Priority Need: Persistently High Infant Mortality Rate
NPM 3: Percent of very low birthweight 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.
The process for all birthing hospitals in Arkansas to assess their maternal and neonatal levels of care is managed under the direction of Arkansas’s Maternal and Perinatal Outcomes Quality Review Committee (MPOQRC). Arkansas Act 1032, signed into legislation in 2019, gave ADH authority to establish the MPOQRC to review data on Arkansas births and to develop strategies to improve birth outcomes. The act requires the committee to submit an annual report to Arkansas legislature. Key information from the report is also shared with policymakers, health care providers, public health professionals, and the public. The 2021 MPOQRC Annual Report was prepared and released in December 2021.
The MPOQRC is currently developing a process for Arkansas hospitals to assess their maternal and neonatal levels of care. The process will involve completion of a written survey and a site visit conducted once every three years for each Level III and IV hospital. The Site Visit Workgroup within the MPOQRC plans to begin site visits in 2022. When complete information on the neonatal level of care for each birthing hospital in Arkansas becomes available, the MPOQRC plans to share this information through an interactive state map on the ADH public website and other communication outlets.
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 system designating risk-appropriate perinatal levels of care in Arkansas is currently in the early stages. A structured system of agreements for transfer is a strategy typically utilized by more established systems. The MPOQRC is also responsible for implementing quality improvement projects. The Quality Workgroup within the MPOQRC plans to address the agreements for transfer 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 the unborn child.
Priority Need: Breastfeeding
NPM 4: Percent of infants who are ever breastfed and percent of infants who are exclusively breastfed for six months.
Breastfeeding rates in Arkansas consistently lag behind national averages and Healthy People 2020 expectations.
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: Provide technical assistance and recognition to birth hospitals that achieve Baby-Friendly status.
The Baby Friendly Arkansas Toolkit was developed in partnership with the Arkansas Breastfeeding Coalition, the Arkansas Hospital Association (AHA), AFMC, and UAMS. The toolkit includes educational materials for staff and patients plus sample policies and research studies that support early initiation of breastfeeding.
Strategy 4.2: Provide breastfeeding education and support to WIC-enrolled women.
The ADH continues to facilitate a bimonthly meeting of the Breastfeeding Promotion Taskforce. The Taskforce brings together stakeholders from the Family Health Branch; Arkansas’s 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.
The Arkansas WIC Program offers breastfeeding information and education to all WIC participants online through the WICSmart website (http://www.wicsmart.com) and the USDA’s WIC Breastfeeding Support website (https://wicbreastfeeding.fns.usda.gov). 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.
The Breastfeeding Peer Counselor Program currently serves 17 Arkansas counties and 21 WIC clinics. Peer counselors provide support in a variety of ways including through hospital visits, home visits, text, email, phone, and through support group meetings. WIC clients who live in areas not served by a peer counselor can receive support by calling the WIC Breastfeeding Helpline, which is available Monday through Friday from 8:00 a.m. to 4:30 p.m. (Meet Our Breastfeeding Peer Counselors Arkansas Department of Health). On nights and weekends, calls to the WIC Breastfeeding Helpline roll over to Baptist Health’s Breastfeeding Helpline.
Strategy 4.3: Provide breastfeeding education and support to women enrolled in the Arkansas Home Visiting Program.
Arkansas’s Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program has also focused its efforts to support breastfeeding. The program has a benchmark measure regarding 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 ask mothers about this measure. The fifth program works with children ages 3-5. In addition, the Following Baby Back Home, Healthy Families America, and Parents as Teachers home visiting programs use the Family Map Inventories questionnaire (http://www.thefamilymap.org), which asks “How old was your child when you stopped breastfeeding?” Answer options are: Not applicable, 2 months, 2-5 months, and 6 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 Internet access (https://ahvnti.thinkific.com/).
Strategy 4.4: Provide breastfeeding education and support to communities through African American sororities and fraternities.
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 that the four African American sororities of the National Pan-Hellenic Council have taken up an issue collectively. The Sisters United campaign focuses on 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. This model is based on a train-the-trainer approach, 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 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. Brothers United hosts Tailgate Parties during fraternity chapter meetings. The purpose 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 aimed at increasing breastfeeding rates in the Black community. In response to the uncertainties of the COVID-19 pandemic, the Office of Health Equity expanded the focus topic from breastfeeding to addressing maternal and child health issues affected by COVID-19. In addition to lactation experts, speakers also included licensed therapists to address mental health issues related to COVID-19, nutritionists, fathers, and many others. We also began our Mocha Live-Hispanic Partnership, which is presented in Spanish with topics that affect the Hispanic Community.
Strategy 4.5: Provide breastfeeding education and support through the Arkansas Breastfeeding Helpline.
