DOMAIN: PERINATAL/INFANT HEALTH

Annual Report for FY19-20 (October 19-September 20)

Perinatal and Infant Health – State Priority #2: Reduce infant mortality and morbidity. 

Addressing factors that lead to infant mortality continues to be at the forefront of all NYS's maternal and child health initiatives. Overall, infant and neonatal mortality rates are declining in NYS and are below the Healthy People (HP) 2020 thresholds. NYS’s infant mortality rate was 4.5 per 1,000 live births in 2016, compared with 4.6 per 1,000 births in 2015. The number of infant deaths was 1,045 in 2016, 314 fewer than in 2008. From 2008 to 2016, the infant mortality rate declined 9% for non-Hispanic Whites to 3.45 per 1,000 live births; 28% for non-Hispanic Blacks to 7.85 per 1,000 live births; and 3% for Hispanics to 3.6 per 1,000 live births. Non-Hispanic Asian and Pacific Islanders had the lowest rate in 2016 at 2.87 per 1,000 live births, representing a 13% decrease since 2002 for this group. From 2008 to 2016, the neonatal mortality rate declined by 19% to 3.0 per 1,000 live births, while the post-neonatal mortality rate declined 17% to 1.5 per 1,000 live births.

Despite improvements, striking disparities exist. The ratio of non-Hispanic Black-to-White low birth weight rates was 1.9 in 2016, unchanged from 2015. In 2016, the mortality rate for early term infants (37-38 weeks gestation) was nearly twice the rate of full-term infants (39-40 weeks gestation): 2.32 and 1.31 per 1,000 live births, respectively. The three leading causes of infant death in 2016 were prematurity, congenital malformation, and sudden unexpected infant death (SUID). The NYS Title V program is leading statewide efforts with key stakeholders, agencies, partners, and providers to reduce infant deaths and decrease economic and racial/ethnic disparities in infant mortality rates across NY. Through a variety of focused and collective evidence-based interventions, the NYS Title V program is improving the ability of parents/caregivers to raise healthy infants through several strategies.  This State Priority is measured through NOM #8 Perinatal mortality rate per 1,000 live births plus fetal deaths.  NYS is below the national average at 5.2 per 1,000 live births vs. 6.0 nationally in 2015.  NYS is better than the national average based on National Vital Statistics Data for NOM #9.1 Infant mortality rate per 1,000 live births at 4.5 vs. 5.9 in 2015.  NYS is also lower than the national average for NOM #9.2 Neonatal mortality rate per 1,000 live births (3.20 vs. 3.88) and NOM #9.3 Post-neonatal mortality rate per 1,000 live births (1.7 vs. 2).and NOM #9.4 Preterm-related mortality rate per 100,000 live births (175.9 vs. 200).

 

In order to address priorities, such as infant mortality, on a state, regional, or local level, it is imperative to access comprehensive data for identification, implementation and evaluation of public health initiatives.  The NYS Title V program developed and implemented an expanded plan for analysis and reporting of infant mortality and selected morbidity data.  The New York State Infant Mortality Report, highlighting collaborations and describing trends in NYS’s infant mortality rates between 2002 and 2016, the NYSDOH’s plan to reduce infant mortality was developed and placed in the review and approval process. Additional multivariate analysis was requested prior to final approval and release of the report; this additional analysis is underway.  

 

To monitor progress of improving the health of women, infants, and children and reducing health disparities, Title V staff previously collaborated with the NYSDOH Office of Public Health Practice to develop the Maternal and Child Health (MCH) dashboard that is comprised of National Performance and Outcome Measures as well as State Performance Measures and Objectives.  The MCH Dashboard, which was described in the previous annual report, includes 50 unique measures related to NYS Title V application. This dashboard was released in September 2018 and continues to be maintained. The dashboard serves as an interactive visual presentation of available national, state and county data (where available) that can be used by a wide group of public and private partners to identify trends and issues and develop strategies for improvement. The most current data are compared to previous year data to monitor performance. The dashboard integrates data from multiple sources, includes State and county-level, socio-economic, race/ethnicity and historic data. The measures are presented visually as trend graphs, bar charts, maps, and tables, and compare change over time and as related to 2020 MCH objectives.

 

An important factor in improving birth outcomes and reducing infant morbidity and mortality is ensuring access to comprehensive prenatal care. NYS has long supported access to comprehensive prenatal care for all women. Title V staff continued its collaborative efforts with the NYSDOH Office of Health Insurance Programs (OHIP) to ensure quality prenatal care services are available to NY’s Medicaid (MA) population. Services are available to women up to 223% of the Federal poverty level (FPL) and undocumented women, using State only funding. Supports are also provided to women to promote healthy behaviors and foster infant development.

 

The NYS Title V program is home to the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) initiative that strives to improve the health and well-being of high-risk families and reduce racial/ethnic disparities through 19 evidence-based home visiting programs including eight Nurse-Family Partnership (NFP) and 11 Healthy Families New York (HFNY) in ten high-risk counties. NY MIECHV grantees provided services to 3,023 families in the FY20 (10/1/2019 to 9/30/2020) reporting period. The NYS Office of Child and Family Services (OCFS) receives MIECHV funding through a Memorandum of Understanding (MOU) with the NYSDOH to fund Healthy Families programs.

 

The following items are data on the four constructs within the Maternal and Newborn Health Benchmark related to newborn health.

