NPM #3 Perinatal Regionalization – Ensure risk appropriate care for high-risk infants to reduce infant mortality / morbidity.

 

Similar to national trends, infant mortality rates (IMR) in Missouri have experienced a steady decline over the past two decades. Despite these significant declines, the racial disparities associated with IMR have remained steady and disproportionately affect African-Americans. The 2019 Missouri IMR was 6.0 per 1,000 live births (provisional data), still above the 2018 national IMR of 5.7 per 1,000 live births. The non-Hispanic African-American rate in MO (11.7 per 1,000 live births) continues to be more than twice as the non-Hispanic White rate (4.9 per 1,000 live births). While IMR have decreased across all racial/ethnic groups, the racial disparity associated with them has effectively remained unchanged for the past 50 years – African American infants are twice more likely to die than white infants within the first year. Approximately 50% of infant deaths occur among preterm and very low birthweight (VLBW) infants, and transferring these babies in a timely manner to level appropriate care facilities has been shown to significantly reduce the risk of infant death among these high risk infants. Perinatal regionalization is a standardized mechanism where hospitals are assigned levels of care (Level I, II, III and IV) based on their neonatal intensive care unit capabilities. In 2019 (provisional data), 87.8% of Missouri VLBW babies were delivered at level III or higher facilities. This assessment was based on data analysis from a survey completed by hospitals in conjunction with vital statistics data. VLBW babies delivered at Level III or NICU facilities were highest among Non-Hispanic Black women (92.7%), followed by Non-Hispanic White women (85.8%) and Hispanic women (79.6%). Overall, 8.9% of Missouri infants were born at low birth weight (less than 2500 grams); with non-Hispanic Black low birth weight rate being the highest (15.5%) and about 2 times that of Hispanics (7.7%) and (7.5%). Efforts to reduce infant mortality addressed methods for risk-appropriate care, utilization of 17 Alpha-hydroxyprogesterone caproate (17P), and collaborative initiatives.

 

Risk-appropriate Care

Senate Bill 50 (SB50) requires birthing facilities to annually report their neonatal and maternal levels of care to the Missouri Department of Health and Senior Services (DHSS). At the beginning of 2019, a Levels of Care Assessment Toolkit (LOCATe) survey, developed by the Centers for Disease Control and Prevention (CDC), was administered to approximately 64 birthing facilities in Missouri. The survey results were given a unique identifier and then submitted to the CDC for analysis. Preliminary results suggested that 39% of birthing facilities reported their neonatal intensive care unit (NICU) to be at a level higher than that assessed by the LOCATe. Much of the discrepancy was due to lack of a neonatologist available by either phone consultation or telemedicine. This lack of subspecialty availability lowers a facility from a level II to a level I. Several DHSS internal planning meetings took place to determine the best methods to assist each facility in completing the survey. 

 

Collaborative Initiatives

The Section for Women’s Health (SWH) has a full-time public health consultant nurse position that provides coordination for infant mortality initiatives. This role serves as the expert in infant mortality, fields legislative questions, and disseminates information to the MCH team. This position is actively involved in internal efforts as well as informed about activities throughout the state and takes the lead in representing DHSS when working with MCH stakeholders.

 

DHSS committed to reducing infant mortality and prematurity as identified in the Department’s strategic plan. The strategic initiatives team, assembled in 2018, continued to meet and update the dashboard. The dashboard included four departmental themes: reduce opioid misuse, improve the health and safety of Missourians most in need, enhance access to care, and foster a sustainable, high-performing department. Improving the health and safety of Missourians most in need includes initiatives to address chronic disease and infant mortality. A meeting was held in June 2019 between the Missouri Chapter of the American Academy of Pediatrics (MOAAP) and DHSS to align infant mortality efforts. DHSS discussed the development of the Safe Sleep Strategic Plan in partnership with Missouri’s Safe Sleep Coalition and the National Institute for Children’s Health Quality (NICHQ). The MOAAP was very receptive to the Safe Sleep Strategic Plan and welcomed any opportunities for further collaboration.

 

Collaboration continued with several local and regional initiatives to reduce infant mortality. Efforts involved two Healthy Start grantees, the Maternal Child Health Coalition in Kansas City, and Bootheel Babies and Families in the southeast region. FLOURISH St. Louis, a collective impact initiative working in coordination with Generate Health, also worked to address infant mortality. Although FLOURISH continued to work within their priority focus areas including infant health, prenatal care access, transportation, health communication and navigation, and behavioral health, they prioritized their work to be led fully by the community most impacted. Over 40 community members were recruited to serve on its Community Leaders Cabinet, including community leaders from parent and neighborhood groups, doulas, and community health workers, to elevate the challenges Black families face in the St. Louis region. In addition, FLOURISH continued to be part of CityMatch’s Institute for Equity in Birth Outcomes. This three-year partnership addresses designing and implementing strategies that focus on racial equity. FLOURISH focused on how housing conditions and the lack of quality housing for low-income families impact the health of pregnant moms and babies. They raised awareness of the housing conditions, including broken heat and rodent infestations, and identified potential solutions that would help families. Another collaboration, the Infant Mortality Reduction Initiative (IMRI), funded by the Missouri Foundation for Health, serves two areas, St. Louis and the six county region of the Bootheel in the southeast corner of the state. The purpose of collaborating with the Maternal Child Health Coalition, Bootheel Babies & Families, FLOURISH, and IMRI was to connect local and state efforts and to be a resource to accelerate positive changes.

 

The MCH Services Program contracted with 113 Local Public Health Agencies (LPHAs) to support a leadership role for LPHAs within coalitions and partnerships at the local level to build MCH systems and expand the resources those systems use to respond to priority maternal child health issues, including the prevention and reduction of adverse birth outcomes. The Pike and Phelps-Maries County Health Departments are among several LPHAs working to establish a process for risk identification and referral to community resources in an effort to increase the number of women of childbearing age linked to services for identified needs, with the ultimate intent to improve pre-conception, prenatal, and postpartum health care services for women of childbearing age which inherently prevent preterm labor and promote risk appropriate perinatal care.

