Breastfeeding
Breastfeeding has health and socioeconomic benefits meeting the specific needs of human babies and offers the best combination of nutrients with a nearly perfect mix of vitamins, protein, and fat - everything a baby needs to grow. Breast milk is provided in a form more easily digested than infant formula. Breast milk contains antibodies that help infants fight off viruses and bacteria. Breastfeeding also strengthens the infant’s immune system, improves immune responses to certain vaccines, offers possible protection from allergies and asthma, and reduces the probability of SIDS. Plus, babies who are breastfed exclusively for the first six months, without any formula, have fewer ear infections, respiratory illnesses, and bouts of diarrhea. They also have fewer hospitalizations and trips to the doctor.
Benefits to the mother include reduction of postpartum blood loss, increased postpartum weight loss with no return of weight once weaning occurs, possible delay of fertility, need for reduced insulin in diabetic mothers, psychological benefits of increased self-confidence and enhanced mother/infant bonding, reduced risk of breast, ovarian, and endometrial cancer, and reduced risk of osteoporosis and bone fracture. There is also an economic benefit of breastfeeding for families due to financial savings with as compared to the cost of using formula.
Breastfeeding is convenient and safer because breast milk is always available at the correct temperature, is sterile, and requires no mixing. Located within the DPWH is the State's designated home visitation program (medical model) for Medicaid eligible pregnant women and infants through the first year of life known as the Right From The Start Program (RFTS). Right From The Start uses evidence-based curricula “Partners for a Healthy Baby” to provide in-home education to all enrolled clients on a variety of prenatal and infant issues, including the benefits of breastfeeding for both mother and baby. Education is provided by Designated Care Coordinators (DCCs) who are either a registered nurse or licensed social worker.
Educational tools such as videos, DVDs, medical models and brochures, along with the curriculum are used to provide breastfeeding education and encouragement. Several DCCs are also trained as Certified Lactation Consultants (CLCs) who can provide addition education and support for mothers who are breastfeeding. Population-based home visitation programs in WV (Healthy Families America, Parents as Teachers, Early Head Start, and Maternal, Infant Health Outreach Workers) also provide breastfeeding education and support using evidence-based curriculum designated for their programs.
Although WV lags behind the US average for breast feeding, the State has demonstrated steady improvement. According to the 2015 National Immunization Survey of infants who were ever breastfed, WV was at 68.64%. This is an increase from the 2014 percentage of 65.4. In 2007 only 53.0% of WV infants were ever breastfed. In addition, the State has more than doubled exclusive breastfeeding through 6 months increasing the percentage of infants from 7.0% in 2007 to 20.2 in 2015 and again an increase from the 2013 percentage of 14.4. The 2015 US average for ever breastfed is 85.5% and 24.9% for exclusive breastfeeding through 6 months.
Use evidence-based curriculums to promote breastfeeding, especially during home visits.
The DPWH offered evidence-based education to women prenatally and to new mothers on breastfeeding through RFTS and other home visitation programs. Pregnant women who participated in home visitation programs had better birth outcomes, and the programs have been found to have a positive impact on breast feeding and immunization rates as well as to lower depressive symptoms and stress. WV has a shortage of CLCs to provide support for breastfeeding mothers.
Kangaroo Care is an evidence-based method of holding a baby that involves skin-to-skin contact. One of the benefits of Kangaroo Care is more successful breastfeeding and breast milk supply. Kangaroo Care also provides stabilization of heart and respiratory rates, improves oxygen saturation rates, better regulation of the infant's body temperature, and conserves a baby's calories. The baby, who is naked except for a diaper and a piece of cloth covering his or her back (either a receiving blanket or the parent's clothing), is placed in an upright position against a parent's bare chest. This snuggling of the infant inside the pouch of their parent's shirt, much like a kangaroo's pouch, led to the creation of the term "kangaroo care." A survey of birthing hospitals indicated that all had Kangaroo Care available after an uncomplicated vaginal delivery and most are also offering Kangaroo Care following an uncomplicated term Cesarean Delivery. This has increased the breastfeeding initiation rate at many of these facilities. Project WATCH/Birth Score collects data on exclusive breastfeeding at hospital discharge. In CY 2018, 37.4% of infants were being exclusively breastfeed. The average intention rate is 56% with a high of 78% and a low of 16%. Average exclusive breastfeeding upon discharge from the hospital was 36% with a high of 72% and low of 9% in 2016.
The WV Breastfeeding Alliance (WVBA) maintained educational support for birthing facilities wanting to increase their Improve Maternity Practices in Infant Nutrition and Care (mPINC) scores through the CDC. Technical assistance was available to hospitals, medical schools, and nursing schools to increase breastfeeding rates; such as sample breastfeeding policies and achieving Baby Friendly designation.
The WVBA received a grant from Aetna to develop an educational program for healthcare provers to support women with substance use disorder or currently receiving medication assisted treatment (MAT) who express a desire to breastfeed their babies. Maternal substance use is not a categorical contraindication for breastfeeding. Adequately nourished narcotic-dependent mothers can be encouraged to breastfeed if they are enrolled in a supervised treatment program. (AAP 2012). There have been numerous studies exploring interventions to increase breastfeeding in the general population, little is known about how to support and promote breastfeeding among mothers on MAT The funds are being used to develop protocols for breastfeeding in the substance use disorder population, develop fact sheets and promotion materials, educational materials for mothers and healthcare providers, and to support staff working in hospitals.