• 11.5% of infants, born during the reporting period, were born preterm
• 42% of infants, with mothers enrolled prenatally, were breastfeeding at six months of age
• 65% of infants received the last recommended well-child visit during the reporting period
• 38.5% of primary caregivers who reported using tobacco or cigarettes at enrollment were referred to tobacco cessation counseling or services within three months of enrollment.

 

HRSA requires an 85% filled capacity rate for MIECHV programs. To increase awareness of home visiting in NYS, the MIECHV team worked with NYS Council on Children and Families to develop a new searchable chart that assists families to locate evidence-based home visiting programs in their community. The searchable chart can be found on the NYS CCF Parent Portal at https://www.nysparenting.org/.   

The NYS MIECHV Program was required to update the statewide needs assessment to determine priority counties, gaps and barriers, and strengths in home visiting services in NYS. To gather community input for both the Title V and MIECHV needs assessments, NYSDOH held a workgroup meeting with representatives of community-based programs and their community member partners to engage them in conducting and reporting on community listening sessions. Community-based partner organizations across NYS facilitated open discussions with families and community members about individual, family, and community health and services. A total of 37 forums were held in 18 NYS counties and in the Akwesasne Territory of the St. Regis Mohawk Tribe, with over 700 community members.

Recognizing the need to promote systems change on the local level to improve communitywide MCH outcomes, the Title V program has continued to fund 23 Maternal and Infant Community Heath Collaboratives (MICHC) projects in 32 NY counties, extending their service contracts through September 2021. The MICHC initiative seeks to improve maternal and infant health outcomes for high need, low income or Medicaid-eligible women and their families by supporting the development of multi-dimensional community systems of integrated and coordinated community health programs and services. MICHCs work to improve preconception, prenatal, postpartum, and interconception health of Medicaid-eligible women by working collaboratively with community partners to implement strategies to find and engage Medicaid-eligible women and their families in health insurance, health care and other community services; assess a woman’s needs and risk factors and make referrals to appropriate services; coordinate services across community programs; and promote opportunities and supports for women to engage in healthy behaviors. MICHCs utilize Community Health Workers (CHWs) to assist Medicaid-eligible women of reproductive age to effectively access continuous and coordinated health care and other needed community services responsive to their needs and risk factors. On a systems level, MICHC providers work with community partners in the health and social services arena to assess resources, prioritize community needs and strengths, and implement community-level strategies to address the needs identified. In project year 2019-2020, the MICHC program served 3,160 prenatal and postpartum women and their families.

The following outcomes were achieved:

• 79.7% of postpartum clients engaged prenatal care during the 1st trimester.
• 55.2% of clients attended a postpartum visit, with an additional 35.4% having a scheduled appointment.
• 1,936 babies were born to MICHC clients in 2019, of which 13,6% were born preterm.
• 65% of postpartum clients initiated breastfeeding.
• 70.6% of clients referred for smoking cessation programs completed the referral.
• 64.5% of clients referred to family planning were completed.
• 67.7% of referrals for child primary care were completed.

 

Expanding access to CHW services was a top recommendation made by Governor Cuomo’s Taskforce on Maternal Mortality and Disparate Racial Outcomes and was a common suggestion for addressing maternal mortality made by individuals participating in the NYSDOH Maternal Mortality Listening Sessions conducted in Summer, 2018.  CHW expansion has been implemented through the MICHC program with funding from the Governor’s maternal mortality initiative and has supported 30 new full time CHW positions to provide services to high-need pregnant and postpartum individuals and families.  In addition to outreach, referral and home visiting services, CHW expansion allows for providing childbirth education and support, promoting collaborative childcare and social support networks, assisting with the development of birth plans and supporting increased health literacy.

In response to the COVID-19 pandemic, MICHC agencies were able to maintain CHW services by working remotely. In-person home visits rapidly transitioned to virtual visits, and CHWs continued regular communication with their clients via phone and web-based apps/services (e.g., FaceTime, Zoom, etc.), supporting clients in accessing needed services and support networks. Though MICHC staff were able to make this transition to remote services with little delay, the COVID-19 pandemic has had an impact on the scope and volume of virtual visits conducted.

With the transition to remote working and social distancing practices in place in all communities served by MICHC, community outreach efforts were greatly diminished, resulting in a decrease in the number of overall clients served by MICHC programs. Due to the relative convenience of conducting remote visits, CHWs were able to stay in more frequent contact with existing clients, resulting in almost double the number of contacts with MICHC clients. However, maintaining CHW staffing levels during a pandemic were challenging.

By design and definition, the MICHC program is centered on improving perinatal and infant health outcomes and reducing health disparities in communities that are disproportionately impacted by disparities and is staffed with CHWs that are “indigenous to the communities they serve.” Meaning, oftentimes, CHWs are also disproportionately impacted by these disparities. The COVID-19 pandemic proved no exception, with many MICHC CHWs having to resign from the program due to illness or death in their family, contracting the virus themselves, or from the stress and exhaustion of balancing the remote schooling of their children and lack of childcare options while maintaining a full client caseload. Given these challenges, MICHC agencies were limited in the number of new CHWs they were able to hire in the aforementioned CHW Expansion awards. In addition, as the need for response efforts to the pandemic increased, more CHWs and MICHC supervisory staff across the state were diverted to COVID-19 efforts, particularly for those MICHC projects based in local health departments. With staff deployed to activities, such as contact tracing, testing coordination, and call centers, the scope of MICHC services decreased in these areas. Staff working on call centers were able to refer eligible prenatal and postpartum community members for home visiting services. MICHC programs also received increased referrals from public health nursing, as their nursing staff were fully deployed to the pandemic response.