 

DHSS began a partnership with Healthy Birth Day, Inc. on the Count the Kicks project, a proven stillbirth prevention public health campaign. According to the Centers for Disease Control and Prevention, Missouri has the 21st highest stillbirth rate in the country. Missouri vital statistics show that 458 stillborn babies are born each year in our state. The introduction of Count the Kicks in Missouri has the potential to save 119 babies every year if Missouri’s stillbirth rate decreases by 26 percent, as has happened in neighboring Iowa where the campaign began. Count the Kicks teaches the method for and importance of tracking fetal movement in the third trimester of pregnancy. Scientific studies show that expectant moms should track their baby’s movements once a day in the third trimester and learn how long it normally takes their baby to get to 10 movements. Moms will start to notice a pattern, a normal amount of time it takes their baby to get to 10. If "normal" changes during the third trimester, this could be a sign of potential problems and an indication to call their provider. Particular efforts will be made to eliminate racial disparities while lowering the overall stillbirth rate. Nationally and across Missouri, African American women are more than twice as likely to lose a baby to stillbirth as the general population of pregnant women.

 

Through a public health awareness campaign launched 10/1/2018 through 9/30/2019:

• over 43,000 pieces of Count the Kicks educational materials were distributed to Missouri birthing hospitals, obstetrical offices, midwives, county health departments, and WIC offices. 
• More than 2,200 Missourians visited the Count the Kicks website. Most are going to the "Counting Baby Kicks FAQ" page and 77% are viewing from a mobile device. Nearly 250 Missourians “liked” Count the Kicks on Facebook and engaged in educational videos.
• Nearly 700 expectant mothers downloaded and started using the free Count the Kicks app. 

 

Through a continued partnership with Healthy Birth Day, Inc., DHSS contracts with the organization to ensure Missouri health care providers will continue to be able to order Count the Kicks educational materials free of charge.

 

In October 2018, the SWH provided monetary sponsorship for the 4th Annual Perinatal Nursing Conference:  Improving Outcomes for Mother and Baby presented by the University of Missouri’s Nursing Outreach and the Missouri Section of the Association of Women’s Health Obstetric and Neonatal Nurses. The conference featured the latest evidence-based practices and tools applicable to both inpatient and ambulatory perinatal practice settings. Sessions included clinical updates, innovative perinatal practices, and resilience skills to foster engagement and adaptability in an uncertain and changing environment.

 

17P

DHSS and MOD continued to receive periodic updates from OPTUM regarding their expansion progress with Mekena/17 Alpha-hydroxyprogesterone caproate (17P) services, specifically in the Bootheel region of the state. OPTUM continued to have discussions and data presentations with the managed care organizations and providers located in St. Louis and the Bootheel.

 

The Newborn Health Program contracted with Voxiva to supply free text messages to pregnant women and new mothers up to their child’s first birthday. This Text4baby service had three customized messages that were sent weekly. These messages were customized to Missouri specific phone numbers and websites. Since women who have had a preterm birth can increase their chances of having a full-term birth by taking 17P, early in their pregnancy, enrollees received a message discussing 17P and whether they had a prior preterm birth.

 

Genetics and Healthy Childhood (GHC) funded home visiting services offered in 26 counties and served 1,087 families through the Missouri Building Blocks (BB), Healthy Families Missouri Home Visiting (HFMoHV) and the Maternal, Infant and Early Childhood Home Visiting (MIECHV) programs. These programs implemented the following evidence-based models:

• Nurse Family Partnership model;

• Healthy Families America model;

• Parents as Teachers model; and

• Early Head Start Home Based Option model. 

 

Home Visitors are knowledgeable about the risks for preterm birth and share education with women enrolled prenatally. Data from FY19 indicated that 15% of infants (37/241) were born preterm among mothers who enrolled in GHC supported home visiting prenatally before 37 weeks gestation. Home visitors actively encouraged clients to maintain adequate prenatal care once enrolled in the program and continually monitored expectant mothers for potential complications that might affect maternal and infant outcomes. 

 

The Home Visiting Program shared the following resources with GHC contracted home visitors through the Missouri Home Visiting Gateway Weekly Update during 2019:

• 12/7/18 - New video features a mom who saved her baby by using the Count the Kicks app and how she spoke up to her provider when she noticed a change in movement. 
• 12/20/18 - Premature birth (defined as birth prior to 37 weeks gestation) is the primary driver of infant mortality in the U.S. See how Missouri compares through the state-by-state report cards released by the March of Dimes.

 

Resources

The Newborn Health program distributed 35,074 Pregnancy and Beyond booklets in FFY19. These booklets were distributed to hospitals, doctor’s offices, LPHA’s, birthing centers, and other partners throughout the state. New OB patients were given the booklet to be used as a reference for a wide range of information concerning pregnancy and a child’s first five years of life. The Pregnancy and Beyond booklet also includes sections on perinatal and infant health. Other resources are also shared with health care providers. A response from the Sandy Washington University SYNCHRONY Parent Ed Project stated “I used the Baby Your Baby Health Keepsake for years but do not have any more. I am so excited to see the new publication available on pregnancy and parenting. Thank you so much for making this available to our parents!!!!”

 

Newborn Screening

The newborn screening program continues to distribute the newborn screening educational booklet free of charge to educate new and expectant parents. The booklets are ordered from the DHSS Literature Warehouse by birthing hospitals, LPHAs, pediatric clinics, WIC clinics, obstetrical clinics, independent birthing centers, midwives, Parents as Teachers, ParentLink, and family practice clinics. There were 54,405 newborn screening educational booklets distributed during FFY19.

 

The newborn screening program continues to distribute a quarterly newsletter, Behind the Screens. The intent of the newsletter is to help increase awareness and provide education about newborn screening, including hearing screening and critical congenital heart disease (CCHD) screening in addition to blood spot screening. The newsletter is distributed to “front-line staff,” individuals who are directly involved with the collection of newborn blood spot specimens and conducting hearing and CCHD screenings. The newsletter is emailed to over 200 individuals each quarter for them to read and distribute to their staff and co-workers. The newsletter is also posted on the newborn blood spot, hearing, and CCHD web pages. The Behind the Screens newsletter has received positive feedback from both front-line healthcare workers and laboratorians. Individuals have stated that they find the information useful in their day-to-day practices and enjoy seeing a more personal side to newborn screening through the Patient Spotlight articles. Newsletter recipients have also commented that they have learned something about newborn screening that they were not previously aware of. 

