Massachusetts has two priorities for Perinatal and Infant Health for 2015-2020.

1. Improve environments, systems, and policies to promote healthy weight, nutrition, and active living.
2. Promote safe, stable, nurturing environments to reduce violence and the risk of injury.             

 

Priority: Improve environments, systems, and policies to promote healthy weight, nutrition, and active living.

Progress towards this priority is measured by a) the percent of infants who are ever breastfed and b) the percent of infants breastfed exclusively through six months. Key programs addressing this measure include WIC, Early Intervention Parenting Partnerships Program, Maternal, Infant and Early Childhood Home Visiting Initiative, Welcome Family, Perinatal Neonatal Quality Improvement Network, Early Intervention, and Pregnancy Risk Assessment Monitoring System.

 

NPM 4: A) Percent of infants who are ever breastfed and B) Percent of infants breastfed exclusively through six months

In FY18, Massachusetts Title V implemented programming designed to increase breastfeeding rates—a behavior linked to healthy weights in children. The state demonstrated strong performance in breastfeeding related to its NPM projections, national prevalence, and Healthy People 2020 goals. According to the most recent CDC Breastfeeding Report Card (reflecting 2015 births), 87.4% (±5.7) of Massachusetts infants were ever breastfed, exceeding both the national prevalence of 83.2% (±1.0) and the Healthy People (HP) 2020 goal of 81.9%. In Massachusetts, 55.6% of infants were reported as breastfeeding (in any amount) at six months. While this is statistically comparable to the national prevalence of 57.6% (±1.4), it fell short of the HP2020 goal of 60.6%. However, 26.6% (±6.4) of Massachusetts infants were breastfed exclusively through six months, exceeding both the HP2020 goal and the 2020 objective for this NPM.

 

Although overall rates of breastfeeding initiation, duration, and exclusivity in Massachusetts are high, there are disparities by race/ethnicity and socioeconomic status (SES). PRAMS 2017 data show that by eight weeks postpartum, the proportion of mothers reporting any breastfeeding was 64.8% for Hispanic mothers, 72.4% for White mothers and 73.1% for Black non-Hispanic mothers, compared to 87.4% for Asian non-Hispanic mothers. Mothers with lower SES were also less likely to breastfeed at eight weeks; among mothers with Medicaid, 60.4% breastfed for eight weeks, compared to 80.1% with private insurance, and among mothers ≤100% FPL vs >100%, rates were 58.2% and 76.5% respectively.

 

There are currently 19 Baby Friendly hospitals and approximately four more hospitals on the Baby Friendly pathway. In 2018 Beth Israel Deaconess-Plymouth, Anna Jacques and

St. Luke’s Hospitals became Baby Friendly, and in 2019 Brigham and Women’s, Charlton Memorial, Norwood, and Saint Vincent Hospitals received the designation. Medical providers continue to access and complete “Expanding Clinicians' Roles in Breastfeeding Support,” the online tutorials which meet the three CME training requirement for physicians as part of the Baby Friendly pathway. From 2016-2018 18,450 certificates were issued to providers.  

 

WIC

The average rate of breastfeeding at six months post-delivery among Massachusetts WIC participants in FY18 was 31.2% (WIC program data), a modest increase from the 2017 rate of 29.9%. However, these rates fall short of the HP2020 goal of 60.6% and are substantially lower than the overall Massachusetts rate of 55.6% (see above for MA-NIS rates). In Massachusetts, the rates of breastfeeding duration and exclusivity among WIC participants are significantly lower compared to overall breastfeeding rates. WIC data from FY18 show that only 14.0% of WIC participants exclusively breastfed for three months and only 10.9% exclusively breastfed for six months. Breastfeeding duration at three months is a key performance metric for both state and local WIC agencies. WIC is increasing its capacity to analyze its breastfeeding data by race and ethnicity to inform program activities.

 

In FY18, WIC offered breastfeeding education and support to all enrolled pregnant and breastfeeding women. Breastfeeding Peer Counselors were available in all 31 WIC programs, with more than 75 peer counselors statewide. Phone, text, in-person consultation, and group support were offered to women both prenatally and postpartum to promote longer breastfeeding duration; more than 10,000 contacts with mothers were made per month. WIC continues to offer Breastfeeding Basics training, advanced breastfeeding in-services, Certified Lactation Counselor training, as well as online study modules through Lactation Education Resources to WIC nutrition staff, WIC Peer Counselors, and community partner programs. The “Secrets of Baby Behavior” training continued to help parents understand infant communication and avoid unnecessary formula supplementation. 

 

Since FY16, WIC has examined data on its Breastfeeding Peer Counselors Program (BPCP), an evidence-based strategy to promote breastfeeding initiation, exclusivity and longevity. The evidence-based strategy measure (ESM) for this NPM is the percentage of eligible WIC participants who receive counseling services from a Breastfeeding Peer Counselor. This ESM is supported by the findings of Chapman and Perez-Escamilla (2012) which found that peer counseling interventions greatly improved breastfeeding initiation, duration and exclusivity.[1] Chapman et al. (2010) also found that breastfeeding incidence increased significantly more among mothers attending WIC clinics offering breastfeeding peer counselors.[2]

 

