The Wisconsin Title V Program views infant and perinatal health as part of an ongoing cycle or continuum of women’s health, including pre-pregnancy, pregnancy, delivery, postpartum, and reintegration into primary care. Unfortunately, Wisconsin lacks a coordinated system to successfully engage women throughout this continuum, and the Title V Program is working to build such a system. This work spans both the Women/Maternal Health population domain, as well as the Infant/Perinatal Health population domain. Please review the narratives from both population domains for the most detailed account of this work.

 

Wisconsin’s Title V Program recognizes that not all lactating people use female-gendered pronouns or the term “breastfeeding;” chestfeeding and bodyfeeding are other ways to describe the feeding of human milk to a child. While this document may use the term “breastfeeding,” the Title V Program intends for this information to be inclusive of all families.

 

National Performance Measure 04: Percent of infants ever breastfed; percent of infants breastfed exclusively for 6 months

 

The social and physical environment in Wisconsin does not support all families to meet their human milk feeding goals. In choosing to address this national performance measure, Wisconsin has the following goals:

 

1. Increase the proportion of non-Hispanic Black women who ever breastfeed in Wisconsin from 74% to 80% by 2025. (Baseline: 74%, 2016-2018 Wisconsin Pregnancy Risk Assessment Monitoring System, or PRAMS)

 

	2016-2018 PRAMS	2019-2020 PRAMS
Percent of non-Hispanic Black women who ever breastfed	74%	76%

 

2. Increase the percent of infants who are breastfed exclusively through 6 months in Wisconsin from 33% to 37% by 2025 (Baseline 33.4%, 2018 National Immunization Survey).

 

	2016 National Immunization Survey	2018 National Immunization Survey
Percent of infants who are exclusively breastfed through 6 months	28.9%	33.4%

 

Data from 2019-2020 Wisconsin PRAMS continue to show striking racial disparities in the birth hospital experiences of new birthing persons around breastfeeding support.

 

Evidence-based Strategy Measures

 

	Data Source	Data
Number of hospitals in Coffective’s Community Match Online Platform	Coffective	48
Percent of non-Hispanic Black infants ever breastfed	2021 Birth Records (provisional)	52.7%
	2020 PRAMS	74.7%
Percent of non-Hispanic American Indian/Alaska Native infants ever breastfed	2021 Birth Records (provisional)	62.6%
	2020 PRAMS	80.4%

 

Overall, 53 sites were contacted about 2021 breastfeeding strategies and 23 sites agreed to participate. Several sites were reported to be more than one site type (i.e. community, workplace, and/or childcare), with local health departments supporting sites to improve their lactation support practices in multiple capacities (e.g., for children attending a childcare site and for the employees of the childcare site.)  For this reason, the data from some sites are included in the reports for multiple site types.

 

Work with local and tribal health agencies to increase lactation support in the workplace.

 

Four local health departments and one tribal agency selected the worksite strategy in 2021. Despite capacity limitations due to COVID-19 efforts, 11 worksites received educational materials and resources from a local agency in 2021. Notably, one site established two additional lactation rooms. COVID-19 was a barrier shared by all sites. One site reported slow movement from their board to adopt a policy to protect breastfeeding individuals.

 

In support of the Indigenous community in Wisconsin, a Title V team member participated in the review of a breastfeeding toolkit developed in partnership with the Great Lakes Inter-Tribal Epidemiology Center. The purpose of this toolkit was to provide information and examples for Tribal leaders, health department staff, breastfeeding/ chestfeeding advocates, and community members who are interested in working on developing lactation support laws and policies for their communities. The toolkit focused on policy building in the Indigenous community and builds from the First Food Policy and Legal Scan project. The First Food Policy and Legal Scan project was a scan of laws and policies shared by federally recognized Tribes and Tribal organizations in the Bemidji Area of the Indian Health Service. The project’s goal was to provide information to the Tribes and urban American Indian health centers in the Great Lakes Area about how Tribes and urban health centers are using law and policy to support breastfeeding, and to facilitate the sharing of ideas and approaches across and within communities. The final report for the project is in the process of being released by the Great Lakes Inter-Tribal Epidemiology Center and will be shared widely.

 

Work with local and tribal health agencies to increase lactation support in early childhood settings.

 

Although much of this work was paused in 2021, 7 childcare sites received materials and resources from local health departments. All 7 sites reported COVID-19 was a barrier to their work, and one site also reported staff turnover as an additional barrier. While no new childcare providers were recognized as Breastfeeding Friendly in 2021, 8 programs renewed their recognition status, meaning they still met the 10 Steps to Breastfeeding Friendly Child Care and all staff completed the online breastfeeding training.

 

Without sufficient local health agency capacity to train and support childcare providers in improving their policies and practices related to human milk feeding, state partners continued to collaborate to ensure assistance was available when needed. Childcare providers could access the online training, and 212 individual providers completed the training independently for continuing education credit. The Wisconsin Technical College System continued to include the training in their Early Childhood Education Program’s Infant Toddler Development Course.

 

Childcare programs continued using the Go NAPSACC Breastfeeding and Infant Feeding Self-Assessment and online database with support from YoungStar technical consultants. The process of completing the Go NAPSACC self-assessment is linked to YoungStar – Wisconsin's childcare rating and quality improvement system – and helps providers meet Health and Well-being and/or Family Engagement rating criteria. 74 childcare sites completed Go NAPSACC pre-assessments, and 7 completed post-assessments.

 

The Title V Program, in collaboration with state partners, spent much of 2021 revising and updating the online breastfeeding training and the associated resources provided to local health agencies and coalitions. Local partners and early childhood experts provided input and feedback, focusing on revisions related to inclusive language and images, updated data, best practices, and equity.

 

Work with local and tribal health agencies to enhance local community coordination to improve continuity of care by strengthening consistent implementation of prenatal, maternity care, and postpartum practices that support breastfeeding.

 

Three agencies selected the community strategy. Because of COVID-19 impacts, only the City of Milwaukee Health Department had the capacity to work on this strategy. The Title V Program partnered with Coffective to enhance community coordination efforts by collecting baseline information from local agencies to help identify areas of need and inform recommendations for future work and by providing support for integrating community voice into breastfeeding-related initiatives.

