Perinatal and Infant Health Annual Report 2023

Vermont’s Title V perinatal and infant health domain spans a wide variety of strategies to ensure optimal child health and development and family wellness in the perinatal period. Priorities include increasing breastfeeding and enrollment in WIC, the spread of an innovative pediatric health care model and Brazelton’s Touchpoints, and the expansion of two evidence-based home visiting models. Our partnership with the Vermont Child Health Improvement Program (VCHIP) is key to engaging obstetricians, pediatricians, and others across the healthcare network and ensuring continuous quality improvement (CQI) in these priority areas.

 

WIC and Breastfeeding

WIC (the Special Supplemental Nutrition Program for Women, Infants, and Children), which is administered under the Title V Director, provides individualized nutrition counseling, breastfeeding promotion and support, health screening and referral, and specific nutrient-dense foods to income and nutrition risk eligible pregnant, postpartum, and breastfeeding individuals, infants, and children who are under age 5. WIC families use a “WIC branded” EBT card to purchase their prescribed WIC foods at authorized retail grocers. WIC integrates or coordinates with other programs such as EPSDT, lead poisoning prevention, immunizations, Children’s Integrated Services, nurse home visiting, family planning, and birth defects prevention. WIC provides comprehensive breastfeeding education/training aligned with USDA’s Breastfeeding Essentials curriculum and collaborates regionally to provide training on an ongoing basis. Vermont WIC consistently has the highest WIC breastfeeding rates in the northeast region.

 

In August 2023, Vermont WIC was awarded a Breastfeeding Bonus Grant from USDA for sustained high breastfeeding rates among WIC participants during FFY22. The Morrisville Office of Local Health received the only elite-level Breastfeeding Award of Excellence in the country. The Barre and St. Johnsbury Offices of Local Health received Premiere level Breastfeeding Awards of Excellence. While these awards are point in time, they reflect ongoing work to support breastfeeding across the population.

 

Vermont WIC has been a strong presence in promoting child health, addressing overweight and obesity in pregnancy and childhood, and increasing breastfeeding exclusivity and duration. WIC will continue to play a key role in Title V activities to increase breastfeeding rates as described below.  

 

Families continue to receive in-home lactation consults from Medicaid providers with an International Board-Certified Lactation Consultant (IBCLC) credential. In-home lactation consults are primarily available for families in Chittenden, Addison, Franklin, and Lamoille counties. Many of the Medicaid IBCLCs providing lactation services continue to offer virtual consultations for lactating parents in underserved counties. Vermont has a large number of IBCLC-credentialed individuals, but many are not working in professions licensed by the State and therefore are not eligible to become Medicaid providers. Families in areas without access to a home-visiting IBCLC Medicaid provider may receive home visits through the Strong Families Vermont nurse home-visiting program or receive in-office lactation consults through their pediatric office or hospital outpatient lactation clinic.

 

Vermont Medicaid improved coverage for personal-use breast pumps in January 2024, increasing the coverage for personal-use breast pumps to one pump per pregnancy (rather than one pump every 3 years) and extending the period to obtain a pump to 60 days before the estimated due date through 120 days after the baby’s birth. This brings Medicaid coverage of breast pumps closer to the benefits offered by private insurance, reducing health care disparities.  

 

The latest National Immunization Survey breastfeeding data (for children born in 2019) shows that Vermont exceeds the national breastfeeding rates but has not met either of the Healthy People 2030 goals for breastfeeding. The HP 2030 MICH-15 goal is for 42.4% of infants to be exclusively breastfeeding through 6 months (36.2% in Vermont) and the MICH-16 goal is to increase the proportion of infants who are breastfed at 1 year to 54.1% (54.0% in Vermont). 

 

The CDC Maternity Practices in Infant Nutrition and Care (mPINC) survey results for 2022 show that Vermont scored 87 compared to the National average of 81. The survey assesses maternity care practices and provides feedback to encourage hospitals to make improvements that better support breastfeeding. In 2022, 10 of 11 eligible hospitals in Vermont participated (91%). NOTE: The mPINC survey was redesigned in 2018. Results from the mPINC surveys since 2018 cannot be compared with results from previous mPINC surveys. 