The State's designated home visitation program (medical model) for Medicaid eligible pregnant women and infants through the first year of life is the Right From The Start Program (RFTS). Right From The Start provided in-home education using the evidence-based curricula “Partners for a Healthy Baby” to provide education to all enrolled clients on a variety of prenatal and infant issues, including the benefits of breastfeeding for both mother and baby. These Designated Care Coordinators (DCCs) who provide this education are either a registered nurse or licensed social worker. Educational tools such as videos, DVDs, medical models and brochures, along with evidence-based curriculum hand-outs from the “Partners for a Healthy Baby” are used to provide breastfeeding education and encouragement. Several DCCs are also trained as Certified Lactation Consultants
who can provide additional education and support for mothers who are breastfeeding. Population-based home visitation programs (Healthy Families America, Parents as Teachers, Early Head Start, and Maternal, Infant Health Outreach Workers) also to provided evidence-based breastfeeding support and education to enrolled clients.
Collaborate with WIC to assure all women receive evidence-based breastfeeding education.
The State’s home visitation programs collaborated with the State and local Office of Nutrition Services (WIC) to support and promote breastfeeding. The State’s home visitation programs refer clients to the WIC Program and WIC refers clients to the home visitation programs. This is especially important after case closure with RFTS at one year of age so that mothers and infants continue to receive breastfeeding support. All RFTS clients are automatically eligible for WIC services.
Offer evidence-based provider training.
The OMCFH provided funding to the WV Perinatal Partnership to conduct a statewide Lamaze childbirth education workshop. The target audience was uncertified childbirth educators, nurses, and others interested in providing childbirth education. A total of 6 participants were trained in May 2019. It is expected that a minimum of 50% of participants will pass the certification exam and 90% will conduct childbirth classes. Attempts are being made to track the number of participants that passed the final exam and the number that are teaching childbirth education. Individuals trained will be strongly encouraged to share their knowledge by providing childbirth education.
Childbirth education can help reduce the use of unnecessary interventions and improve overall outcomes for mothers and babies. Knowing that pregnancy and childbirth can be demanding on a woman’s body and mind, Lamaze childbirth education serves as a resource for information about what to expect and what choices are available during the childbirth. The number one tenant of Lamaze childbirth education is, “Let labor begin on its own”. Lamaze childbirth education empowers women to make informed choices in healthcare, take responsibility for their health and to trust their innate ability to give birth. These education and practices are based on the best, most current medical evidence available.
A Lamaze Evidence Based Labor Support workshop was conducted in May 2019 with 44 participants representing 5 different hospitals. This workshop educates labor and delivery nurses to support the laboring mother using relaxation; use of movement; and therapeutic use of items to create a positive environment for the woman and her family. Positive outcomes include lower rates of cesarean birth rates, shorter labors and fewer newborns with a 5-minute Apgar of less than 7. The nurses expressed great satisfaction with the training and confidence in their ability to provide supportive care during labor and birth.
The OMCFH provided funding to the WV Perinatal Partnership to conduct best practice updates in multiple locations and the annual 2018 Perinatal Summit for maternity care providers to share the new guidelines of the American Congress of Obstetrics and Gynecologists (AGOC) and Society for Maternal Fetal Medicine. This education included a post session evaluation. The target audience included physicians, nursing staff, childbirth
educators, and medical and nursing students.
Provide support to hospitals to become baby friendly.
The OMCFH and the WVBA maintained educational support for birthing facilities wanting to increase their Improve Maternity Practices in Infant Nutrition and Care (mPINC) scores through the CDC. Technical assistance was available to hospitals, medical schools, and nursing schools to increase breastfeeding rates; such as sample breastfeeding policies and achieving Baby Friendly designation. West Virginia now has four hospitals designated as Baby Friendly. Site visits from Baby Friendly USA are scheduled in June for two additional hospitals that show strong signs of being approved for designation.
Offer certified lactation training to WV providers.
WV has a shortage of lactation support providers, especially after hospital discharge. Many women do receive lactation support through WIC, but not all women are eligible. A Certified Lactation Consultant (CLC) training was held in September 2018 with 39 participants, 35 of which passed the certification exam. This will increase the number of certified lactation consultants in WV. Funding has been allocated to the WV Perinatal Partnership to conduct another CLC training in 2019. The focus of participants will be for areas where there are low numbers of CLCs and pediatric offices.
Safe Sleep
Each year in the US, there are about 3,500 Sudden Unexpected Infant Deaths (SUID) that occur in healthy infants. These deaths occur among infants less than one year old and have no immediate explained cause. The three commonly reported types of Sudden Unexpected Infant Deaths (SUID) are: SIDS (Sudden Infant Death Syndrome); unknown cause; and accidental suffocation and strangulation in bed. The cause of SUID is unknown, but research studies have provided guidelines for reducing the risk of SUIDs starting with safe sleep practices. Mortality rates for accidental suffocation and strangulation in bed remained unchanged until the late 1990s. Rates started to increase beginning in 1998 and reached the highest rate at 20.8 deaths per 100,000 live births in 2013.
Despite the existence of compelling research and statistics about the importance of safe sleep in reducing our nation’s high rate of infant mortality, the number of babies who die in adult beds and other unsafe sleep environments is on the rise. In fact, of the more than 4,500 sudden, unexpected infant deaths each year, statistics show that as many as 8090% are the result of unsafe sleep practices. An infant’s risk of dying is up to 40 times greater while sleeping in an adult bed, rather than in a safe crib.
The CDC and American Academy of Pediatrics (AAP) have identified several major risk factors that increase the chance of both SIDS and SUID. These risk factors include: sleeping on stomach or side; prenatal smoking and exposure to secondhand smoke after birth; bed sharing (also called co-sleeping) with others, particularly adults; soft sleep surfaces and loose bedding; overheating and use of heavy bedding; and premature birth and low birthweight.
