MCH Block Grant FY21 Application & FY19 Report

Perinatal/Infant Health Domain

NPM-03: Perinatal Regionalization: Percent of very low birth weight (VLBW) infants born in a hospital with a Level III+ Neonatal Intensive Care Unit (NICU)

FY19 Annual Report

Program Activities:

The Performance Measure was achieved. The Performance Objective was 90.0% and the Annual Indicator was 90.0%. Additionally, the Utah results are 7.5% higher than the Healthy People 2020 target of 83.7%.

According to a 2010 review of very low birth weight (VLBW) infants delivered in risk-appropriate settings, the percentage of VLBW infants born in hospital with a level III or higher neonatal intensive care unit (NICU), changed only slightly across all states and jurisdictions between 2000 and 2007 (74.2% to 74.7%, respectively).[1] Historically, Utah’s rate had been higher than the national rate and the Healthy People 2020 baseline of 75% and goal of 83.7%. According to the National Performance Measure 3 Risk Appropriate Perinatal Care Evidence Review, “Five states reported greater than 90% of VLBW births were delivered at level III or higher hospitals, a goal that may not be achievable in all states.”[2]

Accomplishments / Successes:

In comparing the rate of VLBW infants for Utah to the national rate, Utah had a rate of 1.09%, with a nationwide rate of 1.38%. The Utah VLBW rate was 26.6% lower than the national rate in 2018.[3] Utah implemented the CDC Levels of Care Assessment Tool (LOCATe) survey for understanding levels of care that serve pregnant women, mothers, and infants. The CDC LOCATe tool is based on the most recent guidelines and policy statement issued by the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and the Society for Maternal-Fetal Medicine. The results provided the levels of care by facility statewide. Having a standardized assessment of the delivering hospitals levels of care has been helpful in various forums including our Perinatal Mortality Review.

A key focus in FY19 was working with the hospitals on any discrepancies between the hospital level assessment and the LOCATe tool assessment, along with communicating the results to each hospital. Discussions with hospitals involved various emails and phone conversations, and involved more time that was originally anticipated. Each delivering hospital received an electronic summary of their results based on their survey answers and the CDC assessment, with details on their LOCATe assessed Neonatal and Maternal levels. This has been a helpful conversation starter, as well as a tool they can utilize when looking at expanding their services and/or hospitals. A new hospital opened in Utah October 2018, they completed the survey as well. Therefore, all delivering hospital in Utah, who delivered a baby during FY19, havea LOCATe assessed Neonatal Level. 

Utah has also worked to provide the CDC with data to conduct a multi-jurisdictional analysis. The CDC will use this data to assess outcomes by LOCATe level of care and provide additional insights on perinatal regionalization. The Memorandum of Understanding (MOU) with the CDC to share data was executed, and Utah provided this data to the CDC during FY19.

Summary of successes and accomplishments on “Moving the Needle” in relation to NPM-03:

• Worked with hospitals to resolve discrepancies between the hospital level assessment and the LOCATe tool assessment.
• Communicated the LOCATe assessment results to each hospital via electronic letter and summary.
• Executed a MOU to initiate a multi-jurisdictional analysis with the CDC to compile LOCATe data by outcomes and levels of care.

Challenges / Gaps / Disparities:

In 2015, a rule on VLBW Reporting was implemented in Utah. This rule requires hospitals to enter their VLBW data into a REDCap database. REDCap is a secure web application for building and managing online surveys and databases, which allows for robust data analysis and review. There has been decreased compliance with hospitals entering this information since 2017. Additionally, feedback from hospitals indicates that the requirement is burdensome due to the time it takes to pull or enter the data, and that they do not have the resources to compile the information. Therefore, this rule will be reviewed in order to determine if this rule should be renewed. or sunsetted going forward. 

Agency Capacity / Collaboration:

LOCATe has created various opportunities for informed conversations among stakeholders who work in the area of risk-appropriate care. Stakeholders include hospital administrators and clinicians, such as labor and delivery nurse managers and women and newborn directors. The Utah Women and Newborns Quality Collaborative (UWNQC), has Board and Committee members from each of the major health systems in Utah. This diverse support has helped to build collaboration with the Utah Department of Health, and increase understanding on benefits of the work with the CDC on LOCATe. CDC has been a key partner in completing the LOCATe analysis. The plan is to continue to use the results from CDC LOCATe for discussions on how we can continue to improve health outcomes for women and infants.

Summary Progress Report (2020) of ESMs related to NPM-03

The following ESMs were accomplished and have been categorized as “inactive”.

ESM 3.1 - VLBW REDCap Data: Percent of reporting by hospital facilities where VLBW infants were delivered

Goal/Objective:

Increase the percentage of reporting by hospital facilities where VLBW infants were delivered.

Significance of ESM 3.1:

Perinatal regionalization classifies hospitals at risk-appropriate levels in regards to care for both mothers and infants. This ensures that high-risk pregnancies and VLBW, preterm, or other at-risk infants have access to the most appropriate care. In Utah, hospitals self-designate their levels of care, and because of this, there is not uniformity with Utah’s leveling. In an attempt to dig past the surface of a self-proclaimed level and see what is actually happening in our facilities, a database has been created for all Utah hospitals to report the outcomes of every VLBW infant either delivered or transferred to their facility. This data will allow Utah to have a more informed conversation about the importance of perinatal regionalization through the eyes of some of our most ill and vulnerable infants.