 

Coffective met with the City of Milwaukee Health Department monthly to assess current and potential partnerships to build referrals to public health programing. The City of Milwaukee Health Department and their partners were given access to Community Match, Coffective’s online tool to help build partnerships and local networks. A community group leader from Detroit was present at one of the meetings to share lessons learned from a community with a similar landscape to Milwaukee. Coffective continued to provide technical assistance to the City of Milwaukee Health Department on identifying barriers to collaboration, improved access to care, and guidance on building their network of partnerships. Twenty-four agencies in Milwaukee County had profiles in Community Match at the end of 2021, including local WIC agencies, home visiting programs, local health departments, hospitals, and community-based organizations. All community sites received materials and resources from contracted local health departments. COVID-19, scheduling difficulties, virtual work, and space for lactation rooms were reported as barriers.

 

While local capacity for this strategy was limited, the Title V Program worked with Coffective, the Wisconsin WIC Program, and the Chronic Disease Prevention Unit to build state-level partnerships that could help support local community coordination in the future.

 

Support hospital use of quality improvement strategies that align with the Ten Steps to Successful Breastfeeding and/or Baby Friendly Hospital Initiative guidelines.

 

The Title V Program partnered with Coffective and Wisconsin Association for Perinatal Care for this strategy. Coffective facilitated monthly meetings to discuss how to re-launch the Wisconsin Perinatal Quality Collaborative’s Human Milk Feeding initiative. Planning discussions utilized data from the CDC's national survey of Maternity Practices in Infant Nutrition and Care (mPINC), state birth records, and Wisconsin Pregnancy Risk Assessment Monitoring System (PRAMS) to inform future measurement strategies and priority needs for quality improvement. A main goal of the Human Milk Feeding initiative is to improve the quality of maternity care and lactation support by coordinating community-based and hospital efforts related to human milk feeding.

 

Coffective, Wisconsin Association for Perinatal Care, and the Title V Program collaborated to accomplish the following planning activities:

 

1. Streamline current process and outcome measures abstracted from the Electronic Medical Record to be smaller in number, but high in value

 

2. Explore the inclusion of qualitative data gathering using a Birthing Person Survey

 

3. Align benchmarks with Baby-Friendly USA standards

 

4. Provide technical assistance for transition of quantitative and qualitative data to LifeQI or other data platform

 

The Wisconsin Association for Perinatal Care hosted a meeting of stakeholders on November 16, 2021, with the Coffective Clinical Team presenting 2020 mPINC results. The meeting provided a data-based foundation of human milk feeding in Wisconsin, with presentations summarizing data from multiple sources. Attendees actively participated by sharing their concerns and thoughts on strategies. A follow-up meeting was scheduled for early 2022.

 

When the 2020 mPINC survey results were released, Coffective assembled a customized mPINC package to be distributed statewide in Wisconsin which included:

 

Newsletter/email template: overview of the mPINC survey, brief overview of survey results, and the contents of the mPINC package.

 

mPINC Challenge Short Video: overview of mPINC results, the highs and the lows, and quality improvement activities that can be implemented right away to improve practices

 

mPINC Game Board: customized game board that gives a fun way to display statewide mPINC results

 

mPINC Resource Guide: customized quality improvement workplan and virtual file cabinet of resources

 

Coffective also shared a model Infant Feeding Policy Template and Check-off Tool for Wisconsin hospitals. These resources will be available to facilities who participate in the Human Milk Feeding initiative.

 

Develop grant opportunities for community agencies to advance breastfeeding efforts within specific populations experiencing disparities in breastfeeding (initiation, duration).

 

2021 was a planning year for this strategy. Title V staff met with the Michigan Breastfeeding Network to learn more about their efforts to convene local breastfeeding supporters throughout Michigan, elevate health equity within their statewide network, and prioritize the Indigenous and African American communities that are most affected by disparities in care. After learning more about potential ways to restructure the Wisconsin Breastfeeding Coalition, Title V staff began to meet with the Mobilizing Action Toward Community Health group at the University of Wisconsin to formalize a partnership to promote health equity within the Wisconsin Breastfeeding Coalition’s policies and practices.

 

Support the work of the Wisconsin Family Foundations Home Visiting Program led by the Wisconsin Department of Children and Families to increase social connections for breastfeeding families participating in the Family Foundations Home Visiting Program.

 

The implementation of this strategy was not realized due to the on-going impact of COVID; however, during 2021 there was opportunity for planning for future implementation. A survey poll was completed to identify which programs have parent groups and which programs would have the opportunities to support social connectedness. Feedback and results from the survey identified gaps in knowledge, skills, and trainings (surrounding breastfeeding) as opportunities for future professional development. Twenty seven out of the 36 programs participated in the survey, of which 87 percent provide some type of education and training on breastfeeding, and 11% offer a breastfeeding parent support group. Reported barriers to providing a support group included: limited staff, funding, time, transportation, and COVID- 19. During the pandemic there were many barriers to efficiently supporting lactation; however, there were also bright spots. For example, in rural areas, where there was much reassignment and limited staff capacity, there has been increased collaboration among WIC and home visiting programs.  Specifically, a local home visiting program identified that their local WIC contact was reassigned and not available to support lactation services. Therefore, one of the lactation certified home visitors began providing services for both the local implementing agency and the WIC clientele. This collaboration is still occurring with WIC referring lactating clientele to the home visiting program.

 

State Performance Measure 01: Rate of infant mortality in babies born to non-Hispanic Black mothers

 

Infants born to non-Hispanic Black mothers in Wisconsin are dying preventable deaths. Wisconsin’s goal is to reduce the infant mortality rate of babies born to non-Hispanic Black mothers from 14.6 to 13.0 per 1,000 live births by 2025. (Baseline is 2016-2018 infant mortality from Vital Records).

 

	2020 Vital Records	2021 Vital Records (provisional)
Infant mortality rate in babies born to non-Hispanic Black mothers, per 1,000 live births	14.6	12.7

 

Strengthen Prenatal Care Coordination as a resource and support during pregnancy through training, resource tools, and quality improvement efforts.