 

During the 2017 legislative session, a bill was passed that requires Missouri to screen for Spinal Muscular Atrophy (SMA) and Hunter syndrome by January, 2019. Full population pilot screening for Hunter syndrome began in late 2018 and SMA began in January 2019. Live screening for both Hunter syndrome and SMA began in October 2019. 

 

The newborn screening follow-up nurses continued to serve as liaisons for both professional and lay midwives, helping to ensure families have access to newborn screening. Continued outreach, education, and open communication has helped to foster a positive relationship between the Missouri Newborn Screening Program and the home birth community.

 

Neonatal Abstinence Syndrome

The Department’s Neonatal Abstinence Syndrome (NAS) Stakeholder group, led by the Title V Director, continued to meet to align efforts and address maternal opioid use and neonatal abstinence syndrome. In FFY19 the focus included defining the scope of the group by identifying objectives and developing a vision statement and an action plan, discussing stakeholder involvement, and identifying similar groups throughout the state to establish opportunities for collaboration and avoid duplication of services. The group also discussed having a broader platform to address substance exposure beyond just opioid use and becoming a centralized hub for information.  

 

The Prenatal Substance Use Prevention (PSUP) Program promoted healthy pregnancy by abstaining from all substances through several outreach projects in FFY2019. 

• The prenatal exposed infant manikins are educational resources provided through 30 community placement sites (CPS), throughout the state, to improve birth outcomes. The CPS used the prenatal exposed infant manikins in 250 education sessions and displayed to 5,455 individuals. Participants are able to compare three infants together (a prenatally drug exposed infant, an infant with fetal alcohol syndrome, and a healthy infant) to demonstrate the effects of substance use during pregnancy. The visual resource allows participants to see the possible outcomes of an individual’s behavior to improve birth outcomes. The PSUP Program collaborated with a Mid-Missouri NAS workgroup by combining community outreach efforts. The goal of the workgroup is to provide educational sessions to those at risk of using substances during pregnancy and create a train-the-trainer course to expand outreach.
• Online tools for health care providers were available to help assess pregnant women and refer for treatment along with free educational brochures.
• Missouri’s Chapter of the National Organization of Fetal Alcohol Syndrome collaborated with DHSS to participate in the Red Shoes Rock campaign by wearing red shoes to show support for Fetal Alcohol Spectrum Disorders.
• Two Facebook giveaway campaigns reached 31,761 individuals with 13 posts and 844 individuals answered a question regarding prenatal substance use to enter into a giveaway. There were 36 randomly selected individuals who won a prize pack that included educational materials such as:  a Pregnancy and Beyond booklet, This Side Up infant t-shirt, TEL-LINK note pads, Drugs and Pregnancy brochure, Smoking Kills Your Taste Buds-sunflower seeds, and more.

 

During FFY2019, the maternal and child health services resource, TEL-LINK, connected 39 callers directly to the Tobacco Quitline, Substance Abuse Treatment Centers, and the Domestic Violence Help Line. Callers were given referrals and transferred immediately to the appropriate agency to access alcohol and drug treatment programs with ease and confidentiality.

 

SPM #1 Breastfeeding – Improve health outcomes for Missouri mothers and infants by increasing breastfeeding initiation and duration rates.

 

According to the 2019 National Immunization Survey, 77.5% of Missouri infants were ever breastfed compared to 84.1% nationally, and below the HP2020 goal of 81.9%. Over half of Missouri mothers were still breastfeeding at 6 months (56.7%) and fewer were exclusively breastfeeding at 6 months (27.2%). Based on PRAMS 2018, 85.1% infants were ever breastfed compared to 82.1% in 2014.

 

This success may be attributed to the implementation of the MO “Show-Me 5” hospital initiative that is based on the Baby Friendly Initiative, launched in 1991 by UNICEF and the World Health Organization (WHO) to ensure that hospitals become centers of breastfeeding support. Based on PRAMS 2018, Missouri mothers reported that hospitals provided breastfeeding information (95.4%), allowed “rooming in” or staying with baby in same room during hospital stay (90.6%) and a few Missouri infants were not given a pacifier while in the hospital (37.9%).

 

Employment has been identified as a barrier to breastfeeding duration, but relatively easy supports can be put in place to help new mothers reach their breastfeeding goals when returning to work. Supplementation with infant formula for non-medical needs has also been identified as a barrier to breastfeeding duration. Based on the 2018 CDC’s breastfeeding report card, 14.0% of breastfed infants received formula before they were two days old, an increase from 10.9% in 2016.

 

The American Academy of Pediatrics (AAP) continues to reaffirm its recommendation of exclusive breastfeeding for the first six months of a baby’s life. This recommendation is supported by positive health outcomes, as well as social and economic advantages for mothers and children, making it a public health issue and not only a lifestyle choice. Families require an enabling environment to achieve optimal breastfeeding. Multiple methods across different venues were used in Missouri to increase support for breastfeeding.

 

Hospitals

During this reporting period, two Missouri hospitals were recognized as Missouri “Show-Me 5” hospitals, for a total of nineteen. Hospitals seeking this recognition have implemented five out of the Ten Steps to Successful Breastfeeding, a set of evidence-based measures developed by the WHO and adopted by the Baby Friendly Hospital Initiative (BFHI). The MO DHSS course titled “Fundamentals of Breastfeeding: an 18 Hour Course” was offered at two sites in the state. This training brings together health care providers from hospitals, health departments and the Women, Infants and Children (WIC) program to learn basic information on breastfeeding. Attending this course can assist hospitals in getting the staff training necessary to meet the standards of the BFHI. DHSS was able to provide a 45-hour exam preparatory course at no cost to potential International Board Certified Lactation Consultants (IBCLCs) during this period, thanks to grant funding from the Centers for Disease Control’s (CDC) State Physical Activity and Nutrition (SPAN) grant. The state breastfeeding coordinator facilitated this training in the St. Louis area, and it was attended by 40 participants from WIC local agencies, health care facilities, and community partners. This training will be offered in partnership with the Bureau of Community Health and Wellness (BCHW) once per year for the next four years, at locations around the state. This will increase the number of IBCLCs available to support Missouri mothers.