 

Breastfeeding peer counseling has been shown to increase breastfeeding initiation, duration, and exclusivity. The Vermont WIC program provides peer counseling services in all 12 local health offices. Breastfeeding peer counseling services have waxed and waned over time, due in large part to funding shifts. Twenty-five percent of pregnant and breastfeeding WIC participants received peer counseling services in 2022. Currently, 30% of pregnant and breastfeeding WIC participants receive peer counseling services based on an average of monthly data from the last 12 months.  

Breastfeeding Peer Counselor job descriptions were revised in 2023 to accurately reflect current work. The updated job specifications were submitted in conjunction with the annual temporary position request, resulting in an upgrade in pay grade. The intention is to achieve a balance between recruitment and training costs and compensate breastfeeding peer counselors more equitably going forward to improve retention. However, efforts to recruit and retain bilingual peer counselors have been challenging.  

Maternal Mortality Review Panel

Vermont’s Maternal Mortality Review Panel (MMRP) was established by legislation in May 2011 to conduct a comprehensive, multidisciplinary review of perinatal deaths in Vermont to identify factors associated with the deaths and make recommendations for the prevention of future perinatal deaths. Vermont legislation requires an annual report to the legislature from the panel regarding the panel activities, data, and recommendations for the prevention of perinatal death. MMRP work has been informed by national and state focuses on health equity and the recommendations put forth by this panel will inform aspects of upcoming enhanced PQC-VT work. The MMRP has a focus on substance misuse and mental health conditions among pregnant and postpartum individuals. (For more on MMRP work see Women and Maternal Health report). The overwhelming majority of Vermont maternal deaths happen in the postpartum period, specifically in the later postpartum period.

 

Vermont Child Health Improvement Program (VCHIP) and Perinatal Quality Collaborative (PQC-VT)

While Vermont has among the best perinatal and child outcomes in the country, our system needs strengthening with improved coordination, clearer referral pathways for providers and patients, additional expertise and capacity related to disparities, and attention to workforce resilience. Vermont has a strong history of perinatal continuous quality improvement (CQI) in OB, neonatal, and pediatrics. VCHIP and the FCH division adopted the collaborative approach and strategic planning supported by the Vermont Perinatal Quality Collaborative (PQC-VT) to maintain obstetrical and newborn excellence and enhance access to community support in the clinical sphere. Under a CDC grant obtained in 2023, the PQC-VT has expanded its capacity to improve outcomes and promote health equity in clinical and community settings.

 

Before the PQC-VT, the state made significant improvements in the care of pregnant Vermonters, newborns, and infants through initiatives like OB-Outreach, Alliance for Innovation on Maternal Health (AIM), Vermont Regional Perinatal Health Project, and Improving Care for Opioid-Exposed Newborns. These projects have been combined under the umbrella of the PQC-VT. The PQC-VTs mission is to optimize care and health outcomes of Vermont’s pregnant people, newborns, and their families through collaborative CQI.

 

This year, 16 Perinatal Quality Collaborative (PQC) faculty and leaders convened perinatal partners and conducted CQI activities across Vermont; and 112 PQC partners from ten birth hospitals engaged and participated in the Perinatal & Neonatal Statistical Review Conference. Numerous community-based organizations and the Offices of Local Health FCHCs worked to create the community-facing Perinatal Public Health Reports for all 12 AHS regions, highlighting clinical and public health, MMRP, and nurse home visiting data. The PQC-VT is also enhancing its existing Patient and Parent Advisory Committee to review and inform all PQC-VT projects.

 

One example of this clinical partnership is the Comprehensive Obstetrical Services Program, administered by OB/GYNs at the University of Vermont Medical Center, who provide comprehensive, team-based, maternity care to women who are socially/economically at-risk. The care coordination team includes an obstetrician, a social worker, a nurse, and a nutritionist. Services include comprehensive prenatal care, lab, and genetic testing, birth and postpartum services, enrollment in WIC, breastfeeding support, contraceptive counseling, and referrals to Help Me Grow for service coordination and connection to intensive services for women living with substance use disorder.

