrics Safe Infant Sleep Policy Recommendations. Safe Sleep CoIIN funds are used to provide wearable blankets and safe sleep board books to all parents who participate in the program and provides Cribette play yards for families in need so they can keep their baby safe while sleeping.
The pilot program began in five counties in November 2018 and has expanded to 14 counties located in the Southeast (Delta) and Mid-south regions. The counties served in the Delta region include Arkansas, Ashley, Bradley, Chicot, Desha, Drew, Jefferson, Lee, Lincoln, Phillips, and St. Francis counties. The Mid-south region covers Garland, Pulaski, and Sebastian counties. Since the launch of the program in 2018 1,278 families have been educated on safe sleep.
- The Safe Sleep CoIIN team worked with the WIC program to develop questions about safe sleep environments that the program added to their SPIRIT charting system. The questions are printed on a laminated job aid (one side is English, the other is Spanish) for the WIC staff to use during certification appointments. An identical post card is also given to the client. There are two questions, one for pregnant women and one for new mothers/caregivers:
- Where do you plan for your baby to sleep? (Pregnant Women)
- Where does your baby sleep? Alone? On his/her back? In a crib, bassinet, or play yard? (New mothers/caregivers)
The staff member will educate the client on safe sleep using the laminated job aid and safe sleep hand out cards based on the client’s response and will refer the client to Arkansas Children’s Injury Prevention Center if they indicate that they do not have a safe place for their infant to sleep. Since the program launched in September 2019, 99 referrals have been made to Arkansas Children’s Hospital’s Injury Prevention Center for parents in need of a safe sleep environment for their infant.
The Child and Adolescent Health Section of ADH houses two critical infant programs responsible for facilitating early identification and intervention of birth disorders: Infant Hearing Program (IHP) and Newborn Screening Program (NBS). These programs work to efficiently monitor the Triple Threat: heel stick, pulse oximeter, and hearing test to ensure excellent health for Arkansas’s babies.
Priority Need: Infant Hearing
SPM 5: Percent of newborns with timely follow-up of a failed hearing screening.
The most recent state available data (2019) on the percent of infants receiving diagnostic testing by three months of age after failing the newborn hearing screen indicates the following:
- 54% of infants failing the newborn hearing screen received diagnostic testing by three months of age.
The IHP serves as the Early Hearing Detection and Intervention program for the state of Arkansas. Under the guidance of Act 1559 of 1999 the IHP strives to ensure all newborns receive a hearing screening before one month of age, a diagnostic test before three months of age for infants who do not pass the initial screening, and enrollment in early intervention services before six months of age for infants receiving a diagnosis of hearing loss. The IHP documents the progress of children ages birth to three years old throughout the screening process in the Electronic Registration of Arkansas Vital Events (ERAVE) information system. Birthing hospitals, primary care physicians, and other hearing screening and diagnostic testing providers from Arkansas and out-of-state facilities document relevant information in ERAVE.
In 2019, the ERAVE Hearing Screening and Follow-Up Survey Report revealed that 149 children who failed the newborn hearing screening received diagnostic testing. Of the 149 documented diagnostic tests completed, 81 children (54%) received a confirmatory diagnosis by three months of age. Challenges to increasing the number of timely diagnosis are attributed to the lack of awareness of steps in the process, the IHP’s inability to consistently contact parents, and families’ access to qualified providers in rural areas.
The IHP faced challenges getting correct demographic information from ERAVE based on data initially entered during the newborn hearing screening. The IHP continues to address data quality issues by providing specialized training to all IHP staff, increasing communication with health care professionals, and promoting awareness of the Early Hearing Detection and Intervention program statewide using social media. Additional educational opportunities were provided to ERAVE users to support increased documentation of each aspect of the Early Hearing Detection and Intervention process. These trainings were offered in-person, virtually, and as an independent study course on Arkansas TRAIN. Increased instruction on the importance of data quality was provided to birthing facilities as part of the Monthly Hospital Report Cards, which rates performance. Additionally, the IHP increased the effectiveness of intra-agency partnerships by gaining access to agency databases (i.e. Common Customer and WebIZ) to assist in identifying correct contact information for families. The IHP collaborated with NBS and WIC programs to increase notifications of next follow-up steps. Lastly, the IHP implemented a social media campaign to increase awareness of timely hearing screening and diagnostic testing amongst new and expectant parents (Figures 2 and 3). Analytics show 72,768 (55% women and 45% men) were reached during this campaign.
