In this section, Nebraska MCH Title V reports on the accomplishments and activities in the Perinatal-Infant Health Domain for the period October 1, 2022, to September 30, 2023. This represents the third year of activity in the Title V needs assessment cycle. The numerical sequence of headings used to organize the narrative below correspond to the narrative guidance for the Annual Report year as found on page 42 of the Title V Maternal and Child Health Services Block Grant to States Program: Guidance and Forms for the Title V Application/Annual Report, OMB Number 0915-0172, Expiration Date 1/31/2024.

From the 2020 Needs Assessment, the Nebraska Priorities selected in the Perinatal Infant Health Domain for 2022-2023, with NPM, SPM, and ESM statements for the period are as follows:

Priority: Premature Birth

SPM: The percent of preterm births

ESM: None

Priority: Infant Safe Sleep

NPM: A) the percent of infants placed to sleep on their back; B) Percent of infants placed to sleep on a separate approved sleep surface; C) Percent of infants placed to sleep without soft objects or loose bedding

ESM: The percentage of clinics receiving outreach that become Champions of the "Nebraska Safe Babies Campaign"

1. Context: The State of the Perinatal-Infant Population Domain

In the priority area of Preterm Birth, stakeholders identified prematurity in the population as a problem that is increasing and characterized by significant disparities among income and racial/ethnic groups. Stakeholders emphasized the influence of social determinants of health (SDOH) on prematurity and encouraged Title V to consider opportunities to address SDOH in addition to interventions in clinical settings, such as clinical decision-making tools for providers to identify risk for prematurity. Stakeholders pointed to national best practices from March of Dimes, Centers for Disease Control, and other credible and invested organizations for effective strategies to address prematurity.

In the priority area of Infant Safe Sleep, stakeholders continue their focus on a topic that has been carried forward from the 2015-2020 period and characterized by several innovations and effective activities in the Nebraska Safe Babies campaign. The Nebraska Safe Babies campaign was launched in March 2017, with a focus on safe sleep practices. In July 2018, Abusive Head Trauma prevention was added to the campaign. In 2019, outreach was expanded from birthing hospitals to include OB/GYN pediatric and family practice clinics.

In the Issue Brief created on the topic of safe sleep, stakeholders pointed to a pattern of data showing improvements in safe sleep practices and advocated for the work to continue. Additionally, while breastfeeding was not selected as a priority on its own, stakeholders identified how much of a protective factor it is and encouraged Title V to identify nuanced messaging around safe sleep practices that emphasize the importance of both breastfeeding and a safe sleep surface for babies. For effective interventions, stakeholders recommended continuing the Nebraska Safe Babies campaign with expansion to include pediatric, family practice, and OB-GYN clinics as well as birthing hospitals as pledged and champion organizations.

For the 2020-2025 Needs Assessment, Title V worked with the Nebraska Association of Local Health Directors to bring forward a summary of current priorities identified through the Community Health Needs Assessment and Community Health Improvement Plans that local public health departments regularly undertake in their respective jurisdictions. This summary allowed stakeholders to consider degree of alignment with local priorities when determining which issues should be included in Title V’s final list of priorities for the upcoming five-year period. While some local public health departments in Nebraska identified low birth weight as a priority, none have explicitly identified prematurity or reducing infant death through Community Health Needs Assessment or Improvement Plans. However, multiple national and state level organizations have identified both premature birth prevention and safe sleep as priorities, providing a strong network for NE Title V to align with.  

Key actors for this domain include the Title V Maternal Infant Health Program and the Nebraska Perinatal Quality Improvement Collaborative (NPQIC). The Maternal Infant Health Program launched and executed the Nebraska Safe Babies campaign, which has emerged as Nebraska Title V’s signature effort to address safe sleep and abusive head trauma. NPQIC has partnered with the University of Nebraska Medical Center and the Partnership for a Healthy Nebraska to form “ALIGN Nebraska.” This group advocates for early and adequate prenatal care for all Nebraskans and is developing a public education campaign to educate Nebraskans on the importance of early and adequate prenatal care.