 

Additionally, DHSS partnered with the Missouri Breastfeeding Coalition to hold the Fourth Annual MotherBaby Summit to promote the Missouri “Show-Me 5” and the Baby Friendly Hospital Initiatives to hospital stakeholders, including hospital administrators and labor and delivery nurse managers. A total of 135 maternity leaders from 35 of the state’s 63 maternity facilities attended the one-day event, which was an increase from the previous year with 128 attendees from 37 hospitals. This event not only provided education for hospital staff, it also served to provide networking opportunities. There was no need (during this reporting period) to contract with physicians or nurses to provide training at hospitals on “Show-Me 5” steps. The MotherBaby Summit was generously funded by Dr. Bobbi Philipp of Boston Medical Center, through her grant with the W.K. Kellogg Foundation and in part by the SPAN grant from the CDC. 

 

Local Public Health Agencies (LPHAs)

One hundred eleven of the 114 LPHAs reported active promotion of breastfeeding initiation at birth and the continuation of breastfeeding through the first six months of life, and of those, 56 LPHAs reported working with community partners to promote breastfeeding. The MCH Services Program contracted with 113 LPHAs to improve health outcomes for Missouri infants, and many LPHAs are intentionally focused on improving health outcomes for Missouri mothers and infants by increasing breastfeeding initiation and duration rates. The LPHAs promoted breastfeeding initiation and continuation through encouraging increased community participation related to the support of breastfeeding in local breastfeeding coalitions and task forces and ongoing educational efforts to increase awareness and knowledge of the benefits of breastfeeding.

 

Specific areas of LPHA activities worth highlighting include:

Breastfeeding Peer Counselor/ IBCLC

• Dunklin County Health Department participated in state, regional, and local breastfeeding coalitions and has one IBCLC on staff who provided breastfeeding supportive and lactation consultation services.
• Callaway County Health Department’s breastfeeding peer counselor continued to promote breastfeeding friendly worksites. 
• Laclede County Health Department has two IBCLCs and one breastfeeding peer counselor who supported breastfeeding and provided education through the WIC program and offered lactation consultations; the breastfeeding peer counselor is available for support after-hours.
• Scott County Health Department was recognized as a Breastfeeding Friendly Worksite and partnered with Ferguson Medical Group (Scott City, MO) to establish three lactation rooms available to staff and clients at Ferguson Medical Group.
• Benton County Health Department’s breastfeeding peer counselor offered breastfeeding support and utilized referrals to a lactation specialist when needed.
• Butler County Health Department participated in a breastfeeding task force with local hospital and WIC staff to enhance local breastfeeding education and support to breastfeeding mothers.
• Sullivan County Health Department’s breastfeeding peer counselor provided breastfeeding support and hosted a monthly MOMS (Moms Offering Moms Support) group on a wide variety of topics. 

Breastfeeding Support Groups

• Dunklin County hosted breastfeeding support groups with Baby Cafes every other month and offered nine breastfeeding classes each month.
• Laclede County Health Department hosted breastfeeding support groups and quarterly meetings open to the community.

Breast Pump Lending Programs/Resources

• Cole, Dunklin, Jasper, Knox and Osage county health departments offered a breast pump lending program.
• Carroll County Health Department loaned breast pumps to WIC and non-WIC mothers and maintained a lending library of educational materials related to breastfeeding.

Baby Fair/Community Wide Baby Shower

• Callaway County Health Department held their fourth annual public Mommy & Baby Fair.
• Barton County Health Department held its annual spring and fall baby showers open to WIC and non-WIC participants.
• Phelps-Maries County Health Department held their fourth annual Breastfeeding Walk with 146 participants.

 

Breastfeeding Friendly Sites

Efforts to promote worksite lactation support have continued through the Missouri Breastfeeding Friendly Worksite Program. A total of 21 new worksites were recognized during this reporting period, covering a total of 3568 new employees. This brought the total number of Breastfeeding Friendly Worksites to 560. DHSS continued to collaborate with the Missouri Breastfeeding Coalition on hospital, worksite and childcare initiatives. Bimonthly conference calls were held with attendance from DHSS, local health departments, local breastfeeding coalitions, hospital nurses and other breastfeeding professionals. DHSS also provided lactation rooms to support state employees who were pumping breast milk at work for their infants.

 

BCHW collaborated with Missouri Council for Activity & Nutrition’s (MOCAN) Worksites Workgroup to help businesses by providing free resources to offer a wellness program for staff. The goal is to decrease health care costs and improve productivity, engagement, and performance. A component of the Toolkit and accompanying Award describes breastfeeding accommodations. The Breastfeeding Friendly Worksite Program is a requirement of the Missouri Workplace Wellness Award, which publicly recognizes employers that invest in creating a culture that supports healthy behaviors. The WorkWell Missouri Toolkit assists employers with reducing risk factors for the most costly, common, and preventable chronic diseases. The Toolkit helps organizations plan and improve workplace wellness policies and practices. Also provided were sample promotional items, campaigns, and tools to assist employers with wellness.

 

BCHW continued to recognize child care providers supporting breastfeeding families. An online training about breastfeeding support for child care providers was created and is now available for providers to gain one clock hour and fulfill one requirement of the Breastfeeding Friendly Child Care Program. BCHW recognized 10 child care providers as a Breastfeeding Friendly Child Care during FY19 with a total of 85 providers currently recognized. The Missouri Breastfeeding Coalition and local breastfeeding coalitions, newsletters and emails from the Child and Adult Care Food Program, Child Care Health Consultants, and Division of Regulation and Licensure promoted the DHSS recognition programs. Trainings provided by LPHAs also promoted these programs.

 

Mini grant funding ($500 each) was awarded to 26 businesses to create or improve lactation rooms, all of which were then designated a MO Breastfeeding Friendly Worksite. Other collaboration included partnering with the Missouri Council for Activity and Nutrition, Missouri Chamber of Commerce, and the Missouri Chapter of Society of Human Resource Managers to educate employers on the Affordable Care Act (ACA) provision for employers to provide workplace accommodations that enable breastfeeding employees to express breast milk.  

