In 2021, BWCH's infant and perinatal priorities focused on reducing infant mortality and morbidity and promoting equitable and optimal care and protective factors for mothers and infants before, during, and after pregnancy.

To support NPM 4: Breastfeeding, the ADHS Bureau of Women’s and Children’s Health (BWCH) partnered with the ADHS Bureau of Nutrition and Physical Activity (BNPA) to support breastfeeding initiatives through training, technical assistance, policy and procedures, and direct support services. In addition, BNPA, through the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program, was able to provide ongoing training and support opportunities for International Board-Certified Lactation Consultant (IBCLC) certification. Early childhood home visiting programs continued to educate families about infant toddler development, mental health, the critical importance of bonding, injuries in the home, safe sleep, immunizations, and the effects of Adverse Childhood Experiences (ACE). Arizona was also involved in efforts to monitor the incidence of neonatal abstinence syndrome (NAS) and work with child welfare and other state agencies on collaborative strategies to prevent and reduce opioid use and stigma reduction as part of the larger public health response to the opioid epidemic.

BWCH programs continued to experience a level of interruption/impact due to the COVID-19 pandemic; however, stakeholders worked together to shift strategies, establish revised processes, and implement remote/virtual resources to continue supporting infants.  The 2021 Perinatal/Infant Health Annual Report will include program updates addressing COVID-19 impact and the strategies implemented to sustain the programs/services. Impact of COVID-19 is addressed within each strategy and new partnerships/strategies developed as a result of COVID-19 are included at the end of this narrative. The following sections detail the 2021 implemented strategies.

In 2021, BWCH continued work to identify programmatic measures and indicators that apply to all BWCH home visiting programs, which include MIECHV-funded home visiting programs, the state- and MIECHV-funded Health Start program, and the state- and Title V-funded High Risk Perinatal Program (HRPP).  MIECHV, Health Start, and HRPP Community Health Nursing have worked collectively with BWCH’s Office of Assessment and Evaluation (OAE) to implement a coordinated home visitation data management system, Efforts-To-Outcomes (ETO).  In 2021, we achieved the goal of producing a state-wide home visiting internal service utilization report across state-agency funded evidence-based and promising practice programs.  The Service Utilization Report shows data across five (5) home visiting models and three (3) state agency funders. It allows immediate access to live data regarding the number of enrolled families, service area, funder, model and disenrollment rates. The Interagency Leadership Team (IALT) priority workgroup for the Data Management System continued to work on developing system reports with the goal of completing a total of three (3) within 2021. The workgroup surpassed that goal by completing six (6) reports. These reports include the service utilization report; priority populations; demographics; missing data reports; staff funding; data by zip code; and data by Primary Care Area.

In 2021, the Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) in Arizona provided funding to these evidence-based home visiting programs: Healthy Families (through Arizona Department of Child Safety), Nurse-Family Partnership (through Maricopa County Department of Public Health, Pima County Health Department, and First Things First), Family Spirit (through Coconino County and San Carlos Apache Tribe) and Parents as Teachers (provided by three Native American Tribes: Cocopah, Hualapai, and Navajo Nation). In addition, the AZ MIECHV grant was approved to provide funding to three (3) of the Health Start sites as a promising approach. Through the home visiting programs listed above, MIECHV served 1,831 families in at-risk communities through 25,351 visits, coordinating services across Arizona’s early childhood system.

MIECHV supported the 2021-2025 Title V priority needs by implementing various strategies. The strategies and outcomes for 2021 are included in the Children’s Health Annual Report. Phase I of the 2020 MIECHV Needs Assessment was completed in April 2020. Phase II of the MIECHV Needs Assessment began in 2021.  More information can be found in the Children’s Health Annual Report.

Arizona’s Health Start Program, funded through MIECHV and state lottery funds, uses community health workers (CHWs) to conduct home visits. In December 2021, a Health Start Program Evaluation Impact Report was completed which summarized the results of the assessment of the impact of the Health Start Program from 2006 - 2016. The key findings of the report found that participation in the Health Start Program across this period is associated with decreases in adverse birth outcomes, increases in the level of prenatal care and higher immunization rates of children. The full report is also available in Appendix G.

