Perinatal/Infant Health

Annual Report Year

Priority: Decreasing perinatal disparities.

Accessing and receiving quality health services are instrumental in eliminating preventable infant deaths, as well as maternal and child morbidities. Health characteristics of women who had live births during 2015 – 2016 demonstrate stark differences when stratified by race/ethnicity. Non-Hispanic Black women had higher proportions of experiencing a previous preterm birth (4.92%), smoked prior to pregnancy (7.05%), being overweight or obese (55.44%), had diabetes prior to becoming pregnant (1.26%), and had hypertension prior to becoming pregnant (3.52%) than their White counterparts (1.04%, 0.94%, 21.31%, 0.25%, and 1.12%, respectively). Similarly, Hispanic women had a higher proportion of experiencing a preterm birth prior to the current pregnancy (2.55%), were overweight or obese (46.48%), and had diabetes prior to their current pregnancy (1.42%) compared to their White counterparts.

The 2020 Breastfeeding Report Card (2017 data) states that 88.0% of infants in the District of Columbia have ever breastfed, this is almost 4% higher than the national rate. Breastfeeding generally decreases as the age of the infant increases, with rates in the District at 64.7% by six months and 39.3% by twelve months. The 2020 Report Card rates demonstrate an increase over the last few years, as the 2016 Report Card rates were 82.8% for ever breastfeeding, 57.4% for breastfeeding at 6 months, and 33.1% at 12 months. While the overall “ever breastfed” rate is high, breastfeeding initiation rates can vary widely by race and socio-economic status – the DC WIC breastfeeding initiation rate in 2018 was 62%, but can be as low as 30.9% at DC WIC clinics in predominantly African American areas of the city. Breastfeeding has been shown to reduce infant mortality, and also plays a major role in infant health and development. Continuing to increase rates of breastfeeding, particularly among low-income and African American women, can lead to decreased disparities in infant mortality, and improved health of infants and children. Promoting breastfeeding, ensuring quality newborn screening programs and availability of appropriate newborn and infant care supports for families and building collective impact helps achieve equitable perinatal and infant health outcomes.

Goal 1: Decrease infant mortality.

DC Health continues to house the Safe Sleep Program (SSP), supported through Title V funding. The SSP educates and empowers parents with information related to risk factors for Sudden Infant Death Syndrome (SIDS)/Sudden Unexpected Infant Death (SUID), including infant sleep position, exposure to smoke, overheating, inappropriate infant bedding, bed sharing, as well as strategies to reduce the risk of SIDS and prevent accidental suffocation/asphyxiation in sleep. Using a “Train the Trainer Model,” the SSP trained staff from 28 community based partner organizations in areas with high density of low-income residents across the District on how to educate their clients on the American Academy of Pediatrics Safe Infant Sleep Recommendations. Housing instability is a social determinant of health that affects infant health outcomes in many District families. As a result, the SSP continued to expand its focus on providing easily accessible safe sleep education and crib distribution in District shelters. The SSP also maintained a strong relationship with the Office of the State Superintendent of Education (OSSE) to provide training to licensed childcare center staff in the District and Child and Family Services Agency divisions, such as Child Protective Services (CPS). The SSP also participated in: monthly Infant Mortality Review Committee meetings led by the Office of the Chief Medical Examiner; Newborn and Fetus sub-committee meetings held by the DC chapter of the American Academy of Pediatrics; and DC WIC State Agency staff meetings to ensure WIC participants receive information to attend safe sleep classes. In FY19, the SSP educated 1027 District parents, provided training for 377 community partner staff (including all licensed child development center staff) and distributed 899 portable cribs.

Title V supports the District of Columbia’s Universal Newborn Hearing Screening Program also known as the Early Hearing Detection and Intervention (EHDI) Program. The overarching goal of the EHDI program is to support the development of statewide programs and systems of care that ensure that deaf or hard of hearing children are identified through newborn and infant hearing screening, and receive evaluation, diagnosis, and appropriate intervention that optimize their language, literacy, and social-emotional development. EHDI adheres to the national hearing loss intervention guidelines of 1-3-6. The 1-3-6 guidelines are: every newborn will receive a hearing screening by one month of age; every infant who did not pass the initial hearing screening and rescreening will have completed a diagnostic audiological exam by three months of age; and all infants confirmed as deaf or hard of hearing (D/HH) will be enrolled into early intervention services by six months of age.