 

Prenatal Care Coordination is a Wisconsin Medicaid benefit that helps pregnant women, and their families gain access to medical, social, educational, and other services related to pregnancy. Prenatal Care Coordination services are provided through local and tribal health departments, clinics and HMOs, and community-based agencies. Studies have found that Prenatal Care Coordination protects against low birthweight, preterm birth, and NICU admission. The Prenatal Care Coordination Program aims to ensure that eligible pregnant women:

 

• Are identified early in pregnancy

 

• Receive individual psychosocial support and services

 

• Receive early and continuous prenatal care

 

• Receive health and nutrition services

 

• Are referred to available community services

 

• Receive assistance in accessing services

 

A series of educational modules on substance use and pregnancy were developed in collaboration with Title V, Wisconsin Department of Health Services’ Overdose to Action grant, the Wisconsin Association for Perinatal Care, people with lived experience, and content experts. Topics included:

 

• Overview

 

• Substance Use Screening Tools

 

• The Screening Conversation

 

• Screening, Brief Intervention and Referral to Treatment

 

• Finding Local Resources

 

• Referral Guidelines

 

• Wisconsin Reporting Laws

 

• Stigma and Support

 

• Medication Assisted Treatment

 

• Effects on the Baby

 

Two modules addressing Perinatal Mood and Anxiety Disorders were developed by the Wisconsin Child Welfare Professional Development System. Content from a webinar presentation was included in modules for on-demand viewing.

 

In addition to educational sessions, new tools and resources were developed to support Prenatal Care Coordination providers. A Prenatal Care Coordination Postpartum Assessment Tool (F-02774) was developed and approved as an optional resource to support the delivery of Prenatal Care Coordination services during the 60 days after delivery. A revised Pregnancy Questionnaire was drafted and shared with the Division of Medicaid Services. Both forms were based on assessment tools utilized by the Comprehensive Perinatal Services Program of the California Department of Public Health. The tools assess psychosocial, health education, and nutrition needs to align with components of the Medicaid Prenatal Care Coordination benefit.

 

New and existing resources were compiled and shared with Medicaid to support the future development of a Prenatal Care Coordination Resource Page on the ForwardHealth (Medicaid) portal. A Prenatal Care Coordination Task Force was convened twice in 2021 and provided an opportunity for Prenatal Care Coordination providers from across the state to provide input to Medicaid and Title V. Task Force members identified technical assistance strategies, provided input on revisions for the initial assessment, and discussed the benefits and barriers of establishing professional development requirements for Prenatal Care Coordination providers.

 

Support policy and practice changes to integrate doula services into Medicaid coverage.

 

The doula pilot project was identified as a state initiative to target maternal and infant mortality and reduce racial inequities in health outcomes. The Title V Program collaborated with the Division of Medicaid Services to plan an integrated Prenatal Care Coordination and Doula service for women at high risk of an adverse birth outcome at three pilot sites. Medicaid funded Public Health Madison Dane County with a subcontract to Harambee Village Doulas to plan the implementation of Prenatal Care Coordination. The City of Milwaukee Health Department also worked with Medicaid to explore the integration of their Prenatal Care Coordination services and their Birth Outcomes Made Better doula project.

 

Title V supported the African American Breastfeeding Network to strengthen and expand their partnerships with community-based doulas and Prenatal Care Coordination providers. Integrated Prenatal Care Coordination-Doula services were implemented. However, the Prenatal Care Coordination partner dropped out of the pilot mid-year. Discussions began with a potential new Prenatal Care Coordination provider within a Federally Qualified Health Center. A focus group was facilitated with the African American Breastfeeding Network doulas participating in the pilot, and valuable input was collected.

 

The identification of data metrics for the pilot projects were aided by consultation with Maternity Neighborhood, a company that provides data collection tools and technical assistance to doulas and other community-based maternity care providers across the county.

 

Develop and implement best practices to increase data capacity of existing data sources and expand partners’ capacity to use and leverage data to demonstrate impact and increase funding.

 

The Title V program facilitated the development of educational sessions called The Perinatal Health Series to support program providers to deliver a consistent core set of information and support services. The Perinatal Health Series was informed by and featured data from the Wisconsin Pregnancy Risk Assessment Monitoring System and was developed by community-based providers serving Black birthing people. State Children and Youth with Special Health Care Needs staff developed additional modules. The series includes the following modules:

 

Pregnancy Health: addresses linkages to medical prenatal care, labor and birth expectations, warning signs during pregnancy, nutrition, assessments, and referral resources.

 

Postpartum: emphasizes the needs to support screening for perinatal mood and anxiety disorders, tobacco cessation, ongoing medical care, nutrition, and physical activity.

 

Breastfeeding: explains the value of breastfeeding, identifies common challenges, and shares 10 tips for breastfeeding success.

 

Social Support: explores “Who’s in your village?” and focuses on supporting personal, family and community strengths.

 

Housing: identifies multiple resources to support safe and stable housing for birthing people.

 

Family Planning: discusses reproductive life planning and birth spacing to support healthy birth outcomes.

 

Children and Youth with Special Health Care Needs: provides an overview of the network of programs to support families and providers who support them.

 

Newborn Screening: describes the state public health program that identifies infants with treatable disorders to avoid or prevent adverse outcomes.

 

In 2021, the Wisconsin Title V program received data from the 2020 PRAMS oversample of Indigenous birthing people, featuring supplemental questions on housing stability, economic impacts of COVID-19, and intrapartum care. The Wisconsin team collaborated with academic partners and the Great Lakes Inter-Tribal Epidemiology Center to develop an analysis and dissemination plan for these data.

 

Additionally, Title V-funded epidemiologists, in collaboration with Council of State and Territorial Epidemiologists Fellows, began a Perinatal Periods of Risk Assessment for Black and Indigenous racial disparities in infant mortality to inform the state’s infant mortality reduction plan.

 

Align with and support work of the Maternal and Infant Mortality Prevention Unit and the community partnership specialists.