In 2021, the Health Start Program continued to train Health Start home visitors in developmental screening in support of ESM 6.1 (number of home visitors trained to provide ASQ3 and SE2 training over the next five years). In 2021, the program trained two new staff members virtually through trainers at their sites. The program did not meet the annual objective of 10 home visitors trained in 2021, due to the COVID-19 pandemic and the barriers it created to setting up annual in-person training.

Health Start will continue to provide developmental screening for children ages 10-17 months to increase early identification and treatment of developmental delays. In 2021, Health Start provided at least one Ages and Stages Questionnaire (ASQ) screening to 195 children under one year of age (64% of enrolled children).  The number of children screened using the ASQ increased slightly during 2021 but was lower than years prior due to the COVID-19 pandemic and the decrease of in-person visits.

Health Start continued to provide the Arizona Survey on Children’s Health (ASCH) in 2021 at all 16 sites.  There were 305 ASCH surveys completed with families with children ages 11-13 months. There were slightly more surveys completed this year but less than prior years due to COVID-19 and the lack of in-person home visits.  This survey was difficult to provide to families during the pandemic.  Health Start screened 800 prenatal and postpartum women for substance use; of which, 44 were using tobacco. Of those using tobacco, 24 (55%) accepted education on quitting and referrals to the Arizona ASHline for cessation services.                 

In 2021, the Health Start program continued working with internal partners in the Bureau of Chronic Disease and Health Promotion (BCDHP) to provide tobacco cessation training and referrals and with the Office of Epidemiology and Disease Control (Division of Preparedness) to mitigate the syphilis outbreak among women and babies through the promotion of increased testing. Additional activities can be found in the Women’s Health Annual Report.

The High Risk Perinatal Program (HRPP) is Arizona's oldest home visiting program. The HRPP's purpose is to reduce maternal and infant morbidity and mortality through a statewide regionalized system of coordinated perinatal care. The HRPP is a primarily state-funded program that leverages Title V funds to increase access and enhance services. The HRPP continued to provide early identification of women and children at risk of morbidity and mortality and educate health professionals, families, and communities on developmental care and the needs of medically fragile infants. The HRPP also continued to link pregnant women and infants to the appropriate level of care hospital and establish standards of care and education once families return home after discharge. The components of the program are: a 24/7 Information and Referral Line, Maternal and Neonatal Transport Services, Hospital and Inpatient Physician Services, Community Nursing Services, and Hospital Developmental Care. As mentioned in the Children’s Health Annual Report, in 2021 over 4,534 infants were enrolled in HRPP, Community Health Nurses documented 8,661 visits to medically fragile infants and their families after they were discharged from the neonatal intensive care unit (NICU), and 505 critically ill pregnant women and 691 critically ill newborns were transported to the appropriate level of care hospital as determined by program contracted physicians.

The HRPP Community Health Nurses (CHNs) continued to support families through the COVID-19 pandemic by continuing to adapt to the circumstances. The CHNs continued to offer virtual visits for families to help mitigate the spread of COVID-19.  The families receive educational materials, ASQ screenings, and Edinburgh Postnatal Depression surveys prior to the visit via email, mail, or dropping the materials off to the families’ home.  Return to In-Person Visit guidelines were released in May 2021 for CHN agencies to begin the transition back to in-person home visits. CHNs continued to provide POST-BIRTH Warning Signs information to all families at the initial home visit to educate the families on signs and symptoms that would require the family to seek medical care after leaving the hospital.

In 2021, the HRPP CHNs completed 545 surveys for the National Survey of Children’s Health (NSCH), which is utilized to improve referrals for children identified as having special health care needs. The CHNs also completed 1,905 initial Ages and Stages Questionnaires (ASQ) and 1,926 Edinburgh Postnatal Depression Screenings (EPDS). Of these EPDS, 215 of the people screened had a score greater than 9, leading them to be referred to mental health services.