ESM 3.1 Progress Report:

Maternal and Infant Program staff worked with Utah's delivering facilities to ensure that morbidity data on 100% of very low birthweight babies (VLBW) were entered into the REDCap system in compliance with rule 433-1. The implementation of the rule has made it possible to collect the data from all facilities and birth certificate data were used to verify reporting by delivering facility. With three years of data collected to date, this will provide information to analyze outcomes by level of care and birth volume and create a report of the findings. This report will help to determine if there are gaps in getting VLBW babies to be delivered in a hospital with a Level III Neonatal Intensive Care Unit (NICU).
 

ESM 3.2 - LOCATe: Percent of hospital facilities completing the LOCATe survey

Goal/Objective:

Increase the percentage of hospital facilities completing the LOCATe survey to 95%.

 

Significance of ESM 3.2:

Perinatal regionalization classifies hospitals at risk-appropriate levels in regards to care for both mothers and infants. This ensures that high-risk pregnancies and LBW, preterm, or other at-risk infants have access to the most appropriate care. In Utah, hospitals selfdesignate their levels of care, and because of this, there is not uniformity with Utah’s leveling. In 2009, a survey was administered collecting the levels of care from all Utah hospital facilities. Since 2009, four additional hospital facilities have opened their doors. In addition to collecting level of care information from these four additional facilities, it will also be valuable to be able to compare our data with hospital facilities nationwide.

 

ESM 3.2 Progress Report:

All but one hospital completed the survey. The hospital that did not complete the survey is a small rural facility with a minimal number of low risk deliveries.

 

ESM 3.3 - Standardized guidelines: Percent of hospitals facilities providing support to build a consensus based model of Utah Standardized Level of Care

Goal/Objective:

Increase the number of hospitals facilities providing support to build a consensus-based model of Utah Standardized Level of Care to 100%.

Significance of ESM 3.3:

A survey carried out by the MCH Bureau several years ago provided objective criteria that indicates that Utah currently has ten hospitals that self-designate as Level III Neonatal Intensive Care Units (NICU). However, the survey data collected indicated that according to published guidelines for Perinatal Care, the number of Level III NICUs in Utah may actually be smaller than originally believed. Currently, Utah regulations that designate Levels of Care for Perinatal Services are imprecise, and there is no regular oversight of NICU services by the UDOH. Through collaboration, the MCH Bureau has worked on developing Utah specific guidelines for Neonatal Care based on the seventh edition of Guidelines for Perinatal Care.[4] However, these Utah specific guidelines have remained in draft form for the last few years. Following the collection of Utah specific data on VLBW infants, we will be able to again approach creation of these guidelines.

ESM 3.3 Progress Report:

This involves collaboration with the CDC LOCATe, which helps to create standardized levels of neonatal care. The Neonatal area of LOCATe is based on the most recent guidelines and policy statements issued by the American Academy of Pediatrics. CDC will collaborate with us to provide technical assistance on interpretation of the data collected. Once the data validation of each delivering facility in Utah is complete, we will present the data to the UWNQC. If needed, UWNQC will provide guidance on the best way to move forward on standardized guidelines for designation of Level III NICUs. Development of consistent statewide neonatal level of care designations will provide helpful information for pregnant women when making delivery decisions. In addition, it may potentially reduce the risk for complications if more women at high risk for a VLBW baby choose to have their baby at a facility that can provide the level of care needed for a safe delivery.

 

*NPM-3 and related ESMs were discontinued following the 2020 MCH Needs Assessment.

MCH Block Grant FY21 Application & FY19 Report

Perinatal/Infant Health Domain

NPM-04A & NPM-04B: Breastfeeding

NPM-04A: Breastfeeding: Percent of infants who are ever breastfed

NPM-04B: Breastfeeding: Percent of infants breastfed exclusively through 6 months

FY19 Annual Report

Program Activities:

NPM-4A: The Performance Measure was not achieved. The Performance Objective was 90.0% and the Annual Indicator was 89.7%.

NPM4B: The Performance Measure was not achieved. The Performance Objective was 28.0% and the Annual Indicator was 27.8%.

The Stepping Up for Utah Babies program continues to work with and recruit delivering hospitals for statewide implementation. During FY19, two hospitals, Castleview Hospital and Layton Hospital, were trained in the Stepping Up program. Castleview Hospital is located in Carbon County, a rural area of Utah. Layton Hospital is located along the populous Wasatch Front. However, it is a brand new hospital, which allows the policies and procedures outlined by the Stepping Up program to be considered the norm, when patients deliver in that facility. After the initial training, the hospitals began working towards implementing at least two evidence-based steps, identified by the Ten Steps to Successful Breastfeeding.

The Utah WIC program developed a statewide goal in FY19 to increase referrals to the Utah WIC Peer Counseling Program. These referrals are documented in the WIC VISION Computer System. Additional goals included that each local agency will offer at least one training on breastfeeding; lactation education courses for WIC Staff, including peer counselors, will be offered as WIC funds allow; and the Utah WIC Breastfeeding Peer Counseling Program continues to collaborate with Utah Department of Health and community organizations.

In FY19, the Utah WIC Program referred prenatal and postpartum WIC participants to the WIC Breastfeeding Peer Counseling Program using the Nutrition Interview, Referrals, and Participant Care Plan screens in the Utah WIC VISION computer system. Additional referrals were made to the Utah WIC Breastfeeding Peer Counseling program by the MotherToBaby Utah (MTB UT) program. Furthermore, each local agency offered at least one training on breastfeeding, and many local agencies asked their peer counselors to participate in the trainings through sharing new breastfeeding research with other staff members. Finally, a 45-hour Lactation Education course was offered to all WIC staff members, including peer counselors.