 

Health Equity

The State Breastfeeding Coordinator and BCHW worked to build a partnership with two Black led businesses to determine how best to support their work of increasing lactation supporters of color in those communities. The state will provide funding (through CDC SPAN grant) during FY20 to help increase the number of Black women working as lactation supporters in Kansas City, St. Louis, and the Bootheel Region. In addition, the state will partner with these organizations, Uzazi Village and Jamaa Birth Village, to support research on the experiences of Black women in Baby Friendly hospitals.

 

The State Breastfeeding Coordinator attended the 2019 United States Breastfeeding Coalitions Convening, a conference aimed at assisting breastfeeding coalitions to grow their work. The subject of the 2019 conference was reducing disparities in breastfeeding and lactation work, applying a racial equity focus to projects aimed at breastfeeding promotion and support, and showcasing programs that are succeeding in this work. Two members of the Missouri Breastfeeding Coalition also attended the conference with the generous support of the United States Breastfeeding Committee. Attending this conference helped to increase understanding of both current disparities and ways to reduce these disparities with intentional program planning.

 

DHSS promoted Missouri Breastfeeding Month through a social media campaign and provided campaign messages to local agencies. The Missouri WIC program continued to provide the Breastfeeding Peer Counseling Program in 88 local agencies, with more than 130 Peer Counselors providing lactation support to WIC families. Peer Counselors are chosen from and are representative of the community in which they practice, which improves culturally appropriate lactation support. Statewide peer counseling training and meetings took place throughout the year, improving the skills of the peer counselors. Local WIC professional staff also continued to be trained on breastfeeding. Forty-six local WIC agencies received designation and additional funding as a Breastfeeding Friendly WIC Clinic, which is a Missouri designation that recognizes WIC local agencies that provide exemplary breastfeeding support. WIC is an important partner with MCH, because the two programs serve the same or similar participants. In many rural communities, WIC staff members are the only lactation support providers. Each WIC office also provides a lactation room that can be used by employees, participants, or other members of the community. WIC staff members, including peer counselors, are encouraged to participate in community breastfeeding coalitions and to partner with their local health care providers and hospitals to increase the continuity of breastfeeding support.

 

Additional Resources

Child Care Providers

In FFY2019, the Child Care Health Consultation (CCHC) Program provided 9.5 hours of breastfeeding continuing education credits. These sessions included information specific to: the benefits of breastfeeding, proper care of breast milk, how to support a breastfeeding mother, and how to become a breastfeeding friendly child care facility. By offering this service, more families and child care providers supported and promoted breastfeeding.

 

Home Visiting

The Bureau of Genetics and Healthy Childhood (GHC) evidence-based home visiting programs promoted breastfeeding prenatally and encouraged sustained breastfeeding postnatally. Among mothers who enrolled in GHC supported home visiting prenatally, data from FY19 indicated that 32% of infants (51/158) who were breastfed continued to receive any amount of breast milk at 6 months of age. The home visiting program also collects breastfeeding data on the zero age form to determine whether the mother breastfed the newborn after delivery, even for a short period of time (includes pumped breast milk and donor milk). The data collected on the zero age form indicated that for FY19, 80% of infants enrolled in home visiting at the time of birth had breastfeeding initiated after delivery. 

 

Women enrolled in GHC supported home visiting are encouraged by their home visitors to enroll and participate in the supplemental nutrition program for WIC early in their pregnancy and are encouraged to meet with WIC peer counselors to receive information and additional support regarding the benefits of breastfeeding. To further support the home visitors as they support new mothers to breastfeed, the GHC home visiting program collaborated with the State Breastfeeding Coordinator to provide a session during the annual home visiting summit on March 7, 2019. The session, entitled, Secrets of Baby Behavior, demonstrated practical knowledge of normal infant behavior including infant sleep states, sleep patterns and crying, and the relationship between infant behavior and appropriate infant-feeding practices. Diagnostic resources were also made available for home visitors and families. Other support provided to all GHC contracted home visiting programs during 2019 included the 4th quarter CQI newsletter, Quality Outlook, provided information by World Alliance for Breastfeeding promoting National Breastfeeding Month and World Breastfeeding Week (August 1-7, 2019) http://worldbreastfeedingweek.org/; and the following resources through the Missouri Home Visiting Gateway Weekly Update:

• 10/12/18 - Improving Our Approach: Better Conversations About Breastfeeding (Webinar)
• 10/19/18 - Better Sleep for Breastfeeding Mothers, Safer Sleep for Babies

• 3/22/19
  • No mother should feel alone on her breastfeeding journey and in an increasingly digital age, telelactation support is a powerful opportunity to increase breastfeeding rates among mothers who cannot access classes.
  • Babies "rooming-in" with mothers after birth not only has the potential to improve health outcomes for moms and babies, but it is a critical strategy for closing equity gaps in breastfeeding and, in turn, equity gaps in maternal and infant health.
• 5/31/19 - Caring for Pregnant and Breastfeeding Women with Opioid Use Disorder on June 11, 2019. (Webinar)
• 8/9/19 - Breastfeeding is beautiful—and it is challenging. That’s why moms and caregivers need health professionals who can support them on every step of their journey. 
• 8/16/19 - In honor of National Breastfeeding Month, we’ve taken time with Lori Feldman-Winter, MD, MPH, an internationally and nationally recognized expert on breastfeeding nutrition, education and policy. 
• 8/23/19 - This publication from the Department of Health and Human Services' Office on Women's Health has how-to information and support to help women breastfeed.
• 8/30/19 - August is National Breastfeeding month. Despite the benefits of breastfeeding for infants and mothers, US rates remain below Healthy People 2020 breastfeeding objectives.  

 

Text4Baby

The Text4Baby program provided pregnant women and new mothers five breastfeeding text messages during pregnancy and three during the first year after baby’s birth. Approximately 11,563 expectant and new mothers received messages pertaining to breastfeeding in FY19. Messages sent during pregnancy included:

• Week 9 – “If you qualify, WIC provides healthy foods, healthcare referrals, nutrition education, & breastfeeding support. Call 800-392-8209 & ask for WIC. If you need help getting food, call the National Hunger Hotline at 800-548-6479.
• Week 25 – “Are you thinking about breastfeeding? Breast milk is the best food for babies. To learn more about breastfeeding, visit text4b.org/028.”
• Week 26 – “Did you know that if you qualify, WIC can help you with breastfeeding? To find a local WIC office, call 800-392-8209 or visit text4b.org/060.”
• Week 33 – “Premature babies need extra help with breastfeeding. Even if your baby can’t breastfeed at first, she can still be fed your pumped milk.”
• Week 39 – “Help protect your baby from illnesses like the flu. Breastfeed right after baby’s born. Your milk can help fight disease & protect your baby. Have questions or concerns about breastfeeding? Call 800-994-9662 for help before pregnancy and once you start nursing baby.”

