Perinatal & Infant Health: Annual Report

 

FY 2022 Annual Report

In 2021, there were 21,203 infants under the age of one residing in Idaho. For the same year, there were 22,427 live births in the state. The percent of preterm infants was 9.0% and the infant mortality rate was 5.2 per 1,000 live births, an 18.2% increase from 4.4 deaths per 1,000 births in 2019. About 33.3% of Idaho births are covered by Medicaid. In 2021, 24.1% of births were a cesarean delivery, including both primary and repeat cesareans. About 5.6% of births occurred in a non-hospital setting, including residences and freestanding birth centers.

 

Based on outcomes from the 2020 Needs Assessment (NA) and stakeholder prioritization process, Idaho continues to support some of the same priorities, strategies, ESMs, and NPMs that were identified in the state action plan for the Perinatal/Infant Health domain in previous years. This includes improving breastfeeding rates (NPM 4), increasing the percent of infants placed to sleep on their backs (NPM 5), and injury prevention for children under 5 years of age (SPM 1).

 

Safe sleep education in rural areas and among Hispanic populations continues to be a priority based on the 2020 NA and key informant interviews. While Idaho compares positively to the national percentage of infants placed to sleep on their back (83% to 79.6%), only 70% of Idaho infants were reported as sleeping alone between 2014-2018. To address this, the MCH Program will continue the priority to support services, programs, and activities that promote safe and healthy family functioning. Strategies to address the identified NPMs and SPM are outlined in more detail below.

 

Breastfeeding

For FY 2022, strategies discussed in the FY 2021 annual report for breastfeeding were continued with some modifications by the MCH Program, WIC, and MIECHV. Key strategies included training for home visitors, sponsoring the Idaho Breastfeeding Summit, and working with WIC’s peer counselor program.

 

Idaho MIECHV serves many women prenatally, and a total of 91 pregnant women were enrolled in FY 2022. Of these women, nearly 97% were covered by health insurance. Approximately 51% of enrolled prenatal women breastfed their infants for at least six months, up from 46% in 2021, and the percent of enrolled women who ever breastfeed was 95%.

 

The 5th Annual Idaho Breastfeeding Summit: Nourishing Breastfeeding Families in Idaho was held from July 14-15, 2022, in Coeur d’Alene with a virtual option for attendees. A total of 73 individuals attended the conference: 55 in-person and 18 virtually (ESM 4). Attendees included breastfeeding advocates, parents, physicians, nurses, therapists, midwives, lactation professionals, health district staff, parents, peer counselors, and other various care providers.

 

COVID-19 Impact on Breastfeeding Strategies

During the COVID-19 pandemic, WIC received waivers from the United States Department of Agriculture (USDA) to provide uninterrupted services to participants remotely. This enabled participants to attend appointments virtually and aided in removing accessibility issues with in-person appointments. With the implementation of eWIC, and the ability to load benefits remotely, this ensured a seamless issuance of benefits.

 

Breastfeeding support was provided remotely to WIC participants. Clinics provided virtual breastfeeding classes in continuance of the services participants received in clinic. The WIC peer counselors also continued their breastfeeding support to participants via text, phone call, and virtual visits.

 

The MCH Program planned to build on the existing collaboration with the MIECHV and WIC Programs to deliver a training event focused on teaching best practices to home visitors to support breastfeeding moms. Due to the ongoing pandemic, and the capacity of WIC staff, the training did not occur. However, MCH Program staff were able to meet with both WIC staff and MIECHV staff to find alternate ways to train home visitors. The MCH Program is pursuing the option of working with two physicians from Today’s Baby who will discuss supporting breastfeeding moms and promoting safe sleep practices. See the Infant and Perinatal Health Application Report for FY 2024 activities.

 

COVID-19 changed the delivery of the Idaho Breastfeeding Summit. Organizers continued a hybrid approach with an in-person event and an online option to address the uncertainty of the local COVID-19 trends during the June 2022 conference. The summit sessions were recorded and shared with attendees for the opportunity to also watch at a later date.