Figure 2: Social Media Campaign Figure 3: Social Media Campaign
Priority Need: Newborn Screening
SPM 5: Percent of newborns with timely follow-up of a failed hearing screen.
The newborn screen starts with a simple heel stick to collect a few drops of blood to test. The results of this simple screen can determine the presence of permanent disabilities in infants. Newborn screening for inborn conditions became mandatory as a result of Act 192 of 1967, which required screening of all newborns for phenylketonuria (PKU). Since that time, the number of conditions screened for at birth has grown to over 31 core disorders (29 genetic disorders and two points of care tests, one for hearing and one for congenital heart disease). In 2019, 99% of the approximately 36,000 babies born in Arkansas received a newborn screen and 104 confirmed cases were identified and referred for treatment (Figure 4).
Figure 4: Total 2019 NBS Confirmed Cases = 104
The NBS program continued continuous quality improvement efforts by monitoring time of birth to time of collection, time of collection to time of receipt in the lab, and time of receipt to time of reporting results. Timeliness is monitored on a monthly basis and the combined goal for all three data points is less than 168 hours. In 2019, the goal was met each month with an average of 144 hours from birth to reporting of test documented. Each birthing facility receives a quarterly Hospital Timeliness Report (Figure 5) to identify the number of specimens collected and received by the NBS lab within 48 hours of collection. The program provides support to partner hospitals with virtual education opportunities and technical assistance to ensure effective collection to receipt in the lab for processing. Any facility that does not meet the goal of 80% of specimens reaching the lab with 48 hours is contacted to discuss potential issues related to timely specimen submission.
Figure 5: Hospital Timeliness Report Example
The NBS program continues to provide annual education opportunities for birthing facility staff, licensed lay midwives, and health care providers to increase awareness of NBS protocols and processes. These educational opportunities typically are offered as an onsite in-service, online course, or via annual conferences. Participants also receive an NBS toolkit. They are also eligible to earn continuing nursing education contact hours.
Success Story
Since the inception of the addition of Severe Combined Immunodeficiency (SCID) to the screening panel May of 2015, no confirmed SCID cases have been reported. However, other diagnosis affecting the baby’s immune system were identified as a result of SCID testing. For example, the NBS program received results indicating a presumptive positive for SCID. The baby was in NICU at the time and closely monitored. Once the baby was discharged, they were seen in the immunology clinic and evaluated quickly in accordance with NBS follow-up protocol. Confirmatory testing identified the baby did not have SCID, but was noted to be severely lymphopenic, which is the condition of having an abnormally low level of lymphocytes in the blood. The immunologist quickly ordered the baby to not to receive any live viral vaccines until further notice. The NBS team was able to flag the chart and enter this directive in the child’s Arkansas Immunization Information (WEBIZ), “HOLD all LIVE viral vaccines if any questions contact the NBS Follow-up program (501) 280-4780 for any assistance.” Due to the note located in WEBIZ, the immunization was held, and follow-up was conducted by the immunologist. The potential for severe complications or death could have occurred if the baby received a live virus. This is an outstanding example of how NBS testing assists medical professionals in caring for Arkansas babies by identifying underlining disorders that could potentially lead to unnecessary early death.
As noted throughout the application, the Arkansas Maternal Mortality Review Committee (AMMRC) was authorized by Act 829 of the 92nd General Assembly of 2019. Act 1032 is companion legislation to Act 829 and authorized the formation of the Maternal and Perinatal Outcomes Review Committee. This legislation placed Arkansas in a position to develop and maintain a multi-disciplinary committee intended to reduce maternal mortality.