Infants diagnosed with Neonatal Abstinence Syndrome (NAS) are automatically eligible for HRPP home visiting follow-up services. Of the 4,534 infants enrolled in 2021, 732 (16%) of these were diagnosed with NAS and 951 home visits were provided to these infants over the course of the year. The HRPP expanded services to meet the needs of infants diagnosed with NAS and began contracting with Hushabye Nursery in July 2021. The mission of Hushabye Nursery is to 'embrace substance-exposed babies and their caregivers with compassionate, evidence-based care that changes the course of their entire lives.'  Eighty-three (83) infants were enrolled over the first six months of the Hushabye Nursery HRPP contract in 2021.

In 2021, the annual High Risk Perinatal Program Conference was integrated into the Strong Families AZ Home Visiting Conference, an annual conference for home visitors in Arizona hosted by ADHS.  The four-day conference included one day with a priority population focus specific to the High Risk Perinatal Program population.  The conference attendees for that day consisted of Community Health Nurses and Neonatal Intensive Care Nurses across the state of Arizona.  This provided an opportunity for Community Health Nurses and Neonatal Intensive Care Nurses to receive professional development targeted to their role and the services that they provide to families.

BWCH continued to implement the Pregnancy Risk Assessment Monitoring System (PRAMS). BWCH leveraged Title V and other federal and non-federal funds to further support its ongoing implementation. In 2021, PRAMS continued to use data collected to describe the maternal and infant populations in Arizona and to assess possible associations between perinatal health outcomes and maternal characteristics. Additional information regarding PRAMS is mentioned in the Women's Health 2021 Annual Report and 2023 Application.

Information on Arizona's Child Fatality Review (CFR) program is included in the Children's Health section of the application, with exception to the Safe Sleep and Sudden Unexpected Infant Death (SUID) efforts listed here.

Title V funding is provided to the Office of Injury and Violence Prevention (within the Bureau of Chronic Disease and Health Promotion) to carry out a variety of strategies dedicated to Safe Sleep. The Safe Sleep Task Force continued to partner with key stakeholders from around the state to accelerate improvements that prevent and reduce infant deaths. In 2021, the Safe Sleep Task Force met on a quarterly basis and, due to the pandemic, virtually.  Partners included the Arizona Department of Economic Security (DES), Arizona Chapter of the American Academy of Pediatrics (AzAAP), Arizona Health Care Cost Containment System (AHCCCS; Arizona’s Medicaid program), March of Dimes, partners from birthing and non-birthing hospitals, home visitors, Safe Kids coalitions, county health departments, South Phoenix Healthy Start, Child Care Licensing (within ADHS), Prevent Child Abuse Arizona and Candelen (formerly, Association for Supportive Child Care). Although the COVID-19 pandemic proved to be a barrier in providing education and resources to new parents, our partners found a way to continue educating their communities.  At first moving education to virtual platforms proved to be a challenge; however, once the kinks were smoothed out, most agencies were able to continue education.  However, not every partner had that success; some faced challenges due to staff being reassigned or for others technology was a barrier. A goal of the task force is to decrease the sudden unexpected infant death (SUID) mortality rate by 5%  by promoting safe sleep practices. The task force also worked toward reducing SUID disparities between White and Non-Hispanic Black and between White and American Indian/Alaska Natives by 3%.

Arizona safe sleep work continues to focus on providing safe sleep education and support to families through birthing hospitals, home visiting programs, local county health departments, and licensed and unlicensed child care. Arizona's activities include: adding safe sleep modeling to annual skills training for nurses in hospitals; using safe sleep Bassinet Cards as visual reminders for nursery staff; standardizing safe sleep messages for all home visiting programs; standardizing education and training for home visitors on current American Academy of Pediatric (AAP) guidelines; developing standardized safe sleep messages at ADHS with input from community partners; partnering with community tribal elders on AAP guidelines; engaging grandparents and caregivers on the recommended AAP guidelines; providing training for nursing and medical schools and helping hospitals establish policies.

In 2021, using Title V funding, the Office of Injury and Violence Prevention partnered with the Strong Families home visiting alliance, which is housed within BWCH, to develop a Safe Sleep Toolkit that is easily accessible on the Strong Families website and also available on the ADHS website. The Safe Sleep Toolkit contains suggestions for partners and providers for social media posts, posters that can be printed and commercials that can be added to individual or organizations’ social media pages. 

