Maternal and Infant Health (MIH) Consultant – Division of Child and Family Health

Injury and Violence Prevention Program – Division of Prevention and Health Promotion

MCH Epidemiology – Division of Population Health Data

Division of Death Prevention – Office of the Chief Medical Examiner (OCME)

Local Health Districts

MATERNAL INFANT HEALTH (MIH) CONSULTANT: The MIH Consultant position was vacant from February 2020 through August 2022. The MIH Consultant serves as subject matter expert who partners closely with an array of state and local partners, including the Virginia Neonatal Perinatal Collaborative (VNPC), the Maternal Mortality Review Team, the state Child Fatality Review Team, and the Five-Star Breastfeeding Friendly Hospital Program. The MIH Consultant facilitates the monthly Sister Agency meeting that includes representatives from Department of Medical Assistance Services (DMAS), Department of Behavioral Health and Developmental Services (DBHDS), and Department of Social Services (DSS), MMRT, and VPNC. The MIH Consultant consults with LHDs regarding perinatal health work and provides support where possible. In addition, the MIH Consultant analyzes proposed maternal child health legislation and budget requests and is responsible for resulting requirements upon passage such as work groups or task forces where appropriate. The MIH Consultant builds and sustains a variety of partnerships that serve Title V priorities and seeks out additional funding to expand the MCH work in Virginia.

INJURY AND VIOLENCE PREVENTION PROGRAM: The Injury and Violence Prevention Program (IVPP) supports promising and best practice activities statewide that address leading or emerging injury issues at the population health level. The program seeks to build solid infrastructure to improve the health of Virginians by increasing awareness, action, and technical assistance for and by local and state partners to assess the burden of injury, assure interventions, and facilitate policy development.

MCH EPIDEMIOLOGY: The MCH Epidemiology and Evaluation Unit is a centralized epidemiology unit within the Division of Population Health Data headed by the MCH Epidemiology Supervisor who serves as the Lead Epidemiologist for Title V. The team has additional capacity available through a MCH Epidemiology Coordinator, Reproductive and Perinatal Health (RPH) Epidemiologist and a Newborn Screening (NBS) Epidemiologist, a Dental Health Epidemiologist/Evaluator, and two program evaluators supporting MCH programs regarding home-visiting (i.e., Healthy Start, MIECHV), and child and adolescent health. Additional cross-cutting support is provided by the Injury and Violence Prevention Epidemiologist.

DIVISION OF DEATH PREVENTION:  The Division of Death Prevention, located in the Office of the Chief Medical Examiner, is responsible for several epidemiological surveillance and fatality review programs, including the Maternal Mortality Review and Child Fatality Review Teams. The MMRT is a multidisciplinary group with representatives from academic institutions, behavioral health agencies, hospital associations, state chapters of professional associations, state medical societies, and violence prevention agencies.  The MMRT collects data on and reviews the deaths of all Virginia residents who were pregnant within a year of their deaths regardless of the outcome of the pregnancy or the cause of death.  These deaths are termed “pregnancy-associated deaths”.  The MMRT is dedicated to the identification of all pregnancy-associated deaths in the Commonwealth and the development of recommendations for interventions in order to reduce preventable deaths.  Each case is reviewed by the MMRT to determine the community-related, patient-related, healthcare facility-related and/or healthcare provider-related factors that contributed to the woman’s death.  The MMRT also assesses and recommends needed changes in the care received that may have led to better outcomes.  Consensus decision-making is used to determine whether the death was preventable and/or related to the pregnancy.

DENTAL HEALTH PROGRAM: The DHP performs many duties including the provision of the following:  Educational activities and resources to a wide variety of partner groups to promote proper oral hygiene and support prevention services and access to dental care; direct clinical preventive services and assistance with establishing a dental home; quality assurance review to assure a competent public health oral health workforce; and, surveillance and evaluation activities to monitor and track dental disease rate and trends as part of program assessment for effectiveness and planning. 

VDH LOCAL HEALTH DISTRICTS:  Each of VDH’s 35 local health districts (LHDs) receive Title V funds to drive and support maternal and child health programmatic initiatives at the local level.

Infant mortality is a hallmark of overall health status of a population, which is why it remains an objective of both Healthy People 2030 and Virginia’s Title V. In 2021, 568 infants died before their first birthday in Virginia, making the overall infant mortality rate across all races 5.9 per 1,000 live births. This rate is an increase from 2020; however, since 2012, the overall infant mortality numbers have remained relatively consistent, with a slight increased trend. Additionally, this rate varies by race and ethnicity. For example, the infant mortality rate among the non-Hispanic white population was 4.6, while the rate among non-Hispanic Black infants was 10.1, which has remained stable in recent years. This disparity in infant mortality rates shows that Black infants were 2.2 times more likely to experience infant mortality than their White counterparts. As such, one of Virginia’s State Outcome Measures is to decrease the black/white infant mortality disparity ratio to 1.