During FY19, the Healthy Living through Environment, Policy and Improved Clinical Care (EPICC) program continued to reach out to, and collaborate with Utah worksites to create lactation policies that comply with federal and state laws. EPICC utilizes various worksite assessments to collect lactation data. During FY19, eight-nine worksites completed either the CDC Worksite Health Scorecard, Healthy Worksite Award, or EPICC Mini-Scorecard. Of those, thirty-two worksites currently have an existing breastfeeding policy in place that complies with federal standards. Forty-five worksites have created a new policy, formal communication, or revised and updated a policy for breastfeeding/lactation support for employees. EPICC staff and Local Health Departments (LHDs) reach out to worksites to provide technical assistance and breastfeeding support materials to ensure federal lactation law compliance and policy development.

Accomplishments / Successes:

Intermountain Healthcare continues to fully support and encourage all of member hospitals to implement the Ten Steps to Successful Breastfeeding through the Stepping Up program. As of FY19, all Intermountain Hospitals have been trained and created a breastfeeding policy that addresses the implementation of all ten steps. During FY19, participating hospitals successfully implemented a total of eighty-eight steps. Additionally, one hospital completed all ten steps and became the first hospital in Utah to complete the Stepping Up for Utah Babies program and certify as a “Breastfeeding Friendly Facility.”

We had some success in recruiting hospitals outside the Intermountain Healthcare system with the training of a rural, independent hospital.

The number of WIC Breastfeeding Peer Counseling Program referrals made in FY19 decreased from 9,606 to 9,026. However, the number of breastfeeding peer counselors employed by WIC increased from thirty-four to thirty-six. Utah rates for WIC’s ever breastfed prevalence, and the breastfeeding at six months, stayed consistent at 88% and 37%, respectively. Additionally, exclusive breastfeeding rates at three and six months stayed consistent at 31% and 19%, respectively. The breastfeeding at twelve months rate, decreased from 33% to 32%. The number of duplicated contacts to WIC participants for FY19 decreased to 14,514 prenatal contacts and 25,749 postpartum contacts.

Collaborating with the MTB UT Program was beneficial as its referrals contributed to the consistent breastfeeding prevalence rates. MTB UT provides information to help women initiate and continue breastfeeding when they have questions about medications or other exposures. One woman stated, “I thought I’d have to stop breastfeeding my baby for the two weeks I have to take this medicine. My milk supply isn’t good, so I was worried I’d lose it. Thanks so much for letting me know I can keep feeding her while I take it. You guys are real life savers!” It is common for women to ask questions about medications and exposures while breastfeeding, including pain relievers, cold medications, antidepressants, antibiotics, and herbal supplements. Women often hear conflicting information and need a trusted source for explaining why one provider says one thing and another provider says something that seems very different.

Additional accomplishments of the Utah WIC Breastfeeding Peer Counseling Program included extending outreach to local hospitals, medical offices, community programs, and community events. Several local agencies developed trailers that provide nursing mothers with a place to breastfeed at community events, such as local fairs. Three agencies created and hosted events to promote breastfeeding for World Breastfeeding Month. The Davis County WIC program hosted an annual Breastfeeding Conference, the Salt Lake County WIC Program hosted a Women’s Health & Breastfeeding Fair, and the Utah County WIC program held a Breastfeeding Conference. All of these events were available for WIC staff, community partners, and community members to attend. Furthermore, more local agencies are expanding the communication methods that peer counselors can use to contact WIC participants, such as through email, texting, social media, and after-hours breastfeeding hotlines. All of these communications methods improve the ease of providing breastfeeding assistance to WIC participants. 

To address the common challenge of inadequate pay to retain WIC Peer Counselors, the Salt Lake County WIC program began working with their human resources department to increase the pay rate for WIC Peer Counselors in their agency.

EPICC staff attended three worksite-networking events to increase exposure and collect worksite contacts. During these events, EPICC staff was able to connect with ten worksites to talk about lactation accommodations and provide resources and breastfeeding material. The EPICC program was able to provide breastfeeding support material, including and offered “Your Guide to Breastfeeding” packets to attendees at the Utah Worksite Wellness Conference. Fifteen worksites reached out for additional support and help in developing policies. EPICC was able to present in front of one Chamber of Commerce meeting and distribute breastfeeding resource. Local health department staff continue to conduct their own assessments, have reached out to twenty-three worksites within their jurisdictions, and promoted breastfeeding accommodation at the workplace. The EPICC Program is in the process of creating an on-demand breastfeeding webinar that explains the federal and state laws and describes the importance of breastfeeding support in the workplace. This will be shared with worksites in Utah. Additional materials on legislation and lactation in the workplace have been compiled and shared with LHDs and worksites as well as the EPICC website.

Summary of successes and accomplishments on “Moving the Needle” in relation to NPM-04:

• Intermountain Healthcare has endorsed the Stepping Up for Utah Babies program and has recommended that all hospitals in their system implement the program. As of this reporting, all Intermountain Healthcare Hospitals have been trained and have created a breastfeeding policy that addresses the implementation of all 10 steps.