Participants eligible for BPCP services included pregnant women who indicated they plan to breastfeed at least partially or were unsure of their breastfeeding intention, and women who were already breastfeeding. In 2018, 63.4% of eligible WIC participants who gave birth to singletons received BPCP services, a substantial increase from 53.4% in 2017. Both ongoing consultation with WIC staff about the importance of peer counseling, and improvements in documentation of peer counseling services are likely responsible for the increase in BPCP services reported. A continuing challenge to increasing the number of peer counselors is that the BPCP counselor exam is available only in English. This limitation makes it challenging for some peer counselors to pass the examination, resulting in less support for non-English speaking WIC mothers. While eligible Spanish-speaking, Portuguese-speaking, and English-speaking mothers had similar percentages of having at least one BPCP contact (66.4%, 64.1%, and 67.5% respectively), only 57.9% of mothers who spoke another language had at least one BPCP contact (p-value<0.001), suggesting that language may be a deterrent for some mothers to receive BPCP services. While Black and White mothers were equally likely to receive at least one BPCP service (66.3% vs. 67.0% respectively), Asian mothers were significantly less likely to receive BPCP services (50.6%). Asian mothers were also less likely to exclusively breastfeed at all compared to White mothers (21.8% vs. 31.1%), but were as likely to breastfeed at three and six months (25.5% vs. 26.8%; 10.0% vs. 9.9% respectively). After adjusting for race, Hispanic ethnicity and language, women with a recorded BPCP service had greater than 40% increased odds of initiating breastfeeding compared to women “eligible” for BPCP but without a service recorded (adjusted odds ratio [aOR]=1,43 [95% confidence interval (CI) 1.31-1.57]).

 

In measures of breastfeeding duration and exclusivity among women who delivered singletons in 2018, women with a BPCP service had a 37% increased odds of breastfeeding for six weeks (aOR= 1.37 [95% CI 1.29-1.45]), a 55% increased odds of exclusive breastfeeding for six weeks (aOR=1.55 [95% CI 1.43-1.69]), a 30% increased odds of any breastfeeding for 12 weeks (aOR=1.30 [95% CI 1.22-1.39]) and a 45% increased odds for exclusive breastfeeding for 12 weeks (aOR=1.45 [95% CI 1.31-1.59]), compared to women eligible for BPCP but without a BPCP service recorded. Improving utilization and documentation of BPCP services remains a WIC priority. Training of WIC staff on the importance of referral and documentation of BPCP services is ongoing. WIC has increased its capacity to analyze BPCP data and will examine the relationship of type (e.g., text, prenatal group, in-person one-on-one) and frequency of Breastfeeding Peer Counselor’s contacts with mother on rates of breastfeeding.

 

In addition to its BPCP, local WIC agencies offered Happiest Baby on the Block services, providing WIC families with classes that teach parents methods to calm their fussy babies without overfeeding. The WIC Learning Center continued to offer Baby Behavior training to help parents communicate better with their infants in an effort to improve breastfeeding rates and better interpret signs of hunger.

 

Early Intervention Parenting Partnerships Program (EIPP)

Exclusive breastfeeding is a key topic of discussion, education, support and referral in EIPP. Home visitors collect data on breastfeeding at birth, two, four, and eight weeks, and at six months. There were 321 families enrolled in EIPP in FY18, of which 68.2% breastfed their infant at birth. Of these mothers, 48.1% exclusively breastfed, and 17.8% continued to breastfeed their infant at six months postpartum, with 11.83% of those exclusively breastfeeding. Among the 321 EIPP participants, 62 were referred to WIC services, 43 were referred to lactation support, and 22 were referred to breastfeeding support groups. Key barriers to exclusive breastfeeding include personal reasons (30.5%), medical reasons (24.4%) and not producing enough breast milk (13.4%).

 

EIPP staff continue to work with Fallon and Neighborhood Health Plan insurers to access free breast pumps for EIPP participants as well as free breastfeeding classes from Tufts and Neighborhood Health Plan insurers. EIPP staff also collaborate with community WIC programs, OB/GYNs, lactation consultants, and pediatricians to promote breastfeeding during the first six months after birth. Strategies include support groups, individual lactation support, and increased home visits during the first few weeks postpartum. EIPP sites bill MDPH directly for lactation consultation services for EIPP participants.

 

Welcome Family

Welcome Family nurses are all certified lactation consultants. They offer breastfeeding support to new mothers through education, brief intervention, and referrals to ongoing services as needed, such as to a lactation consultant or breastfeeding support groups to improve duration rates. Among the 1,946 families served through Welcome Family in FY18, 72% breastfed their infants all or some of the time at the time of assessment, which occurs between two and eight weeks postpartum. This is an increase from 70% in FY17. For participants who reported that they breastfeed their infants ‘some of the time’ or ‘none of the time,’ the primary reasons for not exclusively breastfeeding included the mother’s belief that she does not have enough milk (36%), personal reasons (17%), and the baby self-weaned (12%).

 

After the home visit, participants are invited to complete an online survey to share their experience and satisfaction with the program. Families commonly cited the breastfeeding support they received as what they liked most about the visit:

“It was so helpful to have a lactation consultant come right when my milk was coming in, to help us figure out strategies to successfully breastfeed.”

 

“My nurse taught me how to properly establish a latch during breastfeeding. I was in so much pain before unknowingly doing it incorrectly. This was so helpful because I almost wanted to give in to formula.”

 

MA MIECHV

During federal FY18, MA MIECHV home visitors provided education, brief intervention, and referrals to improve breastfeeding initiation and duration rates. Through the efforts of MA MIECHV home visitors, 19% of infants (among mothers who enrolled in MA MIECHV prenatally) were breastfed any amount at six months. During FY18 MA MIECHV home visitors were required to receive training on nutrition and breastfeeding.

