Perinatal/Infant Health Progress Report (October 1, 2021-September 30, 2022)

The 2020 comprehensive Title V needs assessment process led to the development of the Priority Need: To improve access to risk-appropriate care through evidence-based enhancements to perinatal systems of care. Several strategies were identified and incorporated into the state action plan to impact the following performance measures:

NPM 3: Percent of very low birth weight infants born in a hospital with a Level III+ NICU

Maintaining a high level of communication between regional perinatal center staff and DHEC staff to monitor the Perinatal Regionalization System (PRS) is an essential strategy to impact this performance measure. MCH/Title V staff continued to provide oversight to the Perinatal Regionalization System in SC, which has proven helpful to promoting effective messaging regarding maternal mortality and morbidity. These hospitals have a designated RPC (Regional Perinatal Center) which provides regional education and simulations of child births throughout their respective regions.

The Title V program adopted an additional strategy and currently monitors the detailed functioning of the system using VLBW self-monitoring tools completed by hospital staff for every VLBW delivery in a Level I or Level II hospital. Title V/MCH proceeded to monitor the system on a continuous basis; staff received quarterly reports in addition to email notification of any VLBW babies delivered at Level I and II facilities. Title V/MCH staff systematically reviewed these incidences during the quarterly meetings with the RSDs to identify the cause or circumstances surrounding the birth and determine if system breakdowns or transport issues occurred. If system issues were identified, the team determined the best course of action if intervention was needed. Although the PRS is focused on risk-appropriate care for the neonate, the Perinatal Regionalization team continued to ensure high risk mothers delivered at birthing facilities best equipped provide the appropriate level of care.

Two strategies in this population health domain and one in the women/maternal health domain were developed to address provider education, screening and intervention/treatment around perinatal substance use and the need to standardize diagnoses and protocols for care.

A state focus on neonatal abstinence syndrome (NAS) through a partnership between SC’s Title V program, the Managing Abstinence in Newborns (MAiN) project, and the SC BOI is promoting enhanced interest in and awareness of the scope of opioid dependence and NAS in SC. The MAiN project is a model of care providing supportive care and pharmacotherapy (when needed) to opioid-exposed newborns and has been pioneered at PRISMA Health-Upstate Mother/Baby unit for over fifteen years. The MAiN model has been established as a safe, lower cost, and more family-centered approach than the traditional model of prolonged NICU care. The MAiN project supports education to healthcare staff whose engagement can also impact the outcomes of ongoing primary and secondary prevention efforts. The MAiN Expansion efforts align with DHEC’s MCH Bureau and Title V Program in the following ways:

• The MAiN Expansion project has strengthened the referral network for women who screen positive for substance misuse (in the Women/Maternal Health Domain) because its web-based curriculum has been offered to obstetric providers and includes comprehensive information about statewide resources for the treatment of substance use disorders, as well as promotion of SBIRT screening during prenatal care. 
• The MAiN Expansion project has developed training materials for providers to have "non-punitive" conversations regarding substance use, educating women about the risk of NAS and infants exposed to other drugs and alcohol in the prenatal period. Its web-based curriculum has been offered to hospital and outpatient providers and health care staff and includes training on motivational interviewing, trauma-informed care, and the importance of using non-stigmatizing language and empathetic communication methods. 
• The MAiN Expansion project has provided education to providers on the need to standardize protocols for NAS intervention/treatment. Its web-based curriculum is free to participants and has been offered to obstetric, family practice, pediatric and medicine-pediatric providers involved in the care of NAS-affected newborns.  Training includes the full scope of NAS care and promotes the use of evidence-based tools and processes to create a standardized protocol for each engaged facility.

During the reporting period, 9 SC hospitals had access to the curriculum; 309 healthcare staff have completed the web-based curriculum to date, since 2019; and 41 healthcare staff completed the curriculum during FFY2021. Several posters and presentations were shared at educational and research conferences in the state on the MAiN Model and using a family-centered approach to address perinatal opioid use and SUD.