• The Utah WIC Breastfeeding Peer Counseling Program extended outreach to local hospitals, medical offices, community programs, and community events.
• EPICC staff was able to connect with ten worksites to talk about lactation accommodations and provide resources and breastfeeding material. The EPICC program was able to provide breastfeeding support material, including and offered “Your Guide to Breastfeeding” packets to attendees at the Utah Worksite Wellness Conference. Fifteen worksites reached out for additional support and help in developing policies.
• During FY18 and FY19 five hospitals have completed all ten steps and have become certified as a Breastfeeding Friendly Facility under the Stepping Up for Utah Babies program.

Challenges / Gaps / Disparities:

An ongoing challenge to hospitals that have begun work on the Stepping Up for Utah Babies program, is the amount of additional duties administrators, nurses, and educators must take on to accomplish the requirements set by the program. However, this year, the first Intermountain Healthcare facility completed all ten steps. As a result, many of the other facilities were motivated to step up their timeline and complete steps. Furthermore, outreach to non-Intermountain facilities have proven challenging in identifying and talking to the correct person in the facility about the program.

One challenge that the Utah WIC Breastfeeding Peer Counseling Program faced during FY19 included inadequate funding to Peer Counseling program to provide current Peer Counselors with adequate pay or to provide them with benefits. The inadequate pay may contribute to the high turnover of Peer Counselors. Despite this challenge, there was an increase in the number of employed peer counselors from thirty-four to thirty-six between FY18 and FY19. An additional challenge reported by some local agencies was a lack of support of Utah WIC’s Breastfeeding Peer Counseling program at local hospitals.

The challenges outlined above may have contributed to the decreased number of WIC Breastfeeding Peer Counseling Program referrals and the decreased breastfeeding prevalence at twelve months rate. 

The EPICC program and LHDs continue to have difficulty with worksites not following up after initial contact has been made. Worksites often mention that they are not interested in working on breastfeeding policies, as other topics are a higher priority. Another common challenge worksite frequently state that they do not have employees who breastfeed or pump and there is no need for a policy. There is also confusion over the actual lactation accommodation law, what is required, what is considered “private space” and “reasonable break time.”

One emerging issue that the Utah WIC Breastfeeding Peer Counseling Program experienced in FY19 is the decreasing WIC caseload. Because the Utah WIC Program’s overall caseload is decreasing, there is a smaller caseload for the breastfeeding peer counselors, which limits the amount of hours that are available for them to work. Additionally, several local agencies reported that there is a lack of training resources for new peer counselors. To improve the resources available to peer counselors, the state WIC office applies for additional funds for 45-hour lactation courses for WIC staff, including peer counselors, to attend. A 45-hour lactation education course was offered in September 2018.

Agency Capacity / Collaboration:

Stepping Up for Utah Babies staff and staff from the EPICC program continue with a close partnership. Staff from the EPICC program advises Stepping UP staff on upcoming professional development opportunities, new breastfeeding research, and they use their community engagement opportunities and social media platforms to discuss and market the Stepping Up program.

The Utah WIC Program collaborates with all Utah Department of Health and MCH programs, as well as community organizations such as hospitals, medical offices, La Leche League, and the Utah Breastfeeding Coalition to optimize breastfeeding support for moms and babies. The Utah WIC Program also collaborates with local county events such as fairs, in order to provide a designated spot for breastfeeding moms to nurse. In addition, the Utah WIC Program receives and addresses consumer calls on breastfeeding referred by the MTB UT program.

The EPICC program will continue to partner with local health departments to assess new worksites on breastfeeding policy, accommodations, and leave time and provide information, resources, and technical assistance to assist with the implementation of breastfeeding policy and accommodations. The EPICC program is currently working with the Utah Worksite Wellness Council to create a separate “breastfeeding accommodation award,” as well as to provide additional outreach to worksite within their network and contacts. Additionally, EPICC will review the current resources on our website and the webinars offered to identify gaps and provide updated material to share with Public Employees Health Plan and insurance brokers.

Summary Progress Report (2020) of ESMs related to NPM-04

*ESMs 4.1- 4.3 have been deactivated following the 2020 MCH Needs Assessment.

Following is a progress summary of the old ESMs. The new ESMs are provided in the Annual Plan section.

ESM 4.1 - Stepping Up for Utah Babies: Number of Utah hospitals, that deliver babies, that have implemented some of WHO's evidence based Ten Steps to Breastfeeding Success*

Goal/Objective:

Increase the number of steps being implemented in Utah delivering hospitals.

Significance of ESM 4.1:

Advantages of breastfeeding are indisputable. The American Academy of Pediatrics recommends all infants (including premature and sick newborns) exclusively breastfeed for about six months as human milk supports optimal growth and development by providing all required nutrients during that time. Breastfeeding strengthens the immune system, improves normal immune response to certain vaccines, offers possible protection from allergies, and reduces probability of SIDS. Research demonstrates breastfed children may be less likely to develop juvenile diabetes, may have a lower risk of developing childhood obesity and asthma, and tend to have fewer dental cavities throughout life.

The bond of a nursing mother and child is stronger than any other human contact. A woman's ability to meet her child’s nutritional needs improves confidence and bonding with the baby and reduces feelings of anxiety and post-natal depression. Increased release of oxytocin while breastfeeding, leads to a reduction in post-partum hemorrhage and quicker return to a normal sized uterus over time. Mothers who breastfeed may be less likely to develop breast, uterine, and ovarian cancer, and have a reduced risk of developing osteoporosis.