2. Summary of Programmatic Efforts and Use of Evidence-based or Evidence-informed Approaches to Address Priority Needs

Priority: Premature Birth

2022-2023 Objectives and Strategies

Objective PIN2a: By 2025, decrease preterm birth by addressing disparities among women of childbearing age, increasing access to care, and providing education.

Strategy PIN 2a(1): Title V staff will continue to participate in a cross-sector multidisciplinary group led by NPQIC to identify and make recommendations on action to prevent premature birth.

Strategy PIN 2a(2): Title V staff will release a funding opportunity to improve birth outcomes in Native American communities directed towards local organizations.

Summary of Programmatic Efforts

In 2022-2023, Title V staff participated in the ALIGN Nebraska work group led by the Partnership for a Healthy Nebraska. In February 2023, ALIGN Nebraska released the “ALIGN Nebraska Prenatal Care and Infant Mortality Policy Brief” that included policy recommendations to promote early and adequate prenatal care. Title V staff also participated in a committee working with Nebraska’s Managed Care Organizations and providers through the state looking at the gaps in coverage and getting pregnant women into prenatal care as early as possible.

Collaborative efforts to promote prematurity prevention included meetings with the Office of Rural Health, Nebraska Tribal partners, and Medicaid Managed Care Organizations. At meetings with each of these partners, the Maternal-Infant Health Program Manager shared materials for prematurity prevention, including the Nebraska-developed “Warning Signs to Know During and After Pregnancy” fact sheet. The “Warning Signs to Know During and After Pregnancy” fact sheet is geared towards empowering birthing people with critical information to advocate for their own health and birth outcomes.

During this period, two community-based organizations that primarily serve Black families expanded access to culturally relevant and trusted providers, community-based care, and various kinds of birth workers by developing doula training programs. Title V championed their work, while also reflecting on how doula services fit into the perinatal landscape and how NDHHS could promote their work. Title V considered the possibility of Medicaid reimbursement for doula services, wondering if doula services equated to those of a community health worker, or if doulas services were distinct enough to require their own scope of work and certification/credentialing process. NDHHS supports Medicaid reimbursement for community health workers, noting that doula services require additional specialized training. At the end of this period, there was no immediate direct path to doula service reimbursement through NDHHS.

Strategy PIN 2a (2) was incorporated into existing subawards with the tribes. Each year, Title V sets aside roughly $200,000 to support the four federally recognized Tribes in Nebraska. In the 2022-2023 period the Tribes used a portion of the funds to support prenatal care, vaccination during the perinatal period, education about infant safe sleep, breastfeeding, the importance of prenatal appointments, and infant care. Title V staff review the tribal work plans each year and offer suggestions and supports to strengthen the offerings and ensure activities align with federal requirements of the funding. Title V staff provided technical assistance to the Santee Sioux Tribe of Nebraska and the Omaha Tribe of Nebraska to develop their work plans and identify relevant actions and performance measures to meet their goals and objectives.

Objective PIN2b: By 2025, continue implementation of the Nebraska Maternal Mortality Review Committee.

Strategy PIN2b(1): The Nebraska Maternal Mortality Review Committee will implement a process for developing actionable recommendations.

Strategy PIN2b(2): The Maternal Mortality Review Committee and Child Death Review Team will utilize results from PRAMS and Hospital Discharge Data linkage analyzing outcomes related to prematurity.

Summary of Programmatic Efforts

In the 2021 Maternal Death Review Team Report, the Nebraska Maternal Mortality Review Committee (MMRC) offered 21 recommendations from case reviews for data years 2014 to 2019. The recommendations, evaluated by MMRC staff, were determined to be wide ranging and comprehensive. However, the recommendations need to be prioritized to move data to action and make progress on the MMRC’s goal of reducing preventable maternal mortality.

During the current reporting period, the MMRC completed an informal landscape analysis to see what partners are already engaged in this work. MMRC is prioritizing care continuity and medical care access and developing a pilot project to turn these recommendations into action.

