Perinatal/Infant Health Annual Report

 

Breastfeeding Report

 

The Nevada Women, Infants, and Children (WIC) Breastfeeding Program in collaboration with Title V Maternal and Child Health (MCH) continued statewide campaigns to improve infant feeding practices in maternity hospitals and increase community and business support for breastfeeding mothers. Nevada WIC supported participants by providing free professional lactation services, breast pumps and an enhanced food package to breastfeeding mothers.

 

Nevada WIC continued to promote and support breastfeeding through the use of an existing (previously CDC-funded) campaign to model Baby Steps to Breastfeeding Success (BS to BS): http://azdhs.gov/prevention/nutrition-physical-activity/breastfeeding/index.php#hospitals-baby-steps.

 

Maternity hospitals were given the opportunity to participate and past participants were offered a refresher training.  BS to BS educates maternity hospitals on how they may implement five evidence-based low or no-cost practices to support breastfeeding:

1. Initiate breastfeeding in the hour after birth,
2. Promote 24-hour rooming-in,
3. Avoid giving infants any food or liquid other than breast milk unless medical indicated,
4. Avoid artificial nipples for healthy term infants,
5. Give mothers a breastfeeding resource to help with breastfeeding questions after discharge.

 

Three additional Nevada maternity centers received BS to BS training in FFY 2018 (Humboldt General, Northeastern Nevada, and Henderson Hospital) and one previous participant received a refresher training (University Medical Center). Four Nevada hospitals, St. Rose San Martin, St. Rose Siena, and Carson Tahoe are already “Baby Friendly” designated. Henderson Hospital received the “Baby Friendly” designation after completing the BS to BS training.

 

Two WIC breastfeeding campaigns were designed to increase awareness, promote WIC breastfeeding services and normalize breastfeeding in public locations. For the Breastfeeding Welcomed Here campaign, Nevada businesses were asked to pledge their commitment to provide welcoming environments to breastfeeding mothers. This campaign included statewide print and social media posts. As of January 2019, 89 Nevada businesses have signed this pledge. The 2018 Breastfeeding Peer Counseling (BFPC) campaign used social and digital media to target potential WIC participants. WIC peer-to-peer support and breastfeeding services were promoted in both Washoe and Clark Counties where BFPC services are offered. 

 

To assist with a statewide goal of normalizing breastfeeding, Nevada WIC helped distribute 4,500 2018 Nevada Breastfeeds promotional calendars to medical providers and local community members. Calendars featured photographs of Nevada mothers breastfeeding in mostly public locations.

 

Nevada WIC continues to link participants to Internationally Board-Certified Lactation Consultants (IBCLCs) through the Pacify smart phone application (app).  Once downloaded, mothers have access to IBCLC support 24 hours a day, 7 days a week in English or Spanish. Nevada has 1.8 IBCLCs per 1,000 births, which is lower than the recommended 8.6 IBCLC’s per 1,000 births (Mannel & Mannel, 2006; CDC, 2016). Statewide Pacify coverage began in July of 2017, and approximately 950 WIC mothers utilized Pacify services in FFY 2018.  

 

In June of 2018, Nevada WIC was invited to participate in the Association of State Public Health Nutritionists’ (ASPHN) Children’s Healthy Weight Collaborative Improvement and Innovation Networks’ (CHW CoIIN) Breastfeeding Stream at the intensive learning level, in partnership with MCH. Nevada’s project focuses on promoting breastfeeding support to partners of WIC mothers through education and targeted outreach with the intent of increasing breastfeeding rates. The project will continue until September of 2019.

 

Breastfeeding Success Story

 

Angel on her Breastfeeding Peer Counselor Maria:

 

“With my first child I was young and didn't have much support during the journey. I only breastfed him until he was 8 weeks old and then I stopped. I was always worried he wasn’t getting enough or that I was doing something wrong. When I had my daughter, I struggled at first until I met Maria. She made me feel so comfortable, doing what is natural.  We struggled with mastitis and engorgement, nursing strikes- you name it. No matter what Maria was there to help me with everything. She always provided so much info and advice I successfully breastfed my daughter until her first birthday. Now currently with my 4-month-old, she has been breastfeeding since 10 minutes after her birth…. Even with this being my third baby there are still a bunch of questions I have and again I am lucky to have Maria as my breastfeeding counselor. It is so worth the special moments.” (Consent was provided by participant to share this story)