 

In 2021, the Family Health Section data team, in collaboration with the Maternal and Infant Mortality Prevention Unit staff, completed a Perinatal Periods of Risk Assessment for both African American and Indigenous babies. These assessments identified the “maternal health” and “infant health” periods of risk that contribute the most to the observed racial disparities in infant mortality.

 

The Community Partnership Specialist also met with more than 93 community partners throughout the state in 2021, including federally qualified health centers, faith-based organizations, and community-based organizations to learn about their current efforts to prevent infant deaths and identify opportunities for alignment. Unit staff also began development of a workplan that identifies opportunities to best support current Title V performance measures and outlines a strategic plan for the unit in 2022.

 

The Wisconsin Infant Mortality Reduction Plan uses data from Perinatal Periods of Risk Analysis to inform recommendations. Opportunities were also explored to provide funding to community-based organizations that support capacity-building in infrastructure and community health workers. The team worked to identify capacity-building needs of partners such as trainings for community-based organizations focused on grant writing, developing a board of directors, budgeting, and how to create a scope of work. The team identified the need for opportunities to provide educational opportunities including community doula training, certification lactation counselor/certified breastfeeding counselor training, and prenatal/postpartum health education.

 

Support Fetal Infant Mortality Review (FIMR) and Maternal Mortality Review (MMR) efforts.

 

The Title V Program supported the Children’s Health Alliance of Wisconsin to promote and support the use of a standardized process and data system for all local Child Death Review and Fetal Infant Mortality Review teams. Title V funding also supported local health departments to participate in child death reviews for their jurisdictions.

 

In July of 2021, Wisconsin released a report on Pregnancy-associated overdose deaths (2016-2019), which was a collaboration between Title V staff, CDC-funded Wisconsin maternal mortality staff, and the University of Wisconsin Prevention Research Center. This report included both an overview of related data and comments and recommendations from community partners.

 

Support social connections for African American women who have experienced an infant loss.

 

The impact of an untimely death, especially that of an infant, can have long-term effects on individuals, families, and communities. The need to support individuals in a holistic manner, including support for individuals and communities during time of grief and bereavement, is vital.

 

In 2021, the Wisconsin Title V program began funding culturally specific grief support for African American families through Healing Our Hearts, a community-based grief support organization and education service supporting families who have experienced a loss. This new work supplements the Infant Death Center that Title V funds through the Children’s Health Alliance of Wisconsin for families who have experienced a stillbirth or sudden infant death.  The founder, a person with lived experience, recognized that there were not any groups that offered support aimed to address experiences unique to Black women related to a loss. Services include a monthly grief support group, one-on-one support from a grief support specialist, support kits with handmade items from small minority-owned businesses, grief resources and referrals to wraparound services.

 

In 2021, the Healing Our Hearts Foundation served forty-six families with grief and loss supportive services and continues to build capacity through word of mouth, advertisement, and referrals. Eighteen hundred brochures were distributed and collaborative partners such as Harambee Village Doulas, Black Maternal Child Health Alliance of Madison, Wisconsin Children’s Health Alliance, African American Breastfeeding Network and St. Mary’s Hospital provided organizational referrals. Healing Our Hearts also co-hosted the ‘Empty Stoller Walk’ with the Alana Rose Foundation and the ‘We Been Not Breathin’ event with Harambee Village Doulas.

 

Implement implicit bias trainings for internal staff and grantees.

 

Workgroups within the Bureau of Community Health Promotion were established in 2021 to support the implementation of recommendations from the Division of Public Health “Health Equity Advisory Team.” One recommendation was to create infrastructure to “build and sustain capacity for equity work.” Activities to address this recommendation for Title V staff have included requiring engagement in health equity-related professional development activities and at least one job-related activity to advance health equity through the annual staff review process of Performance, Expectations and Planning. Additionally, a book club for internal staff was piloted in 2021 with facilitated discussion regarding Up from Slavery by Booker T. Washington. Learning objectives for the book club included:

 

1. Increase understanding of cultural and historical narratives of the African American population

 

2. Address dominant narratives, bias, misconceptions and stereotypes of the African American population

 

3. Opportunity to discuss, reflect and connect/engage with colleagues

 

4. Facilitate engagement in conversations to explore multiple perspectives

 

5. Apply conversation into action within state programming

 

One of the 14 participants commented that “Reading was quick...the thoughts that it provoked will stay with me forever.” Another participant commented that “I feel strongly we need this activity as a unit.” The book club was deemed a success as every completed evaluation showed that participants either agreed or strongly agreed that learning objectives #1-4 were met and 50% strongly agreed or agreed that learning objective #5 was met.

 

The Title V Program hosted a virtual “Maternal and Child Health Summit” series of four webinars in 2021 for Title V grantees, including all Wisconsin local and Tribal health departments. The theme of this summit was “Health in All Policies,” and included expert speakers on historical trauma among Black and Indigenous communities and affecting the social determinants of health through public health work. Please see Social Connections strategies for more information on the 2021 Maternal and Child Health Summit.

 

Support local and tribal health agencies to advance health equity for the maternal and child health population and enhance representative participation using the Community Engagement Assessment Tool.

 

The Title V Program funded a Health Equity and Community Engagement objective with local and tribal health agencies. Only 6 local agencies were able to implement the objective in the context of the pandemic. Participating agencies completed a Health Equity Checklist (based on the Foundational Practices for Health Equity) and the Community Engagement Assessment Tool. Based on the assessments, areas for improvement were identified. Action plans were developed and implemented to support practice changes to advance health equity and enhance community engagement.

 

The Walworth County Public Health Department engaged Health and Human Services staff and leadership in health equity education. A survey was conducted to gather baseline data on training needs and a health equity workgroup offered listening sessions to Health and Human Services staff for discussion on health equity topics.

 

The City of Milwaukee Health Department developed a plan for six staff retreats to provide high-quality training for all staff and increase public health content knowledge to develop a shared language. Local Milwaukee organizations were recruited to provide Diversity, Equity, Inclusion training.