SUID is one of the leading causes of post neonatal deaths in WV and comprises a spectrum of possible infant death circumstances and subsumes many deaths that would have previously been attributed to SIDS. With the institution of more effective death investigation practices, certain deaths that previously would have been classified as SIDS have been reported as accidental suffocation or strangulation in bed or undetermined cause of death. During calendar year 2016, there were 35 resident infant deaths identified by the WV Health Statistics Center. These infant deaths were identified with a cause of death listed on the death certificate as ICD codes R95 - R99 Sudden Infant Death Syndrome, Other Sudden Death, Cause Unknown, or Other Ill-Defined and Unspecified Causes of Mortality), W75 (accidental suffocation and Strangulation in Bed), Y12 (poisoning by Narcotics and Psychodysleptics, Hallucinogens, Undetermined), Y34 (Event of Undetermined Intent) and P04,2 (Newborn Affected by Maternal Use of Tobacco). The most prevalent identified risk factors in SUID deaths for 2016 were co-sleeping/bed sharing, hazardous bedding and smoke exposure. Co-sleeping/bed sharing was reported in 34% of cases with 31%of cases having unknown sleeping status. Hazardous bedding was reported in 71% of cases with 29% having unknown bedding status. Maternal smoking during pregnancy was reported in 57% of the cases and second-hand smoke exposure in the home was reported in 29% of cases, with 57% of cases having unknown status of smoke exposure in the home. Medicaid was reported as the primary source of insurance in 80% of ese infant deaths.
West Virginia has improved the number of infants placed to sleep on their backs from 66% in 2007 to 86.1% in 2016, a 30% increase. This improvement exceeds the Healthy People 2020 goal of 75.8%.
The OMCFH has been an ongoing participant in the national Back to Sleep campaign since its inception in 1996 and now participates in the expanded Safe to Sleep campaign. The Office continued disseminating pertinent, current information about risk factors such as co-sleeping/bed-sharing, early prenatal care, maternal smoking during pregnancy, infant exposure to second hand smoke, and a safe sleeping environment. The Office continues to make ongoing efforts to provide current, relevant educational material statewide to health care providers as well as parents, grandparents, and other caregivers of WV’s infants in an effort to decrease the State’s infant mortality rate.
“Our Babies: Safe and Sound” is an educational campaign that provides parents and other caregivers of infants under the age of one, as well as expectant parents and professionals, with information and tips on ways to keep babies safe while sleeping, and how to keep your cool when babies cry by providing information/skills needed on how to respond in order to reduce risk of abuse. The overall goal of the campaign is to help prevent WV infants from injury and death. “Our Babies: Safe and Sound” is administered by "To Eliminate Abuse and Maltreatment" (TEAM) for WV Children. This initiative is funded by the WV Department of Health and Human Resources, WV Children’s Trust Fund and additional support from the Claude Worthington Benedum Foundation. The TEAM for WV Children is a charitable organization founded in 1986. TEAM has emerged as a statewide leader in prevention by offering programming, training and advocacy on behalf of our state’s children. By the close of calendar year 2018, twenty-three of the twenty-four birthing hospitals were delivering safe sleep education through the Say Yes to Safe Sleep for Babies initiative to parents and/or caregivers before leaving the hospital. One hospital located in a bordering state (Garret County Memorial -Oakland Maryland) which serves WV families also participates in the Say Yes to Safe Sleep for Babies initiative. This represents 99.5% of all births in WV occurred in birthing hospitals participating in the Say yes to Safe Sleep for Babies initiative. Our Babies Safe and Sound launched a pediatric campaign in early 2019. The campaign targeted pediatric practices to deliver the safe sleep message. 14 practices, involving 89 pediatric providers, joined the Say Yes to Safe Sleep campaign and are providing reinforcing education to parents and caretakers consistent with AAP recommendations. Over 60 WVU pediatric residents were introduced to the campaign and were provided with educational materials at the AAP Spring meeting held in March 2019. Strategies for the pediatric expansion included a preprinted prescription for safe sleep.
The Office in partnership with the Perinatal Partnership and Our Babies: Safe and Sound, hosted the Say Yes to Safe Sleep for Babies Annual Competency Training in May 2019. The purpose of this training was to bring national, state, and local partners together to share the latest knowledge, tools, and best practices to reduce and prevent infant deaths from unsafe sleep and abusive head trauma. The training was attended by 60 individuals, representing each birthing hospital and multiple home visitation programs.
The OMCFH became a partner with “Cribs For Kids”. The mission of “Cribs for Kids” is to prevent infant deaths caused by unsafe sleep practices by educating parents and caregivers on the importance of
practicing safe sleep for their babies and by providing Pack ‘n Play portable cribs to families who, otherwise, cannot afford a safe place for their babies to sleep.
A pediatric recruitment campaign began in early 2019. With support from the WV chapter of the American Academy of Pediatrics 14 pediatric practices involving 89 pediatric providers have joined the Our Babies Safe and Sound campaign and are providing reinforcement of safe sleep education to parents and care givers. Additionally, over 60 pediatric residents were introduced to the campaign and provided with educational materials. The pediatric recruitment campaign was presented at the National Cribs for Kids conference in April 2019.
Mail “Safe to Sleep” materials to all families with a birth record.
The OMCFH continued to mail “Safe to Sleep” materials to all families with a birth record. This mailing contained current information about risk factors such as co-sleeping/bed-sharing, early prenatal care, maternal smoking during pregnancy, infant exposure to second hand smoke, and a safe sleeping environment. The OMCFH also provided current, relevant educational material statewide to health care providers as well as parents, grandparents, and other caregivers of WV’s infants in an effort to decrease the State’s infant mortality rate. In order to more accurately capture the number of families who receive the “Safe to Sleep” materials, the OMCFH implemented a tracking system to collect the number of postcards which are returned as undeliverable.
Offer evidence-based provider training.
The OMCFH is a partner of “Our Babies: Safe and Sound” project. Over 240 community partner organizations have used the “Say Yes to Safe Sleep” educational materials with their families, clinicians and home visitation programs. “Our Babies: Safe and Sound” provides on-site as well as on-line training to hospital staff, clinicians, and home visitation programs on how to present safe sleep education and implementation of safe sleep practices. Multiple resources were available including literature and DVDs. Home Visitation providers were encouraged to provide safe sleep education on the first home visit after a child’s birth. The providers also asked primary caregivers to report on sleep practices used in the home environment.