 

Pregnancy Risk Assessment Monitoring System (PRAMS) Report

 

The Nevada Pregnancy Risk Assessment Monitoring System (PRAMS) is part of a national effort to reduce infant mortality and adverse birth outcomes. The PRAMS questions cover the period before, during and shortly after pregnancy. The PRAMS questionnaire packets include a cover letter, a question and answer brochure, and a consent document. If a mother does not respond after three questionnaires are sent, an attempt is made to reach her by telephone. Mothers who complete the survey by mail or telephone are offered a $10 Walmart gift card (funded by PRAMS). PRAMS data will be used to monitor progress of national and state pregnancy and birth-related health measures. PRAMS will also identify and monitor self-reported maternal behaviors and experiences occurring before, during, and shortly after pregnancy among women who deliver live-born infants.

 

Nevada PRAMS started collecting data in September 2017. For 2017 births, Nevada PRAMS completed 7 batches. For 2018 births, Nevada PRAMS completed a full year of 12 batches. The weighted data from the 2017 births had a response rate of 40.6%, which falls below the CDC-required threshold of 55%. Since Nevada’s response rate for 2017 data is below the threshold, Nevada was unable to publish the data, but was able to use the data for grant applications and program planning. 2018 weighted data is expected to be completed in the fall of 2019.

 

PRAMS entered its third and fourth year of funding in May 2018 and May 2019. Title V MCH provided funds to cover the costs of printing and distribution of PRAMS survey covers, informational brochures, and posters. Title V MCH has supported efforts to increase the survey response rate through funding a Nevada Broadcasters Association media campaign airing of PRAMS television and radio advertisements in both English and Spanish.

 

Infant Mortality Collaborative Improvement and Innovation Network (IM CoIIN) Report

 

To address issues relating to birth outcomes and Social Determinants of Health, Nevada Title V Maternal Child Health (MCH) is involved in several statewide initiatives as part of the Infant Mortality Collaborative Improvement and Innovation Network (IM CoIIN) 2.0 in partnership with the Association of Maternal Child Health Programs (AMCHP). Nevada CoIIN partners include: Nevada Healthy Start Program, Southern Nevada Health District (SNHD), Washoe County Health District (WCHD) Nevada Medicaid, and March of Dimes (Nevada Chapter).

 

The aim of the IM CoIIN 2.0 is to build state and local capacity and test innovative strategies to shift the impact of social determinants of health and equity in birth outcomes by developing evidence-based policies, programs, and place-based strategies.

 

Messaging on the importance of 17-alpha-hydroxyprogesterone caproate (17P) and long-acting reversible contraception (LARCs) is embedded in CoIIN efforts. The Nevada Title V MCH program funds two Home Visiting sites where birth spacing data is gathered. Data was reviewed by the Nevada CoIIN team and technical assistance advisors to monitor learning network activities and provide recommendations, as well as increase postpartum visit rates and birth spacing intervals.

 

Title V MCH continues to foster Perinatal Quality Collaborative (PQC) development efforts, engage partners and expand Nevada’s PQC and Infant Plan of Safe Care workgroup, which includes Title V MCH staff. Title V MCH staff participated in the provider-led Birth Safety Network, a PQC in Southern Nevada with plans to expand statewide. Nevada submitted an application to be an Alliance for Innovation on Maternal Health (AIM) state, as well.

 

Fetal Infant Mortality Review (FIMR) Report

 

The Title V MCH-funded Washoe County Fetal Infant Mortality Review (FIMR) Program at Washoe County Health District (WCHD) received 78 new cases. Data was abstracted from local hospitals and health care providers.  Almost half of the total cases (38) were received between July 1, 2018 and September 30, 2018. The Washoe County FIMR Case Review Team (CRT) met nine times and reviewed 49 cases between October 2017 and September 2018. The CRT reviews five to six cases per meeting. 

 

A total of three maternal interviews were conducted during this grant period. Barriers to completing maternal interviews continue to be transiency, invalid phone numbers, and incomplete information. Interviews are not attempted for cases involving litigation, patients with psychiatric comorbidities, out of jurisdiction, and complex, extenuating circumstances.