In addition to partnering with OSSE and Strong Start, DC EHDI continued to contract services from Maryland/DC Hands and Voices (MD/DC Hands and Voices). MD/DC Hands and Voices is an organization dedicated to supporting families with children who are D/HH, without bias around communication modes or methodology. MD/DC Hands and Voices operates a program called “Guide By Your Side”, which provides support and mentorship to parents of children newly identified as D/HH through “guides.” The guides are parents of children who are D/HH and may also be D/HH themselves. The Guide By Your Side staff worked with Strong Start staff to assist them in understanding the needs and experiences of parents of newly identified D/HH children. Hands and Voices also assisted with the identification of the breakdown in the DC EHDI system from infant identification and diagnosis to entry into services. DC EHDI contracted an educational audiologist that collaborated with OSSE to work with the child until they age out of the program. DC EHDI also continued to strengthen and develop new partnerships with Healthy Start, Help Me Grow and the District of Columbia Interagency Coordinating Council. DC EHDI’s program coordinator worked closely with hospital staff to improve data quality, accuracy and timeliness. The focus on data quality allowed DC EHDI to ensure that hospitals performed newborn hearing screening services at birth and coordinated the appropriate follow up services (outpatient rescreening) when necessary. The program continued to collaborate with the District’s neighboring border states of Maryland and Virginia to ensure that out-of-state infants received appropriate care and follow up. DC EHDI also collaborated with other state EHDI coordinators to learn about the successful implementation of evidence-based practices and novel approaches to improve the EHDI system and family interaction within the system. Finally, DC EHDI worked to strengthen and mobilize the DC EHDI Advisory Board and DC EHDI Learning Community. The Advisory Board is a small group of stakeholders that reflect the comprehensive DC EHDI system. The DC EHDI Learning Community is a select group of potential adopters and stakeholders who engage in a shared learning process to facilitate adaptation and implementation of innovations; it addresses the importance of early hearing detection and intervention and active family engagement within the DC EHDI system.

DC EHDI had successes related to overcoming the challenges experienced in FY18. This included increasing technical assistance to facilitate improved timeliness of data entry by hospital screening staff. The main challenge faced by the program in FY19 was the inconsistent, and sometimes nonexistent, communication with Hands and Voices’ Guide By Your Side program when contacted by the DC EHDI staff.  The program continued to face a delay in the documentation of screening results in the database from audiology sites. There has also been significant turnover with EHDI program staff; the Perinatal and Infant Health Division Chief position, which oversees the EHDI program, became vacant in December 2018 and the new Perinatal and Infant Health Division (PIHD) Chief was hired in July 2019; from December 2018 – July 2019 there was an interim Division Chief. The DC EHDI evaluator also left her position in January 2019. These personnel changes have resulted in the inability to conduct robust quality improvement activities. However, despite these fluctuations with staff, the core functions of the newborn hearing screening program were maintained by the State EHDI Coordinator. By the end of the fiscal year, 13,416 babies were born in the District of Columbia, with 13,263 newborns receiving at least one hearing screening and 11 parents opting out of the hearing screening for their newborns.

The Newborn Metabolic Screening Program, supported by Title V funding, ensures all newborns born in the District of Columbia receive timely screening and follow-up for metabolic and genetic disorders. Program staff receive e-fax notifications from the public health laboratory (PerkinElmer) and follow-up with birthing hospitals, Primary Care Providers (PCPs), specialists, and families regarding positive, inconclusive, and unacceptable results. In FY19, the program continued to support the District’s Committee on Metabolic Disorders in its advisory role for the District. With the support of the program, the Committee approved the inclusion of second tier testing for three additional disorders (Pompe Disease, X- Linked Adrenoleukodystrophy (X-ALD) and Mucopolysaccharidosis (MPS1)). The Newborn Metabolic Screening Program distributed communications and implemented the change across District birthing facilities. With support from DC Health, the Community Health Omnibus Act of 2017 went into effect in April 2019, which helped to streamline the Districts various newborn screening programs through the development of procedural regulations and ensure the provision of comprehensive newborn education across birthing facilities.

The Newborn Metabolic Screening Program encountered several challenges in FY19, including: accessing contact information to assist with coordinating care between birthing hospitals, pediatricians, and families, considerable staff turnover, and delays in implementing evaluation and QA/QI activities. In FY19, 13,512 metabolic screenings were provided. Areas for improvement include quality assurance and quality improvement strategies, data utilization and interoperability, and seamless coordination across the newborn metabolic screening system.

The DC Community Action Network (CAN) was established in FY17 under the Healthy Start program, however has oversight and assistance from staff supported by Title V. The CAN uses a collective impact model to achieve equitable birth outcomes in DC. Collective impact is based on the principle that addressing complex social issues, like infant mortality, comes from maximizing cross-sector coordination, not from isolated efforts of individual organizations. The CAN brings together a variety of stakeholders, including health providers, government agencies, and community-based organizations to align their work to a common goal of reducing infant mortality (See Table 1).