 

Massachusetts Perinatal Neonatal Quality Improvement Network  

The Massachusetts Perinatal Neonatal Quality Improvement Network (PNQIN), an umbrella collaborative that unites the efforts of the MA Neonatal Quality Improvement Collaborative (NeoQIC) and the MA Perinatal Quality Collaborative (MPQC), is committed to improving breastfeeding among high risk infants including very low birth weight (VLBW) infants, infants with neonatal abstinence syndrome (NAS) and substance exposed newborns (SEN). MDPH received funding from CDC to support PNQIN’s work, which is overseen by BFHN’s Office of Data Translation Director (who is also the SSDI Director). The goal of the grant is to apply a quality improvement (QI) approach to make measurable improvements in the care and outcomes of women affected by perinatal opioid use and SEN, using a life course approach.

 

One of the primary objectives of this project is to increase family engagement and partnership in the care of newborns at risk of NAS, measured primarily by the percentage of SENs receiving their mother’s own milk (MOM) at the time of hospital discharge. Audit data from the previous NAS collaborative suggests the rate of breastfeeding at discharge for infants with NAS (defined at the time as requiring pharmacologic therapy) at Massachusetts hospitals increased from 17% to 30% from 2012 to 2015. In 2017, we began to monitor rates of breast milk use for all opioid-exposed newborns (OENs) at risk for NAS. Among Massachusetts hospitals participating in PNQIN, approximately 54% of OENs received any mother’s milk during hospitalization and approximately 43% received mother’s milk at the time of discharge. Among OENs eligible to receive their mother’s milk by hospital policy, approximately 78% received mother’s milk at any time during hospitalization, and 64% received mother’s milk at discharge. These rates did not change significantly from 2017 to 2018.

 

In addition, in 2017 PNQIN began monitoring the percent of OENs who require pharmacologic therapy. Between January 2017 and December 2018 the percent of OENs requiring pharmacologic therapy declined from 64% to 19%. There is a growing interest in “Eat-Sleep-Console (ESC) as an approach to caring for infants at risk for NAS built around rooming in and non-pharmacologic care and an alternative symptom assessment care. ESC was pioneered at Yale and first adopted in Massachusetts by Boston Medical Center. Both Yale and BMC have published on their dramatic results related to pharmacologic therapy and length of stay. Dr. Elisha Wachman and colleagues at BMC, Yale and Dartmouth have developed a robust training toolkit with manuals and videos that are all online at https://www.neoqicma.org/eat-sleep-console. PNQIN has organized an ESC roll-out with training webinars and workshops. Over 30 hospitals are participating in the roll out and 10 have already adopted ESC. A total of 137 infants were scored with ESC during 2018-2019.

 

PNQIN and MDPH use birth hospitalization as an opportunity to engage and partner with families with SEN, OEN and NAS in the care of their newborn and to assure adequate connections with community based supports and outpatient providers. Breastfeeding can reduce the need for pharmacologic treatment in infants with OEN and NAS, and also appears to reduce maternal stress, maternal smoking and addiction behaviors, and improve mother-infant bonding and infant safe sleep practices. Increasing the percentage of SEN receiving MOM at discharge requires successful family partnership at numerous stages of care, including appropriate prenatal maternal treatment, adequate family education, and family engagement throughout the newborn hospitalization. The role of PNQIN in addressing the opioid crisis among pregnant and parenting women is further discussed in the Women’s/Maternal Health Domain.

 

As part of an initiative to increase the use of breast milk among VLBW infants, with all 10 level III NICUs in Massachusetts participating, PNQIN led a QI effort, conducting Plan, Do, Study, Act cycles to improve breast milk feeding for VLBW infants. Metrics used to monitor the success of these efforts included percentage of prenatal consultations promoting benefits of breast milk; time to first pump/hand expression; any breast milk fed to infant during hospitalization; and any breast milk given in the 24 hours prior to infant discharge/transfer. Family education materials focused on breastfeeding were created, with input from families, International Board Certified Lactation Consultants, nurses, and physicians, to support preterm infants in the NICU. The materials have been well-received by families and providers during the pilot testing.

 

With support from the Kellogg Foundation, PNQIN developed five videos in English and five videos in Spanish that are each one to three minutes long and address key breastfeeding support topics. The videos portray the perspectives of NICU families and are both educational and motivational. The videos are designed to be easily viewed on a phone or tablet directly at the bedside. PNQIN also developed four educational handouts on key breastfeeding support topics. To ensure that the materials are useful for as many families as possible, they are written at a 6th grade reading level and have been translated into nine languages. Materials were translated and back translated to ensure accuracy of all messages. These are available at www.neoqicma.org.

 

PNQIN observed improvements in key process measures from FY15 to FY18. For example, prenatal human milk education increased from 57.6% to 76.6%, first milk expression within six hours of delivery increased from 36.6% to 57.1%, and any skin-to-skin care in the first month increased from 31.2% to 39.0%. However, the measure of any or exclusive mother’s milk at discharge or transfer remained at 63.7%.

 

Additional activities to improve environments, systems, and policies to promote healthy weight, nutrition, and active living

Women who enter pregnancy overweight or obese and women with excessive pregnancy weight gain are more likely to have a Cesarean delivery and to develop gestational diabetes, hypertension, and preeclampsia compared to women with normal BMI and recommended weight gain. Infants of women who are overweight or obese, gain excessive amounts during pregnancy, or have diabetes are more likely to be born large for gestational age and may be more likely to develop obesity in childhood. Women who gain insufficient weight during pregnancy or who start pregnancy underweight are at risk for preterm birth, having a small for gestational age infant, and requiring Cesarean delivery. WIC and School Health Services play a significant role in efforts to address this priority.