 

The Kenosha County Health Department identified a goal to create a culture of ongoing learning and conversation about equity, diversity, and inclusion, and another goal to foster development of community-driven programming through community partnership and engagement. They worked to expand the work of their Health Equity Taskforce – made up of community leaders of color – to inform their programs and services, and to hire a full-time staff person dedicated to investigating inequities within policies, processes, and programs, and developing recommendations for equitable change.

 

Local agencies were supported by the Mobilizing Action Toward Community Health Group, a program within the University of Wisconsin Population Health Institute. The program was led by Paula Tran until the end of 2021 when she was appointed Wisconsin Division of Public Health’s State Health Officer and Administrator. Activities for 2021 included the following:

 

• Completion of one on one’s with all agencies who chose the Health Equity GAC Objective

 

• Reviewing assessments, action plans, and needs

 

• Sending health and racial equity resources and tools to support communities

 

• Providing technical assistance for local agencies requesting partnership on implementing their action plans

 

State Performance Measure 02: Percent of women receiving care within the first trimester; percent of women receiving a quality* postpartum visit

 

*Quality is defined by those who report receiving these services on the Wisconsin Pregnancy Risk Assessment Monitoring System survey (Question 70): postpartum depression screening, tobacco use, and EITHER contraception OR birth spacing discussion

 

Wisconsin lacks a comprehensive, high-quality, regionalized perinatal care system that successfully engages women throughout the continuum of care from preconception through the postpartum transition to ongoing well woman care. Wisconsin set the following related goals:

 

1. Increase the percent of non-Hispanic Black and Native women receiving prenatal care in the first trimester in Wisconsin from 60% to 66% by 2025 (baseline is from 2016-2018 Pregnancy Risk Assessment Monitoring System, or PRAMS).

 

	2020 Vital Records (WISH)	2019-2020 PRAMS
Non-Hispanic American Indian Alaska Native	62.5%	72.45%
American Indian Alaska Native (includes Hispanic)	-	74.1%
Non-Hispanic Black	62.8%	78.4%

 

2. Increase the percent of women receiving a quality* postpartum visit in Wisconsin from 56% to 67% by 2025 (baseline is from 2016-2018 Pregnancy Risk Assessment Monitoring System).

 

	2019-2020 PRAMS
All respondents	54%
Respondents who indicated they had a postpartum visit	60%

 

Convene multiple partners to develop a strategic plan for comprehensive risk-appropriate perinatal care in Wisconsin.

 

The goal of levels of maternal care risk assessments is to reduce maternal morbidity and mortality, by assuring access to risk-appropriate care, specific to maternal health needs. The Title V Program will support partners including the Wisconsin Association for Perinatal Care, Wisconsin’s Perinatal Quality Collaborative, the American College of Obstetricians and Gynecologists, and others to promote the use of a risk assessment tool with health systems and facilities to: Designate their level of perinatal care; Ensure all women have access to services; Identify risks early; Provide linkage to the appropriate level of care facility at time of delivery; Promote efficient use of resources; and Ensure adherence, continuity, comprehensiveness of care at the time of delivery through postpartum.

 

The Wisconsin Association for Perinatal Care has promoted a risk assessment document and toolkit for Wisconsin hospitals to self-assess their level of neonatal and maternal care for several years. To date, more than half (53%) of Wisconsin’s birthing hospitals providing obstetric care have not completed the Wisconsin Association for Perinatal Care’s Level of Care Self-Assessment. To address this, a newly established workgroup will explore opportunities for increasing uptake.

 

 

The workgroup is also exploring a shift to a standardized, national tool (CDC LOCATe) with a focus on a tool which is updated quickly with the most recent guidelines and policy statements issued by the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, and the Society for Maternal-Fetal Medicine and allows review of data from surrounding border states where Wisconsin women and infants might receive care.

Agencies participating on the Wisconsin Perinatal/Neonatal Levels of Care work group/task force include Children’s Hospital of Wisconsin, Froedtert and the Medical College of Wisconsin, University of Wisconsin Hospitals and Clinics, Wisconsin Association for Perinatal Care/Wisconsin Perinatal Quality Collaborative, and the Title V Program.

 

A representative from the Children’s Hospital of Wisconsin led efforts to convene task force members and met with the Wisconsin Association for Perinatal Care and other stakeholders to address the maternal/neonatal levels of care in Wisconsin. The Children’s Hospital of Wisconsin contacted the CDC regarding levels of care information, and it was brought to their attention that the Wisconsin Department of Health Services was also working to address this structure and system. The Department of Health Services’ first meeting with this previously established Wisconsin Perinatal/Neonatal levels of care workgroup was on December 11, 2020. This workgroup developed a worksheet to address four questions:

 

1. What is the current problem?

 

2. What is the anticipated result if nothing is done?

 

3. What is the current opportunity to do things differently?

 

4. What is the anticipated future result if these opportunities are achieved?

 

The workgroup compared the self-assessment tool with the CDC LOCATe tool to determine which tool most accurately identifies the Level of Maternal/Neonatal Care and determined that the LOCATe tool identifies the capacity and capability of a facility, while the self-assessment tool identifies the quality of the care of the facility.

 

It was determined that the Wisconsin Association for Perinatal Care would work with the facilities to assure comprehensive services are in place to identify the following:

 

• Monitor and work on the quality of care that the facilities are receiving based on their level of care

 

• Facilitate partnership agreement between critical access hospitals and higher-level care facility to serve the needs of high-risk women and neonates

 

• Ongoing monitoring and assessment to assure the facilities continue to meet the determined level of care

 

• Work with all facilities on levels of care to advance to the highest level of their capacity and competency to address the needs of all birthing people and newborns

 

Collaborators include the Title V Program, the Wisconsin Association for Perinatal Care, the Wisconsin Perinatal Quality Collaborative, and the Children’s Hospital of Wisconsin. Levels of care information will be stored on the the Wisconsin Association for Perinatal Care’s website.  Committees and work groups were restructured in 2021 to better meet the needs of their community and partners and new goals include: Identify key partners; Begin the implementation planning process; Disband the current risk-based care committee; Post and recruit for the redesigned levels of care workgroup.