At the onset of the pandemic, MICHC programs reported an overwhelming need among clients for basic necessities, such as food, diapers, toiletries, masks, and other PPE, as these items quickly became scarce or increasingly expensive based on supply. To meet these immediate needs, NYSDOH allowed MICHC programs to use a small amount of unobligated funds to purchase emergency supplies for their clients in need. Title V staff also worked with partners in WIC and NYCDOHMH on a statewide effort to distribute emergency supplies to food pantry sites in high-need communities.

Data observations for MICHC in this reporting period include:

• More diverse clients sought MICHC services, with an increase in the percentage of Hispanic and non-Hispanic black clients from 52.4% to 59.2%.
• Referrals issued per client increased from 3.4 to 4.6.
• Referrals issued for food pantry and clothing/baby care items increased noticeably, largely due to the changing needs of communities impacted by the pandemic.
• For prenatal clients, transportation no longer ranked in the top five for needs, presumably due to access to telemedicine and virtual home visiting services. Instead, Family Planning, Family Resource Center and food pantry were the most common needs among the top five reasons for referrals made.
• For postpartum clients, adult primary care and housing were the most common needs among the top five reasons for referrals, which had previously been child primary care and home visiting services referrals.

 

To support MICHC program efforts during the pandemic, Title V staff provided MICHC agencies with COVID Maternity guidance documents they developed in support of the NYS COVID Maternity Task Force. (Guidance materials may be found here: https://coronavirus.health.ny.gov/protecting-public-health-all-new-yorkers#pregnancy-guidelines)

 

Improving birth outcomes requires greater coordination of referrals and services on the local level. Stakeholders, including pediatricians and home visiting grantees, expressed concerns and confusion about where to enroll women into home visiting, when multiple home visiting programs are operating in close proximity. In addition, the length of enrollment as well as the number of home visits otherwise known as “dosage” has an impact on outcomes. It is important to match families to home visiting programs that can best meet their needs to maximize the family’s ability to stay to dosage and so communities can use all the home visiting programs available. 

 

The Coordinated Intake and Referral System Pilot project ran from 2017 to 2019 with formal technical assistance and training to community teams. In 2019, the community teams had been provided with the tools and training needed to plan and implement a coordinated system in their community. Title V and MIECHV staff remain available for one-on-one training and technical assistance for any community team.

 

Addressing a public health issue, such as infant mortality, requires coordination of all available resources to address the complex factors leading to infant deaths. MICHC initiatives are located in areas of NYS also served by federal Healthy Start (HS) grantees, namely in Queens, Brooklyn, Staten Island, Harlem, Bronx, and Syracuse; four of the six NY HS grantees are also MICHC grantees. Title V staff meet quarterly with the HS grantees to discuss communication, collaboration, and coordination between the HS, MIECHV, and MICHC programs to maximize existing resources and improve community infrastructure. The calls also served as a means to ensure collaboration with the HS grantees in NYSDOH initiatives, including Medicaid’s First 1000 Days and the Infant Mortality CoIIN. The calls also help Title V staff connect local grantees to local HS efforts, such as the coordinated intake project that the Brooklyn HS program is developing. 

 

The NYS Title V program continues to enhance local systems building efforts through training, technical assistance, data collection and analysis, and quality improvement for NYS Title V funded community-based perinatal and infant programs. Quarterly calls continued and included topics, such as maternal depression, annual data reports, collaborative outreach, and improving referrals.

 

For the MIECHV continuous quality improvement (CQI) cycle from October 1, 2019 to September 30, 2020, all nineteen MIECHV-funded programs selected CQI projects based on measures for which the agency underperformed relative to state MIECHV benchmarks. To help reduce burden, the programs selected data collection tools and their preferred CQI tools. The most commonly selected measures were behavioral concerns and parent child interaction. NYS MIECHV staff offered technical assistance to programs in the form of webinar presentations and one-on-one calls. The calls are used to check in with local implementation agencies (LIAs) on their progress and problem solve any challenges they may be facing in running their Plan-Do-Study-Act (PDSA) cycles. A few programs indicated that they were unable to provide support for their projects due to COVID-19 related disruptions in service, such as difficulties conducting parent child interaction observations remotely.

NYS MIECHV selected increasing referrals to home visiting programs as the state level CQI project for 2020 and continues to seek and obtain technical assistance for this work from the MIECHV TA provider. Building upon years of work, by our partner OCFS, to increase referrals to HFNY programs by WIC local agencies, NYSDOH MIECHV, OCFS and Title V staff created a simplified, educational referral tool for use by WIC local agencies for each county of the state in which an NFP, HFNY, or MICHC is in operation. The tool was approved for use by NYS WIC, which supported its use over the multitude of referral documents in circulation, in early 2020, with implementation of the tool planned for the Spring. However, due to the COVID-19 public health emergency, implementation was deferred until late July 2020, when it was presented to both state and local WIC staff, and each county’s form made available in the NY WIC online library for use. Both quantitative (number of referrals from WIC, number of enrolled clients from WIC) and qualitative (anecdotal reports and survey data from home visiting agencies) from each home visiting program are being collected to drive future changes to the form and its use. Communication and coordination with NYS WIC on this work is ongoing. Data collection and the CQI process will continue into 2021, with technical assistance being supplied by the MIECHV TA provider.