 

WIC

WIC plays an important role in helping families achieve positive nutritional habits and healthy weights. All WIC participants receive anthropometric assessment and dietary assessment and counseling. Healthy childhood weight status was a metric for the WIC Performance Management system. Local programs had the opportunity to select this metric as a focus for a QI project and received quarterly data updates to track their progress. The 2018 state average for WIC children aged one to five years at a healthy weight (neither at risk for/underweight or overweight/obese) was 70.7%, slightly higher than the baseline of 70.6% for the previous year. Prenatal weight gain, a variable believed to affect the weight status of infants and children, was also monitored through the Performance Management system. Physical activity was discussed during WIC nutrition counseling and through the WICSmart online nutrition education system for participants.

 

The WIC program continued to offer the WIC food package containing whole grains, low-fat dairy, and fruits and vegetables to children. The Farmers’ Market Nutrition Program coupon program had another successful season, with more than 43,900 WIC participants receiving $20 in Farmers’ Market coupons at local program distribution days. WIC also offered cooking classes and shopping tours for WIC parents in several local programs across the state. The Good Food Project, a related initiative funded by USDA, concluded its pilot phase at six WIC programs. The project’s programming around healthy cooking and shopping was shown to significantly improve WIC food utilization and retain more preschool children in WIC. The Good Food Project was subsequently rolled out to 12 additional programs. In the summer of 2018, three local WIC programs partnered with local Summer Food sponsors and became distribution sites of more than 1,000 summer meals to participants, their families, and other children in the community.

 

School Health Services

BMI screenings are conducted in grades 1, 4, 7, and 10 in all public schools. In the 2017-18 school year, 82% of students in those grades were screened. Preliminary data revealed that 32.6% of students in those four grades were either overweight or obese (15.8% were overweight and 16.8% were obese). There were considerable disparities, however, with a higher prevalence of overweight and obesity in lower income school districts, and the lower the income level, the greater overweight and obesity prevalence.

 

Priority: Promote safe, stable, nurturing environments to reduce violence and the risk of injury.

Progress towards this priority is measured by the percent of infants placed to sleep on their backs. Key MDPH programs addressing this measure include the Injury Prevention and Control Program, Child Fatality Review, the Perinatal Neonatal Quality Improvement Network (PNQIN), Welcome Family, the Massachusetts Maternal Infant and Early Childhood Home Visiting Program, WIC, Early Intervention Parenting Partnerships Program, Early Intervention, and the Center for Unexpected Infant and Child Death.

 

NPM 5: A) Percent of infants placed to sleep on their backs, B) Percent of infants placed to sleep on a separate approved sleep surface, and C) Percent of infants placed to sleep without soft objects or loose bedding

According to MA PRAMS data, 83.7% of infants were placed supine to sleep in 2017, demonstrating a modest improvement since 2011 (79.6%), but a slight decrease from 2016 (86.3%). Disparities in this indicator persist when examined by race and ethnicity, with 91.0% of White infants placed supine to sleep in 2017 compared with 66.0% of Black infants and 73.1% of Hispanic infants.

 

NPM 5B and NPM 5C were new performance measures in FY17. Baseline data from MA PRAMS 2017 show that 32.3% of infants were placed to sleep on a separate approved sleep surface and 55.3% were placed to sleep without soft objects or loose bedding. MDPH projects modest improvements to 33.5% and 56.0%, respectively, by 2020.

Sudden unexpected infant death (SUID) is described by the American Academy of Pediatrics (AAP) as “any sudden and unexpected death, whether explained or unexplained, including sudden infant death syndrome (SIDS) that occurs during infancy” (Moon 2011). In Massachusetts during 2016, SUID was the leading cause of infant death after the first month of life. From 2014-2016, the three-year rolling average rate of SUID in MA was 44.3/100,000 live births, large disparities exist by race/ethnicity. During the same period, White non-Hispanic infants had a SUID rate of 40.8/100,000 compared to 56.9/100,000 for Hispanic infants and 75.8/100,000 for Black non-Hispanic infants. Factors associated with SUID include unsafe sleep environment, including sleep position, sharing the sleep surface with another person, soft bedding, and having caregivers who smoke and/or use substances. Preterm birth is another risk factor associated with SUID and SIDS; the risk of SIDS is two to three times higher among infants less than 36 weeks gestation compared to infants born between 40-41 weeks. The AAP Task Force on SIDS recommends that preterm infants be placed supine when they reach 32 weeks gestational age, if they are clinically stable. Despite these recommendations, preterm infants are less likely to be placed supine in the hospital and after discharge. A MA QI initiative demonstrated that safe sleep practices can be integrated into the care of preterm infants (see PNQIN section below). It is important to be aware of cultural and linguistic differences regarding infant and family sleep practices, and to support breastfeeding while educating families on the importance of maintaining a separate sleeping environment for the infant. Additional challenges to safe sleep practices include addressing family’s lack of financial resources to establish a safe sleep environment.

