Perinatal/Infant Health - Annual Report

State Perinatal Program

NPM 3-Percent of very low birth weight (VLBW) infants born in a hospital with a Level III+ Neonatal Intensive Care Unit (NICU)

ESM 3.2 - To improve the system of perinatal regionalization statewide in order to increase the number of very low birthweight (VLBW) deliveries at an appropriate level of care facility.

Alabama continued to focus on preterm births with the ESM to address improving the system of perinatal referral and transfer for high risk mothers and infants. SPP staff worked to establish the comprehensive system of regionalized perinatal care in Alabama. AHA and ADPH continued to meet with State Health Planning and Development Agency (SHPDA), to ensure the questions related to perinatal levels of care were include in the annual hospital survey. The questions corresponded with the Alabama Perinatal Regionalization System Guidelines. The survey was provided to all delivering hospitals to self-declare their neonatal level of care as a baseline assessment. In May 2019, Dr. Richard W. Hall, University of Arkansas Neonatologist, a national expert in perinatal regionalization implementation provided an overview of the steps taken to implement perinatal regionalization in Arkansas. Dr. Hall shared the importance of data to depict the true picture of the problem, utilization, processes, and policies required to develop an evidence-based system of regionalized care. A total of 27 people attended the sessions, that included healthcare providers and hospital women services staff. The attendees discussed the challenges, barriers, and obstacles associated with the current regionalized system of perinatal care and suggestions of how to improve the system.

NPM 5-Percent of infants placed to sleep on their backs

ESM 5.1 -To conduct the Direct on Scene Education (DOSE) Train-the-Trainer Program to first responders in order to reduce Alabama's high rate of unsafe sleep-related deaths in infants less than one year of age

Activities related to the DOSE Train-the-Trainer Program remained stagnant in FY 2019.

In 2018, there were 70 SUID deaths in Alabama. That number was a decrease of 47 sleep related deaths from 2017. ADPH continues to provide pack-n-plays and safety kits to families in Alabama who are in need of a safe sleep environment for their infant.

Alabama Safe Sleep Outreach Project

ADPH continued to collaborate with the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). In August 2018, the NICHD extended the Alabama Safe Sleep Outreach Project. The Perinatal Regional Coordinators continue to provide quarterly education to hospital women service’s nurse managers. NICHD has provided Safe to Sleep Campaign materials in bulk to the state to utilize in its promotion of safe sleep and are to be provided to all county health departments. The materials are housed in the ADPH warehouse and can be obtained by electronically requesting the materials. The Safe Sleep Team/Taskforce continues to meet quarterly and provide community outreach. The taskforce participates in health fairs, faith-based events, conferences and other events to raise awareness of the importance of a safe sleep environment for infants. In August 2019, the NICHD, Palladian Partners and ADPH collaborated to coordinate a photo shoot featuring Alabama infants less than one year of age in their safe sleep environment. In March 2019, 2014-2018 infant mortality data was analyzed to determine zip codes with the high rates of SUID. The information will be utilized to determine areas of targeted infant sleep education to the public and healthcare providers. The agency continues to distribute the Sleep Safe and Snug books both in English and Spanish to women that deliver within the state. The books are provided to the delivering hospitals to be provided to the parents before discharge. These books are shipped on a quarterly basis to the delivering hospitals. One challenge encountered with this initiative has been one hospital declined to participate indicating that the book was against Baby Friendly guidelines because one picture in the book shows an infant with a pacifier in his mouth. The books in this county are now being distributed through the Medicaid Maternity Care Providers to parents.

Alabama Baby Box Initiative

The statewide initiative was launched in March 2016. DHR is the lead agency for Alabama. ADPH has collaborated with the project from initiation by identifying education topics and presenters for the educational videos. The Baby Box funders committed to 100,000 free boxes for Alabama participants in the original conversations; however, the funder now has committed to as many baby boxes as needed indefinitely to Alabama participants. As of November 2019, the Baby Boxes were no longer available for free to parents. The parents will have to pay to receive the box and are not required to view the educational videos to obtain a baby box.  DHR has purchased Baby Boxes to make them available for free to parents who view the educational videos. The Baby Box liaison employee continues to provide safe sleep education to obstetrics and gynecology offices, delivering hospitals, and collaborating agencies throughout the state.

Ongoing activities in Alabama to improve birth outcomes and reduce morbidity and mortality:

Early Elective Deliveries - Ongoing education efforts to reduce the number of non-medically indicated early elective deliveries continued statewide.

FIMR-In 2019 State Perinatal Program staff abstracted and reviewed a total of approximately 200 fetal and infant deaths.

In September 2018, ADPH repealed and replaced the Fetal, Infant, and Maternal Mortality Review Administrative Rule which was approved by the State Committee of Public Health. In 2018, the State Perinatal Program was expanded to include nurse abstractors for FIMR. These abstractors continue to focus on abstracting all infant deaths that occur within their regions. In 2019, FIMR case review teams (CRT) continued to meet at a minimum quarterly to review infant deaths and make recommendations to improve infant health and reduce infant mortality.

Collaborating Partners and Initiatives for the MCH Population

ABC - ADPH continued to collaborate with the ABC on initiatives to promote and increase breastfeeding statewide. Several ADPH staff served as board members on the ABC.