 

The goals of the Pathways to Success initiative, funded by the federal Office of Population Affairs beginning July 1, 2017 through June 30, 2020, are to strengthen community systems serving pregnant and parenting teens and young adults; improve the health, development, and well-being of young parents and their children; improve young parents’ self-sufficiency through educational attainment; and increase awareness of resources available to expectant and parenting teens and young adults. The initiative is focused in New York City based on 2015 NYS Vital Statistics data showing Kings, Bronx and Queens counties with the highest birth rates among females who were between the ages of 15 and 24.

 

The Pathways to Success grant supports three community colleges (Hostos, LaGuardia and Borough of Manhattan) and a community-based organization (Public Health Solutions) to develop, expand, and sustain supportive communities to help expectant and parenting teens/young adults maintain their health and meet educational or vocational goals. The funded projects collaborate with Title V programs, such as MICHC and MIECHV for home visiting supports and other programs, to strengthen support networks and referral systems for pregnant and parenting teens and young adults in these communities.

 

Pathways to Success utilizes an Asset and Risk Assessment Tool that assesses the student’s financial, social, and educational support, as well as mental health, employment status, housing, food, clothing, health care, transportation, parenting skills, and touches upon developmental assets in all eight categories. All students and community members enrolled in the initiative receive healthcare referrals for prenatal, interconception, and postpartum care, social service referrals to the Special Supplemental Nutrition Program for Women, Infants and Children’s program (WIC); local Department of Social Services (DSS); and educational or vocational supports to better ensure academic/career success. The goals of this program align with the Title V priorities including support and enhance adolescent social-emotional development and relationships, increase use of primary and preventive health care services, early identification and support for children’s special health care needs, and promote supports and opportunities that foster healthy and safe home and community environment.

 

The Pathways to Success program ended June 30, 2020 due to a lack of federal funding. From July 1, 2019 to June 30, 2020, the program served 532 expectant and parenting students or community members, developed 29 new partnerships, and made 844 referrals. The most frequently cited needs of the program participants were help obtaining information, resources, or services for child needs; food insecurity; child café resources, referrals and supports; parenting education; and resources; housing assistance; self-sufficiency and other supports; academic/educational supports; and home visitation.

 

In addition to strong community supports and services, improving birth outcomes necessitates a strong system of perinatal hospital services, ensuring pregnant and postpartum women and newborns receive a comprehensive level of care to meet their needs. Perinatal regionalization is essential to improving the health of pregnant and postpartum women and infants. NYS has achieved long-standing leadership in the field of perinatal regionalization by ensuring pregnant and postpartum women and their newborns receive care from, and deliver at, a perinatal hospital with the appropriate level of expertise. In 2018, 92.2% of very low birth weight (VLBW) infants were delivered at facilities for high-risk deliveries and neonates, well above the Healthy People (HP) 2020 target of 82.5%. NYS’s system of regionalized perinatal services includes a hierarchy of four levels of perinatal care provided by the hospitals within a region and led by the Regional Perinatal Center (RPC). The regional systems are led by RPCs capable of providing all services and expertise required by the most acutely sick or at-risk pregnant women and newborns. RPCs provide or coordinate maternal-fetal and newborn transfers of high-risk patients to and from their affiliate hospitals, and are responsible for support, education, consultation, and improvements in the quality of care in the affiliate hospitals within their regions.

 

Due to the changing landscape of the health care system as well as standards of perinatal care, the NYSDOH is fully supporting efforts to update perinatal hospital standards in NYS. The NYS Title V program has developed a process to update standards for perinatal regionalization in NYS, re-designate all obstetrical hospitals and birthing centers, and develop standard metrics to assess maternal and neonatal outcomes to identify opportunities for quality improvement. This work began in 2017 and is jointly led by the NYSDOH Office of Primary Care and Health Systems Management (OPCHSM), which is responsible for regulatory oversight of hospitals, and is being accomplished in close partnership with key partners, including birthing hospitals, clinicians, hospital associations, professional organizations and other key stakeholders.  

To ensure standards for the NYS system of regionalized care aligned with current standard of practice, Title V staff began this initiative by researching standards of care for perinatal levels of regionalized care as well as conducting an extensive review of research and literature for evidence-based and promising practice.  An expert panel, co-chaired by the Executive Director of American College of Obstetricians and Gynecologists District II of New York (ACOG-NY) and the Associate Commissioner of NYSDOH at the Western Region Office, was then established that consisted of maternal fetal medicine specialists, obstetricians, and nurses for RPCs, Level III and Level II perinatal hospitals across NYS. In addition, the panel consisted of representatives from the NYSDOH OHIP, NYS Association of Licensed Midwives, Healthcare Association of NYS, Greater NY Hospital Association, Community Healthcare Association of NYS, March of Dimes, NYS Academy of Family Physicians, NYS Nurses Association, and representatives from health plans and the NYS Department of Financial Services. To gain a national perspective, the panel also included a representative from the Association of Women’s Health, Obstetric and Neonatal Nurses, and a representative from the ACOG Maternal Care Consensus Panel from the University of North Carolina. 