The ESM for this NPM was previously the percent of in-state resident births that occur at hospitals that have implemented safe sleep policies. In 2018, 81.3% of infants born in-state to resident mothers were born in birthing facilities that implemented safe sleep policies, reaching Title V’s goal for 2020 (80%), and representing a significant increase from the baseline (66.6% in 2016). However, the biannual survey of birthing hospitals that served as the data source for this ESM will not be continued, and the ESM is therefore changing this year. The new ESM is the “percent of MIECHV and Welcome Family home visiting participants who report always placing their infant to sleep on their backs and in a crib, cradle, or bassinet.” The baseline for this measure (for federal FY18) is 81%, and the goal is to reach 85% by 2020. This ESM is supported by evidence from the Strengthen the Evidence for Maternal and Child Health Programs review of NPM 5 that was completed in February 2017, which found emerging evidence of the effectiveness of caregiver education interventions. Two studies focused on training and education for caregivers and had favorable outcomes.[3],[4]

 

Injury Prevention and Control Program (IPCP)

In FY18 a state-wide interagency safe sleep task force comprised of representatives from MDPH, the Department of Children and Families (DCF), the Executive Office of Health and Human Services, UMass Medical School, and the Office of the Child Advocate met every other week to identify opportunities to improve safe sleep services coordination. Recognizing higher rates of infant mortality among Black infants and families involved in child protective services, the group explored inequities in morbidity based on race/ethnicity, geographic area, and risk and protective factors. For example, data from MA PRAMS pointed to more frequent bed sharing among Black non-Hispanic families as compared to White non-Hispanic families. To address these differences, the task force developed a public education campaign that launched in October 2018, directed at high risk populations, including people in disproportionately affected geographic areas, Black non-Hispanic families, and caregivers who smoke and/or use substances. By the end of this grant reporting period, the group had conducted a literature review, identified geographic priority areas, and established a plan for focus testing the campaign concept to assure cultural competency with mothers and fathers of children under the age of two years. They also established plans to revise the safe sleep website to make it more accessible and provide deeper information about practicing infant safe sleep.

 

The group also strategically assessed agency policies, regulatory requirements, practices, programs, and training to assure a consistent approach and message across agencies that adheres to the 2016 American Association of Pediatrics (AAP) Infant Safe Sleep Policy and addresses the needs of populations at greatest risk for infant death. In March of 2018, the IPCP team at MDPH updated their Safe Sleep Policy assuring readability and alignment with the AAP policy. The MDPH policy was endorsed by the Office of the Child Advocate, and approved by members of the interagency safe sleep task force. By the end of this grant reporting period, the Office of the Child Advocate agreed to conduct an assessment of alignment between state agencies policies, programs, and trainings as they relate to safe sleep. This work is resulting in a unified message about the prevention of SUID, and a collective understanding of how complicated behavior change can be.

 

In FY18, MDPH’s Injury Prevention and Control Program staff trained 40 MDPH program staff and neonatal intensive care unit staff on safe sleep risk and protective factors and practices.

 

The MDPH Child Fatality Review (CFR) epidemiologist also continued to work collaboratively with the Office of the Chief Medical Examiner (OCME) to abstract data from OCME files to create a SUID database. The purpose of the SUID database is to examine the circumstances of SUID cases across the state and to inform prevention efforts. The data abstraction protocol was formalized in May 2018, and results from that project were presented at the November 2018 state CFR meeting.

 

Child Fatality Review (CFR)

With the onboarding of a new IPCP manager who became co-Chair of the State CFRCFR Team in January 2018, and a new Chair of the State CFR Team at the OCME, much strategic planning and reorganization of the CFR program occurred in FY18. The year began with the release of results from the Office of the Child Advocate’s Local Teams needs assessment in July 2017, and a second State Team assessment in spring 2018. Based on the findings from that report, the IPCP team revised the local team guidelines to provide clarity on case selection, protocols, and expectations. They also established state team guidelines for the first time. The draft guidelines were released to the state team in July 2018. During that time, IPCP also identified a consistent point of contact to attend all local team meetings, updated the case and recommendation reporting forms, and planned for communication and state team work flow improvement. Local CFR teams continued to collect and review information on fatalities of children aged less than 18 years. Based on these reviews, local teams submited recommendations for change in policies and practices. The results from this work so far are more active and engaged local teams, deeper understading of expectations of local and state team members, and improved, actionable recommendations.

 

Massachusetts Perinatal Neonatal Quality Improvement Network (PNQIN)

Title V staff continued leading, in collaboration with the NeoQIC, the NICU Safe Sleep Improvement Project, a structured quality improvement initiative aimed at increasing safe sleep practices among high risk infants discharged from Massachusetts NICUs. As most SUID deaths are due to unsafe infant sleep environment and positioning, birthing hospitals play a unique role in preventing these deaths by modeling safe practices and educating parents and caregivers. Incorporating safe sleep practices into the routine clinical care of preterm infants while in the NICU may increase awareness about the risk of SUID among both providers and parents, and effectively engage parents in safe infant sleep practices prior to and at the time of discharge. Through this Initiative, MDPH partnered with Level III NICUs to train staff about safe sleep practices, developed a model safe sleep policy for the NICU, and facilitated the expansion of safe sleep practices to the Newborn and Special Care Nurseries in Level I and Level II hospitals.

 

In FY18 the initiative included all 10 NICUs in the state and seven level II special care nurseries, with additional nurseries developing plans to join. Compliance data on safe sleep practices in the NICU were collected using audit forms. From its launch in 2015 through FY2018, overall compliance with safe sleep practices increased substantially from 55.5% to 88.2%. Although overall compliance with all components of safe sleep practices ranged from 76.6% in FY18 Q1, to 88.2% in FY18 Q4, individual components of safe sleep ranged from 95.8%-98.3% for flat position, 82.5%-91.0% for sleep space empty of dolls and fluffy blankets/animals, 93.5%-96.0% for sleep space free of positioning devices and 90.6%-95.6% for supine position. These data were shared among participating hospitals through NeoQIC and PNQIN meetings (discussed below).

 

Measuring adherence to safe sleep practices by parents after hospital discharge has been challenging since most units do not have a post-discharge follow-up system in place. Establishing an initiative that monitored post-discharge safe sleep adherence in the home was a goal of the project during FY18-FY19 (see Welcome Family below). Through Redcap, NeoQIC began collecting data from participating hospitals on post-discharge safe sleep practices in the home. These data will be presented at the next Safe Sleep Forum in FY20.