 

The levels of care work group is committed to broad membership inclusion, embracing the idea that a diverse member representation improves the team as it addresses perinatal and neonatal care from a variety of perspectives. Specifically, the workgroup seeks professional, geographic, economic, gender, racial and ethnic diversity. Factors to be considered for work group membership include experience of prospective members and the ability to commit the time that is required to participate.

 

Collaborate with Medicaid on a quality improvement project to schedule postpartum visits in advance of delivery.

 

The Title V Program plans to expand a quality improvement project implemented for the Preconception Collaborative Improvement and Innovation Network (CoIIN) completed in 2018. This project was implemented to improve rates of postpartum visits through clinic messaging efforts and was a collaboration between the Title V Program and Medicaid. A script and patient tools were developed to describe the importance of the postpartum visit emphasizing post-delivery care, contraception and planning future pregnancies, physical activity, breast health/breastfeeding, emotions/mental health, and ongoing medical care. A brief presentation providing overview of historical/background information, findings of the pilot and a proposal to scale up this project was presented at a Division of Public Health-Division of Medicaid Services Title V coordination quarterly meeting. A comprehensive Power Point outlining the quality improvement project and the experiences of the two pilot sites was prepared to share with Medicaid Health Management Organizations.

 

Support Prenatal Care Coordination providers to strengthen postpartum Prenatal Care Coordination services to include depression screening, tobacco use, and reproductive life planning (contraception OR birth spacing discussion).

 

The Medicaid Prenatal Care Coordination benefit continues during the postpartum period, through 60 days after delivery. A Prenatal Care Coordination Postpartum Assessment Tool was developed as an optional resource to support the delivery of postpartum Prenatal Care Coordination services. The tool collects basic information including date and type of delivery and the baby’s birth weight, length and gestational age. Additional questions relate to psychosocial needs, health education needs and nutrition to align with components of the Medicaid Prenatal Care Coordination benefit. The optional Postpartum Assessment Tool was designed to support providers to identify needs and plan services such as referral to resources and education on specific health and nutrition topics, including perinatal mood and anxiety disorders, tobacco use and reproductive life planning.

 

Educational modules were developed for a Perinatal Health Series to provide on-demand education on topics of interest to Prenatal Care Coordination providers, home visitors, doulas, and others providing services to birthing people. Data from the Pregnancy Risk Assessment Monitoring Systems informed the presentations and demonstrates the need for quality improvement.

 

The American College of Obstetricians and Gynecologists recommends a comprehensive postpartum visit four to six weeks after delivery. Provider counseling during the postpartum visit should include a full assessment of physical, social and psychological well-being. According to 2018-2019 PRAMS data on what they discuss during provider counseling:

 

• 92% of Wisconsin mothers are asked about feeling depressed

 

• 68% of Wisconsin mothers are asked if they are smoking cigarettes

 

• 65% of Wisconsin mothers are asked if someone is hurting them emotionally or physically

 

• 52% of Wisconsin mothers are told to take a vitamin with folic acid

 

• 50% are counseled on how long is healthiest to wait before becoming pregnant again

 

Collaborate with Medicaid to increase enrollment for eligible participants in Text4Baby when applying for Medicaid services.

 

Text4Baby is a free digital support service offered in English and Spanish for pregnancy and parenting moms via interactive text, app, web and video messaging regarding their pregnancy and baby’s first year. While the free Text4Baby tool continues to be available, there is no way to access Wisconsin data regarding the number or participants enrolled in the program or data which measures improvement in maternal and birth outcomes. Title V Program met with the Division of Medicaid Services to discuss potential collaboration; however Medicaid is not considering any new projects for at least 18 months.

 

Due to the considerable cost associated (>$20,000) with simply obtaining data on their basic service program for any Wisconsin birthing persons who enroll – not including any customized content we might want to create or additional data points we might want to request – this strategy will not be pursued at this time.

 

Continue to collaborate with Wisconsin Women’s Health Foundation to advance health equity and expand First Breath partnerships with health and social service agencies, to provide evidence-based tobacco cessation services to pregnant/postpartum women and other caregivers throughout the state.

 

First Breath is an evidence-based program that has provided tobacco treatment services to over 23,000 pregnant and postpartum people (birthing people) in Wisconsin since 2001. In the First Breath model, trained perinatal healthcare professional screen pregnant and postpartum (birthing) people for tobacco use, provide brief intervention, and refer them to First Breath. Once referred, individuals receive one-to-one, intensive counseling and/or text message support from pregnancy through six months postpartum. First Breath uses a family-based approach and thus partners, caregivers, and household members are also eligible to receive services. First Breath strives to advance health equity by addressing the root causes of tobacco use and by engaging deeply with-and allocating resources to-the communities with the highest tobacco-related burden.

 

In 2021, 117 new perinatal healthcare providers completed a First Breath onboarding training and 20 new First Breath sites were established. First Breath provided training and technical assistance to the entire network through monthly activity reports, quarterly e-newsletters, and refresher trainings. There were 68 caregivers and 794 pregnant and postpartum people referred to First Breath by healthcare professionals. There were 87.5% (63 of 72) of Wisconsin counties that had at least one person referred to First Breath in 2021, and the program reached approximately 16% of all pregnant smokers in Wisconsin.

 

In an annual provider survey, 50% of 212 respondents reported that the COVID-19 pandemic impacted their ability to implement First Breath. Despite impacts of COVID-19, at least one formal First Breath site in each of the 72 counties in Wisconsin remained open.

Regarding one-on-one services, 28 caregivers received one-on-one education sessions and 303 pregnant and postpartum (birthing) people received intensive one-on-one services.

 

First Breath maintains a texting program with program participants. In 2021, 852 new pregnant and postpartum people joined the texting program, and at the end of the year, 2,403 pregnant and postpartum people were subscribed. In addition, 51 new caregivers joined the texting program for a total of 266 subscribed caregivers by the end of the year.

 

The average age of First Breath participants was 31 years. Over half (57%) were unemployed and over a third (36%) were single. Many participants were on Medicaid (86%), receiving WIC (65%), and/or had a mental health disorder diagnosis (63%). Nearly a third (31%) had a substance use disorder diagnosis. Some participants also reported high stress (34%) and/or receiving low social support (22%).