 

Three meetings of the expert panel were held at which the panel reviewed standards of care and made recommendations to the NYSDOH regarding standards of care for birthing centers, Level I, II, III perinatal hospitals and RPCs. The standards included recommendations for requirements and qualifications of clinical and ancillary staffing, facility requirements and equipment, and laboratory requirements among others.  Subcommittees were formed to address several topics, including the role of the RPC, neonatal and maternal subspecialists requirements, behavioral health, patient transfers, volume and acuity standards, and finance. Recommendations have been finalized with subcommittee discussions to address final recommendations regarding subspecialists, volume and acuity standards, and finance. In addition to receiving input from the expert panel, Title V staff held conference calls with lower level birthing hospitals from around the state to ensure their perspective is captured in the recommendations to the standards and in relation to the perinatal system.

 

The final meeting of the expert panel on May 10, 2018 was an opportunity to review and discuss the proposed recommendations made by the expert panel through the first two in-person meetings and the multiple subcommittees. In 2016, legislation was passed allowing midwifery-led birthing centers in NYS. Regulations related to midwifery-led birthing centers were adopted November 13, 2019. The new standards will include physician-led and midwifery-led birthing centers as the first level of care, followed by Level I through III hospitals, while RPCs represent the highest level of perinatal care. ESM PIH-2: Percentage of birthing hospitals re-designated with updated standards was established to evaluate this work.  The goal of this important initiative is to strengthen the perinatal regionalized system in NYS to ensure all birthing centers and obstetrical hospitals in NY meet current standards of care, and are affiliated with a strong RPC, so that all pregnant and postpartum patients and newborns receive the best care possible at an appropriate level perinatal hospital.

 

In response to the COVID-19 pandemic, Governor Andrew Cuomo issued a series of executive orders, including EO 202.25, issued on April 29, 2020.  This order suspended sections of Title 10, New York Codes, Rules and Regulations, and allowed the Commissioner to approve and certify temporary birthing sites operated by currently licensed birthing hospitals and birthing centers.  This led to the approval of two temporary birthing centers – Jazz Birthing Center (Manhattan), an expansion the existing Brooklyn Birthing Center, and Refuah Health Center, a Federally Qualified Health Center.  These two birthing centers expanded access to non-hospital based birthing options during a time when pregnant people in New York State were concerned about exposure to COVID-19.  Title V staff are involved in review and approval of all birthing center and birthing hospital applications, along with staff from OPCHSM.

 

Additionally, the executive order expedited NYSDOH’s need to establish an application process for midwifery-led birth centers.  These entities had been allowed by public health law, and regulations had been adopted in November 2019. In June 2020, the NYSDOH issued guidance on the certificate of need licensure process for midwifery-led birth centers.  While there have not been any approved midwifery birth centers at the time of reporting (there is one application under review), this provides New Yorkers another option for appropriate birthing care.

 

Title V staff continued efforts to enhance and expand the use of telehealth services for prenatal and postpartum birthing people.  This includes ongoing efforts related to a series of efforts announced by Governor Cuomo in January 2019, including providing funding to regional perinatal centers that serve rural communities, and completion of the Westchester Medical Center’s Perinatal ECHO pilot program.  The COVID-19 pandemic, and its’ impact on state resources did negatively impact the NYSDOH’s effort to provide up to $5 million in capital funds to increase regional perinatal center, rural birthing hospital, and private provider access and capacity for perinatal telehealth services.  Discussions of how to continue to support healthcare providers in these efforts are ongoing.

 

The five funded RPCs in the Rural Perinatal Telehealth Initiative (with one-time Title V funding) were also affected by COVID-19.  While the increased interest and use of telehealth to provide virtual visits increased exponentially, it also challenged hospital’s information technology (IT) departments.  These staff were integral to the rural telehealth initiative, and deliverables had to be delayed in order to enhance hospital-wide capacity.  All five contractors were in various stages of their plans when COVID-19 impacted the health care system but have been able to restart and continue efforts by late Fall 2020. The Department has issued no-cost time extensions for all projects, acknowledging the need for additional time lost to COVID-19.

 

Finally, in collaboration with OPCHSM, Westchester Medical Center (WMC) launched a pilot Project ECHO™ (Extension for Community Health Outcomes) on perinatal health in June 2019.  This pilot project represented only the second perinatal-focused ECHO program in the country since its’ inception in 2003 by the University of New Mexico Health Sciences Center.  The WMC Perinatal ECHO Pilot continued into January 2020 with the following presentations:

• Late Preterm Infants – NOT Just “Small” Babies (October 24, 2019) by Dr. Jordan Kase, MD, FAAP (14 attendees from 7 affiliate hospitals and private practices);
• Prevention of Preterm Birth (November 7, 2019) by Dr. Desmond White, MD, MFM, FACOG (12 attendees from 9 affiliate hospitals and private practices);
• Perinatal HIV (December 12, 2019) by Dr. Nina Arlievsky, MD (7 attendees from 7 affiliate hospitals and private practices); and
• Cell Free DNA Prenatal Testing (January 23, 2020) by Dr. Geetha Rakendran, MD (10 attendees from 7 affiliate hospitals and private practices).