 

Certain newborn populations in the NICU posed challenges to adhering to safe sleep practices, namely infants with NAS, severe reflux, and those requiring positioning devices for medical conditions. The collaborative developed guidelines for initiating safe sleep practices for these more complex infants so that uniform recommendations are adhered to by all participating units. Although overall compliance with safe sleep practices improved, particular components of safe sleep such as removal of unsafe objects like blankets, burp clothes, and dolls were more difficult to improve for these infants. During NeoQIC and PNQIN meetings, hospital safe sleep teams discussed effective interventions to remove these unsafe items from cribs.

 

Welcome Family

Home visitors play a key role in increasing parental knowledge about creating a safe home environment, including a safe infant sleep environment. At the Welcome Family home visit, nurses collect data on the percent of participants who report placing their infant to sleep supine and the percent who report placing their infant to sleep in a crib, cradle, or bassinet. In FY18, Welcome Family served nearly 2,000 families. A majority of participants reported engaging in safe sleep practices – at assessment, 97% of participants laid their infant to sleep on their back, and 96% put their infant to sleep in a crib.

 

In FY18 Welcome Family continued its collaboration with birth hospitals in two Welcome Family communities – Lowell and Boston – to track safe sleep practices for infants discharged from the NICU or special care nursery (SCN). NICUs/SCNs across the state have been implementing continuous quality improvement projects to model safe sleep practices and provide discharge education to parents. However, it has been challenging to follow up with parents about sleep practices after the infant is discharged. Collaboration between the NICUs and Welcome Family affords an opportunity to share aggregate data on safe sleep practices for infants referred to Welcome Family from the NICUs back with the hospitals. From August 2017-August 2018, families discharged from Lowell General Hospital demonstrated high rates of safe sleep position and location. At the time of the Welcome Family home visit, 97% of mothers referred from the SCN reported that they most often lay their baby down to sleep on their back, compared to 99% non-SCN referrals, and 99% of mothers referred from the SCN reported that their baby usually sleeps in a crib, cradle or bassinet, compared to 97% non-SCN referrals. Boston Medical Center and Tufts Medical Center have not referred enough infants to Welcome Family to allow sharing of their safe sleep data. MDPH convened a learning network to include NICU/SCN staff and the local Welcome Family agencies to discuss ongoing successes and challenges with referring families to the program and sharing data with the hospitals.

 

To further support this collaboration, MDPH revised the Welcome Family Assessment Tool to add a question regarding education received about safe sleep practices before the baby was born, during the hospital stay, and/or after the baby came home. These data will be included in the reports shared with the hospitals.

 

MA MIECHV

MA MIECHV home visitors play an important role in improving newborn health and reducing child injuries. Home visitors receive training on safe sleep messaging as part of comprehensive injury prevention training and discuss recommended safe sleep practices and other injury prevention topics with participants at developmentally appropriate times. During FY18, MA MIECHV continued collecting data on safe sleep practices by documenting responses to the following three questions: 1) Do you always place your child to sleep on his/her back? (yes/no); 2) Do you always place your child to sleep without bed sharing? (yes/no); and 3) Do you always place your child to sleep without soft bedding? (yes/no). The MIECHV performance measure assesses the percent of infants aged less than one year enrolled in home visiting who are always placed to sleep on their backs, without bed-sharing or soft bedding. During FY18, 41.8% of MA MIECHV infants met this performance measure, increased from 33% in FY17. This result is known to be an underestimate due to incomplete reporting.

 

WIC

According to 2017 data, PRAMS respondents who were also WIC recipients were less likely to lay their infant down supine compared with non-WIC respondents (73.3% vs 89.1%, respectively). For WIC, this is a slight, but not statistically significant, decrease from 2016 when 75.8% of WIC participants reported supine infant sleep positioning. In FY18, WIC provided direct services and information on safe sleep position and location to more than 40% of all infants born in Massachusetts, including Black and Hispanic infants who are less likely than White infants to be placed to sleep on their backs.

 

All new WIC staff received safe sleep training as part of their orientation. Competency reviews of WIC staff’s safe sleep knowledge verified staff knowledge and understanding of the material to successfully educate parents. The Coordination Unit collaborated with the Injury Prevention and Control Program to share timely child safety messages and product recalls with local WIC programs and through WIC’s social media channels.

 

In FY18, in partnership with Tufts Medical Center, the WIC Nutrition Education Specialist represented BFHN on the National Action Partnership to Promote Safe Sleep Improvement and Innovation Network (NAPPSS-IIN). The Massachusetts Breastfeeding Coordinator also participated in this effort. NAPPSS-IIN is a National Institute for Children’s Health Quality (NICHQ) initiative beginning in 2018 that aims to make infant safe sleep and breastfeeding the national norm. It aligns 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. Massachusetts was one of five participating states.

Early Intervention Parenting Partnerships Program

Families served through EIPP receive health education, brief intervention and counseling appropriate to the families’ needs and based on a comprehensive health assessment completed by the end of the second face-to-face contact with the EIPP participant. Key educational topics included safe sleep practices. In FY18, 95.3% of the 321 EIPP participants were taught safe sleep practices.

 

Early Intervention (EI)

In FY18 Massachusetts Early Intervention served 50,788 children, of which 41,076 were enrolled with IFSPs. This demonstrates significant capacity to connect with families to reinforce safe sleep practices. EI partnered with IPCP to provide consistent safe sleep messaging and provided strategies for parents to enhance the caregiver-infant relationship and to support engagement with their infant socially during awake times. EI staff participated in MDPH safe sleep activities to ensure that updates and/or revisions to current messaging was communicated with the EI community.