A media campaign supported by MIECHV and Title V with newly developed creative was pushed out through digital platforms and within healthcare provider waiting rooms. As a result of this campaign, 213,200 unique users visited the strongfamiliesaz.com/abcsafesleep website.  

In 2021, 21 out of Arizona’s 36 birthing hospitals participated in the distribution and education of the Crib Cards. Crib Cards are still being distributed to all of our birthing hospitals as needed. Title V funds covered the printing of 60,000 crib cards distributed to hospital partners in 2021. Through the Safe Sleep Task Force and partnerships, there was consensus to recommend that all birthing hospitals participating in the distribution of the Crib Cards should also develop a safe sleep policy to further educate staff and ensure the same standard of care. Lastly, AzAAP developed a computer-based training on Safe Sleep for pediatricians to improve professional practice, which was rolled out in 2021. Providers can also earn credit for Maintenance of Certification (MOC) Part 4 by taking the training.

In 2021, there were 1170 Pack ‘N Plays, purchased with Title V funds, distributed to Apache, Mohave, Pinal, Maricopa, Yuma County and San Carlos Indian Community. To receive a pack ‘n play, families receive education about safe sleep and how to follow the ABCs of safe sleep prior to receiving a pack ‘n play. Education and pack ‘n plays are provided through the partner agencies that receive Title V funded pack ‘n plays.

ADHS provided technical guidance on the final activities of the Border Health CoIIN initiative carried out by Mariposa Community Health Center in Santa Cruz County for their participation in inter-statewide meetings to increase by 10% the utilization of early and adequate prenatal care amongst Latina women on the US-Mexico Border.

In 2021, Arizona continued to support Neonatal Abstinence Syndrome (NAS) and Substance Exposed Newborn (SEN) prevention efforts through various collaborative efforts. In 2021, ADHS staff attended meetings and collaborated with stakeholders to discuss ideas and next steps around care coordination processes for substance-exposed newborns and their mothers. ADHS continued to implement two specific action steps identified in the NAS Strategic Plan that was developed in conjunction with other key state agencies and stakeholders, as part of a Learning Lab project under the National Governors Association in 2018 (which has been sunsetted).  These two action steps include: 1. development of a stigma reduction media campaign for women using substances and 2. the improvement and enhancement of the NAS/SEN data collection and surveillance system.

The stigma reduction media campaign for women using substances was developed using Title V funds. It was initiated September 7, 2021, and will continue through 2022. The campaign was targeted towards women, families, and providers and included radio spots, billboards and posters, digital media and publications. Messages and information for pregnant people who use substances and their families are available at azhealth.gov/hopeheals and messages and resources for providers who serve pregnant people with substance use disorder are available at azhealth.gov/seemedifferently.

In 2021, an internal ADHS work group convened that is reviewing the definition of NAS and NAS data collection and reporting processes in an effort to improve the accuracy and integrity of the data. This will help ADHS and statewide partners have a better understanding of the incidence and distribution of NAS statewide to guide future prevention efforts. The Bureau continued to monitor the incidence of NAS and worked with child welfare and other state and local county agencies on collaborative strategies to prevent and reduce opioid use specifically, including stigma reduction, as part of the larger universe of efforts addressing the opioid epidemic. 

ADHS hosted the annual Maternal and Infant Mortality Summit (Sep 28-29, 2021). A total of 627 clinical and non-clinical professionals participated in the virtual conference. One session provided an overview of infant mortality in Arizona; discussed Arizona’s approach to assessing disparities across socioeconomic characteristics; and shared results from the Perinatal Periods of Risk (PPOR) analysis conducted by Arizona’s Title V Program for 2014-2018 fetal-infant deaths in Arizona (view session recording here). Another session focused on Safe Sleep. Given that 40% of excess infant deaths in Arizona are related to safe sleep, the purpose for this session was to hear from a panel of community providers about strategies to address safe sleep as a primary risk factor for Arizona’s infants (view here).There were also presentations on: access to maternal and infant health care, the importance of preconception and interconception health, the impacts of social determinants of health, and other information on improving maternal and infant health outcomes. More information on the Arizona Maternal and Infant Mortality Summit can be found in the 2021 Women’s/Maternal Health Annual Report.