Another strategy identified to address the above-mentioned priority need includes the expansion of the Baby and Me, Tobacco Free program across the state.  The Baby & Me, Tobacco Free program is an evidence-based, smoking cessation program created to reduce the burden of tobacco on the pregnant and postpartum population.  SC DHEC began offering this program in 2016 as a pilot in the 4 counties of the state with the highest rates of smoking during pregnancy based on birth certificate data.  Those counties were Cherokee, Union, Laurens and Oconee, all located in the Upstate region.  Smoking during pregnancy has long been identified as a significant issue for both mother and baby and can lead to prematurity and/or low birth weight, two leading risk factors for adverse birth outcomes.  Because of this elevated risk and great potential for impact, pregnant tobacco users have been identified as a priority population for the intervention, which includes personalized cessation counseling (4 prenatal, 12 postpartum); individualized monitoring (saliva/CO testing); and diaper/wipe incentive ($25 for each eligible session up to $350) for proven success.

Efforts were made to expand the program to all 11 counties in the Upstate Region following a successful pilot, and 4 additional counties were added during FFY22.

The Title V needs assessment also led to the development of the priority need to Strengthen implementation of evidence-based practices that keep infants safe, healthy and prevent mortality. Several Title V internal program initiatives that promote this need are listed below:

• Count the Kicks, a national, evidence-based stillbirth prevention campaign, focused on providing educational resources to healthcare providers and expectant parents. Through a partnership with Healthy Birthday Inc., DHEC’s MCH bureau implemented a statewide project during FFY2021 to encourage maternal health professionals to have open conversations about the importance of “kick counting” and fetal movement monitoring by parents. In FFY2022, the campaign promoted stillbirth prevention through several press releases, English and Spanish-language virtual baby showers, social media ads, outreach materials and educational webinars.  The MCH bureau worked with DHEC’s WIC program and South Carolina’s Birth Outcomes Initiative to promote the app to families and provider groups to increase awareness of the campaign. In FFY2022, the campaign received over 600 downloads, had over 31,185 website visits, and reached over 100 providers across the state. We plan to continue our support of Count the Kicks and increase the reach to more providers and women in FFY23-24.

• The NBS Program continued and completed multiple projects and training opportunities. The implementation of an electronic patient case management system to enhance IT infrastructure progressed. The system allows NBS healthcare staff to electronically document all newborn screening patient diagnostic case data and outcomes, replacing paper processes. In September 2022, SMA (Spinal Muscular Atrophy) was added to SC’s NBS test panel as well as provider/patient resources to the DHEC website.

• The MCH Bureau’s First Sound program continued ongoing training to new staff at hospitals to improve screening outcomes and reporting compliance. Collaborated with family support partner to provide training and education to staff at early childhood centers to promote periodic hearing screening beyond the newborn period. Hosted five virtual events through The CARE Project - two for parents of deaf and hard of hearing children, two for professionals, and one parent/professional collaborative experience.  One of seven states selected to participate in the "Impact of Family Support and Engagement" Learning Community directed by NCHAM and FL3 national technical resource centers. Continued internal partnerships with CYSHCN and SCBDP for data sharing and consultation and initiated a collaboration with WIC regarding childhood hearing loss education. 

• During this time period, the MCH Bureau’s Birth Defects Prevention Program continued to prioritize prevention, research, and referrals through partnerships with internal and external partners. All liveborn infants identified with a birth defect were referred to BabyNet/Early Intervention in South Carolina, all women with pregnancies impacted by neural tube defects were referred to Greenwood Genetic Center, and the program continued a new initiative to refer infants with hearing loss to the agency's Early Hearing Detection and Intervention program, First Sound. 

• The program continued to work as a grantee for the CDC CHD STAR grant and focused on enhanced surveillance surrounding critical congenital heart defects detection. Additionally, the program used clinical data to support Emory University's efforts to develop a machine learning algorithm to identify congenital heart defects through claims data. As an CDC grantee for Advancing Population-Based Surveillance for Birth Defects grantee, the program also worked on data quality initiatives.