 

Center for Unexpected Infant and Child Death

The Massachusetts Center for Unexpected Infant and Child Death provides individualized and compassionate bereavement support to individuals, families and communities of infants and young children (0-3) who die suddenly and unexpectedly. Current federal and statewide data indicate that SUID continues to be a leading cause of death among Massachusetts-born infants. The Center recognizes that many of these deaths are associated with at least one of the following risk factors for SUID: non-supine sleep position, compromised sleep environment, or non-recommended sleep location.

In FY18, the Center provided direct support to 19 families whose infants and young children under the age of three died suddenly and unexpectedly. In addition, the Center provided training and consultation to the Boston Public Health Commission, as well as to a wide network of licensed, community-based health care professionals from many disciplines including medical doctors, nurse practitioners, registered nurses, and social workers. The Center also initiated a robust training partnership with the Massachusetts DCF, and has conducted sessions at Boston, Central, and Western region Area Offices, with plans for expansion in FY19. The Center participated in all statewide and county-based child fatality review team meetings. In honor of October’s National SIDS awareness month, the Center participated in the official launch of the new statewide campaign for the prevention of SUID at the Massachusetts State House on October 23rd. The Center also facilitated its Annual Walk to Remember to support families who have been affected by infant, child and prenatal loss. This free public event brought together families, friends, professionals and communities to increase awareness of this important cause and provide a meaningful way to honor children’s lives.

 

Additional activities to improve Perinatal/Infant Health

Other MDPH activities to improve perinatal/infant health not specific to the performance measures are discussed below.

 

Birth Defects Monitoring Program (BDMP)

BDMP ascertains major, structural birth defects diagnosed in Massachusetts residents up to age one. Excellent data quality (i.e., completeness, timeliness and accuracy) are hallmarks of the Massachusetts program. It has met the highest data quality standards of the National Birth Defects Prevention Network (NBDPN) consistently since 2015 (it missed meeting the timeliness standard only in the first year of assessment, 2014, considered a transition year). Prenatal reporting, which began with 2011 pregnancies, has been integrated into the BDMP database and has enhanced the multi-source approach of BDMP and improved the accuracy and completeness of case ascertainment substantially. As a result, the Massachusetts birth defects prevalence rates are now similar to national estimates. Prenatal reporting also serves as a valuable tool for surveillance for emerging threats to pregnant women, as during the recent Zika virus epidemic in which prenatal reporting helped in the rapid and complete identification of Zika-associated birth defect cases.

 

In 2018, the Massachusetts Center for Birth Defects Research and Prevention (The Center) was awarded the NBDPN State Leadership Award, recognizing its contributions in data collection, surveillance methods, quality improvement, leadership commitments, and data dissemination and research. The Center was lauded as one of the best birth defect surveillance systems in the country and was especially acknowledged for its quick and effective response to gathering timely information in response to the Zika virus epidemic.

 

BDMP data are currently available through 2016 and are integrated into other data systems to increase utility and public health value of those systems. The systems include the Pregnancy to Early Life Longitudinal data system, Environmental Public Health Tracking state and national portals, and MDPH’s Public Health Information Tool. The Center also shares lessons learned through data calls by NBDPN member states, and through the Zika virus public health emergency response, which includes steps to aid Zika-affected families that have relocated primarily from Puerto Rico in the aftermath of Hurricane Maria (see below).

 

As one of seven CDC-funded sites to carry out the Birth Defects Study to Evaluate Pregnancy Exposures (BD-STEPS), Massachusetts actively participates in the design and implementation of BD-STEPS protocol and related activities, provides advanced training and mentorship to prepare junior investigators for careers in birth defects research, pediatric and perinatal epidemiology, and performs etiologic research studies into modifiable risk factors for specific birth defects.

 

In 2018, the Center competitively applied for and was awarded BD-STEPS II to continue its work and contributions for both the “core” part of the grant as well as the grant’s Stillbirth component, which had only been a pilot component in BD-STEPS I. Stillbirths are a vastly understudied area even within the field of maternal and child health. Massachusetts is one of only two sites awarded the 5-year stillbirth component. 

 

In 2011, the U.S. Secretary of Health and Human Services recommended that screening for Critical Congenital Heart Defects (CCHDs) be added to the Recommended Uniform Screening Panel for newborns. In Massachusetts, BDMP in partnership with the Bureau of Health Care Quality and Safety led the efforts to implement this screening in birth hospitals across the state. In 2012 BDMP conducted surveys and established a CCHD Advisory Group and collected data from the hospitals. In 2014 BDMP published a paper in the journal Pediatrics on timing of diagnosis (timely vs. delayed) of CCHD cases in Massachusetts pre-recommendation and is currently preparing a follow-up paper to be published in 2019 analyzing data post-recommendation. Since March 2014, Massachusetts has required hospitals and birth centers to screen for CCHD in newborns prior to discharge. The number of infants screened for CCHD in FY18 has decreased – this is likely an artifact of the reporting being voluntary. See FY20 for plans to address decrease in screening.

 

Zika Response Efforts including Hurricane relocation response

BDMP has continued to respond to the public health threat of Zika virus and birth defects by participating in national and local efforts, most notably the U.S. Zika Pregnancy and Infant Registry (USZPIR) in cooperation with MDPH’s Bureau of Infectious Disease and Laboratory Sciences (BIDLS), and the Zika Birth Defect Surveillance (ZBDS) efforts.

