Overview

The Perinatal Health unit at the Department of Health (DOH) resides in the Community Health Improvement Linkages section of the Office of Family and Community Health Improvement in the Division of Prevention and Community Health.

In 2020, there were 82,483 births in Washington. Births have declined each year since a historic peak in 2016 of 90,489. In 2019, 58 percent of births were to white, 19 percent to Hispanic, 11 percent to Asian, 5 percent to Black or African American, 1 percent to American Indian/Alaska Native, 1 percent to Native Hawaiian or other Pacific Islander, and 5 percent to multiracial mothers. Births have become more racially diverse over the past 10 years, decreasing among white and American Indian/Alaska Native, while increasing among Asian, Black or African American, and multiracial populations.

While birth outcomes are generally favorable in Washington, persistent disparities continue to disproportionately impact some populations, including Black, Indigenous, and people of color (BIPOC).

Incidences of low birth weight and preterm births were analyzed using a 3-year roll up to create a more stable estimate of these indicators for infant and perinatal health. Low birth weight among singleton births was higher among Black and African American (7.9 percent), Asian (6.8 percent), and American Indian/Alaska Native (6.8 percent) births, and lower among Native Hawaiian or other Pacific Islander (6.2 percent), multiracial (6.0 percent), Hispanic (5.5 percent) and white (4.3 percent) births. Pre-term births were more common among American Indian/Alaska Native (11.4 percent), Pacific Islander (8.5 percent), and Black or African American (8.4 percent) births, and less common among multiracial (7.8 percent), Hispanic (7.6 percent), Asian (7.0 percent), and white (6.2 percent) births (see figure below).

The most recent infant mortality data, from 2018, align with disparities seen in other birth outcomes. Infant mortality (infant deaths per 1,000 livebirths) was higher among Black or African American (9.7), Native Hawaiian or other Pacific Islander (7.6) and American Indian/Alaska Native (6.7) infants, and lower among Hispanic (4.9), white (3.8), and Asian (3.3) infants.

Breastfeeding initiation and continuation show disparities by Medicaid coverage status, often used as a proxy for family income. Most infants were breastfed, with 98 percent of non-Medicaid and 93 percent of Medicaid-covered mothers reporting having initiated breastfeeding in 2019. At the time of the PRAMS survey (2-4 months postpartum), this disparity had increased to 89 percent among non-Medicaid and 68 percent among Medicaid-covered mothers. Breastfeeding initiation rates were lower among Native Hawaiian or other Pacific Islander and Hispanic infants at 92 percent, and by 2-4 months Native Hawaiian or other Pacific Islander breastfeeding fell to 59 percent, a full 14 percent lower than any other group. While lower, neither of these were statistically significant when compared with other racial/ethnic groups. Both initiation and breastfeeding at 2-4 months have remained steady since 2010 (Pregnancy Risk Assessment Monitoring System [PRAMS]).

In 2019, 89 percent of non-Medicaid-covered mothers reported placing infants on their back to sleep (the preferred method for minimizing risk of sudden unexpected infant death [SUID]), compared with 76 percent of Medicaid-covered mothers. Infant sleeping on stomach, a known risk factor, was only reported by 3 percent of Medicaid-covered and 4 percent of non-Medicaid-covered mothers.

The overall SUID death rate per 1,000 infants declined 12 percent (0.8 to 0.7) from 2010 to 2019, and was lower than the 2019 national rate of 0.9. Using a 5-year roll up from 2015 to 2019, the SUID rate per 1,000 infants was highest among American Indian/Alaska Native (2.8), Native Hawaiian or other Pacific Islander (2.7), and Black or African American (1.1) infants, and lowest among Asian infants (0.2).

The Perinatal Health unit offers resources and technical assistance to parents, child care, foster care, group care, juvenile and correctional institutions, community action groups, and others on how to prepare and keep infants safe and healthy. We work with many organizations to promote health care standards associated with infants and pregnant women.

The DOH Screening and Genetics program identifies babies who have hearing loss through the Early Hearing-loss Detection, Diagnosis and Intervention (EHDDI) program. We also promote early identification of individuals with, or at risk of, genetic disorders or birth defects, and help connect people with the health and social services resources they need.