 

The FIMR Community Action Team (CAT), which aims to implement recommendations of the CRT, continues to meet in conjunction with the Northern Nevada Maternal Child Health (NNMCH) Coalition. Staff continued to provide brief FIMR updates at NNMCH coalition meetings. 

 

The Go Before You Show (GBYS) public awareness campaign was recommended by the CAT based on 2015 FIMR Annual Report recommendations from the CRT.  Title V MCH funds the GBYS through the Nevada Statewide MCH Coalition to encourage early and on-time prenatal care. Flyers, social media and other advertising modalities have been disseminated in various locations across the state. FIMR staff networked with Community Health Nurses and Tribal Health providers in rural Northern Nevada counties to help promote this campaign. FIMR staff also contacted several local prenatal care providers to encourage them to update 2-1-1 information which has contributed to the success of this campaign.

 

The CRT made some progress addressing birth spacing through improved access to long-acting, reversible contraceptives after delivery. Some local providers are administering Depo Provera, inserting intrauterine devices (IUD) or birth control implants while mothers are still in the hospital. The CRT has been evaluating fetal movement awareness strategies, maternal substance use challenges, progesterone treatment to help prevent premature birth, maternal obesity and other issues. One of the objectives identified by the CRT was the need for a support group for Spanish-speaking women who have suffered fetal or infant loss.  Pregnancy and Infant Loss Support Organization of the Sierras (PILSOS) has agreed to implement this support group.

 

FIMR brochures and various educational materials continue to be disseminated at WCHD and local hospitals. The FIMR program is prepared to serve diverse populations with interpreter services provided in many languages. Sympathy cards and educational materials are also available in English and Spanish.

 

FIMR staff attended Washoe County Child Death Review (CDR) meetings every other month and presented summaries of infant death cases which were not under investigation by Child Protective Services or local law enforcement. FIMR staff also attended PILSOS committee meetings and assisted with a “Day of Remembrance” event in October 2017. Staff provided safe sleep education and Cribs 4 Kids information at the Binational Health Week event at Little Flower Catholic Church on October 14, 2017.

 

FIMR staff represented WCHD at various community meetings, including Join Together Northern Nevada (JTNN), Children’s Justice Act (CJA), CDR, and Northern Nevada Breastfeeding Coalition. FIMR staff served on a statewide workgroup for the Washoe County CDR: “Increasing the Impact of Safe Sleep Education.” WCHD nurses also continue to provide safe sleep training and Pack ‘N Play crib distribution, including group classes in partnership with the WCHD WIC program. Staff received training to participate in the Baby & Me Tobacco Free program.  FIMR staff participated in a “Sudden Infant Death & Sleep Environment: An Update on Safe Infant Sleep” webinar on October 19, 2017. The FIMR program supervisor attended the Association of Maternal and Child Health Programs (AMCHP) Conference February 10-13, 2018 and participated on the Infant Mortality Collaborative Improvement Innovation Network (IM CoIIN) Social Determinants of Health Nevada State Team on February 13-14, 2018 in Arlington, Virginia.  Staff presented information about the FIMR program at the Saint Mary’s Perinatal Loss Committee on February 28th 2018.   Additionally, staff participated in an “Infants with Prenatal Exposure and their Parents: Family Approach of Yale New Haven Children’s Hospital” webinar on March 21, 2018. Other webinars included: “Straight Talk About Infant Safe Sleep: Strategies for Helping Families Adopt Safe Sleep Habits” on April 25, 2018 and “FIMR Case Reporting System Tutorial Webinar” on June 5, 2018.

 

Safe Sleep Report

 

The Regional Emergency Medical Services Authority (REMSA), with Title V MCH Block Grant funding, operates as the lead agency for the Cribs for Kids (C4K) Program in Nevada. C4K provides educational resources to parents and caregivers on the importance of practicing safe sleep behaviors with infants to prevent mortality. Partner agencies participate in train the trainer sessions, which include evidence-based, best practice Safe Sleep Education endorsed by the American Academy of Pediatrics (AAP). Safe Sleep Survival Kit for infants are provided to families who cannot afford to purchase a crib for their infant. Safe Sleep Survival Kits include a Pack and Play Crib, a crib sheet with the safe sleep message, a Halo Sleep Sack, Safe Sleep ABC photo magnet, Philips Soothie Pacifier, Safe Sleep educational materials (brochure, door hanger, and flyer), a Safe Sleep DVD, and a “Sleep Baby Safe and Snug” children’s book. Materials are available in English and Spanish.      