 

Safe and Healthy Family Functioning

Safe Sleep

Strategies aligned with this priority include providing safe sleep education materials using a family-centered approach, training MIECHV home visitors, and implementing an Idaho-specific media campaign to assist with NPM 5 and the goal of reducing infant sleep-related deaths by September 2025. Strategies to promote safe sleep education and practice have shifted to allow Title V to take the lead on implementation rather than relying solely on community partners.

 

The MCH Program was able to achieve many of the proposed activities as outlined in the 2022 Infant and Perinatal Health Application Plan. This includes: purchasing Cribs for Kids® cribs for distribution to local home visiting programs, supporting the distribution of Charlies Kids© “Sleep Baby Safe and Snug” board books through the PRATS survey, re-engaging with MIECHV home visitors to provide safe sleep education, cribs, and sleep sacks to families in need, and strengthening the link with the work of the Idaho Child Fatality Review Team (CFRT) by using recommendations to guide strategies to eliminate preventable deaths among children.

 

As part of a three-pronged approach to addressing safe sleep in Idaho that has spanned across fiscal years, social media campaign ads were run in October over the last four years (2019-2022) for Safe Sleep Awareness Month. In 2019, the MCH Program worked with the DHW media vendor on the creation of an animated PSA educating viewers on the American Academy of Pediatrics’ (AAP) recommended safe sleep guidelines. The video was filmed in English from the perspective of the infant as he is laying in his empty crib on his back. He begins to remind the viewers about the importance of following the ABCs of Safe Sleep, while finishing his narrative by encouraging viewers to visit the DHW website for more information. In conjunction with the media development, a logo for the safe sleep campaign was created with the messaging, “Alone. Back. Crib. Every Nap. Every Night.” that was used throughout the video PSA and printed on the educational brochures and swaddle sacks. The animated PSA ran on YouTube and Facebook ads for the entire month of October. The MCH Program also supported the use of a Google Paid Search ad as another avenue to promote the redesign of the webpage and increase PSA views. Whenever certain keywords such as “SIDS” or “safe sleep” were searched in the Google search engine, the DHW safe sleep webpage would appear at the top of the screen with the intent for users to be more inclined to click on our webpage.

Figure 1 - Safe Sleep Program Logo

 

In FY 2020, the MCH Program continued to broaden the safe sleep campaign by creating Spanish versions of the PSA, Facebook and Instagram ads, and Google Paid Search ads to run alongside the English versions. Additionally, a Spanish radio ad was also created. In 2021, the MCH Program ran a more complete, well-rounded campaign in both English and Spanish for the entire month of October.

 

In FY 2022, The MCH Program worked with the new DHW media vendor to rerun the campaign in both English and Spanish on Facebook, Instagram, YouTube, as well as the Google Paid Search and Spanish radio ads. The table below provides an overview of 2022 campaign analytics:

 

Safe Sleep Media Campaign Outcomes (10/1/2022 – 10/31/2022)
	Clicks	Impressions	Click Through Rate (CTR)	Cost Per Click (CPC)	Cost Per Mille/ 1,000 (CPM)	Views	Cost Per View (CPV)
Google Paid Search	356	5,657	6.29%	$2.77	NA	NA	NA
YouTube Ads	286	257,936	0.11%	NA	$14.59	243,048	$0.02
Facebook/Instagram	856	157,237	0.54%	$1.57	$9.30	NA	NA

 

The Paid Google Search CTR was nearly double the benchmark (3.27%) and was the top driver of the target audience to the Safe Sleep website. The top 4 cities with the most clicks on the Paid Google search platform were Nampa, Boise, Idaho Falls, and Rexburg, Idaho. The YouTube ads had a very high view rate, with the vast majority of impressions and views going to the six second ad. On Facebook and Instagram, the 15 second Spanish PSA had the highest CTR at 0.72%. The overall number of clicks from both YouTube, Facebook, and Instagram have decreased over the last few years, but it’s difficult to pinpoint the exact factors that may contribute to that, especially with the change in media vendor.

 

The Spanish radio ad was placed on three popular local Spanish radio stations. Two stations were located in Boise and one was located in Twin Falls, reaching audiences in the Treasure Valley and Eastern Idaho. These specific areas of Idaho have high Spanish-speaking populations. Radio ads ran for the entire month of October and there was a total of 258 radio spots placed.                          