In 2020, 99 percent of Washington-born infants were screened for hearing loss. However, some challenges remain, including ensuring screening for infants born out-of-hospital. The EHDDI program increased the percentage of out-of-hospital births who received a hearing screening from 17 percent in 2011 to 70 percent in 2019 through providing hearing screening equipment and training to midwives. In partnership with pediatric audiologists, we were also able to decrease the percentage of infants who did not receive a needed comprehensive diagnostic evaluation from 24 percent in 2011 to 3 percent in 2019. However, challenges still exist in the Washington state EHDDI system. In 2019, only 68 percent of infants identified as deaf or hard of hearing were identified by three months of age, as is nationally recommended. Too many infants do not receive timely diagnostic evaluations and the COVID-19 pandemic created further challenges for families needing EHDDI services.

PRAMS is a survey conducted by DOH’s Surveillance and Evaluation section and the Centers for Disease Control and Prevention (CDC), which gathers information from new mothers about their experiences before, during, and after their most recent pregnancy.

National Performance Measure 4 - Breastfeeding

Percent of infants who are ever breastfed.

Percent of infants breastfed exclusively through 6 months.

According to the 2020 CDC Breastfeeding Report Card, the percentage of infants born in 2017 who were ever breastfed was 92.5 percent, an increase from 87 percent in 2013 before the Breastfeeding Friendly Washington program launched. The percentage of infants who were exclusively breastfed through 6 months was 28.9 percent, compared to 28 percent in 2013. These rates are above the national average. DOH updated its state report on post-partum breastfeeding in 2017, which addresses overall breastfeeding rates as well as rates for specific populations, including those receiving Medicaid benefits, racial/ethnic populations, and by maternal age.

Hospitals play an important role in supporting breastfeeding. The Baby-Friendly® Hospital Initiative is an international designation program developed by the World Health Organization and the United Nations Children Fund and implemented by Baby-Friendly USA. DOH recognized that becoming a Baby-Friendly designated hospital may be challenging administratively and financially for facilities. Therefore, we designed the Breastfeeding Friendly Washington initiative to promote and support breastfeeding in our state, even for hospitals that have financial barriers to becoming Baby-Friendly, as our program requires no fees. 

In late 2015, DOH launched the recognition program for hospitals; in early 2016, we launched the same program for free-standing birth centers, and in 2017 we launched a clinic program for all health care facilities that serve pregnant and breastfeeding parents or breastfed babies and children. This program is coordinated by our Breastfeeding Coordinator.

Our evidence-based strategy measure (ESM) is the percentage of eligible hospitals and birthing centers certified “Breastfeeding Friendly Washington” by DOH. There are 75 total eligible birthing facilities (57 civilian birthing hospitals plus 18 outpatient birth centers) in the state. We now have 37 hospitals certified, and eight free-standing midwife operated birth centers, for a total of 45 birthing facilities across the state. Our percentage of eligible birthing facilities now certified is 60 percent, exceeding our ESM goal. In addition to these birthing facilities, 11 clinics are Breastfeeding Friendly Washington sites. DOH uses social media and other means to recognize and celebrate Breastfeeding Friendly sites.

The Breastfeeding Coordinator, along with the interagency DOH Breastfeeding Workgroup, coordinates activities around breastfeeding. The workgroup includes representatives from the American Indian Health Commission (AIHC); the Breastfeeding Coalition of Washington and local breastfeeding coalitions; Women, Infants, and Children Nutrition Program (WIC); and Title V staff, including the Perinatal/Infant Nurse Consultant. Partners including the American College of Obstetricians and Gynecologists, the Childhood Obesity Prevention Coalition, Mahogany Moms Community Coalition, Midwives Association of Washington State, Washington Chapter of the American Academy of Pediatrics, Washington Chapter of the American Academy of Family Practice Physicians, Washington State Hospital Association, and Washington State Perinatal Collaborative also take part in meetings as appropriate. 

The Breastfeeding Coordinator:

• Coordinates breastfeeding messages and educational resources across programs within DOH.
• Reviews applications and modifies the Breastfeeding Friendly Washington program together with the DOH Breastfeeding Workgroup.
• Maximizes opportunities for cross-program collaboration across various sectors.
• Provides leadership and technical assistance to DOH, other state agencies, and the public in the area of breastfeeding promotion, support, and health equity.
• Uses evidence-based interventions to achieve Healthy People 2030 breastfeeding objectives.
• Maintains up-to-date work plans that reflect current best practices and research in lactation promotion and support.
• Provides worksite support and technical assistance for Executive Order 13-06, which is mandated for all state executive agencies. Part 1.b. of this order mandates conditions and facilities to provide for breastfeeding wellness needs.