ESM 4.1 Progress Report:

The care that a new mother receives during her hospital stay for delivery, postpartum, and newborn care can greatly influence breastfeeding initiation, exclusivity, and duration outcomes. Institutional changes through adoption of evidence-based policies to support breastfeeding can significantly increase rates of breastfeeding.

The "Ten Steps" are evidence-based maternity care practices that demonstrate optimal support of breastfeeding, as well as improved care experiences and outcomes for non-breastfeeding families. These steps are endorsed by the American Academy of Pediatrics and the American Academy of Family Physicians and are promoted by the American Academy of College of Obstetricians and Gynecologists. Additionally, the "Ten Steps" are recommended breastfeeding interventions and, the 2010 White House Task force on Childhood Obesity's Report to the President: Solving the Problem of Childhood Obesity within a Generation, and the National Prevention Council's National Prevention Strategy.

During FY20, MIHP staff trained one new hospital in the Stepping Up for Utah Babies program. Additionally, nine previously trained hospitals successfully implemented 27 steps during this time period.

A major success is that four hospitals were certified in all ten steps and are now considered a “Breastfeeding Friendly Facility” in Utah. These achievements garnered local media attention with newspapers and television news covering the story. MIHP staff also provided an on-air live interview with the local CBS station, KUTV, on the Stepping Up for Utah Babies program.

Since the inception of this program in 2015, 20 hospitals have implemented a total of 112 steps.

ESM 4.2 - Worksite lactation policy: Number of worksites that have created a lactation policy that complies with federal standards

Goal/Objective:

Increase the number of worksites that create or revise a lactation policy or formal communication.

Significance of ESM 4.2:

For infants not breastfeeding, there is an associated increased risk of infant morbidity and mortality, and significantly higher risk of many diseases including diabetes, obesity, leukemia, SIDS, NEC, etc.

Duration rates are greatly affected by mothers returning to work to businesses that are not meeting the federal workplace accommodation law. Policies must be in place and implemented to provide an environment that is conducive to supporting breastfeeding women.

ESM 4.2 Progress Report:

During FY20, EPICC program continued to reach out to, and collaborate with Utah worksites to create lactation policies that comply with federal and state laws. During FY20, eighty-three worksites completed either the CDC Worksite Health Scorecard, Healthy Worksite Award, or EPICC Mini-Scorecard. Of those, 61% of worksites currently have an existing breastfeeding policy in place that complies with federal standards. Sixteen worksites have created a new policy, formal communication, or revised and updated a policy for breastfeeding/lactation support for employees and 84% of the worksites provide private space and provided paid or unpaid break time for expressing breast milk. EPICC staff and LHDs provided technical assistance and breastfeeding support materials to worksites that do not have policies or are not compliant with lactation accommodation law. 

ESM 4.3 - Breastfeeding Peer Counselor Program (BFPCP): Number of WIC-eligible clients that are referred to the Breastfeeding Peer Counselor Program

Goal/Objective:

Increase the percentage of eligible pregnant and postpartum WIC participants who received at least one contact from a WIC Breastfeeding Peer Counselor.

Significance of ESM 4.3:

Breastfeeding is the normative standard for infant feeding and nutrition and can result in improved infant and maternal health outcomes. Mothers who receive help and support when they need it are more likely to reach their breastfeeding goals and meet their infant’s complete nutritional needs. A mother’s ability to begin and continue breastfeeding can be influenced by a host of community factors, and programs like WICs breastfeeding peer counselors can provide important coaching to enable and sustain breastfeeding efforts in WIC clients. Peer counseling interventions greatly improve breastfeeding initiation, duration, and exclusivity.

ESM 4.3 Progress Report:

The Utah WIC Program refers prenatal and postpartum WIC participants to the WIC Breastfeeding Peer Counseling Program using the Nutrition Interview, Referrals, and Participant Care Plan Screens in the Utah WIC Program computer system entitled VISION. The MTB UT Program also makes referrals to the Utah WIC Breastfeeding Peer Counseling Program. For FY19, the absolute number or referrals were 9,026, which was below the target objective of 10,900 referrals. The number of employed peer counselors increased from 34 to 36. The number of duplicated contacts to WIC participants for FY19 decreased to 14,514 prenatal contacts and 25,749 postpartum contacts. Utah WIC’s breastfeeding prevalence rates primarily remained consistent between FY18 and FY19, with the only decrease in prevalence seen for the Breastfeeding Prevalence at 12 months, which decreased from 33% to 32%.

The performance objective set for FY20 is a total 9,700 referrals. To date, there have been 7,293 referrals to the WIC Breastfeeding Peer Counseling Program in FY20. The number of duplicated contacts to date are 12,670 prenatal contacts and 18,551 postpartum contacts. Current Breastfeeding Prevalence rates for FY20 include the Ever Breastfed Prevalence rate staying consistent at 88%; the Breastfeeding Prevalence at 6 & 12 months at 35% and 31%; and the Exclusive Breastfeeding Prevalence at 3 & 6 months at 31% and 18%. 

MCH Block Grant FY21 Application & FY19 Report

Perinatal/Infant Health Domain

SPM-01: Preterm Birth: Percent of live births occurring before 37 completed weeks of gestation

FY19 Annual Report

Activities:

The Performance Measure was achieved. The Performance Objective was 9.4% and the Annual Indicator was 9.4%. This rate is below the 2018 U.S. preterm birth rate of 10.0% and the hits the Healthy People 2020 goal of 9.4%.   