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 eighth 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/services/labor-delivery/breastfeeding-support/). Call volume continues to be measured in the following ways: Calls between the hours of 8:30 a.m. to 5:00 p.m., Calls between the hours of 5:00 p.m. to 8:30 a.m., Calls from WIC participants, and Resident of Pulaski County or outside of Pulaski County. During the 2021 federal fiscal year, the helpline received a total of 5,203 calls. The number of calls reported during this period increased by 700 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. A main goal 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, AFMC, UAMS, 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. The current focus is strengthening lactation support to incarcerated mothers. The Task Force has continued to meet virtually during 2021-22.
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: Provide training for hospital staff on safe sleep and how to encourage safe sleep by their patients.
Only one hospital was safe sleep certified prior to Safe Sleep Collaborative Improvement and Innovation Network (CoIIN) implementation in 2015. To date, all 40 hospitals have received the safe sleep toolkit. Currently, 39 of Arkansas’s 40 birthing hospitals are safe sleep certified. Two of the 40 are not currently birthing babies. Most of the hospitals are working on recertification 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.
Strategy 5.2: Collaborate with CoIIN partners on safe sleep activities and trainings.
The Safe Sleep CoIIN to reduce infant mortality funded by HRSA has ended. However infant mortality in Arkansas is still a priority as shown by the continuation of CoIIN’s projects. 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’s 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.
The Safe Sleep CoIIN team includes partners representing the ADH’s Family Health Branch, Office of Health Equity, WIC Nutrition Program, Emergency Medical Services for Children (EMS-C), and the Nurse-Family Partnership home visiting program as well as Arkansas’s Infant and Child Death Review Program, Arkansas Nursery Alliance, ACH’s Injury Prevention Center, Arkansas Hospital Association, AFMC, ADHS’s Division of Child Care and Early Childhood Education, ACHI, UAMS, Baptist Health Community Outreach, March of Dimes, and the Zeta Dove Foundation. The Safe Sleep CoIIN funding ended in November 2020. The CoIIN team continues to provide training. The ACH Injury Prevention Program partners with local communities to provide Safety Baby Showers for expectant mothers. Safety Baby Showers participants who attend the showers receive education in safe sleep, shaken baby syndrome/crying babies, home safety and child passenger safety. In 2021 ACH Injury Prevention Program conducted a total of 50 Virtual and 5 face to face Safety Baby Showers educating 237 participants, a total of 16 train the trainer events training over 171 educators and participated in 2 Facebook lives addressing safe sleep/infant safety. They provided safety products to 20 satellite sites across the state. Train-the-trainer participants were members of law enforcement, fire departments, public health educations and medical staff.
Strategy 5.3: Provide safe sleep education and support to WIC-enrolled mothers.
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 focused on enhancing secure attachment and reinforcing education provided by the mother’s birthing hospital and her pediatrician/primary care physician. In 2021, 742 parents received safe sleep education through WIC Baby and Me Module Zero.
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 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 babies safe while sleeping.
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. This was completed in 2019 with the questions being 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 postcard 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)
Due to COVID-19, most certifications occurred by telephone, which did not allow staff to show participants the safe sleep materials. All parents of infants were asked where their infants sleep and were asked information about and provided information about safe sleep environment. This process was completed 30,043 times in 2021.
If a safe sleep referral was selected from the WIC list, a small safe bassinet is given to the family. The safe sleep referral was selected 356 times in 2021.
WIC has continued to offer a nutrition education module on safe sleep. However, due to the pandemic, fewer “non high risk” nutrition education sessions occurred in 2021. If the safe sleep nutrition education was offered (whether in person or over the phone), a total of 17,940 times (infants 7,299; women 10,640).
SPM 1: Percent of newborns with timely follow-up of a failed hearing screening.
The FHB 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.
Newborn screening for inborn conditions has been mandatory in Arkansas since Act 192 of 1967 stipulated screening of all newborns for phenylketonuria. Since that time, the number of conditions screened for has grown substantially. The program oversees follow-up on over 30 genetic disorders screened using the blood spot card in addition to two point-of-care tests, hearing screen and critical congenital heart disease, for a total of 34 core disorders. In 2020, 98.3% of the approximately 34,259 babies born in Arkansas each year are screened for genetic disorders. The total of 2020 confirmed cases was 107.
The NBS program continued the 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 2020, yearly average was 153.2 hours from birth to reporting of test documented, which met the overall goal. Each birthing facility receives a quarterly Hospital Timeliness Report to identify the number of specimens collected and received by the NBS lab within 48 hours of collection. Any facility that does not meet the goal of 80% of specimens reaching the lab within 48 hours is contacted to discuss potential issues related to timely specimen submission. At the end of 2020, a yearly comparison report of all birthing facilities had an average of 87.2%. 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. In March 2020, Spinal Muscular Atrophy (SMA) disorder was added to the testing panel and along with X-linked Adrenoleukodystrophy (X-ALD in November 2021, bringing the total to 30+ disorders along with Critical Congenital Heart Disease (CCHD) and hearing screening which is completed at the birthing facility. The plan to increase the blood testing panel within 2022 by adding Glycogen Storage Disease Type II (Pompe), and Mucopolysaccharidosis Type 1 (MPS-1).