 

To build on NYS’s rich system of perinatal care and aim to provide the best and safest care for pregnant and postpartum people and infants, Title V staff leads the New York State Perinatal Quality Collaborative (NYSPQC) initiative through collaboration with RPCs, RPC-affiliate birthing hospitals, perinatal care providers, community-based organizations, NYS hospital associations, the National Institute for Children’s Health Quality (NICHQ), and other key stakeholders. The initiative aims to prevent and minimize harm through the translation of evidence-based guidelines to clinical practice. During the reporting period, several initiatives under the scope of the NYSPQC have focused on reducing infant mortality and morbidity including the: New York State Infant Mortality CoIIN Community-based Safe Sleep Project, National Action Partnership to Promote Safe Sleep – Innovation and Improvement Network (NAPPSS-IIN), NYSPQC Enteral Nutrition Improvement Project, and NYS Opioid Use Disorder (OUD) in Pregnancy & Neonatal Abstinence Syndrome (NAS) Project.

 

The NYSPQC has supported birthing hospitals during the COVID-19 pandemic by hosting two webinars on neonatal best practices at which experts shared experiences and answered questions submitted by hospitals. In addition to the COVID-19 specific webinars, discussions around COVID-19 were integrated into two NYSPQC project Coaching Call webinars.

Staff from the NYSPQC have participated on several national webinars related to COVID-19, and its relation to obstetric and neonatal outcomes.  On these webinars, NYSPQC staff and affiliated birthing hospital providers had several opportunities to share their experiences in relation to COVID-19.

 

A COVID-19 Resources section was added to the NYSPQC website.  The page contains both CDC and NYS specific materials.  It also includes links to recordings of all COVID-19 related webinars hosted by the NYSPQC.  These materials can be accessed by NYSPQC participating birthing hospitals and the general public. Additionally, NYSPQC team members have been triaging questions from NYS perinatal providers directed to the project’s listserv since March. 

 

The NYSDOH developed guidance on the care of the newborn whose birthing parent was suspected or confirmed COVID-19 positive. Additionally, a consumer education FAQ document on breastfeeding and COVID-19 was developed and distributed in April 2020.  Additional guidance documentation and consumer education materials were developed and are described in the Women and Maternal Health domain report. These guidance and education materials for birthing hospitals is posted on the Department’s website.

 

NYS also administers a comprehensive Newborn Bloodspot Screening program that collects, analyzes, and reports on newborn specimens for 50 diseases and condition recommended by the American College of Medical Genetics and the March of Dimes. Follow-up is provided through condition specific Specialty Care Centers located throughout NYS with systems in place to better ensure early identification and proper treatment of these infants. 

 

Under the HRSA-led national Infant Mortality CoIIN, the Title V program led a second phase of the NYS Safe Sleep Infant Mortality CoIIN from July 2018 to July 2020, with a focus on community-based organizations (CBOs), to continue to reduce disparities in infant mortality through the promotion of infant safe sleep. Seven pilot sites, including MICHC grantees, participated in the project. The pilot sites administered surveys to caregivers during the postpartum period, 30-60 days after their organization provided the caregiver with safe sleep education. During the reporting period, the project held eight Coaching Call webinars. The webinar topics included breastfeeding and safe sleep, screening and referrals to tobacco cessation services, hazards associated with sitting and carrying devices for infants, recent safe sleep literature, bereavement, and team learning and sharing regarding improvement activities.

 

To support the pilot sites’ efforts, the Title V program provided Sleeping Safely Starter Kits and safe infant sleep clothing (sleep sacks) to each participating pilot site during the reporting period.   One program staff person who supported the COIIN has been deployed full time to support COVID-19 activities. The last months of data collection were impacted by CBOs’ inability to meet with clients and collect surveys due to COVID-19.

 

Additionally, Title V continued to increase awareness and collaboration for stakeholders on one of the leading causes of infant mortality in NY, Sudden Unexpected Infant Death (SUID). The NY Infant Mortality CoIIN develops key projects in partnership with the child welfare system including the NYS OCFS, NYS Office of Addiction Services and Supports (OASAS), and the NYSDOH Division of Nutrition’s (DON), and Special Supplemental Nutritional Program for Women, Infants and Children (WIC) clinics. During the reporting period, the Title V program worked to implement the Governor’s directive that the NYSDOH and the NY OCFS continue their work on an infant safe sleep public awareness media campaign, expand outreach to medical providers, engage community-based organizations (CBOs) by promoting staff education tools, and distributing Safe Sleep Kits to 10,000 caregivers. The kits include sleep sacks, safe sleep literature, and NYSDOH educational materials. In August 2019, NY passed legislation expanding infant safety measures, including a ban on the sale of crib bumper pads.

In 2019, the NYSDOH updated and expanded translations of the patient education materials highlighting the ABCs (Alone, Back, Crib) of safe sleep available at no cost to the public. These safe sleep materials include a brochure available in the thirteen most commonly spoken languages in NYS (six translations were added in 2019), mirror clings, magnets, posters in English and Spanish, crib cards, and a one-minute video in English and Spanish made available on the NYSDOH YouTube channel. The NYSDOH also adapted an anatomical diagram originally created by National Institutes of Health (NIH) to provide patient education on the importance of putting a baby to sleep on his/her back while addressing the concern parents have regarding the potential for babies choking while they are on their backs.  The anatomical diagram was translated into six additional languages in 2019 for a total of thirteen languages available; these were laminated and made available to all NYS birthing hospitals and stakeholder organizations.