In 2021, BWCH developed a draft of the Arizona Fetal-Infant Mortality Action Plan. In 2022, the proposed goal is to share the Action Plan with the People of Color Infant Mortality Workgroup and the Maternal Mortality Workgroup to gain insight and feedback from community partners and clinical and non-clinical professionals.  The draft action plan incorporates the following research and data:

• Findings from Perinatal Periods of Risk (PPOR) analysis for 2014-2018 fetal-infant deaths in Arizona and Arizona’s 2021 Child Fatality Review Report (Nov 2021) indicated the importance of improving maternal health conditions in order to reduce the number of excess infant mortality in communities of color (African American and Native American), especially in deaths due to prematurity or low birthweight.
• Maternal complications are a top cause of infant mortality both in Arizona and nationwide.
• New Title V Block Grant priorities commit Arizona to reducing health disparities related to maternal and infant mortality.
• Causes of mortality in mothers and babies are linked.
• Improved surveillance efforts on maternal and infant deaths establish a relationship between maternal and infant morbidity and other suboptimal outcomes.
• Federal partners encourage integration of prevention strategies for maternal and infant mortality.
•  Child Fatality Review (CFR) and Maternal Mortality Review Committee (MMRC) Report recommendations
• Arizona Health Improvement Plan (AzHIP) - ADHS’s statewide plan
• MIECHV 2020 Needs Assessment

The Bureau of Nutrition and Physical Activity (BNPA) hosted a number of activities in 2021, related to the promotion of breastfeeding with new virtual opportunities to ensure support was not disrupted. In 2021, LATCH-AZ conferences were held in a virtual setting in both January and August.  The intent of LATCH-AZ is to provide education and networking opportunities to breastfeeding promotion and support professionals. These sessions attracted a total of 685 Women, Infants and Children (WIC) program staff, peer counselors, Strong Families home visitors, and community partners.  In addition, the International Board of Certified Lactation Consultants (IBCLCs) Mentoring Program provided five (5) education sessions designed specifically for the candidates to prepare for the examination. A total of six (6) five-day-long Virtual Breastfeeding Boot Camps were also held to educate more individuals on breastfeeding.

In 2021, the program conducted partner outreach and promoted the breastfeeding courses for clinicians’ courses. There are 15 courses available and outreach was conducted among hospital staff. This outreach was facilitated by ADHS and encouraged the Local WIC Agency Breastfeeding Coordinator to also reach out to deepen the relationship and partnership between the organization and birthing facility.  By the conclusion of 2021, there were approximately 2,175 total online courses completed. Breastfeeding promotion and support related to child care centers, health care providers, and workplace accommodation programs were challenged in 2020 and 2021 due to the COVID-19 pandemic.

In 2020, through a partnership with Maricopa County Department of Public Health, ADHS supported the Healthy Arizona Workplace Program (HAWP).  HAWP is an evidence-based public health initiative that provides various resources to employers to develop and implement workplace plans to improve employee health and wellness using the CDC Worksite Health ScoreCard, which includes "Make It Work Arizona." The “Making It Work Arizona” toolkit materials were reprinted and updated in 2020 and can be requested online by employers to better understand how to support breastfeeding mothers returning to work or school.  The toolkit is designed to provide assistance to breastfeeding mothers as well as tools and information for businesses and families. In 2021, 35 employers requested toolkits and reported implementing workplace policies supporting breastfeeding.

To support families, children and parents with newborns, Arizona’s Title V Program funds the Title V Toll-Free MCH Helplines, which are maintained by BWCH and BNPA. The dedicated service includes three helplines: 1. Breastfeeding; 2. Children Information Center; and 3. Women's, Infant, and Children (WIC) Program.  Information is provided in English, Spanish and Telecommunications Device for the Deaf (TDD). Title V Toll-Free MCH Helplines provided callers with information and resources about breastfeeding; the Women, Infants, and Children (WIC) Program; and other resources for children, including sliding fee scale sites for uninsured families and individuals. In 2021, the 24-hour Breastfeeding Helpline provided breastfeeding support to 6,215 calls.

Newborn Screening (NBS) is a coordinated system of care with partners who collaborate to ensure every newborn receives a screening as well as the appropriate follow-up services, care, and intervention. While not within the BWCH, the Office of Newborn Screening (ONBS) partners with the BWCH on cross-cutting activities and initiatives. In the past, Title V funds were used to help support the work of the Newborn Screening Program. 