To further understand outcomes in the pregnancy, birth, and postpartum periods for Nebraskan birthing mothers, the Office of MCH Epidemiology, through the support of the Association of State and Territorial Health Officials, linked Pregnancy Risk Assessment Monitoring System (PRAMS) data to statewide Hospital Discharge Data (HDD) sourced from the Nebraska Hospital Association. These data were analyzed to gain a better understanding of the burden of severe maternal morbidity (SMM) in Nebraska and to refine efforts to reduce SMM. Upon completing the linkage, the datasets underwent an internal validation process. The purpose of the process was to ensure that the estimates produced using the linked data were credible. To achieve this, weighted population estimates derived from the linked datasets were compared to actual population-level data. The project continued throughout the 2022-2023 reporting period.

The linkage of PRAMS and HDD centered maternal perceptions of the perinatal period to identify ways to reduce preterm birth. There are multiple PRAMS questions that add patient voices to prematurity analysis including questions related to pre-pregnancy health care visits, pre-pregnancy chronic disease burden, barriers to receiving prenatal care, satisfaction with prenatal care, pregnancy-induced disease burden, smoking and alcohol use, stressful life events, abuse, and infant and maternal postpartum visit status. Analyzing these data improves knowledge about maternal experiences related to the outcomes of interest, through patient-centered outcomes research to further refine efforts to reduce prematurity. These results will be made available to the Maternal Mortality Review Committee and Child Death Review Team.

Use of Evidence-based or Evidence-informed Approaches in this Priority

Priority: Infant Safe Sleep

2022-2023 Objectives and Strategies

Objective PIN3a: By 2025, decrease Sudden Unexplained Infant Death rate by promoting safe sleep practices particularly separate sleep surface; racial disparities; and protective factors such as breastfeeding.

Strategy PIN3a(1): The Title V Maternal Infant Health Program will partner with the Office of Rural health on continued expansion of NE Safe Babies campaign in rural family practice, pediatric, and OB-GYN clinics across Nebraska.

Strategy PIN3a(2): The NDHHS Maternal Infant Health Program and MCH Epidemiology Office will develop strategies to increase use of the new Sudden Unexplained Infant Death Investigation Form and training opportunities, targeting specific user groups such as law enforcement, first responders, county attorneys, etc.

Strategy PIN2a(3): The NDHHS Maternal Infant Health Program will continue to develop collaborations with community partners and rural health clinics.

Summary of Programmatic Efforts

During this reporting period, the Safe Babies Campaign continued to focus on infant safe sleep education to providers throughout the State of Nebraska. The Safe Sleep Campaign started in the hospital setting to educate and review safe sleep practices with providers. Beginning in the fall of 2019, the Campaign spread to the clinic setting, providing education on Safe Sleep, Abusive Head Trauma Prevention, and the CRYing Plan to pregnant people prior to birth and the same information at the well-baby visits through-out their first year of life. The Maternal Infant Health Program collaborated with the Office of Rural Health to promote the Nebraska Safe Babies Clinic Campaign to rural providers. During this period, one new clinic became a Clinic Champion. Low uptake was attributed to several factors, including market saturation.

Responding to recommendations from stakeholders, the Office of MCH Epidemiology created a fillable form for use during investigations of Sudden Unexplained Infant Death, with an accompanying self-directed, web-based training in 2021. The recommendation was spurred in part by a recognition that the data collected on-scene during investigation is critical to effective evaluation of the death by Child Death Review Team later, and tools were needed to support investigators in their work. The Office of MCH Epidemiology encouraged members of the Child Death Review Team to advocate for the form when working with partners across the state.

Use of Evidence-based or Evidence-informed Approaches in this Priority

In May 2020, HRSA released MCH Evidence Resources for Nebraska, which included an ESM Development Guide, and an Agency-specific ESM brief. In this document, readers are pointed to strategies which have proven effective in addressing NPM 5A-C: Percent of infants placed to sleep on their backs, percent of infants placed to sleep on a separate approved sleep surface, and percent of infants placed to sleep without soft objects or loose bedding. Evidence-linked and promising practices are described.

The Nebraska ESM in the Perinatal-Infant Health domain: the number of clinics that become Champions of the Nebraska Safe Babies Campaign, aligns with an emerging evidence-linked strategy, caregiver, and parent education by home visitors. MCH Evidence, in the ESM Review & Resources Agency Brief, identifies the ESM of the NE Safe Babies Hospital Campaign as Measuring Quantity of Effort.