 

During the reporting period, the NYSDOH, in collaboration with Title V staff, developed a safe sleep campaign to promote the ABCs of safe sleep and a new message: Baby should sleep in a smoke-free home. NYSDOH created three 10-15 second videos for the campaign and a new safe sleep poster in English and Spanish, all of which featured the new message. The videos were created to run on Facebook and Instagram, reaching women ages 16+, grandparents and caregivers. The out-of-home and social media campaigns were launched on November 4, 2019 and ran through January 2020. For the out-of-home print campaign, NYSDOH targeted NYS counties with the highest infant mortality burden with bus shelter ads and posters in convenience stores and bodegas. Additionally, Title V staff updated the Department’s safe sleep website (www.health.ny.gov/safesleep) to include information about tobacco cessation and the updated patient education materials.

 

The Title V team, in collaboration with NICHQ,  released the electronic NYSDOH Safe Sleep Toolkit in September 2020 (https://www.health.ny.gov/diseases/conditions/safesleep/docs/toolkit.pdf), which features change ideas, presentations, materials, tools, references and key insights from hospitals and community-based organizations that are working to improve infant safe sleep practices. The target audience is public health and health care professionals.

 

Title V staff are collaborating with the National Action Partnership to Promote Safe Sleep – Innovation and Improvement Network (NAPPSS-IIN).  NAPPSS is an initiative to make infant safe sleep and breastfeeding the national norm by aligning stakeholders to test safety bundles in multiple care settings to improve the likelihood that infant caregivers and families receive consistent, evidence-based instruction about safe sleep and breastfeeding.  In 2019, the project, which is funded by HRSA’s Maternal and Child Health Bureau (MCHB), expanded from five pilot site hospitals in five states, including NYS, to twenty hospitals in ten states.  NYS’s representative hospitals during the reporting year included New York Presbyterian (NYP) Lawrence (Westchester), Montefiore Medical Center – Wakefield Division (Bronx) and Crouse Hospital (Onondaga). The Title V team will continue to participate in and hold conference calls with statewide and national safe sleep and breastfeeding stakeholders to disseminate, spread and scale best practices to improve safe sleep practices, breastfeeding rates, and reduce disparities in both areas.

 

NYS’s efforts related to safe sleep are measured by NOM #9.5 Sleep-related Sudden Unexpected Infant Death (SUID) rate per 100,000 live births.  NY is far below the national average at 58.3 vs. 91.2 nationally as reported in 2017, which demonstrates the efforts NY has made to reduce the incidence of SUID. 

 

The NYSPQC initiative also focused on an Enteral Nutrition Improvement Project that aimed to reduce the percentage of newborns born prior to 31 weeks’ gestational age discharged from a Neonatal Intensive Care Unit (NICU) below the 10th percentile on the Fenton Growth Scales. Outcome, process, and balancing measures were calculated for infants born prior to 31 weeks’ gestation, admitted within 48 hours of birth to a NICU, and discharged alive. Key measures were the percentage below the 10th percentile for discharge weight, difference in Z-scores for birth and discharge weights, incidences of comorbidities nosocomial sepsis and necrotizing enterocolitis, post-menstrual age at discharge (days), and median initial length of stay (days).

 

With efforts and results shared through monthly Coaching Calls, quarterly performance measure data reports, and yearly Learning Sessions, all NYS RPCs began participation in 2010 and an additional 20 Level III facilities joined the project in 2016. Throughout the project, RPCs exhibited longer lengths of stay, higher percentages of breastmilk feeding, and higher rates of growth restriction at discharge, which may reflect greater clinical severity of their patients as well as the breastmilk paradox, where breastmilk fed babies grow more slowly. The initiative appears to have significantly improved growth, as measured by a sustained decrease in the percentage of infants weighing below the 10th percentile at discharge, with the rate among RPCs dipping significantly below the baseline and nearing the lower rate reached by the Level IIIs.  There were no significant changes in the incidences of comorbidities or in discharges above the 75th percentile for weight, further substantiating that the interventions were safe. The goal of reducing baseline percentages by 10% was exceeded; for RPCs change was from 32.6% to 29.3%, and for Level IIIs change was from 30.8% to 27.7%. This project has ended. An in-person closing Learning Session was planned for March 2020, but due to COVID-19 was delayed to a virtual event in June 2020. We estimate that over 370 additional babies were discharged above the 10th percentile for weight, and more than 750 babies received exclusive breast milk at their first full feedings because of the initiative’s efforts, and therefore conclude that our project was highly successful overall.

 

The NYSPQC Project Team has conferred with the Vermont Oxford Network (VON) and California Perinatal Quality Care Collaborative (CPQCC) and hosted an onsite meeting with the NYSPQC’s Neonatal Clinical Expert Work Group, NICHQ, and Joseph Shulman, MD, from California’s DOH for an in-depth review of an additional QI project relevant to high-risk neonatal populations.  This meeting took place in January 2020.  Topics under consideration include the “Golden Hour,” i.e., appropriate fetal and newborn interventions at the time of and immediately after delivery; antibiotic stewardship in the NICU; transition in care, including from NICU to home; and health equity/family-centered care.

 

Further, the NYSPQC, in partnership with ACOG-NY, Healthcare Association of NYS (HANYS) and the Greater New York Healthcare Association (GNYHA), and with support from NICHQ, is leading the NYS OUD in Pregnancy & NAS Project.  This learning collaborative, which kicked-off in September 2018 at 17 pilot site birthing hospitals, seeks to identify and manage the care of pregnant people with OUD, and improve the identification, standardization of therapy, and coordination of aftercare of infants with NAS. To date, topic areas of focus have included verbal screening related to substance use for all pregnant people during the prenatal period and on admission to the birth hospitalization, trauma informed care, improved communication between obstetrics and pediatrics, reducing stigma, training clinical staff on the signs and severity of NAS, improving both pharmacologic and non-pharmacologic care for infants with NAS, Eat Sleep Console as a method of treatment for infants with NAS, considerations for breastfeeding for women who use substances, and linkages to care. A statewide project expansion was planned for Spring 2020 and due to COVID-19 was delayed to September 2020.  The NYSPQC is participating in the National Alliance for Innovation in Maternal Health (AIM) through this initiative. 