The Reduce Preterm Birth Committee of the Utah Women and Newborns Quality Collaborative (UWNQC) created a Preterm Birth Prevention Resources summary that is available online at our updated website (https://mihp.utah.gov/uwnqc/reduce-preterm-birth). This website highlights the resources developed to address preterm birth including the Preterm Birth Prevention Video Series, the Utah Screening and Progesterone treatment process and care protocol, What to Do to Prevent a Preterm Birth: 17P (Progesterone) Guide for Providers, 17P for Preventing Preterm Birth Fact Sheet (English and Spanish), and What to Do After a Preterm Birth Guide for Families (English and Spanish). The resource also outlines how to implement changes and track improvement at hospitals. The committee disseminated these resources to hospitals and various clinicians at staff meetings.

Data Collection has been a key program activity. The Utah Birth Certificate tracks progesterone use during pregnancy with the question, “During your most recent pregnancy did a doctor, nurse or other health care worker try to keep your new baby from being born too early by giving you a series of weekly shots or daily vaginal suppositories of a medicine called Progesterone, Makena or 17P (17 alplahydroxyprogesterone)?”. Via a REDCap (Research Electronic Data Capture) database, our two largest health systems now provide data on women with a history of preterm birth who were offered, and utilized progesterone in their current pregnancy. From this data, we are able to track 17P usage by hospital and show the run charts for UWNWC hospitals at UWNQC Reduce Preterm Birth Rate Committee meetings. Using 17-P utilization run charts for individual hospitals and for statewide tracking, has helped to visualize baseline utilization, and have discussions with hospitals on how they can improve the number of eligible women who they are having a discussion about 17P to reduce their risk.  

Accomplishments / Successes:

Vital Records staff presented to providers statewide on the importance of accurately reporting prior preterm births on the birth certificate. This included packets of information with UWNQC resources such as a 17P for Preventing Preterm Birth for Providers. Having the collaboration of Vital Records for our data collection and training providers has been a helpful resource. One of our contacts at Vital Records serves on one of our UWNQC committees, this allows her to see our activities and understand why capturing the data is important. 

The University of Utah, one of our major health systems, has a data sharing agreement with MIHP and UWNQC. They created a spontaneous PTB section in their Electronic Medical Record (EMR) EPIC. This helps captures patient history of spontaneous preterm birth, whether 17P was offered, if the patient took 17P injections, and if so, when they were started. The data will help to establish a baseline and identify potential barriers to optimal treatment. 

Multiple births are a factor in the preterm birth rate. In 2018, 2.2% of total births were multiples (twins, triplets, quadruplets, or higher), and this represented 23.7% of the total preterm births. The UWNQC committee has been focused on spontaneous singleton births, as the committee cannot affect preterm birth that occurs in multiple gestations. When excluding multiple births, the preterm birth rate in Utah during 2018 was 7.4% of all singleton births vs. 9.4% when multiples are included.  

There were three LHDs in 2018 that had preterm birth rates over 10%. Two of these three were in rural areas. There are currently some telehealth programs in place that offer resources specific to rural residents.

Reviewing the rates of preterm birth by race and ethnicity, the rates for women who reported being white, Alaskan or American Indian, and Asian, went down in 2018 in comparison with 2017. The highest rate for the past five years is among Native Hawaiian or Other Pacific Islanders (NHPI). Since 2012, the Utah Office of Health Disparities (OHD), in collaboration with public health and health care professionals and community partners, has been working to address this issue, along with infant mortality. A final product of these efforts is the “It Takes a Village: Giving our babies the best chance (ITAV)” project. ITAV raises awareness and educates NHPI families and community members about maternal and infant health in the context of Pacific Islander cultural beliefs and practices. ITAV is one of the outcomes of a birth outcomes disparities project that was originally rooted in the theoretical framework from the National Partnership for Action to End Health Disparities. The curriculum includes discussing topics such as birth spacing, which can reduce the risk for preterm births.

Stakeholders from the key major health systems in Utah, Intermountain Healthcare, MountainStar (HCA), Steward Health, and the University of Utah, work with the UWNQC board and committees. This collaboration helps us to educate providers, collect preterm birth data, and implement statewide standard protocols and algorithms. There is also collaboration with the March of Dimes and the local leader is a member of the UWNQC board. Government collaborations include working with Local Health Departments statewide and with hotlines such as the Utah Tobacco Quit Line, state resource center, Baby Your Baby, and MothertoBaby. Social Media efforts include public education about how to be heathy prior to pregnancy on the Power Your Life website, along with offering various resources on the UWNQC for providers and the public. The collaboration with the Office of Vital Records is key in obtaining and analyzing 17P data utilization.

Another partnership is with the University of Utah Family Planning Elevated team. They launched a Resource for Education on Pregnancy Planning in the fall of 2018 that included topics such as unintended pregnancy and birth implications and healthy birth spacing, both of which affect the preterm birth rate (https://fpeutah.org/for-providers/). The collaboration between UWNQC and Family Planning Elevated at the University of Utah will continue as the House Bill 12 from the 2018 Legislative session is implemented for a statewide, immediate Postpartum Long-Acting Reversible (LARC) Program. This includes offering a program that provides family planning services to low-income individuals, disseminating educational materials statewide, and training providers. The bill has provisions for family planning services within the state Medicaid program. It includes the Medicaid program reimbursing providers separately for the insertion of LARC immediately after childbirth, and providing family planning services to certain low-income individuals. Unintended pregnancy data will be tracked to determine if a reduction may help to move the needle in reducing preterm births.