 

In FY 2022, the MCH Program also partnered with the WIC Program in October to promote Safe Sleep Awareness Month through the WIC shopper app. A digital banner was displayed on the app with safe sleep educational content encouraging parents and caregivers to follow the AAP recommendations for infant safe sleep. The participant was routed to the DHW Safe Sleep website for additional information and resources by clicking on the banner. The banner received 428 clicks by 387 different participants. There were other banners running through the month of October, but the safe sleep banner was the 2nd highest viewed banner. The average banner clicks in a month is 1,300.

 

In FY 2022, the MCH Program continued to leverage the existing collaboration with the MIECHV Program to offer Cribs for Kids® crib sets and sleep sacks to the Parents as Teachers and Nurse-Family Partnership programs throughout the seven public health districts (PHDs). Home visitors provided safe sleep education to families when they received their safe sleep products and gave crib sets to families who did not have a safe sleep surface for their baby. The following Cribs for Kids® materials were distributed through the MIECHV Program:

 

MIECHV FY 2022 Safe Sleep Data
Number (#) of families provided safe sleep education	275
Number (#) of families supplied with a crib	20
Number (#) of families supplied with sleep sack for infant	86

 

COVID-19 Impact on Safe Sleep Strategies

Lack of community partner referrals has been one of the biggest hurdles for home visiting programs during the public health emergency. However, MIECHV has seen large improvement in the last year and the percent of maximum capacity service (i.e., monthly caseload) has increased from 75% in 2021 to 84% in 2022.

 

Injury and Disease Prevention

In FY 2022, strategies discussed in the FY 2021 annual report for injury and disease prevention were continued by the MCH Program. Key strategies included providing funding to the Epidemiology Program, funding support for the Idaho Poison Control Center, funding and managing the Idaho Newborn Screening Program, distribution of CMV education materials, and participation on the Child Fatality Review Team. Strategy updates and important changes are highlighted below.

 

In FY 2022, the MCH Program provided level funding to the Idaho Bureau of Epidemiology. Due to the lack of specific focus on MCH populations, funding for epidemiology subgrants with PHDs were discontinued at the end of FY 2018. Current funding focuses on state-level systems support for vaccine-preventable and reportable diseases among newborns and children.

 

During FY 2022, the Surveillance Program and Idaho Immunization Program (IIP) in the Epidemiology Section of the Bureau of Environmental Health and Communicable Disease (BECD) continued to partner to prevent the transmission of hepatitis B virus from infected mothers to their infants through surveillance and case-finding activities. BECD surveillance staff (partially funded by Title V) monitor incoming electronic laboratory results (ELRs) daily to identify any laboratory result that indicates a positive hepatitis B virus result in a woman of childbearing age. Routine follow up of these reports occurs by epidemiologists in each of Idaho’s seven PHDs through subgrant agreements not funded by MCH. Epidemiologists conducting follow-up investigation of these reports inquire whether the hepatitis B-infected woman is currently pregnant, plans to become pregnant, or has children. If the woman is not currently pregnant, education is provided regarding behaviors to reduce the risk of transmitting hepatitis B virus to household members, including children. If the woman is planning to become pregnant, additional education is provided regarding the necessity of prenatal care and vaccination of the newborn with the HBV vaccine and HBIG after delivery, and the woman is referred for case management through the Immunization Perinatal Hepatitis B program (not funded by MCH). 

 

ELRs are monitored by surveillance staff for pregnancy status, reason for testing, and ordering provider. If the pregnancy status indicates the patient was pregnant when the test was ordered, the reason for testing was prenatal screening or indicates pregnancy, or the ordering provider is an OB/GYN, the surveillance staff alert state-level epidemiologists who coordinate follow up. This method is used for all vaccine-preventable diseases (e.g., hepatitis B, measles, mumps, rubella, pertussis); sexually transmitted infections (e.g., syphilis, HIV); and other diseases of high-consequence for maternal and fetal health (e.g., listeriosis). Although the volume of electronic reports from laboratories and providers increased 40-fold during peak SARS-CoV-2 transmission waves, BECD maintained priority surveillance activities, including monitoring incoming reports for pregnancy status or ordering provider to identify cases of reportable diseases that have a disproportionately negative impact on pregnant people and pregnancy outcomes.