Our Children and Youth with Special Health Care Needs (CYSHCN) program continued contract activities to promote and support breastfeeding with CYSHCN nutritionists, and the development of feeding teams working with families with infants experiencing feeding difficulties.

The Child Profile Health Promotion System continued to include breastfeeding information in mailings to families with young children in its regular mailings to parents. These mailings include a wide variety of information for new parents. Local WIC agencies continued to provide breastfeeding education and support. Maternity Support Services (MSS) continued breastfeeding messaging and support. Title V staff also continued to disseminate information to the public on the importance of breastfeeding, including through the use of social media and our website.

State Performance Measures 3 and 5 – Native American and Black Infant Mortality

Through our state performance measures (SPMs) on the rates of Native American and Black infant mortality, we continued to track disparities in these populations, and our goal is to ultimately eliminate inequities. We released our report on infant mortality in December 2017, which contained culturally appropriate recommendations using community wisdom.

In 2018, infant mortality among the American Indian/Alaska Native population was 6.7 (2.9-13.2) deaths per 1,000 live births (2018, Vital Stats). Among Black or African American infants, the infant mortality rate was 9.7 (6.9-13.2) deaths per 1,000 live births (2018, Vital Stats), compared with 3.8 (3.3-4.4) deaths per 1,000 live births for white infants. Our 2020 objective for both populations was no more than 3.3 deaths per 1,000 live births (or all groups being equally affected by the infant mortality rate).

Title V funded part of the salary for a Maternal, Infant and Child Health Consultant who managed several maternal and child health contracts, including two focused on increasing health equity and improved birth outcomes for pregnant mothers who are from Black and African American and Native American communities.

Black Infant Health - Health Ministers Program Contract

Black and African American individuals who are Medicaid-eligible are at disproportionately increased risk for poor pregnancy outcomes. The statement of work of this contract supports outreach and linkage to First Steps services (a nurse home visiting program) for Medicaid-eligible Black and African American pregnant people in Pierce County, and provides them with culturally appropriate health messages. Title V staff worked with the Health Care Authority (HCA), the state’s Medicaid administrative agency, and Tacoma-Pierce County Health Department (TPCHD), which oversaw the project, and supported health ministers in their efforts to improve referrals to the First Steps program. TPCHD also networked with and provided information to community groups that address health issues for communities of color.

American Indian Health Commission Contract

DOH worked on a number of initiatives with the American Indian Health Commission and tribal health leaders to address health disparities affecting American Indian communities in Washington. Activities support the Commission’s Healthy Communities: A Tribal Maternal-Infant Health Strategic Plan. The plan identifies interventions likely to make the greatest difference in addressing health concerns identified by the tribes.

The agency’s partnership efforts support the foundational goal of AIHC’s strategic plan, which is to address problems through a policy, environment, and systems change approach. This is reflected in their Pulling Together for Wellness framework and process steps to address chronic disease prevention.

Process steps in the Pulling Together for Wellness framework include:

• Mobilizing at the Tribal/Community Level
• Leadership and Community Engagement
• Recruit and Retain Partners
• Specific Outreach to Youth and Elders
• Engagement of Cultural Resources and Traditional Healers
• Inclusion of Cultural Consideration in the Planning Process
• Use of Storytelling – Balance of Data and Stories
• 7 Generation Strategies – Strength-based
• Integrates Trauma-Informed Strategies

DOH continued to promote the ongoing development of culturally appropriate maternal and infant health strategies most helpful to serving American Indian/Alaska Native parents and babies. DOH continued partnerships with AIHC and HCA to increase awareness and build capacity for the important work of tribal Community Health Representatives, and to support AIHC in community engagement strategies to better understand current maternal and child health programs and services and patient experience.

DOH is committed to honoring the tenets of the Washington State Centennial Accord. This agreement, ongoing since 1989, outlines the government-to-government working relationship between the state and each of the sovereign governments of the 29 federally recognized tribes. The accord provides a structure for building relationships and providing services within a framework of mutually recognized sovereignty.