The Title V program has also prioritized breastfeeding initiation and duration as an evidence-based practice to promote infant health.  Breastfeeding rates in SC DHEC’s WIC Program steadily increased during FFY 2022. In October 2021, 21.6% of infants participating in the program were either fully or partially breastfed. By mid-year, breastfeeding rates had increased to 22.8% and 27.3% by September 2022.

WIC continued to offer 100% remote services by maximizing telecommunications with WIC participants to include certifications, food package issuance, nutrition education and breastfeeding support. Curbside services were available to participants in need of breast pumps and breast pump accessories.  The Lowcountry Public Health Region added a Breastfeeding Support Clinic to provided 1:1 assistance during COVID.

WIC added senior peer counselors to the career ladder roles in WIC for peer counselors. Under the supervision of the regional breastfeeding coordinator, the senior peer counselor will provide basic and more advanced breastfeeding information and encouragement to WIC pregnant and breastfeeding mothers. The senior peer counselor will mentor and assist with training breastfeeding peer counselors.

South Carolina WIC was selected as a subgrantee of the USDA/Tufts THIS-WIC grant (Telehealth Intervention Strategies for WIC Solution) to develop an online, mobile-friendly telehealth technology to provide WIC participants enhanced access to WIC services including high-risk nutrition care planning, breastfeeding education, breastfeeding support, and participant high-risk assessment. The pilot is set to start in late 2023.

DHEC’s MCH Bureau is a close collaborator with SC DHHS and the BOI when it comes to addressing breastfeeding. SC DHHS has a multi-year contract supporting the Mothers Milk Bank of South Carolina. During this reporting period, there were 154 active donors, 118,472 oz of milk donated, and 76,628 oz dispensed. There was an average of twenty-five depot sites and ten hospitals that received milk.

Hospitals recognized nationally as “Baby-friendly” promote breast milk as the standard for infant feeding and demonstrate best practices in the care of mothers and newborns. SC DHHS provided a financial incentive for new hospital designations. Two hospitals received the first-time incentive award during this period. There are 17 Baby-friendly hospitals in South Carolina.

Two major initiatives undertaken in FY22 to keep infants safe, healthy and prevent mortality safe sleep education and awareness and the re-establishment of the Fetal Infant Mortality Review Committee.

The MCH Bureau, in partnership with the SC Birth Outcomes Initiative met and formalized a new brochure to promote the latest AAP Guidelines regarding safe sleep for infants. We are using social media platforms, medical provider offices, medical facilities, and newborn home visits to promote safe sleep practices.

SC DHHS partners with DHEC’s MCH Bureau to support other Safe Sleep Initiatives. On October 5, 2021, the Safe Sleep Initiative held its annual Safe Sleep Summit. The summit consisted of one presentation weekly during the month of October. Governor McMaster signed a governor’s proclamation proclaiming October 2021 as Safe Sleep Awareness Month. The Safe Sleep Initiative workgroup is currently working on updating the Safe Sleep brochure.

The MCH Bureau began planning for implementation of a Fetal Infant Mortality Review committee in September 2022. The FIMR Core Team met with staff from the National Center for Fatality Review & Prevention (NCFRP) and brainstormed on ideas to implement the program in SC and what resources were available through (NCFRP). Invitations have been extended to potential members and the first FIMR meeting is scheduled for June 12, 2023, where policy and procedures will be decided. The committee professions will include partners from the Coroner’s Office, Healthy Start, Law Enforcement, Domestic Violence, Substance Abuse, Neonatal Intensive Care, Neonatologists, Pediatricians and other physicians, Epidemiologists, Social Services, Medicaid, Nursing and Psychiatry.

Table 2. Significance* Testing for Perinatal/Infant Health Measures

*p<0.05