3. Assessment of Alignment of NPMs, ESMs, SPMs, and SOMs with Priority Needs

Priority: Premature Birth

SPM: The percent of preterm births

ESM: None

Alignment: The SPM is aligned with, and directly measures, the priority. There is no ESM assigned to this priority.

Priority: Infant Safe Sleep

NPM: Percent of infants placed to sleep on their backs; placed on a separate sleep surface; placed to sleep without soft objects or loose bedding

ESM: The percentage of clinics receiving outreach that become Champions of the "Nebraska Safe Babies Campaign"

Alignment: The Priority and NPM are aligned, with the NPM measuring the Priority. The ESM does not measure individual family practices directly, but as a measure of the number of clinics adopting the NE Safe Babies campaign standards addresses upstream change such as the necessary policies, practices, and education that systematically must be in place to routinely educate new parents.

4. Progress in Achieving Established Performance Measure Targets along with Other Programmatic Impact

Since 2015, Nebraska Title V has been writing and utilizing Results-base Accountability (RBA) measures to make annual impacts and achievements more discernable to front line staff and stakeholders. In addition, use of RBA has specifically highlighted inclusion and equity-focused efforts that have been transforming Title V work.

Discussion – Other Programmatic Impacts

Collaborations with new partners have allowed Title V staff to reach new audiences to promote prematurity prevention. Title V staff were able to reach rural hospitals, utilizing the reach of the Medicaid Managed Care Organizations in Nebraska, and support for tribal initiatives.

Discussion – Other Programmatic Impacts

Safe Sleep, and Nebraska Safe Babies, continue to provide the foundation for many partnerships for Title V in Nebraska. All birthing hospitals are in regular communication with Maternal Infant Health Program staff.  

5. Challenges and Emerging Issues

Beginning in the summer of 2020, the country experienced significant unrest, which led to national discussions about the quality of maternity care and treatment of mothers who are Black, Indigenous, or people of color (BIPOC). In 2021, Nebraska began working with partners to better center BIPOC women in population- and systems-level efforts to improve birthing outcomes, shifting focus from data points describing the average status towards data that describes the most disadvantaged groups. This work continues with a focus on supporting work initiated by the four federally recognized Tribes of Nebraska.

In the area of Safe Sleep, changes to strategies have reflected changes in partnerships. A previous strategy to collaborate with Omaha Healthy Start has been broadened to allow for more opportunity with other community partners, and the previous discussion around Fetal Infant Mortality Review has shifted to working more with law enforcement, first responders, and other investigators involved in Sudden Unexplained Infant Death cases. Updates to reflect progress, challenges, and changes in the work environment keep Title V staff and partners focused on long-term goals while still effecting short term change. As Title V plans for the 2024-2025 application, it will turn to evaluation of success and needs for safe sleep sustainability after this five-year period ends.

6. Overall Effectiveness of Strategies and Approaches: Addressing Needs and Promoting CQI

As of September 30, 2023, there were 54 Safe Sleep Champion Hospitals with one hospital pledged to complete the steps. To further the campaign spread, NDHHS shifted from a focus on the hospitals to the Family Practice, Obstetric, and Pediatric Clinics throughout Nebraska. Six clinics are NE Safe Babies Clinic Champions. As few clinics have become Safe Sleep Champion Clinics, Title V activities have shifted towards collaboration to promote the Nebraska Safe Babies Campaign.

The NPQIC Prematurity Steering Committee responded to the question of how to prevent prematurity in Nebraska by promoting tobacco cessation to medical providers in Nebraska. After reviewing data and trends in both prematurity and risk factors for prematurity, the group identified tobacco cessation as a strategy that could reduce risk for all pregnant people. The promotion of tobacco cessation increased registrations for Nebraska Tobacco Quitline Online Provider Trainings. While this doesn’t measure use of tobacco cessation resources or a reduction in prematurity, it does suggest that providers found and were interested in the resources to improve patient health.