Utilize evidence-based curriculum to educate families on safe sleep environments.
The partnerships that the OMCFH has with “Our Babies: Safe and Sound” and with “Cribs for Kids” provide access to the latest evidence-based materials to educate families and the general public. The multiple home visitation programs within WV all use evidence-based curriculum to provide in-home family education on safe sleep practices.
Work with Hospitals to develop safe sleep practices.
“Our Babies: Safe and Sound” continued to provide training to hospital staff, clinicians and others on safe sleep practices. Technical assistance was offered to hospitals to develop and implement safe sleep policies and procedures. All 25 WV birthing facilities (24 in-state hospitals, one out of state hospital) have received training from “Our Babies: Safe and Sound”. Of these facilities, 22 have received certification as National Safe Sleep Hospital through Cribs for Kids. Assistance will be offered by the “Our Babies: Safe and Sound” team to complete the application process.
Substance Use Disorder
In 2016, WV continued to lead the nation in overdose deaths at 52.0 per 100,000 population compared to the national rate of 19.8 (West Virginia Health Statistic Center and CDC Wonder). Preliminary 2017 data indicates that overdose deaths increased yet again from 2016 to 2017 (WV Health Statistics Center). This is just one indication of the extent of the drug epidemic in the state. One of the many consequences of the drug epidemic is neonatal abstinence syndrome (NAS). NAS is a withdrawal syndrome that develops soon after birth when there was prenatal exposure to drugs; NAS can be a result of exposure to prescribed or illicit drugs. Not all infants that are exposed to drugs in utero develop NAS, but these infants can still experience consequences from prenatal drug exposure. In the past two years, more data has become available on rates of NAS. Not only does WV have the highest rate of overdoses, the state also has the highest rate of NAS in the nation. Uniform billing data indicates that the rate of NAS in 2013 in WV was 33.4 per 1,000 hospital births, compared to the national rate of 6.0 per 1,000 hospital births (Ko et al, 2016). In 2010, the WV rate was 0.5 per 1,000 hospital births and the national rate was 1.2 per 1,000 hospital births. In three years, the rate of NAS in WV grew from 0.5 to 33.4 per 1,000 births and is over five times the national average.
Hospital discharge data is good for comparing national prevalence rates, but is not a timely data source, making evaluation of the problem and efforts to address it difficult. The OMCFH believed it was imperative to establish a surveillance source that could provide timely data to define and address the problem of NAS in WV. The OMCFH was successful in implementing a NAS surveillance data system in 2016 (more detail can be found in the APR section). Data collected from October 1, 2016 to May 31, 2016 showed the rate of NAS in WV at 5.3% of births in WV birthing facilities, or 53 per 1,000 hospital births. Even more concerning is the rate of drug exposed infants in WV, which is 14.2% or 142 per 1,000 births at WV birthing facilities. This number is high, but in 2009 a “Cord Blood Drug Study” was sponsored by the OMCFH using federal Maternal and Child Health Block Grant funds to assess the prevalence of maternal substance abuse. This study, which had some limitations, found that approximately 19% of cord blood samples from infants born at the participating birthing facilities tested positive for drugs. While
14.2% may seem high, this number is less than the 19% found in the cord blood study and indicates the OMCFH data collection is catching a substantial number of cases. Not all birthing facilities have universal toxicology screening of mom and infant at birth, which can decrease the number of cases of prenatal drug exposure found. Data remained consistent throughout 2017. For calendar year 2017, 14.3% of infants born in WV were exposed to drugs, either illicit or prescribed, prenatally. Of infants born in WV in 2017, 5.1% were diagnosed with NAS.
The OMCFH has taken recommendations by Agency for Healthcare Research and Quality (AHRQ) and Association of State and Territorial Health Officers (ASTHO) under consideration and as such has strategies that are associated with primary, secondary, and tertiary prevention to address NAS at all levels. Primary prevention strategies to reduce the incidence of in-utero opioid exposure are to work with healthcare providers to develop recommendations for identifying NAS, offer evidence-based provider training to facilitate appropriate diagnosis of NAS, and the development of a comprehensive surveillance system for monitoring NAS to inform program and policy development, which is essential to reducing the number of infants born with NAS. These primary strategies are related to establishing consistent data reporting so reports used to inform policies, procedures, and education are accurate and applicable to the state. Some of these strategies are also secondary prevention strategies. The secondary prevention strategies to treat known and in-utero opioid exposure are to increase the number of Prenatal Risk Screening Instruments (PRSI) completed and submitted to the OMCFH and establish referral processes between Maternal Risk Screening (MRS) and the OMCFH home visitation programs. These efforts are undertaken to reduce disease severity. And finally, the Office seeks to provide care to infants diagnosed with NAS through already established referral processes. Infants diagnosed with NAS are evaluated by and receive services from various programs within the OMCFH through established procedures and protocols. Next steps include evaluation of referral systems to ensure they are being utilized. Taken together, the combined strategies address public health consequences of NAS across the prevention spectrum.
In an effort to address the public health crisis, the WV Bureau for Public Health developed a Response Plan for the State of West Virginia. The plan was developed through public engagement and expert input to address this opioid crisis on all fronts. One of the recommendations was to increase the utilization of long acting reversible contraceptives (LARC), especially in women with substance abuse disorders. The goal is to reduce unintended pregnancies and the rate of infants born with NAS. The WV Legislature gave on-time supplemental funding to provide LARC during harm reduction/needle exchange programs, immediate postpartum, and in correctional facilities prior to release.