Strategy 1:  Develop and mobilize strong interagency, multisector, and community partnerships to address infant mortality due to preventable injury

The IVPP education package is an initiative advancing statewide delivery of prenatal and postpartum education on 1) general infant injury prevention to newborn and infant parents and caregivers prior to their maternity hospital discharge to home or setting after birth and/or as they access community level settings, 2) child maltreatment education in partnership with the Virginia Chapter of the Academy of Pediatrics and Virginia Commonwealth University, transportation safety education in partnership with the Virginia Chapter of the Academy of Pediatrics, and school aged injury prevention education, inclusive of concussion management in partnership with George Mason University. Priority populations are the general public of childbearing and childrearing age and caregiving age, students, and service delivery providers.   

Due to the demands on health systems, community programs, and families during our statewide COVID-19 response continuing in FY22, the IVPP’s general education initiative advanced to Version 2.0, transitioning from in person instruction to virtual for hospitals, libraries, health departments, and other prevention programs. After receiving input from maternity hospitals and health systems during the COVID-19 response, implementation of live in person injury prevention parental classes were not part of outpatient/community nursing education instruction. Version 3.0 is encompassing a repository of references that will helpful in educating families. These resources include a ready-made no cost injury prevention toolkit with facilitator instructions, Baby TV modules, VDH IVPP technical assistance, and parent resources. During the reporting period, IVPP continued to undergo a transition to development of an Injury Prevention Education virtual room visual platform designed for parents as the audience in receiving the intervention, by partnering with a state approved audio/visual vendor. All modules have been created. This evidence informed toolkit of evidence-based materials contains the necessary preparations and minimum level benchmarks according to the American Academy of Pediatrics, the Centers for Disease Control and Prevention, and the American Public Health Association Injury and Violence Prevention Core Competencies. The curriculum includes modules in child passenger safety, drowning prevention, poisoning prevention, traumatic brain injury prevention, injury by children’s products prevention, safe sleep strategies, and prevention of shaken baby syndrome.  100% of Virginia’s maternity hospitals were offered the general injury prevention curriculum. In addition, 100% of youth services libraries were offered the curriculum through the LOVA. In future years, VDH IVPP staff will provide intensive technical assistance to have these curriculum sets permanently implemented.  

Strategy 2: Develop, coordinate, and implement an action plan for substance-exposed infants based on the 2020 Report to the General Assembly

In November 2016, the Virginia opioid addiction crisis was declared a public health emergency.  In 2017, the governor and General Assembly directed the Secretary of Health and Human Resources to convene a workgroup to study barriers to the identification and treatment of substance-exposed infants in the Commonwealth.  Related to the workgroup’s recommendations, the Code of Virginia (§32.1-73.12)) was amended during the 2018 General Assembly session to identify the Virginia Department of Health (VDH) as the lead agency to develop, coordinate, and implement a plan for services for substance-exposed infants.  The plan must:

1. Support a trauma-informed approach to the identification and treatment of substance-exposed infants and their caregivers and include options for improving screening and identification of substance-using pregnant women
2. Include the use of multidisciplinary approaches in intervention and service delivery during the prenatal period and following the birth of the substance-exposed child, and in referrals among providers serving substance-exposed infants, their families and caregivers

Various state and local agencies, health systems, and community partners are involved in efforts to provide services and resources for substance-exposed infants and their families.  However, VDH identified a lack of coordination and knowledge of these efforts and resources among partners and health systems.  Many partner organizations know what is available within their respective communities, but this does not transcend to resources and services external to the community.  In FY20, under the direction of the Maternal and Infant Health Coordinator, VDH convened four different “pillar” workgroups to develop a statewide strategic plan for family and infants impacted by substance exposure and maternal substance use.  Due to the COVID0-19 pandemic, the full workgroup was invited to a series of three meetings in April 2020 and given an opportunity to review and provide feedback to the full draft strategic plan.  In August 2020, a final draft was provided via email to over 300 stakeholders across the Commonwealth to review a final time and provide suggested edits and feedback. VDH is required to report to the General Assembly annually regarding the implementation of the plan.

There were two significant disruptions to the progress of this plan starting in FY21 – COVID-19 and the vacancy of the Maternal and Infant Health Consultant position, which continued vacant throughout FY21 and FY22. With this critical position filled in August 2022, the MIH Consultant reviewed the plan, examining opportunities for revision, targeted partnerships with LHDs and community stakeholders in parts of the state where there are higher rates of NAS.  Additionally, a position for Substance Exposed Infants Program Coordinator is under revision and projected to be posted and hired during FY24.  