In Fiscal Year 2019, MotherToBaby Utah provided education to women and their providers about medications used during current pregnancies or while planning a pregnancy to treat conditions that could result in preterm births such as mental health conditions, cardiovascular conditions, respiratory conditions, the use of tobacco and other drugs, autoimmune conditions, and influenza. MotherToBaby Utah provided education to women, their providers, their partners, and other clients regarding the benefits and risks of medications compared to untreated conditions during pregnancy in an effort to help women remain healthy and avoid complications that could result in preterm births.

Summary of successes and accomplishments on “Moving the Needle” in relation to SPM-01:

• Created Preterm Birth Prevention Resources summary and posted on UWNQC website https://mihp.utah.gov/wp-content/uploads/Preterm-Birth-Prevention-Resources-Summary.pdf
• Tracked 17P usage by hospital and showed the run charts for UWNWC hospitals at UWNQC Reduce Preterm Birth Rate Committee meetings. This includes the University of Utah, one of our major Health Systems, creating a spontaneous PTB section in their Electronic Medical Record (EMR) for reporting.
• UWNQC and Family Planning Elevated at the University of Utah collaborating on implementation of House Bill 12 from the 2018 Legislative session for a statewide, immediate Postpartum Long-Acting Reversible (LARC) Program. This offers a program that provides family planning services to low-income individuals, disseminating educational materials statewide, and training providers. 

Challenges / Gaps / Disparities:

The preterm birth rate for Medicaid recipients increased from 10.26% in 2017 to 10.67% in 2018. This is a population to continue to determine ways to provide recipients with preterm birth risk reduction resources. Another challenge is limited evidence informed interventions to reduce preterm birth.

Agency Capacity / Collaboration:

Stakeholders from the key major health systems in Utah, Intermountain Healthcare, MountainStar (HCA), Steward Health, and the University of Utah work with the UWNQC board and committees. This collaboration helps us to educate providers, collect preterm birth data. and implement statewide standard protocols and algorithms. There is also collaboration with the March of Dimes and the local leader is a member of the UWNQC board. Government collaborations include working with Local Health Departments statewide and with hotlines such as the Utah Tobacco Quit Line, state resource center, Baby Your Baby, and MothertoBaby. 

Social Media efforts include public education about how to be heathy prior to pregnancy on the Power Your Life website, along with offering various resources on the UWNQC for providers and the public. The collaboration with the Office of Vital Records is key in obtaining and analyzing 17P data utilization.

Another partnership is with the University of Utah Family Planning Elevated team. They launched a Resource for Education on Pregnancy Planning in the fall of 2018 that included topics such as unintended pregnancy and birth implications, and healthy birth spacing, which both affect the preterm birth rate (https://fpeutah.org/for-providers/). The collaboration between UWNQC and Family Planning Elevated at the University of Utah will continue as the House Bill 12 from the 2018 Legislative session is implemented for a statewide, immediate Postpartum Long-Acting Reversible (LARC) Program. This includes offering a program that provides family planning services to low-income individuals, disseminating educational materials statewide, and training providers. The bill has provisions for family planning services within the state Medicaid program. It includes the Medicaid program reimbursing providers separately for the insertion of LARC immediately after childbirth, and providing family planning services to certain low-income individuals. Unintended pregnancy data will be tracked to determine if a reduction may help to move the needle in reducing preterm births.  

*SPM-01 was discontinued following the 2020 MCH Needs Assessment.

Other activities in the Perinatal/Infant Health domain that contribute to improvement in the National Outcome Measures 

Utah works to adhere to the three-tier framework outlined in the MCH Block Grant guidance. While the focus of most activities is the ESM →NPM→ NOM framework, activities on improving NOMs outside of the NPMs transpires in parallel. The following programmatic activities also work to improve outcomes in this domain. 

National Outcome Measures (NOM)

NOM 4: Percent of low birthweight deliveries (<2,500) grams)

In Fiscal Year 2019, MotherToBaby Utah provided education to women and their providers about medications used during current pregnancies or while planning a pregnancy to treat conditions that could result in low birth weight deliveries such as mental health conditions, cardiovascular conditions, respiratory conditions, and the use of tobacco and other drugs. MotherToBaby Utah provided education to women, their providers, their partners, and other clients regarding the benefits and risks of medications compared to untreated conditions during pregnancy in an effort to help women remain healthy and avoid complications that could result in babies with lower birth weight.

NOM 8: Perinatal mortality rate per 1,000 live births plus fetal deaths

In Fiscal Year 2019, MotherToBaby Utah provided education to women and their providers about medications used during the perinatal period. Education was provided about the risks of the untreated conditions, such as hypertension, diabetes, tobacco and other substance use, and maternal infections, and the potentially teratogenic medications used to treat those conditions, such as angiotensin converting enzyme (ACE) inhibitors, non-steroidal anti-inflammatory drugs (NSAIDS including aspirin and ibuprofen), and valproate, that could result perinatal complications and/or death. MotherToBaby Utah provided education to women, their providers, their partners, and other clients regarding the benefits and risks of medications compared to untreated conditions during the perinatal period in an effort to help women remain healthy and avoid complications that could result in perinatal deaths

Utah's Perinatal Mortality Review Program reviews deaths to infants due to perinatal conditions. Infant death cases are reviewed by a multidisciplinary committee which assesses preventability and makes recommendations for prevention.