The Family Planning Program was the lead on these projects. Comprehensive family planning services are to be provided in accordance with Title X guidelines. Training and technical assistance was provided to each site. Only harm reduction clinics certified by the Bureau for Public Health were eligible. Applications were received from 10 of the 14 certified harm reduction clinics and the approved sites included 8 local health departments and 2 free clinics. Eleven of WV regional jails and 1 prison have chosen to participate in the project also. The funding was to be used to hire additional clinicians and to purchase birth control methods. Participating sites indicated delays in increase of service provision due to establishing rapport with harm reduction clients and initial or continued distrust in signing up for family planning services due to perceived loss of anonymity, despite provision of confidential services. Sites have strengthened counseling efforts and are beginning to see increases in people interested in receiving services. Jails and prisons are not eligible for Title X Family Planning Program contraceptives because health care at these locations is contracted with a for profit provider agency. Birth control methods were to be offered and made available to inmates prior to release. The use of LARC is strongly encouraged, but not mandatory. The Division of Corrections was unable to purchase all contraceptives prior to the funding expiring, but this initiative has shown increased uptake in 2019, with education being provided to all inmates at Lakin Correctional Facility and 5 Regional Jails: 10 inmates received hormonal contraceptive injections, 9 received Nexplanon implants, 1 had an IUD inserted, and many received parole packs which include condoms. Other avenues for providing funding for contraceptives are being explored. The Cabin Creek Health System, a participating Family Planning site, is working to establish an MOU with Corrections to provide a full range of comprehensive services, including LARCs in the facility. This will allow Cabin Creek to be reimbursed by the Family Planning Program and use Family Planning Program supplies, as it will be an extension of the Title X site and the clinic area will be provided in-kind. The hospital project offered a $500 incentive to hospitals that provide immediate postpartum LARC insertions above the 2017 baseline number of insertions. This was to help off-set costs incurred with purchasing the devices, changes in workflow, and other barriers expressed by the hospitals. Despite heroic efforts by the Family Planning Program, only 5 hospitals entered into MOUs to participate in the project. Only 2 of those actually completed claims with a total of 70 immediate postpartum LARC insertions. Less than $20,000 was expended.
The OMCFH is also an active member of the WV Perinatal Partnership’s Substance Abuse In Pregnancy committee, which includes numerous stakeholders including healthcare providers to ensure direct input of professionals addressing NAS each day. WV is also involved with the Preventing Substance Use in Pregnancy and Promoting Consistent Interventions Statewide initiative, which is working to integrate the efforts of: The Governor’s Advisory Council on Substance Abuse, the 3-Branch Department of Health and Human Resources (DHHR) Initiative, and the WV Perinatal Partnership’s Substance Use in Pregnancy Committee. OMCFH remains active in these various workgroups to address the prevalence of NAS, the proper interventions needed to decrease NAS rates, and improve outcomes after neonatal drug exposure.
There is rising concern by partners about the rate of alcohol use during pregnancy. Alcohol use during pregnancy is a significant public health issue globally, nationally, and in the state of WV. In an effort to understand this issue, the OMCFH provided funding to the WV Perinatal Partnership to conduct an alcohol use during pregnancy study. This study used data from a sample of all residual Dried Blood Spot (DBS) specimen cards of infants born in the state from November 2017 to January 2018 to examine the prevalence of Prenatal Alcohol Exposure (PAE) using phosphatidylethanol (PETH). PETH is a long-term biomarker of alcohol ingestion, which can be detected and measured in the DBS,30 and indicates PAE in the month prior to birth.19 The DBS specimens were analyzed at USDTL using previously published methods. The results demonstrated that PAE in the last month prior to delivery was 8% among all births and 7.6% among WV residents. These prevalence rates are much higher that what was previously known for the state of WV. Although the prevalence rate of PAE in WV was much higher that what was previously known for the state, the prevalence is lower than the national and global estimates (7.6% for this study verses 11.5% nationally, and 9.8% globally). This may be due to several reasons. First, PAE in our study captures exposure during the month prior to birth, which likely underestimated the true prevalence of PAE over the entire pregnancy. Second, PETH does not detect occasional intake but detects moderate to heavy alcohol consumption. OMCFH is working with the state perinatal collaborative on preventive measures to reduce PEA.
Work with healthcare providers to develop recommendations for identifying NAS.
The bulk of work on developing recommendations for identifying NAS has been completed. Each birthing facility in the state is identifying and reporting NAS. With the implementation of NAS surveillance data, the OMCFH and partners now have timely data to inform next steps and priorities. However, to ensure quality and accuracy of the data, activities associated with this strategy in the coming year will be focused on quality improvement. Furthermore, the OMCFH and partners continued to explore a sample comprehensive policy related to NAS scoring, treatment, breastfeeding, and discharge planning. The problem of NAS is an emerging issue; therefore, there is little information available on best practices. The OMCFH and partners continue to educate themselves through literature, but consensus about best practices and the evidence to support them can be elusive. Lessons learned the previous year continued to be felt this year. Identification of an infant diagnosed with NAS brings with it involvement of multiple organizations to ensure the infant is in a safe environment and receiving proper care. Discussions and processes continue to be ongoing to guarantee all agencies charged with the infant’s care are meeting organizational requirements, to allow the infant to thrive in a safe environment.
The OMCFH participates in numerous workgroups, advisories, and committees that are constantly evolving based on needs and actions. Through these collaborations, the OMCFH met with neonatal care specialists, pediatricians, and maternity care providers as well as other stakeholders. Active participation in these meetings continue to assess the current screening, diagnosing, and reporting criteria for NAS and intrauterine drug exposure, including alcohol, with partners. The NAS data work group brought together partners across all bureaus of the WV DHHR,
insurance carriers, and other healthcare and community partners. This group met on a quarterly basis to share data on NAS prevalence and associated costs. This workgroup has evolved with a more general focus on perinatal topics. Some topics have a direct impact on NAS rates, such as the use and availability of long acting reversible contraceptives (LARCs) and their use in women who are currently using drugs. NAS has transitioned to an agenda item at this more general meeting. OMCFH continues to promote utilization of LARC as well as other contraceptive methods.