After the Act 829 was enacted the ADH Family Health Branch staff set to work laying the foundation and building the infrastructure of the AMMRC. Branch staff developed a guidance document that outlined the policies and procedures of the AMMRC. A memorandum of understanding with the CDC was put in place for use of the Maternal Mortality Review Information Application data system, and the ADH Family Health Branch entered into an intra-agency memorandum of agreement with the ADH Office of Vital Statistics to obtain maternal death certificate, birth certificate, fetal death certificate, and hospital discharge data. The Branch epidemiologist and other internal staff worked with the ADH Health Statistics Branch to identify and verify maternal deaths in January 2020 and began abstracting cases in late February. The AMMRC’s first review meeting was scheduled for April 2020 but was postponed due to COVID-19. The AMMRC was able to safely hold its first meeting to review cases on June 30, 2020 and plans to meet again in August and October 2020.
The AMMRC currently consists of 20 members who have committed to serving a two to three-year renewable term. Arkansas has five public health regions and each region is represented on the committee. The members represent various organizations, disciplines, and specialties but share experience of professional engagement with maternal health. With representation from each of the five public health regions, members of the Committee bring unique geographical insight as well as technical expertise.
The AMMRC reviews and makes decisions about each case based on the case narrative and abstracted data. The Committee examines the cause of death and contributing factors and determines:
- If the death pregnancy-related
- Underlying cause of death
- If the death was preventable
- Factors that contributed to the death
- Recommendations and actions that address those contributing factors
- Anticipated impact of those recommendations and actions if implemented
These data help the Committee understand the drivers of maternal mortality, pregnancy complications, and associated disparities. Reviewing data with clinical and non-clinical partners supports improvements in quality of care and social determinants of health. The information collected through the AMMRC will help the Committee determine what interventions will have the most impact at the patient, provider, facility, system, and community levels. The data will also direct the development and implementation of initiatives in the right places for the families and communities that need them most.
The Committee’s findings and decisions will be entered into the CDC’s Maternal Mortality Review Information Application data system within two years of death as required. In addition, the AMMRC is required to submit annual reports to the legislature. The first reports are due on or before December 31, 2020 and include 1) a report to the House and Senate Committees on Public Health, Welfare, and Labor that includes maternal and perinatal outcomes and recommendations and 2) a report to the Legislative Council that includes the findings and recommendations of the committee along with an analysis of information obtained from the review of birth outcomes. The report will include only aggregate data.
As noted earlier in the report, Act 1032 of 2019 gave the ADH the authority to establish the Arkansas Maternal and Perinatal Outcomes Quality Review Committee (AMPOQRC). This Committee not only assumed the responsibilities of the former Perinatal Regionalization Committee to establish risk-appropriate levels of perinatal care guidelines and to provide oversight of the system, but the legislation also delegated the authority to the AMPOQRC to function as the State’s perinatal quality collaborative (PQC). According to the CDC, state PQCs are “state or multistate networks of teams working to improve the quality of care for mothers and babies. PQC members identify health care processes that need to be improved and use the best available methods to make changes as quickly as possible.”
In 2016 Arkansas established its own version of a PQC, the Arkansas Perinatal Forum (APF), and has been engaged in and contributed to various perinatal care quality improvement initiatives over the past four years. The APF has never initiated quality improvement projects, however, because it was designed to be a hub to provide a collaborative space for existing teams, or what the APF called “workgroups,” to share information and resources. While the APF still has value and can continue to function as a resource hub, it does not truly align with the CDC’s definition of a state PQC like the AMPOQRC does. Act 1032 mandates the AMPOQRC to “develop clear measurements to evaluate targeted outreach, progress, and return on investment;” and to “create a system of continuous quality improvement that will include the ability of designated and non-designated hospitals to compare performance to peer facilities.”