 

Of those who participated in the First Breath Program in 2021, 92% rated First Breath as a “very good” or “excellent” program, and 97% would recommend First Breath to others. Many participants in 2021 achieved a smoke-free home (80%) and/or achieved zero infant exposure to tobacco smoke (82%).

 

The First Breath Program also maintained a Virtual Participant Advisory Group in 2021. In this group, 67 current and past participants with lived experience took part in the group to provide feedback and suggestions about First Breath’s new perinatal substance use branding kit (logo and tagline), and provide feedback and suggestions on a series of patient education handouts.

 

In 2021, First Breath continued to engage in planning to expand the program from tobacco to alcohol, cannabis and other substances. Websites for First Breath participants, and perinatal health care providers, and a showcase of First Breath Success Stories were launched at the end of 2021.

A streamlined referral tracking system was also developed to transfer individuals with complex or unique health and social referral needs to the Well Badger Resource Center. Through this platform, detailed data is collected including referral site and referral outcome. The new system will begin in 2022.

 

Support Title V-funded programs to align with Home Visiting services, with a focus on women of color, to address smoking cessation, depression/mental health, and postpartum visits.

 

The COVID-19 response continued to have an impact throughout 2021.  One of the highlights of that impact was the refinement of virtual capabilities. The Family Foundations Home Visiting State team met virtually with the Title V High Quality Perinatal Care workgroup. These meetings provided opportunity for collaboration and planning 2021 and 2022 measures and activities. Virtual capacity also supported ongoing all-grantee meetings for Maternal Infant and Early Childhood Home Visiting-funded home visiting programs. The All-Grantee meetings were six half-day virtual sessions instead of three full-day in-person sessions. The frequency of meetings allowed increased connection with local implementation sites and the virtual platform allowed increased participation of Title V staff provide professional development. 

 

The High-Quality Perinatal Care team provided presentations from Title V and partners which continue to be supportive resources and referrals utilized by home visitors to support families enrolled in home visiting programs. The Periscope Project provided information about connecting health care providers with perinatal psychiatric support. A substance use module overview was presented as a resource for home visitors to understand approaches to supporting families with substance use addiction. First Breath was shared as a statewide resource for pregnant women, new moms, and their families to quit smoking. The Reproductive Family Health Unit Title X Medical Director provided a training and learning session on supporting families in scheduling and attending the postpartum and annual well-woman preventative visit

 

Collaborate with The Periscope Project to provide maternal psychiatric teleconsultation and resources.

 

The Periscope Project addresses the lack of sub-specialty perinatal psychiatrists as well as the gap in statewide perinatal depression and anxiety screening practices by building the capacity of front-line providers to address perinatal mental health conditions. Periscope (Perinatal Specialty Consult Psychiatry Extension) was launched in 2017 as a program of the Medical College of Wisconsin’s Department of Psychiatry and Behavioral Medicine.

 

The core service of Periscope is tele-consultation between local providers and perinatal psychiatrists to address psychiatric and substance use disorders in people who are pregnant, postpartum, and breastfeeding and is especially critical in the context of COVID-19. Tele-consultations are available Monday through Friday from 8am to 4pm to health care providers. Calls are triaged and providers receive a return call from a perinatal psychiatrist within 30 minutes, but usually within six minutes. Most consultations related to perinatal mood disorders (65%) and anxiety disorders (39%).

 

Periscope’s services include education on topics related to diagnosis and management of perinatal psychiatric conditions. A free 6-month continuing education series was provided in 2021 with over 100 attendees across the sessions. Another core service is providing information on community resources to support the mental health of perinatal women including psychotherapy options and peer-to-peer support groups.

 

Of the three core services offered, there were 2,175 provider-to-perinatal psychiatrist consultations, 833 recipients of community resource information, and 765 attendees of educational presentations (online or in-person).

 

Periscope continues to see an overall increase in the number of inquiries to the program. Periscope is meeting goals to build capacity in front line providers. As providers attend trainings and utilize the consultation service, they become more comfortable in diagnosis and treatment of perinatal mental health disorders. Thus, these providers do not require a call to Periscope with every patient who is struggling with mental health. COVID-19 protocols, funding, and staffing have limited the amount and type of outreach Periscope was able to conduct in 2020 and 2021 which may contribute to slower year or year growth between 2020 and 2021. Periscope developed an outreach plan for 2022 to reach new clinics and providers.

 

Periscope utilization has occurred in counties totaling 94% of where Wisconsin births occur with at least one provider in each of 40 counties using the consultation line at least once. In 2021, Periscope received inquiries from 34 out of the 40 total counties demonstrating how Periscope has become a standard practice for many health care providers across the state.

 

Support the ongoing development of Wisconsin’s Perinatal Quality Collaborative through Title V program participation and technical assistance and support of Alliance for Innovation on Maternal Health implementation.

 

The Alliance for Innovation on Maternal Health (AIM) bundle of Severe Maternal Hypertension was launched in October. There had been a delay in this launch due to COVID-19, however 44 hospitals currently are engaged in the Severe Maternal Hypertension bundle from the Alliance for Innovation on Maternal Health and are working on collecting baseline data, creating specific aims, and deciding their first tests of change related to their existing hypertension work.

 

The Wisconsin Maternal Mortality Review Team and Perinatal Quality Collaborative have maintained open lines of communication and information sharing throughout the year, which helps the Maternal Mortality Review Team recommendations reach a broader audience.

 

Newborn Screening

 

Children from birth to age three with developmental delays and disabilities are eligible for enrollment in Early Intervention in Wisconsin. At the end of 2021, over 97% of children under age three who were diagnosed with hearing loss were referred to Early Intervention. Parents of children who were deaf or hard of hearing were offered parent to parent support through the Wisconsin Sound Beginnings Program Parents Reaching Out service.