Strategy 3:  Local Health Districts: Develop, mobilize, and participate in strong interagency, multisector, and community partnerships to address disparities in maternal and infant mortality rates

Beginning State FY 23 (July 2022), Virginia’s LHDs were transitioned to a new work plan structure more closely aligned with the State Action Plan. Each district was required to select from a list of measurable activities, and then report quarterly to those activities.  Thirteen of 35 local health districts prioritized maternal and infant mortality disparity. Local activities will include:  Conducting local area environmental scans and gap analyses of maternal and infant mortality; strengthening community partnerships to increase referrals for the Black and Hispanic birthing population to home visiting programs; collaborating with community partners, including FQHCs, to develop stronger referral processes for appointments and care coordination of women with chronic medical conditions and those at risk of poor outcomes, including focuses on health literacy and health system navigation; partnering with local housing and food bank resources to strengthen community-centered support; strengthening of current educational resources provided to women who utilize current LHD clinics. Detailed District reporting will occur in FY23 block grant report.  

Strategy 1:  Sustain state maternal mortality and child fatality review programs, engaging with cross-sector partners and addressing social determinants of health in development of MMRT and CFRT recommendations

The Division of Death Prevention is led by Dr. Ryan Diduk-Smith (Director). The Division is responsible for several epidemiological surveillance and fatality review programs, including the Maternal Mortality Review Team and Child Fatality Review Team, local and regional overdose and domestic violence review teams, the National Violent Death Reporting System, Overdose Data to Action project, and the ERASE MM project. The division is 100% federal funded through grants and cooperative agreements through the Centers and Disease Control and Department of Justice. 

Child Fatality Review Team: The CFRT finished its review of adolescent suicides and a report with recommendations is currently being drafted. The current focus on the team is deaths that occurred in daycare facilities throughout the state (n=48).  The Infant and Child Fatality data collection tool was revised and implemented into the REDCap system and is currently being revised based on evaluation data and changes in the landscape related to child deaths. This is an unfunded activity, with the focus being on the facilitation of the CFRT. The CFRT also submitted recommendations from the Citizens Review Panel to the Department of Social Services for their 2023 report. 

NOM 9.1-Infant mortality rate per 1,000 live births and NOM 9.5 Sudden Unexplained Infant Deaths (SUID) rate per 100,000 live births  Other activities included Child Fatality Review Team coordination and facilitation of bi-monthly CFRT meetings: Activities under this activity include case selection for each meeting, requesting records from health, social, and community-based agencies that will be used in the review, review of those records, and determination of inclusion or exclusion in the review, as well as scanning the record for additional information that could be collected from other providers or agencies. After each review team meeting, data from the review team meeting are entered into the CFRT database by the Family Violence Programs Manager and Family Violence Research Assistant. After each review meeting, the Programs Manager is also responsible for maintaining, compiling, and reviewing the recommendations quarterly for applicability and appropriateness based on the review topic and current trends.  

The OCME continued to engage the community through multidisciplinary workgroups, review team meetings, and other activities where appropriate, through the Child Fatality Review Team. The team is chaired by Virginia’s Office of the Chief Medical Examiner and includes representation from education, social service and community service boards, psychiatry, injury prevention, health promotion, pediatrics, and other relevant agencies. The purpose of the team is to review topic specific cases and work to provide policy and programmatic recommendations to address the studied topic.  

Additionally, the Family Violence Programs Manager sits on a variety of community boards and workgroups addressing child death, including the Child Welfare Advisory Committee, FACT, Child Abuse and Neglect Advisory Committee, Suicide Prevention Interagency Advisory Group, and Injury & Violence Prevention Collaborative.  

Additionally under this program, the Family Violence Program strives to conduct epidemiological surveillance. Activities under this activity may include collection of comprehensive data using their-developed Infant and Child Fatality Surveillance Tools. The Family Violence Research Assistant is responsible for collecting data using the tool and entering the data in the Redcap Surveillance Database. The Research Assistant is also working with the Programs Manager to identify data trends, conduct data analysis, including exploring geographic and demographic disparities, and evaluate the tool and the data for quality assurance purposes, as able.  

The goal of the CFRT and MMRT is to develop recommendations that are sustainable, attainable, and measurable. They are also vetted thoroughly to ensure that suggested agencies and programs support the recommendation and would work towards implementing all or some of the recommendation(s) in their scope of practice. During this grant cycle, one goal of the CFRT and MMRT will be to align goals, as they are able, with Title V investments and ensure the recommendations address community, environmental, and healthcare setting factors identified in the fatality review of adolescent suicides and 2021 maternal deaths. The Programs Managers will also analyze data to understand the impact of social determinants of health, and work with the CFRT and MMRT  to continue to engage (and identify if needed) community partners that will address social determinants of health and work towards health equity. 