Babypalooza - Babypalooza is an annual statewide event that educates and informs new or expecting parents about community resources and is held in the five largest cities in Alabama. The event is free to the public and focuses on maternity wellness, child safety, and early learning. The state perinatal coordinators exhibited a booth at each of the events and provided educational literature on an array of perinatal topics that aim to improve birth outcomes, reduce morbidity and mortality, and support healthy moms, infants, and families.

Exhibits - Annually, SPP staff travel to conferences, summits, health-fairs, and other exhibiting opportunities such as the Alabama Chapter-American Academy of Pediatrics, Alabama Chapter-March of Dimes Perinatal Conference, Alabama Section-American Congress of Obstetricians and Gynecologists, Medical Association State of Alabama, the Association of Women's Health, and Obstetric and Neonatal Nurses Conference to provide outreach education and collaboration on perinatal issues that are pertinent to strategies being addressed in Alabama.

Alabama Perinatal Quality Collaborative –In March 2017, the Alabama Perinatal Excellence Collaborative transitioned to the Alabama Perinatal Quality Collaborative.

State of Alabama Infant Mortality Reduction Plan

In December 2017, Governor Kay Ivey convened the Children’s Cabinet to address the issue of infant mortality in Alabama. A subcommittee was created to develop an action plan. This subcommittee was comprised of leaders and staff from DECE, DHR, DMH, ADPH, Medicaid, and OMA. Title V funded program managers and MCH Epi staff developed and implemented strategies and data support for the plan.

Perinatal Regionalization

Enhancing perinatal regionalization is a priority of the State of Alabama Infant Mortality Reduction Plan. For several years, the team has been working and continues to work on implementing a fully coordinated system of perinatal regionalization care in Alabama. The foundation for such a system will be dependent upon relevant data that the workgroup began collecting in year 1. Furthermore, the workgroup, in collaboration with the Alabama Hospital Association and SHPDA, has worked to identify the level of neonatal care of delivering hospitals through self-declaration of the facilities. Baseline data for self-declared neonatal level of care was received from the SHPDA, and pertinent data was requested from the Center for Health Statistics. In March 2019, a conference call was convened with Dr. Wanda Barfield, OB/GYN and Rear Admiral with CDC, to discuss recommendations for engaging providers. In May 2019, Dr. Whit Hall, Neonatologist at the University of Arkansas, traveled to Alabama and met with staff and providers at the three delivering hospitals in Montgomery to discuss opportunities, options, challenges, and barriers. Review of the aforementioned data and support from CDC and experts will further advance the efforts underway to develop a perinatal regionalization system in the state.

Safe Sleep

DHR led the safe sleep education efforts. With sleep-related infant deaths among the top three contributors of overall infant mortality in Alabama, the need for heightened education is evident. The Safe Sleep Campaign was created to provide safe sleep education at the community level to parents, healthcare providers, elected officials, and the general public. A workgroup was created as a part of the initiative to inform safe sleep efforts and is comprised of partners in academia, state government, and healthcare. As part of this initiative, the team proposed to have at least 11 members in the workgroup, yet surpassed this goal in quarter one alone by 36 percent. Future efforts are underway to include in the workgroup representatives from Blue Cross Blue Shield and the American Association of Retired Persons. In addition, the workgroup has provided quarterly updates at the Children’s Policy Council meetings in the targeted counties. In fiscal year one, education was disseminated as outlined below.

• 138,878 Postcards in all counties
• 865 Baby boxes in all counties
• 5 Billboards posted in Montgomery and Macon counties
• 2 Bus wraps displayed in Montgomery county

The team will continue to expand the workgroup and promote safe sleep using effective educational strategies.

Breastfeeding

The hallmark of the breastfeeding initiative has been the utilization of existing and new alliances to increase and advance breastfeeding awareness. A multidisciplinary breastfeeding workgroup was established and includes partners from 18 different agencies. This interagency approach, coupled with multiple views of which to share insight, will strengthen the workforce to tackle issues that inhibit breastfeeding efforts. The team collaborated with the Alabama Extension Office and the Alabama Partnership for Children to implement a Breastfeeding Friendly Childcare Certification Program, which aims to recognize childcare providers who offer welcoming environments within their facilities for breastfeeding mothers. As of September 1, 2019, five childcare centers were certified in Montgomery and Lee counties. Education of pregnant and postpartum mothers is key in communicating the benefits of breastfeeding. As such, a variety of educational outreach methods were implemented throughout the pilot counties, including fliers, social media posts, and ads in Oh Baby!, a published book that is given to expectant mothers. This workgroup will continue to provide diverse perspectives to further advance the team’s objective to use breastfeeding as a way to reduce infant morbidity and mortality in the target counties and statewide.

Increase Utilization of 17P

The use of 17P in women with previous spontaneous singleton preterm births has proven to reduce the incidence of subsequent preterm births. The strategies for the 17P program are to identify the baseline utilization of 17P; provide education to both providers and patients; identify barriers to access and/or adherence to the medication; and expand and facilitate access to 17P. Data collection of 17P claims and research on other states’ approaches to 17P expansion remain underway. Targeted interviews of priority stakeholders (e.g., obstetric providers, medical assistants) were completed to map the processes that providers and patients undergo to prescribe, acquire, and administer 17P. Table 3 outlines the identified problem areas, which indicate a need for programmatic and policy changes. As a result, activities throughout the remaining fiscal years of the initiative will align with implementing solutions to these issues.