The Study of the Associated Risks of Stillbirth (SOARS) is an ongoing, state-specific, population-based survey designed to collect information on maternal experiences and behaviors prior to, during, and immediately following pregnancy among mothers who have recently experienced a stillbirth. SOARS was initiated in 2018 in an effort to find out why stillbirths occur and how to prevent future fetal deaths. Using methodology similar to the Pregnancy Risk Assessment Monitoring System (PRAMS), Utah women who recently experienced a fetal death are mailed a survey. We are awaiting a weighted data set from the CDC to begin analysis and publish findings.

NOM 9: Infant Mortality Rate per 1,000 live births

The safe haven project worked with the Utah state legislature to extend the safe newborn drop off from 3 days to 30 days. With the new changes in the law, the legislature awarded extra funding for education in addition to the current efforts that include a multi-digital campaign using social media and digital radio ads. The safe haven project also worked together with Utah EMS department to develop a training module that will provide education credit for licensing all emergency medical workers that includes medics, paramedics, firefighters and other first responders in law enforcement agencies.

NOM 10: Percent of infants born with fetal alcohol exposure in the last 3 months of pregnancy

In Fiscal Year 2019, MotherToBaby Utah provided education to women and their providers about the risks of alcohol use during pregnancy. They provided information through in-person, telephone, email, chat and text contacts. They provided information through printed brochures, newsletters, social media posts, and television news segments. They worked in collaboration with the Utah Fetal Alcohol Coalition to support projects and activities to educate women about alcohol use in pregnancy and breastfeeding and inform them of resources for families with children with Fetal Alcohol Spectrum Disorders including prevention, screening, diagnosis, treatment, and family support. During FY 2019, 314 English Alcohol brochures, 1,170 Spanish Alcohol brochures, 1,858 English Alcohol Tobacco and Other Drugs brochures, and 257 Spanish Alcohol Tobacco and Other Drugs brochures were distributed to families and providers.

NOM 11: The rate of infants born with neonatal abstinence syndrome per 1,000 hospital births

The Violence and Injury Prevention Program (VIPP) developed the Utah Public Opioid Dashboard and included NAS as an indicator to increase awareness of NAS in Utah. In addition, Through the Overdose Data to Action cooperative agreement with the CDC, the Utah Birth Defect Network works to link mothers and newbors with NAS to services and support systems.

In Fiscal Year 2019, MotherToBaby Utah provided education to women and their providers about medications used during current pregnancies or while planning a pregnancy to treat mental health conditions and pain. MotherToBaby Utah provided education to women, their providers, their partners, and other clients regarding the benefits and risks, including neonatal abstinence syndrome, of medications for mental health, substance abuse conditions, and pain compared to the risks of untreated conditions during pregnancy to promote healthy outcomes.

NOM 12: Percent of eligible newborns screened for heritable disorders with on time physician notification for out of range screens who are followed up in a timely manner

The Child Health Advanced Records Management (CHARM) Program connects data in real time from a variety of programs to present a consolidated record of newborn screening results such as newborn hearing, heel-stick (ranges are included) and critical congenital heart defect (CCHD) results. One way the CHARM system shares the connected data in real time is through its CHARM Web Portal (CWP). Authorized private and public health providers continued to use the CHARM Web Portal (CWP) to look up and view a child's health information/results from the above newborn screening tests to coordinate care, treatment, and follow-up in a timely manner.  Providers also had access to a Medical Home Portal (MHP) link in the CWP. Therefore, when a provider was looking up a child's newborn screening results, they could also click on the MHP link to find diagnostic and treatment information for newborn disorders. In addition, CHARM continued to collaborate on a project with the Early Hearing Detection and Intervention (EHDI) and Vital Records (VR) Programs called the “Birth Certificate Alert Project”. Through CHARM's data integration with EHDI and Vital Records VR, when parents apply for a birth certificate for their child at the state or local health department, a hearing screening alert is generated by CHARM if the child did not pass a hearing screening test, was not screened, or needs to complete the process. When the birth certificate clerk sees the alert, he/she prints out a letter informing the parents or guardian that their child needs a hearing screening follow-up and instructs them to contact the EHDI Program.  From January 1, 2018 - June 18, 2019, 350 hearing alerts were generated for children by the CHARM system; 44% (154) completed a hearing screening test after the alert. This linkage has improved follow-up efforts and care coordination for children that are deaf or hard of hearing.

 

[1] Freeman VA. (2010). Very low birth weight babies delivered at facilities for high-risk neonates: A review of Title V National Performance Measure 17.

[2] Payne E, Garcia S, Minkovitz C, Grason H, Lai Y, Karp C, & Strobino D. (2017). National Performance Measure 3 Risk-Appropriate Perinatal Care Evidence Review. Strengthen the Evidence Base for Maternal and Child Health Programs. Women’s and Children’s Health Policy Center, Johns Hopkins University, Baltimore, MD.

[3] Martin JA, Hamilton BE, Osterman MJK, & Driscoll AK. (2019). Births: Final data for 2018. National Vital Statistics Reports, (68)13. Hyattsville, MD: National Center for Health Statistics.

[4] American Academy of Pediatrics and American College of Obstetricians and Gynecologists (2012). Guidelines for Perinatal Care (7th Edition). Elk Grove Village, IL.