Messages sent postpartum included:

• Week 4 – “WIC supports Moms with healthy foods, referrals, nutrition education & breastfeeding support. Call 800-392-8209 or visit text4b.org/018. Want to check the safety of your medicines during breastfeeding or pumping? Ask your Dr. and search here: toxnet.nlm.nih.gov/newtoxnet/lactmed.htm.”
• Week 8 – “Back to work? You can pump milk at work to save for later. Breastfeeding helps you & your baby re-connect at the end of each work day. Medicine you take while breastfeeding may enter your milk. Ask Dr. /midwife (CNM/CM) or lactation consultant before taking any meds. Or call 866-626-6847.
• Week 24 – “Even if you get sick, you can keep breastfeeding your baby. Worried? Call your Dr., midwife (CNM/CM) or lactation consultant.”

 

SPM #2 Safe Sleep – Percent of infants placed to sleep on their backs.

 

According to the American Academy of Pediatrics (AAP), throughout the first year of life, sleeping babies have died accidentally from: suffocation; smothering; wedging; being trapped under someone else while sharing a bed; being placed to sleep on a sleep surface not intended for an infant; and from Sudden Infant Death Syndrome (SIDS). Infant deaths due to unsafe sleep practices continue to be a significant contributor to infant deaths in the US and Missouri. The AAP has issued evidence-based recommendations for a safe infant sleep environment. The recommendations are based on epidemiologic case-control studies of infants up to one year of age. Even though Safe Sleep was not selected as a top priority during the 2016-2020 needs assessment process, Missouri selected the percent of infants placed to sleep on their backs as a State Performance Measure. According to 2018 data from the Pregnancy Risk Assessment Monitoring System (PRAMS), there was an 8.5% increase of Missouri mothers (84.0%) who placed their infants on their backs to sleep from 2014. This is slightly higher than the U.S. rate of 80.6% (2018) and the Missouri rate exceeded the HP2020 goal of 75.9%. Although women under 20 years old (80.7%)* less commonly placed their babies on their backs to sleep compared to their counterparts aged 20-24 years old (83.1%), and 35 years old and over (83.8%), they did so more frequently than their national counterparts (74.0%). Non-Hispanic Blacks (67.0%) also less frequently placed their babies on their back to sleep than non-Hispanic Whites (87.0%), however, the proportion from 2018 demonstrated a 15.3% increase in this practice from 2016. The frequency of laying infants on their backs for non-Hispanic Blacks was greater in Missouri than for their national counterparts (64.8%). College graduates were the highest proportion of Missouri mothers who laid their infant on their back (89.8%). In Missouri, those with private insurance had a higher percentage of infants placed to sleep on their backs (86.9%) than those on Medicaid (82.1%). Continued education and outreach is needed to increase the awareness of the mothers and caregivers who are not practicing safe sleep.

 

Cribs

Safe Cribs for Missouri

The Safe Cribs for Missouri program provides portable cribs and safe sleep education to low-income families who have no other resources for obtaining a crib. The program utilizes both Title V and state funding from the Children’s Trust Fund. Implementation of the program includes partnering with multiple LPHAs. The overall goal of the program is to support families and reduce the risk of sleep-related infant deaths. Eligibility criteria include participation in two educational sessions using the evidence-based AAP guidelines on the topic of safe sleep. The initial one-on-one education session utilizes a 10-item checklist of safe sleep teaching points. The client and educator both initial each item on the checklist to document that the item was covered. If additional caregivers participate in the education, they also sign the checklist. Brochures on safe sleep, secondhand smoke, and car safety for pregnant women and infants are also utilized. Newborn t-shirts with “This Side Up While Sleeping” printed on the front are also provided. In addition, each participant views the 12-minute Never Shake & Safe Sleep for Your Baby video. The educator demonstrates how to set up the crib, and the client then practices the set-up. The follow-up education session is conducted in the home approximately 4-6 weeks after the crib is received, or when the infant is 4-6 weeks old. The educator observes the infant’s sleep environment, answers questions, addresses any barriers and provides additional education as needed. Pre and post-surveys are used to measure learning and implementation of safe sleep practices.

 

A total of 334 cribs were distributed and 641 one-on-one educational sessions were provided. In addition, the program partnered with Infant Loss Resources, Inc. (ILR) to provide cribs in the St. Louis area. According to Missouri’s Child Fatality Review Program 2017 Report, a black baby in St. Louis is 4 times more likely to die of a sleep-related cause than a white baby. The Safe Cribs for Missouri program also collaborated with several other state agencies in designing a statewide safe sleep strategic plan. One of the five key aims of the strategic plan is focused on health equity and reducing disparities. Given the significant disparities in sleep-related deaths in Missouri, addressing contextual factors around health equity, culture, and tradition is crucial to a successful campaign.

 

Safe Kids

The Bureau of Community Health and Wellness serves as the state lead for Safe Kids Worldwide to implement and facilitate accomplishment of common goals and objectives concerning childhood injury prevention. Nine Safe Kids coalitions cover 54 counties in Missouri. Through this network, more than 850 cribs were provided along with AAP safe sleep education and training. In addition, 200 safe sleep events were held to help reduce the risk of injury and death of infants due to unsafe sleep environments. These events involved more than 2,457participants such as expectant parents, parents, caregivers, relatives, grandparents, and foster parents. These activities were accomplished with support from the MCH Block Grant and alternative sources of funds.

 

Local Public Health Agencies

Specific local agency efforts included the following:

• Camden, Clay, Daviess, Harrison, Henry, Jackson, Linn, Macon, Miller, Morgan Ozark, and TriCounty county health departments provided a Safe Crib Program with safe sleep education and distribution of portable cribs. Ozark County provides Pack-n-play cribs for free through the Safe Sleep for Babies program.