 

BDMP works closely with the BIDLS on the USZPIR – which follows pregnant women and their infants with confirmed or probable laboratory evidence of Zika virus infection – by abstracting their medical records, and by providing expertise on birth defects epidemiology. In FY18, BDMP transmitted data for 339 cases of Zika-associated birth defects to CDC (covering delivery dates from January 1, 2016 – June 30, 2017) as part of ZBDS reporting. Together with data from two other states, BDMP data were used in a CDC publication establishing baseline data for Zika-associated birth defects, which demonstrated that birth defects occurred about 20 times more often in pregnancies with possible Zika virus infection. BDMP staff are co-authors on several more of CDC’s MMWR publications and a JAMA article detailing the effects and epidemiology of the Zika virus outbreak on fetuses and infants.

 

In FY18, the Birth Defects Center successfully pursued and received funding to help with the adjustment of families that relocated after Hurricane Maria primarily from Puerto Rico. In collaboration with the Puerto Rico Zika Active Pregnancy Surveillance System (ZAPSS), BDMP is currently focusing on data sharing to ensure a continuum of surveillance between families registered in ZAPSS and the USZPR, its mainland equivalent.

 

Systems development and quality improvement

On a systems and operations level, BDMP undertook key quality improvement projects refining the efficiency of the surveillance program. As part of the Zika response, BDMP expanded remote access to electronic medical records, allowing for rapid review of medical records first focused on Zika cases, which is now benefitting all case abstraction. Other improvements were made to allow for improved annual case closing activities through the review and continuous improvements to key data reports. The de-duplication of reports and records, central in a multi-source reporting program like BDMP, was addressed in a series of hands-on meetings in FY18 (and continuing in FY19).

 

WIC 

In FY18, WIC collaborated with BDMP to promote birth defects awareness month in January, and to promote through blogs and Twitter feeds the importance of folic acid intake. Additionally, WIC disseminated materials which highlighted the importance of folic acid to local WIC programs. WIC also reviewed the multivitamin use status of every WIC prenatal participant and included folic acid/ folate educational messages to postpartum women exiting WIC in anticipation of a subsequent pregnancy.

 

WIC children also received an immunization assessment at each WIC appointment until the primary series of vaccinations has been completed. Immunization rates remained a key area of monitoring for local WIC agencies. In FY18, 76.5% of all children were verified to have the complete 4-3-1-3 vaccination series by 24 months of age, up from 70.4% in FY17. Collaboration with medical providers regarding immunization data and referrals for immunizations remained priorities for WIC. Massachusetts maintains an Immunization Registry which allows centralization of immunization data, and improves the efficiency by which WIC can assess immunization status and provide appropriate referrals.

 

Massachusetts Pregnancy Risk Assessment Monitoring System (MA PRAMS)

MA PRAMS, administered by MDPH, was selected by HRSA to conduct a Healthy Start Program Evaluation Project with the Boston Healthy Start Initiative, run by the Boston Public Health Commission, and in partnership with Massachusetts Registry of Vital Records and Statistics (RVRS). The National Healthy Start Program was started in 1991 as a presidential initiative to reduce racial and ethnic inequities in infant mortality, improve local health care systems and increase consumer and community voice in health care decisions. Healthy Start targets communities where infant mortality is highest. The evaluation goal is to determine the effects of Healthy Start on changes in participant-level characteristics such as participant behaviors, Healthy Start service utilization and health outcomes. MA PRAMS included Boston Healthy Start participants in its survey sample through linkage of birth data from RVRS with Boston Healthy Start participants who had a live birth in Massachusetts. Data will be used to compare Boston Healthy Start participants with mothers who did not participate in Boston Healthy Start but were also sampled for MA PRAMS. HRSA collected national Healthy Start PRAMS data of mothers who delivered in calendar year 2017 through July 2018.

 

As part of the Boston Healthy Start Initiative evaluation, Healthy Start mothers who delivered in December 2017 were included in the PRAMS oversample in March 2018. MDPH sampled mothers who delivered from December 1, 2017 to July 30, 2018. Boston Healthy Start obtained consent from mothers with an estimated due date through August 30, 2018 because some of them might have delivered in July and would have been included in the last batch. PRAMS drew the last sample (July births) in October 2018 and attempted to contact those mothers by mail and phone through the end of 2018. The MA PRAMS team participated in a Boston Healthy Start program site visit with the CDC PRAMS-Healthy Start Project Coordinator in May 2018 and discussed challenges that the Healthy Start and PRAMS staff faced. These challenges included contacting homeless families (needing an alternative address to receive PRAMS mail survey, i.e. a shelter’s address), low participation among adolescent mothers, and the fears of undocumented women that they would be tracked by immigration services. Boston Healthy Start promoted the importance of the consent/data collection effort to the staff charged with getting consents and assisted them in effective messaging for their clients. Healthy Start translated and printed PRAMS brochures in multiple languages for distribution among participants, and reassured them that their information had not been shared with immigration officials. Data collection for Healthy Start ended in February 2019. CDC PRAMS is working on weighting the data, taking the sample design into account and will release a dataset when ready.

 

MDPH also applied for three supplemental PRAMS grants in August 2018 and was awarded funding for the opioid supplement, the opioid call-back survey, and the disability supplement (see FY20).

 

 

 

[1] http://dx.doi.org/10.3945/an.111.001016

[2] http://dx.doi.org/10.1177/0890334410369481

[3] Goetter M, Stepans M. First-time mothers' selection of infant supine sleep positioning. Journal of perinatal education. 2005;14(4):16-23.

[4] Moon RY, Oden RP, Grady KC. Back to Sleep: an educational intervention with women, infants, and children program clients. Pediatrics. 2004;113(3 Pt 1):542-547.