The OMCFH is an active member of the WV Perinatal Partnership’s Substance Abuse committee, which includes numerous stakeholders including health care providers to ensure direct input of professionals addressing NAS each day. WV is also involved with the Preventing Substance Use in Pregnancy and Promoting Consistent Interventions Statewide initiative, which is working to integrate the efforts of: The Governor’s Advisory Council on Substance Abuse, the 3-Branch DHHR Initiative, and the WV Perinatal Partnership’s Substance Use in Pregnancy Committee. The OMCFH is active in these various workgroups to address the prevalence of NAS, proper interventions needed to decrease NAS rates, and improve outcomes after neonatal drug exposure.
The Drug Free Moms and Babies (DFMB) Project is a comprehensive and integrated medical and behavioral health program for pregnant and postpartum women. The project supports healthy baby outcomes by providing prevention, early intervention, addiction treatment and recovery support services. This three-year pilot project was supported through funding from DHHR, Bureau for Behavioral Health and Health Facilities, the OMCFH and the Claude Worthington Benedum Foundation. In 2012, the WV Perinatal Partnership, the coordinating organization, awarded funding to four pilot project sites for the three-year cycle: Shenandoah Valley Medical Systems, Inc., Thomas Memorial Hospital, Greenbrier Valley Medical Center and West Virginia University Ob-Gyn Department. The goal of the project is to get women into treatment while pregnant and provide follow-up support for her and her baby for two years. The DFMB Project has expanded to 11 active sites and plans to add 5 more before the end of the year.
The percent of participants abusing drugs during pregnancy decreased for all drug types, including tobacco, when compared to use before pregnancy. 95% of participants were enrolled into treatment for drug abuse. Treatment types included 54% into Medication Assisted Treatment and 55% into counseling, these are not necessarily mutually exclusive categories. In addition to referrals for substance use disorder treatment, participants were also referred to other programs such as WIC (62%) and Right from the Start (35%). For those that completed the program, 80% had a positive urine drug screen during the first trimester, which decreased to 21% at birth. Reasons for not finishing the program included personal preference (67%), moved (19%), and incarceration (15%). Results of this evaluation will be used to ensure future activities will help mitigate identified barriers and to help solicit additional funding for maintenance of existing programs.
Dr. Chrisa Lilly, PhD presented the DFMB program at the annual American Public Health Association in fall 2018. Her presentation titled “Quantitative and Qualitative Assessment of DFMB Program in Rural Appalachia”, She presented the evaluation of the program. In summary, the DFMB program reached high-risk medically underserved women with positive maternal health outcomes.
Offer evidence-based provider training to facilitate appropriate diagnosis of NAS.
The OMCFH provided financial support to the WV Perinatal Partnership, the Birth Score office, and other partners to provide training to birthing facilities on the proper and consistent diagnosing and reporting of intrauterine drug exposure and NAS.
The OMCFH continued to financially support outreach and education efforts provided by the WV Perinatal Partnership, which included topics related to NAS such as therapeutic handling of infants diagnosed with NAS and providing additional trainings for nurses that were unable to attend initial trainings. The WV Perinatal Partnership offered curriculum concerning attitudes of professionals who care for and treat mothers with substance abuse disorders. The target audience was nurses, social workers, physicians, and other perinatal providers as well as their office staff. While the medical model of addiction is currently embraced by many, there is still stigma attached to people who use drugs. This can result in frustration by healthcare providers that are caring for a mother and infant diagnosed with NAS. By providing educational training, the OMCFH and partners hope to decrease feelings of burnout that are often reported when caring for mothers and infants diagnosed with NAS.
wrote a guide, “West Virginia Perinatal Loss Guidelines for Care & Legal Paperwork”. The Perinatal Bereavement team prepared tangible resources for each of the Level 1 and 2 hospitals. This includes very small gowns made from old wedding dresses; small crocheted cradles; memory making items and imprint materials for tiny hands and feet. An instructional PowerPoint slide presentation was created and a video interview of a family experiencing a neonatal loss was filmed. The team has begun hospital Nursing Grand Rounds in February 2019 and anticipates that the work will wrap up in a few months. All 24 hospitals and the Birthing Center will have a copy of the materials and a presentation.
Through financial support from the OMCFH, the Perinatal Partnership also arranged infant stabilization courses (STABLE) for nurses and emergency transport personnel. The course aids in resuscitative efforts and stabilization (blood sugar, temperature, airway, blood pressure, lab work and emotional support) prior to transport of the infant diagnosed with NAS. S.T.A.B.L.E. is the most widely distributed and implemented neonatal education program to focus exclusively on the post-resuscitation/pre-transport stabilization care of sick infants. Based on a mnemonic to optimize learning, retention and recall of information, S.T.A.B.L.E. stands for the six assessment and care modules in the program: Sugar, Temperature, Airway, Blood pressure, Lab work, and Emotional support. A seventh module, Quality Improvement, stresses the professional responsibility of improving and evaluating care provided to sick infants. Participants received 8 continuing education credits. Certified instructors are from the three tertiary care hospitals. There were 63 participants from 6 different hospitals during this grant period. The State Emergency Medical Transport (EMT) also provided STABLE training for EMTs for transporting infants.
The OMCFH continued financial support, perinatal education, and outreach for Newborn Day and the annual Perinatal Summit. NAS and topics related to substance use during pregnancy and care of infants were included on the agendas for these professional education opportunities in the state.