• Springfield-Greene County Health Department collaborated with Safe Kids Springfield, hospitals, and other organizations to sustain safe crib distribution and education programs for providers and families.
• Monroe County provided a safe cribs program and conducted home visits for newborns as needed.

 

Child Care Providers

Section for Child Care Regulation (SCCR) provides technical assistance to potential child care providers who seek to become licensed. In Missouri, licensed child care providers who care for children younger than twelve months of age are required to have a safe sleep policy in accordance with the AAP. As the policies are developed, SCCR staff provide technical assistance and resources to assist child care providers in developing and implementing their policy. After they receive a license to care for children under the age of 12 months, regular inspections are conducted to ensure that compliance is met.

 

SCCR monitors compliance for all rules including those relating to infant safe sleep policies and practices during initial licensing inspections and ongoing compliance inspections throughout the state. When violations are cited, SCCR staff provide technical assistance to the provider to educate them on the rules so they can achieve and maintain compliance with the rules regarding infant safe sleep. In FFY19 SCCR cited 261 fewer violations than in FFY18. This shows that child care providers are continuing to improve their policies and practices regarding infant safe sleep. To reduce this number further, SCCR developed and is distributing a poster specifically for child care using the most frequently violated rules. This poster is being used in conjunction with technical assistance to further educate the providers who are directly providing infant care. This information shows that while we have made a significant step in the right direction, there is still more work to be done to ensure that every infant in Missouri is cared for in a safe environment with properly trained caregivers.

 

Infant Safe Sleep training that is in accordance with AAP guidelines is delivered statewide and is required of all child care providers who work in facilities licensed to care for infants. In FFY19 16,224 child care providers successfully completed the online/on-demand infant safe sleep training offered by SCCR. Approved infant safe sleep training must be completed when an individual begins employment and must be repeated every three years, however, when facilities continue to show noncompliance with infant safe sleep rules, SCCR staff encourage this training to be completed annually.

 

In FFY2019, the Child Care Health Consultation (CCHC) Program offered 61.5 hours of continuing education trainings for child care providers, 3 hours of specialized consultation, and 5 technical consultations regarding safe sleep, including policy development. The CCHC Program’s goal through offering these services was to support and promote safe sleep practices in childcare, decrease the number of children exposed to unsafe sleep practices, and increase policy development in the child care setting. 

 

Outreach

Text4baby

There are five customized texts related to safe sleep available from Text4baby, which sends free text messages with health information and helpful tips during pregnancy and until a baby turns one. Participants enrolled in the program received the following messages:

• Week 2 of infancy message "In the crib, use only a firm crib mattress & fitted sheet. Do not use crib bumpers because baby can suffocate. Info at healthychildren.org/safesleep. Blankets can cause baby to suffocate. Have baby sleep in infant pajamas with feet or sleep sacks to keep baby safe & warm: text4b.org/106."
• Week 3 of infancy message "Babies should always sleep on their back in a crib. Even for naps. Keep baby in the room with you but not in your bed. No stuffed animals, blankets or pillows in the crib. Soft things can go back in baby's bed at age 1, but right now they could cause baby to suffocate."
• Week 10 of infancy message "Share with anyone caring for baby the safest way for baby to sleep is on their back, in a crib, with no stuffed animals, blankets or pillows. Smoke raises risk of sickness or death from SIDS. Protect baby & don't let anyone smoke near baby at home or in the car. Info: text4b.org/010."
• Week 16 of infancy message "At this age, many moms have questions about baby's food and sleep. Visit text4b.org/004 for info on feeding. Checking on baby at night? Keep baby in a crib near your bed to help you see he's safe. Safe sleep info: 800-505-2742 or visit text4b.org/106."
• Week 20 of infancy message "The safest way for baby to sleep is alone in a crib on her back. Never put baby to sleep on sofa or pillow. Tell this to everyone who cares for baby."

 

Two messages are also sent prior to the birth of the baby during the 32nd and 38th weeks of pregnancy. These messages reinforce the importance of having a crib, placing baby on their back to sleep, and nothing in the crib while baby sleeps. In FY19 an average of 928 participants were enrolling in the Text4baby program each month.

 

Media

In collaboration with the State Safe Sleep Coalition, consistent safe sleep messages were developed to provide to all partners working with families with young children. This included 33 safe sleep social media messages, E-newsletter articles, and several presentations/webinars. 

 

Birth Certificate Project

The majority of birth certificates issued for children less than one year of age come directly from the LPHAs. The MCH Services Program partnered with 42 LPHAs to provide the Safe to Sleep brochure and information on local safe sleep resources, including sources for free cribs, when the LPHAs issued or mailed birth certificates for children less than one year of age.

 

Collaborative Initiatives

The Title V MCH Director served on the Generate Health/FLOURISH St. Louis Infant Health Action Team, which focused its efforts on the promotion of safe sleep practices, helped facilitate a Safe Sleep Summit in the St. Louis area, and completed Safe Sleep Champion Training. The Title V MCH Director and MCH District Nurse Consultants (DNCs) also served on regional coalitions promoting safe sleep practices, including NurtureKC, a regional MCH Coalition,, Kansas City Metro Safe Sleep Initiative, Kansas City Health Commission on Women, Infants and Children's Health workgroup, Bootheel Healthy Start, Bootheel Babies & Families, Generate Health St. Louis Regional Health Initiative, St. Louis Prenatal Care and Infant Wellness Collaborative, and Safe Kids state and regional coalitions. Safe sleep habits was one of the focus areas of the Bootheel Babies & Families initiative, and the Southeast DNC served as a member of the Executive Committee. As a result of these collaborations, the Title V and MCH Services Program staff build relationships with regional and state partners, resources, networks, and service providers and gain valuable information regarding specific topics, resources, and initiatives. They are then able to share the information gained with the LPHAs and other DHSS programs, make connections between the LPHAs and the regional and state partners, resources, networks, and service providers, and share DHSS initiatives and priorities with the regional and state coalitions/teams.

 

Specific local agency efforts included:

• Scott, Mississippi, Dunklin, Pemiscot, Stoddard, and New Madrid county health departments provided safe sleep education to their communities and were involved with collaborative efforts to promote safe sleep through Bootheel Babies and Families.
• Benton County promoted Safe Sleep through local Head Start events and offered weekly Safe Sleep classes for families and community members.