The CAN uses shared measurement systems (establishing how success will be measured and reported); mutually reinforcing activities (ensuring each participant is doing activities within their expertise and that are coordinated with other participants’ activities); continuous communication (helping to develop trust among organizations that are not used to working with each other and keeping partners engaged); and DC Health as a backbone organization (allowing DC Health to provide the infrastructure for coordination and administration of the initiative). To achieve the most significant and lasting impacts for equitable perinatal health outcomes, CAN aligns and organizes the work of many District stakeholders committed to improving health outcomes for mothers and babies.

In FY19, DC Health had a full-time CAN Coordinator who was responsible for supporting the development of CAN. During the first half of FY19, the CAN drafted and disseminated information received from community listening sessions to help CAN partners understand barriers to prenatal care and explore innovative strategies in their work to address challenges. Some of the identified barriers to prenatal care included:

• limited availability of immediate/short term childcare services while attending prenatal care visits;
• low health literacy of insurance/social support benefits;
• long public transportation routes and;
• perceptions of quality regarding care.

The information gained through the listening sessions helped impact structuring and advocacy efforts of CAN.

Over the second half of FY19, the focus of CAN shifted towards collectively thinking through how to impact quality of care and improve maternal and infant health outcomes in the District. As a follow-up to Mayor Muriel Bowser’s 2019 Maternal and Infant Health Summit, DC Health convened a meeting to discuss issues of quality of care in maternal/infant health and collective strategies to improve services. The meeting brought together CAN partners and other District stakeholders, including: the Department of Health Care Finance, the Mayor’s Thrive by Five Initiative, managed care organizations (MCOs), community based organizations (CBOs), clinical leaders from the district birthing hospitals, federally qualified health centers (FQHCs), and health professional organizations to discuss the status of maternal health and ways to improve perinatal health outcomes and care. The attendees created a Perinatal Quality Collaborative (PQC) to address the issues faced in quality of care for mothers and babies, primarily through the implementation of quality improvement initiatives. PQCs are networks of clinical leaders, community groups and public health professionals. It is the District’s hope that bringing together the knowledge and perspectives of the diverse range of community members and service providers from the existing CAN through the PQC will help address issues in maternal and infant health outcomes in transformative ways.

Table 1. CAN Partner/ Steering Committee List

Goal 2: Increase breastfeeding initiation and duration.

In FY19, Title V funded the DC Breastfeeding Coalition (DCBFC), to provide at least three maternity facilities financial support and technical assistance to achieve and maintain Baby-Friendly designation through the Baby-Friendly Hospital Initiative (BFHI) and educate pregnant women about the benefits and management of breastfeeding, with priority given to subpopulations with lower rates of breastfeeding initiation and duration. Achievements in FY19 made by the following participating maternity facilities include:

• Howard University Hospital (HUH) – Lactation Peer Educators (LPE) provided prenatal breastfeeding education in the OB clinic and in-patient postpartum lactation support. HUH passed all steps except Step 3 (Prenatal Education) of BFHI. This area continues to be a challenge and Dr. Young, Chair/Neonatology Department, has expressed “we are very pleased” to receive the assistance of a peer educator for our prenatal clinics (residency and faculty).
• Community of Hope Family Health and Birth Center (FHBC) - A new Assistant Director of Midwifery was hired to lead the breastfeeding task force at FHBC/COH. She reestablished communication with BFUSA and received access to their Portal for integration into the requirements and processes. Due to the change in staffing, delays were experienced with achieving the activities outlined in the BFHI process. As a result, FHBC paid to enter a second year of Phase 4 (Designation) and requested their Readiness Assessment Phone Interview.
• George Washington University Hospital (GWUH) - For 3 years, DCBFC approached GWUH to invite them to participate in their program; however, each year their invitation was rejected. GWUH has one of the highest delivery rates in the city and serves an increasing number of moms from  priority areas. By the end of FY19, DCBFC established a subcontract agreement with GWUH to undergo the Baby-Friendly designation process. As a result, peer educators had access to provide postpartum lactation support in the hospital.

In FY19, DCBFC drafted a Model Hospital Breastfeeding Policy to provide a template and guidance for non –participating BFHI hospitals and birthing facilities to formulate their own policies and protocols that would satisfy BFHI requirements for designation. The following organizations and agencies’ breastfeeding policies were adapted and/or used as references: 

• American Academy of Breastfeeding Medicine -ABM
• American Academy of Pediatrics- AAP
• American College of Obstetricians and Gynecologist-ACOG
• American Academy of Family Physicians –AAFP
• World Health Organization- WHO 
• United Nations International Children’s Emergency Fund /WHO- Ten Steps to Successful  Breastfeeding
• Association of Women’s Health and Obstetrical Neonatal Nursing-AWHONN
• Office on Women’s Health – OWH
• United States Breastfeeding Committee-USBC
• DC Breastfeeding Coalition
• Baby-Friendly USA

Best practices from several states’ (New York, Illinois, and Maryland) breastfeeding policies were also used to formulate the draft policy. Breastfeeding policies and protocols were provided by the nursing leadership from all the District of Columbia hospitals and birthing facilities.