The AMPOQRC worked throughout 2019 to build capacity to carry out the mandates of the legislation. Several Family Health Branch staff assist with the day-to-day activities of the AMMRC and the AMPOQRC, in addition to their other duties and responsibilities. Progress in rebuilding the AMPOQRC to function as the state’s PQC has been slow but steady.
The AMPOQRC developed a charter that was scheduled to be approved and signed by the Committee co-chairs and the State Secretary of Health in March 2020, but that was postponed due to COVID-19. The charter outlines the policies and procedures of the Committee and guides its work. Family Health Branch staff, including the Medical Director for Family Health, who serves as a co-chair for the Committee, also held discussions on potential partnerships with the Arkansas Hospital Association to carry out year-long perinatal quality collaborative projects. The plan is to use a modified version of the Institute for Healthcare Improvement’s Breakthrough Series Model for Improvement. A hospital survey was also developed to gauge hospitals’ interest in participating in quality collaborative projects and the types of projects they would like to work on. While progress will likely continue to be slow due to COVID-19, ADH will maintain efforts to build the infrastructure necessary to meet the mandates of the legislation,
The Family Health Branch began working with a website developer to build the Arkansas Perinatal Forum website in 2018 and Branch staff began the process of uploading content to the website and creating training materials in early 2019. Work on this effort ceased mid-year of 2019, however, because the passage of two key pieces of perinatal legislation (Act 829 & Act 1032) in April 2019, which led to a shift in priorities. It is intended to repurpose the website for activities related to the legislation.
Arkansas’s Maternal, Infant, and Early Childhood Home Visiting program supports five home visiting models: four evidence-based and one promising approach. The promising approach, Following Baby Back Home, uses a team approach (nurse and social worker) to improve outcomes for children coming out of a neonatal intensive care unit. The overarching goals of the Following Baby Back Home program are to:
Maximize the health and developmental progress of clients within the constraints of their medical conditions
Improve the family’s skill and confidence in providing a safe, stimulating, nurturing home.
In an evaluation of Following Baby Back Home (2012-2104), the program compared its infant mortality rate (death in the first 12 months of life), preterm birth rate (< 37 weeks’ gestation), and low birth weight (<2,499 grams) rates to national and state level data. The evaluation found that the mortality rate of infants served by the Following Baby Back Home Program was six times lower when compared to low birth weight children in Arkansas and the United States, and four times lower when compared to preterm children in Arkansas and the United States.
In federal fiscal year 2019, home visitors from Arkansas’s Maternal, Infant, and Early Childhood Home Visiting program completed 30,871 home visits and served 2,375 households, including 2,375 adults and 2,490 index children. The majority (67%) of the population served were female caregivers and the overwhelming majority (93%) of female care givers were 44 years’ old or younger. Less than 2% of the total population served were male caregivers. Thirty-one percent of the total population served were pregnant. The majority (74%) of pregnant women were between the ages of 18 and 29 years’ old. The largest group of pregnant women (21%) were 18 to 19 years old, followed by 25 to 29 year olds (19%). The index children were divided equally by gender and the majority of index children (95%) were under the age of 3 years.
The majority (53%) of those served had never been married, including pregnant women, 70% of whom had never been married. While 20% of those served did not have a high school diploma, 38% had a high school diploma or GED, 30% had an some college/training, technical training/certification, or associate’s degree, and 11% had a bachelor’s degree or higher. Forty-one percent of pregnant women were employed part- or full-time compared to 46% of female caregivers and 71% of male caregivers. Eight percent of pregnant women, 5% of female caregivers, and 9% of male caregivers were homeless.
The majority (74%) of households served were low income; 32% had a child with a developmental delay or disability; 30% had a family member or child with low student achievement; 14% had a history of child abuse, child neglect, or interaction with child welfare services; 15% had someone who used tobacco in the home; and 8% had a history of substance abuse or were in need of substance abuse treatment.
The majority of all adults (61%) and children (81%) served had Medicaid or CHIP as their primary source of health insurance coverage. Twenty-five percent of adults and 12% of children had private or other insurance coverage.
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