 

During the response to COVID-19, case investigation data about pregnant women and children were analyzed weekly by epidemiologists to help guide outreach and intervention efforts, especially with the introduction of vaccines in December 2020. Although there are no epidemiologists funded through the MCH Block Grant, during the Governor’s Coronavirus Working Group meetings, media briefings, and hospital system meetings, COVID-19 data specific to pregnant women and children were presented and discussed to describe relative risk as well as the epidemiology of severe diseases (e.g., hospitalization) or post-acute COVID-19 disease (e.g., MIS-C). BECD also analyzed the vaccination status of pregnant women who were reported positive with the virus that causes COVID-19 to assess relative vaccination rates for use by IIP in outreach planning and communication.

 

Monitoring children that develop multisystem inflammatory syndrome (MIS-C) was important to understanding the syndrome and the risk factors associated with it. This syndrome is often diagnosed weeks after acute SARS-CoV-2 infection and children may not test positive for the virus at the time they are admitted to the hospital using a viral test. For that reason, BECD typically can’t detect this condition through electronic laboratory reporting. In Idaho, 85% of the MIS-C cases have come to BECD’s attention because of Idaho’s implementation of electronic case reporting (eCR). Idaho has only one specialty children’s hospital located in the southwest part of the state. Children from the northern and southeastern areas of the state are often transferred to children’s hospitals located outside of Idaho. One of the facilities Idaho children are often transferred to is in Salt Lake City, Utah. Because of Utah’s wide adoption of eCR and the current nationwide eCR infrastructure in which Idaho participates, Idaho received eCRs for Idaho children diagnosed with MIS-C rapidly and seamlessly. This allowed Idaho public health officials to respond and investigate quickly.

 

The MCH Program, Idaho Bureau of EMS and Preparedness, Environmental Health Program, and Drug Overdose Prevention Program shared the cost of poison control activities through a contract with the Nebraska Regional Poison Center (NRPC). Monitoring of the NRPC contract shifted from the Bureau of Community Health (BCH) to the BECD in July 2022 with the transition of the Environmental Health Program. The NRPC reports are provided at quarterly and annual intervals. Quarterly reports split the information by case management, opioid related poisonings, and suspected suicides. For 2022, calls from Idaho resulted in 14,054 unique interactions with the NRPC. Of the poisoning exposure calls received by the NRPC, 45% were for children under five years of age. A total of 64% of poisoning exposures were managed at home by NRPC staff. The cost savings from the prevention of unnecessary emergency department visits was $16,776,000.

 

Newborn Screening

Title V funds the personnel and operation costs for the Idaho Newborn Screening (NBS) Program, which is managed under the MCH Section. The NBS Program screens for 51 different conditions using dried blood spots and requires universal screening for critical congenital heart disease (CCHD). In 2021, the NBS Program transferred lab services from the Oregon State Public Health Laboratory (OSPHL) to the Washington State Public Health Laboratory (WSPHL). The WSPHL contract began April 1, 2021, and the OSPHL contract ended April 30, 2021. Starting in 2022, the WSPHL solely provided the first full year of metabolic newborn screening data. Also in 2022, the WSPHL adopted and began working with a new data visualization system, Microsoft Power BI. The transition to a new system meant setting and refining data collection parameters. Within the parameters set in 2022, 97% (21,433/22,140) of live births occurring in the state had at least one metabolic newborn screen completed, and 92% (20,291/22,140) of live births occurring in the state had a subsequent metabolic newborn screen. Preliminary numbers showed there were 24,155 initial screens. The preliminary initial screen count was significantly higher than the estimated Idaho birth data and, according to the WSPHL, the reason for the higher count could be due to some of the subsequent screens not having been correctly linked to their initial screens. If a baby had two screens that were not linked, both screens would have their own identification number and would have been counted as two initial screens. To garner a more accurate estimate, the WSPHL filtered down the numbers in which the identification numbers matched, and the collection was less than 144 hours of birth. The Idaho NBS staff will continue to work with WSPHL to refine data collection during 2023 to distinguish between initial metabolic newborn specimens and subsequent metabolic newborn specimens.