The COVID-19 pandemic has continued to create numerous issues related to timely and complete screening.  For hearing screening, if a mother tests COVID positive, no hearing screening is completed at all.  This delay is compounded by limited to no availability to receive an outpatient hearing screening after discharge.  The newborn screening program created guidance documents related to the timely collection of newborn screens and emphasized to partners that, as a public health standard of care, these timeframes should be maintained wherever possible.  This guidance was sent to pediatricians by the AzAAP chapter as well as posted to the www.aznewborn.com website under COVID-19 Guidance.

In addition, Arizona has experienced a rise in the number of out of hospital births over the last few years — and this number rose by 32% between 2019 and 2020, presumably due in part to the pandemic. The ONBS conducts a program to loan otoacoustic emissions (OAE) hearing screening equipment to midwives who attend home births. Since beginning the loan program, there has been a 50% increase in the number of infants born out of hospital who receive a hearing screening. In the summer of 2021, Title V funding was used to purchase an additional 6 OAE hearing screening kits.  These kits have been deployed to high volume urban practices as well to lower volume, but rural, midwives to increase access to screening for these underserved communities.

Figure 13. Newborn Screening of Out of Hospital Births, Arizona (2014-2021)

Despite the pandemic, newborns continued to be identified with conditions through newborn screening.  For bloodspot screening, preliminary 2021 data documents that 78 newborns were identified with one of the 29 core bloodspot conditions and an additional 172 infants were incidentally identified with a condition through newborn screening.  In addition, for hearing screening, so far, there have been 163 infants identified with permanent hearing loss in Arizona that were born in 2021.

Laboratory analysis is a core function of the ONBS and the program continued to provide data on bloodspot and hearing screening to families and providers in 2021. The ONBS partnered with the CYSHCN Program on a project to lend out otoacoustic emissions (OAE) hearing screening equipment to midwives in the community to ensure that hearing screening is available to those newborns who are born outside of a hospital. The program supports supplies needed to continue to offer this service.

The Title V program also planned on supporting the participation of ONBS staff at national conferences targeted at specific disorders identified through newborn screening, such as the annual National Cystic Fibrosis Conference.  Again, due to COVID-19 conferences were either postponed, canceled, or virtual.

The Arizona Birth Defects Monitoring Program (ABDMP), housed within ADHS’ Bureau of Public Health Statistics, is a statewide, population-based, active surveillance program that collects and analyzes information on children with reportable birth defects diagnosed within the first year of life. Data is ascertained from hospitals and medical facilities throughout the state on live-born children with potential birth defects and all still-born children of Arizona residents. ABDMP works under the guidance of, and collaboratively with, the National Birth Defects Prevention Network (NBDPN) and CDC to compare data and trends, align prevention efforts, and improve referral to services.  With the support of the Title V program, ABDMP shares data to inform internal and external partners, including several programs within BWCH, BNPA, Office of Infectious Disease Services (OIDS), as well as March of Dimes, Arizona Perinatal Trust, and others.

One example is the relationship between ABDMP and BNPA.  ABDMP provides annual data to BNPA to guide and support the state’s folic acid distribution program, PowerMeA2Z.  ABDMP participated in the initial PowerMeA2Z focus groups, and has continued to support and collaborate with the program.  ABDMP promotes PowerMeA2Z at community events, and designs projects aimed at increasing folic acid consumption, specifically highlighting PowerMeA2Z. 

Highlights of ABDMP’s work are best seen through ongoing engagement with partners to foster community support and intervention for families and children with birth defects, promote prevention efforts statewide and nationally, and to provide its unique perspective to partner meetings and collaborations.  The Title V program funds a portion of ABDMP staff salaries, supporting the ongoing efforts in birth defect surveillance, prevention, and intervention.

Through continued engagement with its partners in the Division of Prevention within ADHS, in 2021 ABDMP assumed oversight of enhanced surveillance of neonatal abstinence syndrome (NAS).  Through improved and expanded surveillance, we will have improved data and be better able to provide outreach and services to affected families.