 

Over the reporting year, C4K conducted thirteen (13) statewide train-the-trainer sessions: four (4) in Las Vegas, five (5) in Reno, and four (4) in rural Nevada (three of the train-the-trainer sessions were conducted in hospitals). In addition, C4K conducted one Safe Sleep AAP Update to nurses at Renown hospital, by request. Two (2) Safe Sleep educational sessions, including a question and answer component, were provided to Casa De Vida, a non-profit agency providing home and support services for pregnant young women in the urban Reno area, and to the Life Change Center, a non-profit organization providing recovery services for heroin and prescription medication use. All participating C4K agencies continued to receive technical assistance related to updating the REDCap relational data system to ensure accurate data are reported on parent Safe Sleep classes, survival kit disseminations, and follow-up surveys. REMSA offered continuing education credits for CEUs to nurses and social workers who attended the train-the-trainer sessions.

 

Twenty-two agencies actively participated in the C4K Program by assisting with the distribution of 751 Safe Sleep Survival Kits. A total of forty-five (45) agencies were identified as partners. Ongoing communication efforts are prioritized to ensure Safe Sleep education and materials are widely distributed and participation in C4K activities continue to increase.

 

C4K staff attended 12 community events and health fairs, reaching approximately 2,600 participants, to promote Safe Sleep education and preventive measures to increase first-year infant survival rates. Some of these events focus on family engagement and reach many more people outside the events. During community events and the train-the-trainer sessions, the C4K Program shared additional internal MCH agency materials with the public, including Nevada 2-1-1, the Nevada Tobacco Quitline, and the Nevada Children’s Medical Home Portal. C4K will participate in a minimum of ten (10) community events and health fairs and additional venues, as requested.

 

Title V MCH and C4K Program staff conducted media interviews to raise public awareness of the importance of following Safe Sleep guidelines. The children’s book, “Sleep Baby Safe and Snug”, was offered to all birthing facilities and 11,880 books in Spanish and English were distributed statewide. Safe Sleep brochures were included in the “Protect and Immunize Nevada Kids” (PINK) packets distributed to new parents and families at birthing facilities statewide after the birth of their child.

 

C4K Program staff attended trainings to increase their knowledge on revised AAP Safe Sleep guidelines.  Webinars and events attended included: National Institute for Children’s Health Quality (NICHQ) on Improving Infant Safe Sleep Strategies for Helping Families Adopt Safe Sleep Habits, Renown Grand Rounds presentation on Sudden Infant Death Syndrome (SIDS) by Medical Examiner Dr. Laura Knight, and the Nevada Health Conference. C4K staff also attended bi-monthly Washoe County Child Death Review meetings and Statewide Executive Committee Child Fatality Review meetings.

 

A statewide Impact of Safe Sleep Task Force continued to meet with representation from all local health authorities, hospital staff from northern and southern Nevada, CDR committee members, Title V MCH staff, REMSA’s C4K Program Coordinator, Department of Child and Family Services, and interested stakeholders.  The group aims to raise public awareness on the importance of following Safe Sleep Guidelines and reducing infant deaths. A Safe Sleep infographic was included in water bill inserts in Washoe County to raise awareness on the ABC’s of Safe Sleep in Fall 2017. The infographic was also used on Grocery cart advertisements in five grocery stores, two in Las Vegas, one in Reno, one in Sparks, and one in Elko. Safe Sleep updates were provided for the Statewide Executive Committee on Child Fatality Review meetings, to which the Impact Task provides updates. Alignment of messaging statewide with evidence-based, AAP guidelines is a key focus of the group.