 

Regarding the newborn screening advisory structure, the Umbrella Committee and its eight subcommittees meet biannually to advise on emerging issues, quality assurance, and technology in newborn screening, and make recommendations to add or remove conditions to or from the newborn screening panel. The Secretary’s Advisory Committee on Newborn Screening advised the Secretary of Wisconsin’s Department of Health Services on policy issues related to newborn screening. The Newborn Screening Program, Wisconsin State Laboratory of Hygiene, Wisconsin Sound Beginnings, Screening Hearts in Newborns Project, Vital Records, and Title V Program collaborated to improve data collection, tracking, and integration with other birth data and data systems.

 

The WE-TRAC data system allows for real-time surveillance and tracking of hearing and critical congenital heart disease screening results for all babies born in a Wisconsin hospital or in an out-of-hospital setting to encourage timely interventions that can be applied on behalf of families and babies. The system’s enhancements to allow for critical congenital heart disease result entry and updates took effect in 2020 and have improved workflows for out-of-hospital providers and facilities across the state. The Office of Health Informatics continues to work with Newborn Screening Program data staff to design and implement an integrated newborn screening data system which will allow the program to better coordinate data collection and reporting, while centralizing access to relevant point-of-care (critical congenital heart disease and hearing) screening data for current users and primary care providers.

 

Outreach and Education for Families

 

The Newborn Screening Program provided outreach and education for submitters, providers, and families and worked with the Newborn Screening Education Subcommittee to educate the public and medical providers about newborn screening. Newborn screening information was provided during the prenatal period using the three-screen fact sheet, providing information on blood, hearing, and critical congenital heart disease screening. Newborn screening brochures are available for parents and newborn screening partners, including a Plain community newborn screening brochure developed for the Amish and Mennonite populations.

 

Newborn screening websites disseminated up-to-date information to hospitals and health care providers via educational webinars for hospitals and health care providers. A provider education module incorporating Wisconsin-specific content and material from the Midwest Genetics Network, the Genetics Systems Integration hub, and the Wisconsin Newborn Screening Education Subcommittee remains accessible to support providers in sharing newborn screening information and results with families. Recently, Family Voices of Wisconsin created Newborn Screening video factsheets for families with review and feedback from the Newborn Screening Program and its partners.

 

Outreach and Education for Submitters

 

Overall, the commitment to quality assurance from newborn screening submitters has remained stable and strong. The Wisconsin State Laboratory of Hygiene delivered several modes of quality improvement initiatives, including educational webinars on specimen collection.

 

Following impacts to the Newborn Screening Program’s courier service during the COVID-19 pandemic, which resulted in many hospitals experiencing delays in specimen pick-up and extended transit times, the Wisconsin State Laboratory of Hygiene explored alternative courier options in 2021 and as of Spring 2022, is moving forward with a new service, Gold Cross, in order to ensure that specimens are received within three days of collection.  

 

Newborn Screening Follow Up

 

Hearing: The Wisconsin Sound Beginnings Program supported hospitals and providers to increase the number of babies screened, percentage of babies receiving timely diagnosis of permanent hearing loss, and the percentage of babies enrolling in Early Intervention. Wisconsin Sound Beginnings also aimed to reduce the percentage of babies not receiving follow-up. The Wisconsin Early Hearing Detection and Intervention Tracking Referral and Coordination data system allowed for real-time surveillance and tracking of all babies born in a Wisconsin hospital or in an out-of-hospital setting to encourage timely interventions. Several follow-up positions were supported by the Title V Program including the Pre-Identification Lost to Follow-Up Prevention Coordinator, a Regional Outreach Specialist who focuses on the region in Wisconsin with the highest need, an Early Intervention Coordinator hired in December 2019, and a Social Emotional Development Specialist hired in March 2020.

 

Heart: The Newborn Screening Program provided clinical decision support and guidance to providers while ensuring that infants suspected of or diagnosed with critical congenital heart disease received appropriate follow-up evaluation and care. Enhancements are underway to allow better integration of critical congenital heart disease case report data with existing newborn screening, and vital records data to improve the program’s ability to conduct meaningful analyses of critical congenital heart disease outcomes, and follow-up.

 

Birth Defects Prevention and Surveillance

 

The Wisconsin Birth Defect Prevention and Surveillance Program consists of the Wisconsin Birth Defects Registry and the Wisconsin Council on Birth Defect Prevention and Surveillance as outlined in Wis. Stat. § 253.12. By statute, the program’s mission and work focuses on the three public health core functions of assessment, assurance, and policy development. In addition, the program collaborates with national, state, and local providers supporting the collection, analyses, and dissemination of state and population-based birth defects surveillance data and on the implementation of prevention programs.

 

The Registry

 

The Wisconsin Birth Defects Registry collected information on the child and parents, the birth, referral to services, and diagnostic information for 87 reportable conditions. Due to legislative changes, in 2019 the Wisconsin Birth Defects Prevention and Surveillance Program added the Wisconsin Birth Defects Registry as a module to an existing system in the Wisconsin Department of Health Services known as the Wisconsin Electronic Disease Surveillance System that is used by healthcare providers, laboratory staff, and local health department staff throughout the state for a variety of conditions. Providers enter information manually into the Wisconsin Electronic Disease Surveillance System or through a monthly batch upload. System testing was conducted in early 2020 and went live in April 2020. However, due to the COVID-19 pandemic the rollout of the new system was slower than expected and resolving technical issues with the Wisconsin Birth Defects Registry in the new system was delayed because the Wisconsin Electronic Disease Surveillance System was also where COVID-19 cases were being reported. Data collection was put on hold until information technology staff could resolve outstanding issues with the system.

 

From mid-2004 to the end of 2019, there were 28,888 birth defects reported to the Wisconsin Birth Defects Registry, with cardiovascular birth defects being the most frequently reported.

 

There were 355 babies in Wisconsin born in 2019 with one or more birth defects that were reported in the registry. This is much less than the expected 1 in 33 babies born with birth defects in the US, according to the CDC. This represents not only a significant gap in understanding the prevalence of birth defects, but also the Wisconsin Birth Defects Prevention and Surveillance Program’s ability to provide the necessary family support and services, as well as outreach, education, and prevention activities. However, once necessary fixes are made in the new system and data collection resumes, data quality and completeness will improve.