Strategy 2:  Create a system through which data from existing BabyCare Programs is synthesized and reported  

In Summer 2022, VDH’s Title V program sponsored two interns through the National MCH Work Force Development Summer Internship program.  The interns, Candace Jarzombek (MPH 2023, Boston University), and Leslie Osorio-Pascual (BSPH 2023, East Carolina University) conducted an evaluation of Virginia’s BabyCare Program. BabyCare is a case management and home visiting program for at-risk, Medicaid- or FAMIS-eligible pregnant and postpartum people and their infants. BabyCare is practiced differently across Virginia’s local health districts (LHDs), with some districts fully providing the full spectrum of BabyCare’s services, some providing parts but not all, and others not participating if there are no maternity services offered in their district. BabyCare, in its current form, is not an evidence-based program, which offers flexibility and variability to its use across the LHDs.   Two questions were raised to the Interns:  What is the difference between BabyCare and the evidence-based home visiting programs; how would BabyCare benefit by becoming evidence-based? The Interns evaluated the BabyCare programs in Mount Rogers and Chesapeake LHDs, the two largest programs in the state, providing approximately 500 home visits every month. They conducted key informant interviews with BabyCare nurses in each LHD, reviewed the existing BabyCare program guidelines, tools, and standards for districts, and then compared findings to existing evidence-based programs in Virginia.  The Interns provided several recommendations back to Title V, including the creation of a unified data system across all existing BabyCare programs through which client-related data can be synthesized and assessed which would demonstrate measurable outcomes in those areas that are shared with the existing evidence-based home visiting programs.

During Summer 2023, VDH’s Title V will host two additional interns through the National MCH Work Force Development Summer Internship program.  The interns will be tasked with evaluating the data collection methods of all active BabyCare programs (approximately 10), identifying desired points of programmatic measurements, and create a reporting tool for collection and dissemination of data.

Strategy 1:  Coordinate and expand the Five-Star Breastfeeding Friendly Hospital Program

In 1991, the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) launched the Baby-Friendly Hospital Initiative (BFHI), which is a global program that encourages the broad-scale implementation of Ten Steps to Successful Breastfeeding and the International Code of Marketing of Breast-milk Substitutes, and generating widespread understanding and enthusiasm for best practice infant feeding care. Baby-Friendly USA is the national authority and the accrediting body for the Bay Friendly Hospital Initiative in the United States.  In Virginia, the Five-Star Breastfeeding Program supports birthing facilities in building their capacity to receive the Baby-Friendly USA Designation.  This program housed and administered in VDH’s Office of Family Health Services – with staff from Division of Child and Family Health providing programmatic support for this role in collaboration with the State Breastfeeding Coordinator, housed in the Division of Community Nutrition.

COVID challenged the birthing facilities’ ability to engage in the program, and position vacancies and COVID-related conflicts across the Five-Star Committee slowed down the work and progress tremendously.  In September 2021, the VDH’s State Breastfeeding Coordinator, Title V Director, and Director of Child and Family Health met with the intention of revitalizing the Committee, subsequently reviewed the previous committee composition, reached out to members to assess for continued commitment, and recovened the group to begin rebuilding the program. Committee members also serve as reviewers of the applications submitted for Five-Star designation.  The committee has representation from professionals across the state, including OB/GYN and pediatric physicians, hospital and community IBCLC, breastfeeding educator, and a consumer.  The Committee is currently reviewing existing processes, upgrading the application process, and planning a statewide re-launch educational event in late 2022.

Strategy 2:  Local Health Districts:  Identify the LHD capacity to successfully implement 10 steps to Breastfeeding Friendly Health Department

The Breastfeeding Friendly Health Departments (BFHD) model was created and piloted by the Dakota County (Minnesota) Public Health Department and recognized as a Model Practice Program by the National Association of County and City Health Officials (NACCHO) in 2017.  The BFHD Toolkit consists of ten steps that encourage local health departments to utilize evidence-based breastfeeding policies and practices, and can serve as a resource to help local public health departments develop the capacity to promote breastfeeding in communities.  Additionally, the model is structured such that participating health departments can be acknowledged for participating and success at the bronze (5 steps), silver (7 steps), or gold (all 10 steps) levels.

In collaboration with VDH’s WIC Breastfeeding Coordinator, a survey was designed to assess the current practices within each LHD that are similar to the Ten Steps recommended by the BFHD Toolkit.  The survey was distributed to all 35 LHDs in October 2022. The results of the survey will influence the LHD work plans for FY24.