 

The C4K brochure and poster, as well as the Title V MCH media campaign, were updated in English and Spanish to include recent recommendations from the AAP

 

Safe Sleep Success Story

 

“The State of Nevada`s Cribs for Kids Program is a valuable resource for residents who are in a situation where they cannot afford a safe sleep environment. Most of the participants are low socio-economic status and individuals going through personal and economic hardship. In June 2018, I received a phone call from a soon-to-be first-time mother who was seeking help. She received my number from a family member who attended the Family Fun Festival at San Rafael Park. She was expecting twins in September 2018. She and her husband had just been laid off and were struggling to find jobs while also trying to find a new place to live as they could no longer afford their current apartment. She offered documentation upon documentation to prove their detrimental situation. The mother was terrified of not having a safe location for her twins and didn’t want them sleeping in the same bed as her. After talking to the mother and informing her about the requirements for our program, she had no problem complying and was looking forward to more education on safe sleep. I informed her since she is having twins, she was eligible to receive two survival kits. I also connected her to other community partners who could help with additional services, such as WIC. The mother expressed her gratitude for the Cribs for Kids Program and the program being available to help individuals like her.”

 

(Submitted by Francisco Ceballos, Cribs for Kids Program Coordinator)

 

Safe Sleep Media Campaign Report

 

The Safe Sleep Media Campaign ran from October 1, 2017 through September 30, 2018 with English and Spanish radio and television public service announcements statewide. For this funded period, the Safe Sleep media campaign had a total of 30,511 total spots aired (27,898 radio advertisements and 2,613 television advertisements). All local health authorities promote Safe Sleep messaging. The Title V MCH program works closely with partners across the state and participate.

 

Abusive Head Trauma Report

 

Title V MCH funded the Nevada Institute for Children’s Research and Policy’s (NICRP) Prevent Child Abuse Nevada (PCANV) Program to develop a ‘train the trainer” approach for professionals from Indian Health Service clinics to teach parents how to prevent Abusive Head Trauma/Shaken Baby Syndrome. The training was adapted from the Abusive Head Trauma/Shaken Baby Syndrome Training developed by Massachusetts Citizens for Children, Inc. Their training was specific to health care professionals and incorporates concepts from research-based program; the training was reviewed to ensure it aligned with other DPBH and MCH initiatives, including safe sleep practices, and was revised to be culturally relevant and appropriate for the Native American families.

 

MCH staff facilitated PCANV staff schedule meetings with Southern Bands Health Center, the Owyhee Community Health Facility, and feedback was solicited from all Tribal health center Directors by the Director of the Inter-Tribal Council of Nevada. All feedback received was utilized to adapt a health care provider training, a parent/caregiver brochure and a short 4-minute educational video for parents and caregivers. A pre-and post-survey to measure the impact of the education provided by the health care providers to the parents and caregivers was developed.

 

A two hour “train the trainer” training was provided in Elko and in Reno. Attendees agreed the presentation topic was clear, sufficient detail was provided, there were opportunities to ask questions, the information was culturally appropriate, and the information was practical and useful. Following the Elko session, health care professionals were asked if any changes or adaptions were needed to make the information more relevant for this population, however, suggestions for changes were not provided.

 

Perinatal/Infant Health and Wellness Report

 

Nevada awarded Carson City Health and Human Services (CCHHS), a local health authority in Northern Nevada, Title V MCH funding to promote perinatal/infant health. Infant immunizations and Text4Baby were endorsed through outreach events and health promotion marketing campaigns, inclusive of clinic digital signage and Facebook. Specific focus was placed on increasing the numbers of breastfed infants, breastfeeding education and support, and improving infant immunization rates. Title V MCH funds CCHHS to provide businesses with supplies for a designated breastfeeding area for employees. To identify interest in establishing breastfeeding-friendly workplaces, CCHHS sent 305 letters, 135 emails, and made 80 telephone calls to local businesses. Eight businesses were provided supplies such as privacy screens, refrigerators, and reclining chairs. Businesses send photos to CCHHS of the newly created spaces which are often accompanied by thank you notes from employees expressing gratitude for the private and comfortable breastfeeding areas to support increased duration of breastfeeding and associated health outcome benefits.