 

In FY 2022, NBS staff and the WSPHL epidemiologist worked together in developing “practice profiles” (metabolic newborn screening data specific to a birth facility, midwife, or clinic setting) within the Microsoft Power BI platform and will pilot it with select volunteers in 2023. The Idaho NBS team also completed a laboratory site visit and review of the WSPHL policies and procedures. This effort was a collaboration on the part of both teams and demonstrated commitment to quality improvement towards the common goal of improving the lives of newborns.

 

The Idaho NBS team continued to regularly attend meetings and conferences that had a focus on improving program operations, clinical advancements, and incorporating Recommended Uniform Screening Panel (RUSP) conditions into Idaho’s RUSP. Some of these included: the Idaho Sound Beginnings Advisory Council meetings, the Northwest Regional Newborn Screening meetings, the Association of Public Health Laboratory & the International Society for Neonatal Screening Symposium, the Western States Regional Genetics Network Summit, and the AMCHP Annual Conference.

 

In February 2022, the NBS Program with the assistance of the WSPHL successfully added four new conditions to Idaho’s RUSP: glycogen storage disorder type II (Pompe Disease), mucopolysaccharidosis (MPS-1), X-linked adrenoleukodystrophy (X-ALD), and spinal muscular atrophy (SMA). This was a large undertaking for the program and included large-scale efforts to establish the necessary infrastructure along with communicating the importance of adding the new conditions and the associated fee increase to NBS providers. The NBS Program also developed new diagnostic referral packets for infants who have borderline or abnormal results for the new conditions. NBS Program staff worked with Medicaid staff to identify necessary changes to coverage terms to address diagnosis and treatment for the new conditions. Lastly, the NBS Program implemented a multifaceted approach to communicate news about the four additional conditions and associated fee increase. Idaho NBS staff held a joint virtual training session with the WSPHL on January 19, 2022, and later posted a recording of the training to the DHW website. The NBS Program also issued a press release on January 26, 2022, and conducted a communication campaign that included mailing postcards, faxing FAQ sheets, and emailing announcements to over 900 Idaho newborn screening providers in and around Idaho.

 

During the 2022 legislative session, the NBS Program was invited by Senator Wintrow to attend a Senate Health & Welfare Committee meeting to provide education on the addition of the new conditions along with a parent advocate who had lost an infant to SMA. The NBS Program also participated in other opportunities to provide education on newborn screening and discuss the addition of the four new conditions by presenting at the 2022 Idaho Perinatal Conference and in a quarterly meeting with EMS-C staff. EMS-C staff were educated on what emergency providers should know about the new NBS conditions.

 

During 2022, there were 1,523 metabolic newborn screens that were presumptive positive compared to 777 in 2021. There were 40 confirmed cases compared to 29 confirmed cases in 2021. There were 38 confirmed cases that were referred for treatment compared to 28 in 2021. Of the 40 confirmed cases, two confirmed cases were Pompe Disease and one was SMA, both of which were new conditions added in 2022.

 

The NBS Program has continued to meet on a quarterly basis with the NBS Advisory Group. Participants include Dr. Fleming and Dr. Poskanser, both clinical biochemical geneticists; Dr. Brown, pediatric Cystic Fibrosis (CF) specialist and co-founder of St. Luke’s Health Service’s CF Center of Idaho; Dr. Lundgren, pediatric infectious disease specialist; Dr. Daniel Flynn, a pediatric endocrinologist; Dr. Matt Hansen, a pediatric hematologist-oncologist, and Angela Lindig, Executive Director of the Family-to-Family Center, Idaho Parents Unlimited. The convening of this group was vital in the transition to a new public health laboratory, creation of referral packets, and coordinating follow-up plans and an infrastructure for diagnosis and treatment for the four new conditions added to the Idaho RUSP. The NBS Advisory Group also served as consultants for updates to the Idaho NBS Healthcare Provider Manual and referral packets for the remaining conditions on the Idaho RUSP, all of which were updated in 2022.