The OMCFH also supported additional in person trainings across the state, which included: A Standardized Approach for Treatment of Infants at Risk for NAS, Caring for Infants with NAS, Caring for the Baby Who Is Drug Affected – from Hospital to Home, and Improving Outcomes for Pregnant Women with Substance Use Disorders. In addition to these in person trainings a webinar, West Virginia’s Approach to Addressing NAS, was conducted, and an educational pamphlet for home visitors was developed, Caring for Babies Affected by Drug Exposure.
Maintain a comprehensive surveillance system for monitoring NAS to inform program and policy development essential to reducing the number of NAS infants.
On October 1, 2016, the OMCFH began to collect surveillance data on intrauterine drug exposure and NAS using the Birth Score Instrument. The current rate of intrauterine exposure is 14.2% and NAS is 5.3%. This is higher than the most recent year of available hospital charge data at 4.4% of hospital births. While the rate is increasing, better case finding through training and education may also result in higher rates reflecting a rate that is closer to the true prevalence. The rate of intrauterine substance exposure is higher than data collected on the birth certificate related to maternal use of illicit drugs; this is expected because the OMCFH collects both prescribed and nonprescribed drug exposure. Furthermore, medication assisted treatment is a best practice for a woman that is pregnant and uses drugs; however, the infant can still develop NAS because of exposure. This means that as more women of reproductive age seek treatment, more cases of NAS may be found. It is easier to identify intrauterine substance exposure of prescribed medications than illicit drug exposure. The data has proven to be very popular. This has resulted in the need for a more structured data dissemination plan which is being developed. An additional advantage of NAS surveillance data being captured on the Birth Score is it allows the incorporation of NAS into the Birth Score algorithm to identify infants at risk of morbidity and mortality in the first year of life.
Assess hospital policies and procedures for diagnosing and reporting NAS.
In January 2017, a chart audit of 52% of births in January was conducted to assess the data consistency between medical records and NAS diagnosis recorded on the Birth Score. Of the charts that were assessed, 92% had consistent NAS documentation between the medical record, appropriate ICD 10 code (or lack of code), and the Birth Score. Of the charts with any indication of NAS (record, diagnosis code or Birth Score diagnosis recorded), 87% had documentation on the Birth Score. While the results of the chart audit indicated good reliability between the Birth Score and the medical record, additional guidance to the birthing facilities would be beneficial to increase the documentation of ICD codes in the birth record and to ensure the consistency of the data being collected and disseminated. A second chart audit at the original nine facilities is currently underway to further evaluate data quality and effectiveness of data improvement efforts.
Provide targeted education to improve the integrity and consistency of NAS data that is used to drive policy decisions.
The results of the chart audit mentioned above were presented at three grand rounds at three of the largest hospitals in the state and is available online. The grand round presentation was also presented at the state’s osteopathic school. The presentation not only provides information about the chart audit, but it also contains guidance associated with proper documentation in the medical record for consistent data collection. In the past year, hospital specific data has been given to hospitals by request. This allows the birthing facilities to use their data internally for planning and evaluation needs. Not all birthing facilities have that capability, but it does allow facilities to understand their reported rates.
Establish an automatic referral process to the CSHCN Program using the NAS Surveillance System.
There have been barriers associated with the implementation of automatic referral processes. To ensure care the CSHCN Program has implemented strategies to provide case management oversight for infants diagnosed with NAS. The CSHCN Program now receives referrals from Medicaid MCOs for children diagnosed with NAS. A team of registered nurses review medical documentation to confirm a diagnosis of NAS, as well as other eligibility criteria. Incomplete documentation is common in the medical record. The CSHCN Program will be working with internal and external partners in the coming year to address documentation inconsistencies that can interfere with the NAS diagnosis. OMCFH is also reviewing current policy for referrals from the Birth Score. The Birth Score tool collects surveillance data for infants diagnosed with NAS. The goal is to allow automatic referral to the CSHCN Program.
The OMCFH and the CSHCN Program worked with the Medicaid Managed Care Organizations to implement an automatic referral for all infants diagnosed with NAS and/or prenatal drug exposure to the CSHCN Program for evaluation for program eligibility. This referral process was operationalized into the MOU with the MCOs and is required for the MCO to receive the higher capitated rate for identified CSHCN. The CSHCN Program Nursing Director meets monthly one-on-one with MCO representatives to promote communication and to optimize the referral process. These monthly meetings have facilitated the improvement of documentation inconsistencies that were delaying the eligibility determination. The CSHCN Program continues to collaborate with the MCO’s to identify children diagnosed with NAS. This ongoing discussion ensures consistent application of the CSHCN Program’s organic definition of NAS and prenatal drug exposure for program eligibility. The CSHCN Program strives to incorporate the standardized definition of NAS and prenatal drug exposure. As seen previously in this narrative, this definition is evolving. As the result of these collaborations, CSHCN and the MCO’s are able to identify infants with NAS prior to hospital discharge and promote coordination of care. The CSHCN Program Nursing Director conducts quarterly meetings with the state Medicaid agency and the MCO regional managers to summarize monthly meetings and strategize system processes. The OMCFH recently brokered changes to the data sharing agreement with the Project Watch WV Birth Score office. This data will be matched against CSHCN Program data and MCO referrals in an attempt to gauge the referral rate of infants diagnosed with NAS or prenatal drug exposure to the CSHCN Program.
The CSHCN Program and the HealthCheck EPSDT Program has hired an MCO coordinator to act as a liaison between the OMCFH and the Bureau for Medical Services the contractor for the Medicaid MCOs. This coordinator will act to bridge the gap for children involved in multiple OMCFH programs.
CSHCN will provide case management to infants diagnosed with NAS.