 

Title V MCH funded 0.10 FTE of 12 nursing personnel within DPBH Community Health Services (CHS) for enabling services to educate parents of infants in Nevada’s rural and frontier area on the value of infant immunizations, safe sleep, breastfeeding and nutrition, well-child checkups, reproductive health and promotion of Medicaid coverage for long-acting reversible contraceptives immediately postpartum. CHS nursing personnel were provided with the Edinburgh Postnatal Depression Screen tool to guide nursing personnel in conducting perinatal mood and anxiety disorders (PMAD) screens for new or soon-to-be-mothers. Plans are being made for a web-based training allowing nursing staff to enhance knowledge of PMAD and learn of local referral resources. Nursing personnel distributed perinatal/infant health-related materials provided by the Title V MCH Program. Materials covered safe sleep, substance use in pregnancy, Nevada 2-1-1, and the Nevada Children’s Medical Home Portal.

 

Title V MCH funded Partners Allied for Community Excellence (PACE) Coalition, an entity within the Nevada Statewide Coalition Partnership, was awarded to employ a Community Health Worker (CHW) to participate in MCH activities in Elko County and nearby rural communities. To enhance perinatal/infant health, the CHW taught five Cribs for Kids classes to pregnant women educating about safe infant sleep. Class participants were provided with information about tobacco cessation, Nevada 2-1-1, the PRAMS survey, breastfeeding, local WIC offices, immunization schedules, and baby growth charts. Additionally, the CHW conducted four parenting skill sessions. Recognizing a gap in services, the CHW received PMAD training allowing PACE to assist new or soon-to-be mothers experiencing prenatal and postnatal depression and/or anxiety. Plans are being made for the CHW to become a certified lactation educator as Elko and nearby communities are experiencing a need for lactation support.

 

Perinatal Immunizations Report

 

In fall 2018, plans were made for Title V MCH funding to begin supporting a 0.5 FTE position for Nevada’s Immunization Program. The linkage strengthens the infrastructure of the MCH Program by improving preconception and interconception health among women of childbearing age, linking immunization to interconception and preconception care, as well as supporting cocooning efforts. During immunization compliance visits to obstetrician offices, materials were dropped off for distribution to pregnant women. The materials supplied by MCH contain topics pertinent to improving maternal and infant health outcomes, such as the PRAMS survey and substance use in pregnancy (SoberMomsHealthBabies.org). Obstetricians promoted the benefits of Tdap vaccines early in the third trimester, as well as flu shots at any time during pregnancy. Plans are in place for future collaborations with WIC staff to assess the vaccine status of pregnant women served and provide referrals to immunizing providers. Furthermore, Title V MCH funded one 0.5 FTE Accounting Assistant.

 

The Nevada Early Hearing Detection and Intervention (EHDI) Program Report

 

The Nevada Early Hearing Detection and Intervention (EHDI) program (EHDI) is housed within MCAH Section of the DPBH, but not funded by Title V MCH. EHDI staff and the TV MCH CCHD Registry staff share information.

 

The goals of the Nevada EHDI program are to ensure:

• All infants are screened for hearing loss before one month of age
• Infants who do not pass the screening receive diagnostic evaluation by three months of age
• Infants identified with hearing loss receive appropriate early intervention by six months of age

 

The negative effects of hearing loss can be substantially mitigated through early intervention which may include amplification, speech therapy, cochlear implants, and/or signing. EHDI works with birthing hospitals, audiologists, Early Intervention Services, and non-profits to ensure infants are screened, identified, and enrolled into services within recommended time frames. The program additionally works with all its public and private partners to develop and update best practices and provide parents with education, support, and trained mentors. 

 

Data from 2017 shows 35,483 births in Nevada with 34,743, or 97.9%, documented as receiving a newborn hearing screening. Among the infants who received a newborn hearing screening, 34,312 passed the screening and 431 infants did not pass. For those infants who did not pass, 226 were documented with a diagnosis on file. From the 226 infants who did not pass, 161 were determined to have normal hearing and 65 were diagnosed with hearing loss. Fifty seven of the 65 infants diagnosed with hearing loss were enrolled in Early Intervention programs and 8 infants were not enrolled or their enrollment status was unknown. Of the 740 infants who did not receive screening, 55 passed away and 110 had a parent or family member decline the screening. There were 575 infants whose screening status was unknown or not performed; 410 were home births.