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. Arkansas has approximately 15,000 Marshallese population. The NBS brochure and video is provided in English, Spanish and Marshallese. In 2020, NBS developed a NBS Banner and a Flyer for educational purposes. The goal is to provide parents, medical professionals, and all stakeholders with outreach material about the Arkansas Newborn Screening Program. This material is available on the ADH/NBS website: https://www.healthy.arkansas.gov/programs-services/topics/newborn-screening or by request and will be utilized in promotion setting like conferences, seminars, meetings, and health fairs.
Arkansas Vital Events (ERAVE) to collect, surveil, and monitor newborn hearing screenings (NBHS) and follow-up testing conducted statewide. The preliminary 2021 ERAVE Hearing Screening and Follow-Up Survey Report shows improvement in the number of infants receiving a DHH diagnosis by 3 months of age. Most (53%) of these diagnoses occurred by three months of age in accordance with Joint Committee on Infant Hearing recommendations. Seventy children were identified with hearing loss. The program will continue working toward reaching the goal of 27% or less of infants who fail the NBHS receiving a confirmatory diagnosis by 3 months of age.
One of the strategies for 2021 was to partner with WIC to place an alert on the WIC webpage advising parents to seek additional testing. The alert is in SPIRIT to indicate which additional testing is needed. IHP alerts WIC of patients needing additional testing after not passing the initial newborn screen. WIC flags the record so the family is instructed to contact the IHP office.
The IHP experienced challenges in promoting early hearing detection and intervention (EHDI) during 2021 because of the continuation of COVID-19 by adversely affecting planned in person activities to increase stakeholder engagement and access to daily support activities as well as reduced access to EHDI follow-up statewide. IHP had difficult in facilitating timely follow-up with families due to the lack of valid contact information (i.e., phone number, address and/or primary care physician) in addition to struggles identifying Non-Part C early intervention information for DHH children. Families continued to report challenges in obtaining follow-up care because of lack of transportation, access to a pediatric audiologist near their home and timely enrollment in newborn Medicaid.
IHP staff worked to increase the IHP’s social media presence by publishing weekly posts on various EHDI topics. The program saw an increase in the number of visitors viewing parent information. Current records indicate 80 total views, 63 first time views, and an average of 3 minutes viewing the site. Also, IHP staff has delivered education on key aspects of the EHDI program to 110 health professionals and/or service providers to date. Presentations outlining recommended screening practices, health professionals’ roles in the EHDI system, opportunities for collaboration with the EHDI program and EHDI data occurred during advisory board meetings, state association meetings, and continuing education series. These meetings also provided a forum for stakeholders to provide feedback regarding opportunities for improvement in the EHDI system.
Strategy 1.2: Increase family support through the contact with Arkansas Hands and Voices to increase the implementation of the Guide by Your Side Program offering parent-to-parent support. Parent guides will contact families of children who failed the newborn hearing the newborn hearing screening the first week of life. IHP expanded the current partnership with Arkansas Hands and Voices to increase parental support. The Parent Guides contact the families who did not keep two or more appoints.
The Infant Hearing Program (IHP) continues to use the Electronic Registration of Arkansas Vital Events (ERAVE) to collect, surveil, and monitor newborn hearing screenings (NBHS) and follow-up testing conducted statewide. The preliminary 2021 ERAVE Hearing Screening and Follow-Up Survey Report shows improvement in the number of infants receiving a DHH diagnosis by 3 months of age. Fifty-three percent of these diagnoses occurred by three months of age in accordance with Joint Committee on Infant Hearing recommendations. Seventy children were identified with hearing loss. The program will continue working toward reaching the goal of 27% or less of infants who fail the NBHS receiving a confirmatory diagnosis by 3 months of age.
The IHP experienced challenges in promoting early hearing detection and intervention (EHDI) during 2021 because of the continuation of COVID-19 by adversely affecting planned in-person activities to increase stakeholder engagement and access to daily support activities as well as reduced access to EHDI follow-up statewide. IHP had difficult in facilitating timely follow-up with families due to the lack of valid contact information (i.e., phone number, address and/or primary care physician) in addition to struggles identifying Non-Part C early intervention information for DHH children. Families continued to report challenges in obtaining follow-up care because of lack of transportation, access to a pediatric audiologist near their home and timely enrollment in newborn Medicaid.
IHP staff worked to increase the IHP’s social media presence by publishing weekly posts on various EHDI topics. The program saw an increase in the number of visitors viewing parent information. Current records indicate 80 total views, 63 first time views, and an average of 3 minutes viewing the site. Also, IHP staff has delivered education on key aspects of the EHDI program to 110 health professionals and/or service providers to date. Presentations outlining recommended screening practices, health professionals’ roles in the EHDI system, opportunities for collaboration with the EHDI program and EHDI data occurred during advisory board meetings, state association meetings, and continuing education series. These meetings also provided a forum for stakeholders to provide feedback regarding opportunities for improvement in the EHDI system.
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