DCBFC also increased the number of IBCLC candidates from underrepresented communities; people of color, deaf and hard of hearing, LGBTQI, or differently-abled by offering a Lactation Certification Preparation Course (LCPC). Attendees included: peer educators, certified lactation counselors, a midwife, and a pediatrician. In FY19, the program received 26 applications, all from underrepresented groups. Fourteen applicants were selected to participate in the course, 10 were African American, 2 were mixed race, 1 was West Indian, and 1 was White. To mitigate the issue of cost, DCBFC offered the course that normally costs $750 for $100 (covering meals and course materials), to applicants from participating facilities and those from underrepresented communities in the lactation profession. The course was approved by the International Board of Lactation Consultant Examiners (IBLCE) for up to 75 hours of lactation-specific continuing education points.

DCBFC also maintained its collaborative partnership with Children’s National Health Systems for the continuation of free of charge lactation services at the Children’s National East of the River Lactation Support Center (ERLSC) to:

• conduct prenatal breastfeeding education classes in at least two settings;
• provide lactation counseling and support (both individual and group-based) in at least two (2) locations, including one in Ward 8;
  • a total of 171 unique participants were provided with prenatal and postpartum breastfeeding education at the ERLSC-Anacostia location, as well as HUH, MWHC, and the DC Public Schools, New Heights program
  • 280 face–to-face and 31 telephonic breastfeeding consults were provided at the ERLSC-Anacostia location

In partnership with District of Columbia Public Schools, (DCPS) the LPEs provided 24 prenatal breastfeeding classes to 31 expectant and postpartum students who participate in the DCPS New Heights program. Additionally, DCBFC’s FY19 scope of work included a new partnership with WIC to provide additional in-person prenatal education and IBCLC postpartum lactation support at four WIC sites (Unity Anacostia, Unity Parkside, Howard University Hospital Minnesota Avenue, and Children’s National- MLK) with the lowest breastfeeding rates in Ward 7 and 8. The IBCLC provided group breastfeeding classes, in-person anticipatory guidance for expectant moms and postpartum follow-up consults. Through this partnership,139 families were supported from four WIC sites.

DCBFC connected 95 breastfeeding moms/families to lactation support professionals via Pacify enrollment, a video consultation smartphone app. Of the 95 enrolled, 33 of the clients used the app a total of 132 times, and 69% occurred outside of the Lactation Support Center’s hours. Thirty-six percent of patients who downloaded the Pacify app have used it at least one time in FY19.

DC Health staff continued to support the work with District of Columbia Lactation Commission (DCLC) in FY19. The Lactation Commission was created by Mayoral order to make recommendations “regarding legislative, programmatic, and policy ways to improve the District’s strategies in reducing infant mortality and increase infant and child health outcomes through promotion, awareness, and support of breastfeeding and lactating mothers.” DC Health has membership on the commission and helps facilitate a collaborative partnership between the appointed Commissioners, representing a variety of maternal serving advocacy and community based organizations, and government representatives from the Office of the State Superintendent of Education (OSSE), Department of Health Care Finance (DHCF), Department of Human Services (DHS), and the Department of Human Resources (DCHR). Title V grantee DCBFC was also represented on the Commission and actively engaged with both executive and legislative branches of District government. In FY19, DCLC produced its first Annual Report that provided a brief overview of the current state of breastfeeding in the District including relevant research, related government initiatives, benefits and barriers to breastfeeding among minority women and teen mothers. The report included recommendations for 1) creation of a library of comprehensive and current breastfeeding and lactation education materials, 2) development of a process to collect and store donated breastmilk, 3) increased outreach and education regarding the availability of donated breastmilk in the District, and 4) establishment and staffing of a breastfeeding support hotline. Additionally, during the fiscal year, DCLC provided subject-matter-expertise and feedback on OSSE’s Breastfeeding Rating Standards for Early Childhood Education. The goal of this initiative was to increase rates of breastfeeding duration by assisting mothers to achieve their breastfeeding goals after they return to work. Criteria outlined in the rating standards assess early childcare facilities (participating in the Child and Adult Care Food Program) for their breastfeeding friendly practices. Rating standards will allow District’s childcare facilities to gauge their progress towards supporting the mother and infant breastfeeding dyad and identify targeted, actionable areas to improve. DCLC also worked with the Department of Health Care Finance (HCF) to ensure International Board Certified Lactation Consultants (IBCLC) received reimbursement for services from the DC Medicaid Office. The Commission promoted the transmittal of instructions for IBCLCs to receive reimbursement for services by posting the information on www.dcwic.org, dcbfc.org and distributed the information through the DCBFC membership listserv in the District. By the end of the year, DCLC had 15 members (10 public members, 5 government representatives) and held 10 meetings.