All children with a confirmed diagnosis of NAS are enrolled with the CSHCN Program and followed by a care coordination team comprised of a registered nurse and a licensed social worker. The CSHCN Program’s eligibility criteria was modified to allow for ongoing surveillance of health consequences as a result of neonatal drug exposure into adolescence. During the past year, a comprehensive medical record for each child referred with a possible diagnosis of NAS was reviewed for substance exposure regardless of NAS diagnosis. This information was reported back to the referring agency to support quality assurance of the CSHCN Program’s eligibility criteria and to provide education regarding appropriate documentation of diagnosis of NAS. The CSHCN Program is currently providing care coordination for 27 children diagnosed with NAS. All referred children with a documented diagnosis of NAS are enrolled to the CSHCN Program as soon as medical documentation to support the diagnosis is received so the eligibility process can be completed.
Infants diagnosed with NAS and prenatal drug exposure remain categorically eligible to receive services through the CSHCN Program. In response to CSHCN Program staff concerns that these children required greater oversight, all infants with a diagnosis of NAS are now automatically eligible for a higher level of service.
The MCOs and the CSHCN Program collaborate to coordinate the child’s care across the medical home. Specifically, the CSHCN Program utilizes their community relationships to facilitate contact with the families if the MCO has difficulty making contact.
The majority of these infants have CPS involvement, and the CSHCN Program partners with the Bureau for Children and Families to ensure a comprehensive medical record is developed for all foster children in the state of West Virginia. This medical record is incorporated into the Bureau for Children and Families’ foster care database (FACTS) which facilitates the record in following the child through the foster care system.
CSHCN Program nurse care coordinators identify children with documented prenatal drug exposure and developmental concerns consistent with NAS, but with no documented diagnosis of NAS. The CSHCN Program has communicated this concern to our perinatal and infant health partners to incorporate into their work to improve appropriate diagnosis of NAS.
Increase the number of Prenatal Risk Screening Instruments (PRSI) completed and submitted to the OMCFH.
West Virginia’s Maternal Risk Screening (MRS) Program requires that at the first prenatal visit a Prenatal Risk Screening Instrument (PRSI) be completed and faxed to the OMCFH. The PRSI assesses numerous pregnancy risk factors; among them is alcohol and drug use. The assessment of drug use early in pregnancy is one of the recommendations of the AHRQ for the identification and management of substance use and substance use disorders in pregnancy. There are generally around 16,500 in state WV resident births per year and the OMCFH receives approximately 10,000 to 12,000 PRSIs per year. While this is roughly 60% to 70% of all resident births occurring in the state, the OMCFH plans to increase this rate using different strategies. In the current MRS data system it is hard to track providers that submit PRSIs. Modifications to the data system have been implemented to allow better tracking of individual providers. Outreach to providers that do not submit PRSIs occurred by comparing the PRSIs submitted to birth certificate data by provider. Calls and emails to the individual provider sites were conducted in spring 2019 to encourage submission of the PRSI, remind them of the State law requiring submission and offering technical assistance in completing the form if needed. PRSI completion and submission was also part of the Perinatal Partnership’s outreach and education efforts. The
Perinatal Partnership discussed the PRSI with each maternity care provider, offered technical assistance and stressed the importance of completing and submitting the form. The OMCFH reviews multiple strategies and resources to increase the number of PRSIs completed and submitted.
Establish referral processes between MRS and the OMCFH home visitation programs.
The PRSI also serves as a referral tool to the Right From The Start Program. This program offers resources for prenatal women with multiple risk factors to improve birth outcomes. The home visitation program also provides limited screening and immediate referrals to a mental health provider for substance abuse issues.
Maternal Mortality
Maternal Mortality Over half of maternal deaths occur after the mother has given birth. Common causes of maternal mortality include: cardiovascular and coronary conditions; venous thromboembolism; hemorrhage; infection; mental health conditions such as Postpartum Depression; pre-eclampsia and eclampsia. In partnership with the WV Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) the education for post-birth warning signs was developed. Nursing grand rounds presentations were given in 5 hospitals statewide. AWHONN toolkits and online education were purchased for each hospital. A Quality Improvement initiative (lead by the Perinatal Partnership) is being developed to outline their efforts to reduce maternal mortality and morbidity through discharge teaching.
All women who give birth are at risk of experiencing these life-threatening conditions. To reduce maternal mortality and morbidity, AWHONN developed the POST-BIRTH Warning Signs Education Program to help nurses and clinicians share this life-saving information with their patients and families. The training for the program consists of multiple components: an online education course with CNE offering, an implementation toolkit, The Post-Birth Warning Signs Magnet and Magnet templates, and Save Your Life handouts in English, Spanish, Arabic and Mandarin-Chinese translations. Nursing grand rounds presentations were developed and given in five hospitals across WV. The AWHONN toolkit and an online education module were purchased for each of the hospitals. A Quality Initiative will be developed outlining their efforts to reduce morbidity and mortality through discharge teaching over the next year. Some hospitals have begun using the infographic in their discharge education.
WV participated the Alliance for innovation in Maternal Health (AIM) Hemorrhage Safety Bundle. The AIM is a national data-driven maternal safety and quality improvement initiative based on proven implementation approaches to improving maternal safety and outcomes in the U.S. Our end goal is to eliminate preventable maternal mortality and severe morbidity across the United States. The kick-off for the hemorrhage safety bundle was March 25, 2018. The project will complete in 2019 with 23 of WV’s birthing hospitals participating and completing the required guidelines. Data from a birthing unit survey showed that few hospitals carried out drills with their staff on a regular basis as recommended by ACOG and AIM. As part of their continuous quality improvement, the Perinatal Partnership developed a 6-hour workshop to demonstrate and carry out debriefing simulation drills for staff competency and practice improvement. The low-tech simulation mannequin “Mama Natalie”, was given to each hospital along with sample policies, scenarios and ideas on how to run drill and a hands-on demonstration of quantitative blood loss. Three sessions were held across WV with each hospital sending a team to one of the sessions with approximately 200 nurses and physicians participating.
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