 

Policies & Practices

Hospitals

The Bureau of Genetics and Healthy Childhood works with Infant Loss Resources, Inc. (ILR) and Generate Health St. Louis to provide safe sleep education and technical assistance to hospitals. The goal is to increase the number of Missouri hospitals certified by the Cribs for Kids Safe Sleep Hospital Certification Program.  

 

Local Public Health Agencies

Through the MCH Services contracts, 107 LPHAs reported active promotion of safe sleep practices, and 57 LPHAs reported working with community partners to promote safe sleep practices. LPHA activities to promote safe sleep included promotion of safe sleep policies and practices, safe sleep education, referral to pregnancy and parenting resources, and provision of free portable cribs with accompanying safe sleep education and follow-up in-home assessment of safe sleep practices.

 

Five LPHAs selected safe sleep as a priority health issue for their three-year work plan. FFY 2019 was year one of this plan, during which these LPHAs worked toward system outcomes for safe sleep practices including:

• Increased number of families receiving home visiting services including safe sleep education;
• Increased number of safe sleep policies, practices, and environments at childcare centers, schools, churches, and businesses;
• Increased number of non-licensed, in-home child care settings that implement safe sleep practices for infants in their care;
• Increased number of staff who work in child care or with faith-based organizations who are educated about safe sleep policies and practices;
• Increased number of community members who are educated on safe sleep practices and can identify why they should follow safe sleep practices routinely;
• Increased number of providers (childcare, healthcare providers, etc.) with current materials, and
• Increased support and educational opportunities for parents on safe sleep.

• In addition, Laclede County Health Department developed a “Safe Sleep Crib” to serve as an educational prop during community events and in-house training sessions to help individuals identify safe sleep issues. Jackson County Health Department was able to generate specific zip-code information aggregated by race for infant mortality rates in Eastern Jackson County; staff contacted providers within the higher affected zip codes to distribute materials on safe sleep and the Baby and Me Tobacco Free Program, offered through the LPHA.

 

Home Visiting

GHC funded home visiting services offered in 26 counties and served 1,087 families through the Missouri Building Blocks (BB), Healthy Families Missouri Home Visiting (HFMoHV), and the Maternal, Infant and Early Childhood Home Visiting (MIECHV) programs. These programs implemented the following evidence-based models:

• Nurse Family Partnership model;

• Healthy Families America model;

• Parents as Teachers model; and

• Early Head Start Home Based Option model. 

All GHC supported home visitors actively promote and provide resources on the ABCs (Alone, on their Back, in a Crib) of Safe Sleep. Home visitors also promote safe sleep in obtaining portable cribs for families who do not have and cannot afford a crib for their infant through the Safe Cribs for Missouri program or other local resources. Safe sleep practices are tracked on child age forms at age zero, and follow-up continues on the 1, 2, 3, 6, 9, and 12 month forms. Data from FY19 indicated that 80% of infants (437/544) less than age 12 months enrolled in GHC funded home visiting programs were always placed to sleep on their backs, without bed-sharing or soft bedding. 

 

Additional supports provided to all GHC supported home visitors included:

• October 2018 - SIDS Awareness Month was highlighted to all local implementing agencies through the 1st quarter CQI Newsletter, Quality Outlook, by providing safe sleep tips and a link to Children’s Trust Fund to see the Never Shake & Safe Sleep for your Baby DVD https://ctf4kids.org/never-shake-safe-sleep-for-your-baby-dvd/. The Safe to Sleep® Campaign website, https://www.nichd.nih.gov/sts/about/Pages/faq.aspx also included a helpful FAQ page and safe sleep videos for grandparents.
• March 2019, Annual Home Visiting Summit included a presentation on Home Safety Education and Safe Sleep that home visitors could attend, and several new resources were shared by the GHC home visiting program through resource bags related to safe sleep, including a Home Safety Inventory, a Home Visiting Safe Sleep Assessment Tool, and materials from the DHSS Literature Warehouse and the Consumer Product Safety Commission.

 

Through the Missouri Home Visiting Gateway Weekly Update the following resources were shared:

• 11/2/18 - In honor of Safe Sleep Awareness Month, Children’s Safety Network released a new blog post with data and resources on Sudden Unexplained Infant Death (SUID).

• The Centers for Disease Control and Prevention (CDC) has published an online feature titled "Helping Babies Sleep Safely." - HRSA Home Visiting Digest

• 11/9/18 - There has been a recent trend of cardboard baby boxes for infants that are supposed to promote their sleeping. - Pregnancy/Maternal Health News Medical

• 11/30/18 - Hospitals across the country are developing a set of evidence-based best practices to help health professionals engage families in effective and relevant conversations about safe sleep. - NICHQ
• 12/14/18 - All families deserve to celebrate decades of holidays together. Individualized and culturally relevant conversations about safe sleep and breastfeeding can help make that happen. – NICHQ
• 4/12/19 - Report from Consumer Reports - There have been 32 deaths in a Rock 'n Play Sleeper.

• 4/19/19 - Infant Safe Sleep:  An Introduction and Model Program (Webinar).
• 5/3/19 - Infant fatalities have occurred in rocking sleepers, after infants rolled from their back to their stomach while unrestrained, or under other circumstances. - Consumer Product Safety Commission
• 5/17/19 - Rates for accidental suffocation and strangulation in bed have increased from 6 deaths for every 100,000 live births in 1999, to 23 deaths in 2015. - Children’s Safety Network
• 7/19/19 - Swaddling babies snuggly in a blanket mimics the confines of the womb and can comfort babies and promote sleep. - NICHQ 
  • American Indian, Alaskan Native, and non-Hispanic black babies are most likely to die from sleep-related causes, and face the highest rates of Sudden Unexpected Infant Deaths (SUID). - NICHQ
• 8/9/19 - Infant fatalities have been reported while using inclined sleep products, after the infants rolled from their back to their stomach or side while unrestrained, or under other circumstances. - Consumer Product Safety Commission
• 8/23/19 - What Does a Safe Sleep Environment Look Like flyer includes information on where to find safe cribs and answers to common questions. - Missouri Department of Health and Senior Services
• 9/27/19 - Black families are twice as likely as white families to have their baby die in the first year of life. – NICHQ

 

* Interpret with caution due to sample size limitations.