 

Historically, the NBS Program has had separate metabolic screening brochures in English and Spanish, and one CCHD brochure only available in English. In 2021, program staff began work to create one booklet to cover both the metabolic newborn screening and CCHD screening in English and Spanish, along with referral information to the newborn hearing screening program, Idaho Sound Beginnings. In 2022, program staff completed this work and the new booklet was published and provided to the WSPHL for distribution in newborn screening specimen card orders. The booklet is also available to order for free by any healthcare provider via the Health Tools website.

 

In FY 2022, the MCH Clinical Coordinator provided training to the Idaho Perinatal Leadership Conference regarding quality improvement for CCHD. The MCH Clinical Coordinator also submits regular secure emails to hospital and birthing center management as well as midwives regarding CCHD errors with technical assistance support. During 2022, 99% of non-NICU or non-transferred Idaho born infants received a CCHD screening. There were 187 reported failed screenings; 144 infants received formal follow-up after a failed screening (echocardiogram, transferred to receive an echocardiogram, discharged with a referral, consult with a pediatric cardiologist/ neonatologist, prenatal diagnosis); 192 screens listed as a pass in error received follow-up by the MCH Clinical Coordinator; and 98 reported CCHD parental declinations/religious objections.

 

COVID-19 Impact on CMV Education Strategies

In FY 2022, with in-person events slowly returning, the MCH Program was able to provide partners with CMV prevention supplies and educational content at conferences and family-focused events. This included legislative outreach in response to a request from Senator VanOrden inquiring about CMV educational materials. The MCH Program provided an educational packet that included educational brochures, posters, and prevention supplies.

 

The MCH Program, with input from the CMV Work Group, ran a successful 12-month CMV poster campaign with Valley Regional Transit (VRT). VRT serves the Treasure Valley and is the main provider of mass transit services in Ada and Canyon counties, which are highly populated counties in Idaho. The posters were on display inside VRT buses for one year and provided tips for reducing the risk of CMV infection for pregnant women as well as a QR code and link to the DHW CMV webpage. Additionally, the MCH Program continued to promote CMV Awareness Month through posts on DHW Facebook and Instagram social media pages. The posts provided CMV prevention messaging with a call to action to visit the MCH Program’s CMV webpage for additional tips on prevention and resources.

 

Child Fatality Review Team

The Idaho Child Fatality Review Team (CFRT) was formed by the Governor’s Task Force for Children At-Risk, under an Executive Order, to review deaths to children under the age of 18 using a comprehensive and multidisciplinary process. The CFRT utilizes information gathered by coroners, law enforcement, medical personnel, and state government agencies in their reviews. The CFRT is tasked with identifying opportunities for increased awareness and education about sleep-related deaths. Cristi Litzsinger, Chief of the Bureau of Clinical and Preventive Services (BOCAPS), serves as the Division of Public Health’s representative on the CFRT.

 

The most recent annual report available includes findings and recommendations based on 85 full reviews of a total of 187 child deaths in 2019. Deaths that were not selected for full review included most deaths due to congenital anomalies, malignancies or other diagnosed medical conditions. The majority of deaths the CFRT reviewed were due to unintentional injuries. There were 10 deaths categorized as unexplained infant death, which included Sudden Unexpected Infant Death (SUID). Unsafe sleep environments, co-sleeping, smoking and/or vaping during pregnancy and/or in the home, lack of vaccinations, lack of breastfeeding, and improper swaddling were common risk factors.  The CFRT recommended continued promotion of the American Academy of Pediatrics safe sleep guidelines, scheduled immunizations, and breastfeeding to help prevent SUID deaths. An additional recommendation was to increase understanding of intergenerational maltreatment and continued investment in parent and childcare education. The CFRT found that many SUID deaths occurred in families with a history of Child Protective Services referrals and/or parents who had suffered adverse childhood experiences (ACEs). The MCH Program’s safe sleep awareness month campaign and collaboration to supply MIECHV with cribs were highlighted in the CFRT report under “Recent Actions and Collaborative Efforts.”