 

During the reporting period, the NYSPQC continued participating in the Association of State and Territorial Health Officials (ASTHO) Opioid Use Disorder, Maternal Outcomes, and Neonatal Abstinence Syndrome Initiative (OMNI) Learning Community. The purpose of the learning community is to provide technical assistance, build capacity, and disseminate strategies and best practices to support program and policy implementation on substance use disorder (SUD) among pregnant and postpartum women and infants prenatally exposed to opioids, including NAS.  Agencies and organizations convened as part of this effort include ACOG-NY; HANYS; GNYHA; Northwell Health; NYSDOH OHIP, Office of Drug User Health, and AIDS Institute; NYS OASAS; NICHQ; and Community Health Care Association of New York State (CHCANYS).  The overarching goal of the NYS OMNI team, in alignment with the NYS OUD in Pregnancy & NAS Project’s goal of increasing the percent of pregnant women screened for SUD with a verbal screening tool, is to train prenatal care hospital staff on standardized screening, develop provider resources for screening and referral, and connect diverse work happening across the state.

 

NYSDOH is reinvesting federal savings generated by the Medicaid Redesign Team (MRT) reforms into the Delivery System Reform Incentive Payment Program (DSRIP) to promote community-level collaborations on system reform with a goal of 25% reduction in avoidable hospital use over five years. Safety net providers (Preferred Provider Systems, PPS) are program leads and are required to collaborate to implement innovative community projects in three domains: 1) system transformation, 2) clinical improvement, and 3) population health improvement.

 

One DSRIP project involved a state funded MICHC program Mothers and Babies Perinatal Network in Binghamton, NY, who implemented the Care Transitions Model for newly delivered Moms and Babies by aiming to improve pregnancy and birth outcomes for every woman, infant, and family. Mothers and Babies Perinatal Network and UHS Hospitals collaborated to improve post-discharge results for mothers and newborns with Medicaid coverage. Participating in the Care Transitions project, Mothers and Babies Perinatal Network partnered with two local hospitals to deploy Health Coach services to over 500 new mothers, providing face-to-face visits and follow-up phone calls during the 30-day post maternity discharge. Mothers and Babies and UHS presented the results from their collaborative approach at a Care Compass Network Stakeholders Meeting. The presentation can be seen on YouTube by following this link: https://www.youtube.com/watch?v=c4fTXeblp6I. The outcome goals were parental/family practice of safe sleep strategies for infants, identify and refer post-partum women for perinatal mood disorders/post-partum depression.

 

The project found:

• Safe Sleep for Babies Education: 100% all moms receiving a home visiting and 30-day follow-up (including safe sleep)

• Identification of families with no crib – provision of pack n play

• Depression/mental health screen: provision of PHQ-9 survey. 559 completed (10/1/18 – 9/12/19)

• 24 (4%) scored 10 or more/100% referred

• 90-day phone follow up

• 1/1/19 – 6/30/19: 134 calls made; 58 completed (43%)
• 100% following the safe sleep guidelines
• 0 re-hospitalizations of moms
• 3 re-hospitalizations for babies (all medically necessary)

 

Another DSRIP project involves two NFPs – one in Chautauqua county and the other in Erie county. The Erie county NFP receives MIECHV funding. Catholic Medical Partners in western NY selected establishing or expanding home visiting as one of their strategies. Catholic Medical Partners began implementing an NFP in Chautauqua County in 2016 and began implementing an NFP program in Erie County in October 2018.

 

Through Medicaid Redesign, Health Information Technology (HIT) projects were established in four high need areas (Monroe, Onondaga, Westchester, and Kings counties) to demonstrate the effectiveness of HIT to coordinate perinatal services, reduce costs by streamlining fragmented and redundant systems, increase on-time patient access to medical records, and improve quality of care. In 2017, one of the HIT projects (Westchester County) stopped, as they were not able to meet the planned objectives. The HIT systems are designed to identify the medical, pregnancy, and psycho-social risks of pregnant women and make and track referrals to needed services. During development of the HIT systems, national guidance and state legal counsel addressed system issues related to confidentiality. In 2018, HIT systems went live for all three projects with full data collection in September 2018. Data extract templates were developed for the pilot projects to submit de-identified aggregate data on a quarterly basis to the Department. To date only two of the three projects have reported final data. Final data were due December 31, 2020. During the reporting period, contractors screened 263 clients, identifying 90 at risk health conditions and made over 930 referrals. Final data analysis will be conducted and reported to the state and Medicaid Redesign Team in the first quarter of 2021, presenting the efficacy of the HIT projects in the targeted communities. During 2020, HIT projects continued to expand their provider enrollment within their network and have implemented sustainability plans.

 

The NYS Title V program remains ready to address any public health issue impacting the maternal and child health population including new and emerging public health priorities such as the opioid epidemic and maternal depression. The Maternal and Women's Health annual report and application sections include information related to NYS Title V program’s role in the opioid epidemic and maternal depression.