 

Clinical-community linkages provide enhanced patient support, promote protective factors, strengthen families, and offer more frequent connections with families. Our FCH and VCHIP early childhood team includes staff from the PQC-VT to leverage the PQC-VT Clinical-Community Linkages QI project and we work closely to address identified barriers, improve outcomes, and align communications. The goal of this QI project is to uplift effective and sustainable linkage efforts between clinical care and community-based teams to provide comprehensive and equitable perinatal care, as well as non-clinical support services across the perinatal period. Objectives include:

 

• Build partnerships and relationships with community-based services, community organizations, and public health entities to expand perinatal QI work outside of clinical care
• Improve communication pathways and information sharing between prenatal obstetric services, birth hospitalization, postpartum obstetric services, pediatric practices, and community-based services and supports

 

Perinatal Mood and Anxiety Disorders

Vermont engages in several strategies and programs to improve access to services and reduce the prevalence of Perinatal Mood and Anxiety Disorders (PMADS) to promote optimal infant health and development and family wellness in the perinatal period. Vermont’s FCH program in 2018 was awarded a five-year HRSA cooperative agreement: Screening and Treatment for Maternal Depression and Related Behavioral Disorders Program (MDRBD). Vermont’s program, Screening, Treatment, and Access for Mother and Perinatal Partners (STAMPP), aims to improve the mental health and well-being of pregnant and postpartum women and their families and children. In the fifth year of this award, key accomplishments include:
 

• Increased capacity of the Perinatal Psychiatrist at the Perinatal Psychiatric Consultation Service (PPCS) which provides psychiatric consultation to front-line perinatal providers, especially in rural communities where psychiatrists are few and other mental health supports have long waitlists or do not accept Medicaid. In 2023, she increased her time from 0.3 FTE to 0.55 FTE.
• Funding, planning, and sustainability discussions related to the addition of a Liaison Coordinator position for the PPCS to provide care coordination, training, and practice outreach.
• System improvement efforts to align doula and training efforts with home visiting, CIS services, mental health treatment, and other community supports. Education around doula services to advocates and supporters of legislation to allow Medicaid payment for doulas.
• Partnership and integration with the HRSA-funded Child Psychiatry Access Program, outreach, and evaluation.
• The completion of an economic analysis by Mathematica Inc. on Cost Savings from Expanding Vermont’s Perinatal Psychiatric Consultation Service. Findings from the research conclude that expanding Vermont’s PPCS from a 0.4 FTE to 0.75 FTE psychiatric consultant, and adding a 0.75 FTE liaison coordinator, would cost about $620,000 while saving $1.96 million in the first two years. The cost savings would be a result of increased societal productivity and reduced medical costs from treated perinatal mental health conditions. Subtracting the costs of the consultation service from the cost savings of treated perinatal mental health conditions yields a total savings of $1.3 million over two years of the model’s expansion, or about $3 in savings for every $1 spent on the program.
• Supported a research project with VCHIP on the perinatal experiences of refugee and immigrant women in Vermont to expand qualitative efforts started with the Women with Lived Experience research.
• Expanded statewide outreach with our Support Delivered communications campaign materials to decrease stigma, raise awareness and understanding about PMADs, and increase understanding of supports and services available in the community including culturally and linguistically responsive resources and virtual support options to address barriers.
• Collaborated with a Burlington-based Parent Child Center serving refugee and immigrant families, a Somali Bantu community health worker with specific interest and expertise in perinatal topics, and VCHIP on a PMAD educational video for Maay Maay speaking Somali Bantu community members in the perinatal period and their families and friends. The video will be ready for sharing in the 2023-2024 application period.
• Develop and maintain up-to-date, real-time referral resources at the state and community level via the Help Me Grow Vermont (HMGVT) resource database (see also Child section).

 

STAMPP works collaboratively with the Department of Mental Health, Department of Vermont Health Access (Medicaid and Pregnancy Intention Initiative), Department for Children and Families, VCHIP, UVM Medical Center, Vermont’s designated community mental health centers, HMGVT and MIECHV Strong Families Vermont nurse home visitors.

 

Vermont recently received a new round of HRSA MDRBD funding to support ongoing activities and further sharpening and expansion of this essential work beginning June 1, 2024 (see Perinatal Application Plan).

 

Developmental Understanding and Legal Collaboration for Everyone (DULCE) and Touchpoints Approach Developmental Understanding and Legal Collaboration for Everyone (DULCE) is a crucial evidence-based program and primary strategy supported by Title V to promote optimal infant health and development. Through braided funding from the Vermont Department of Health, including the CDC Overdose to Action grant and Title V funding, One Care, the Center for the Study of Social Policy (CSSP), and one region’s Parent Child Center, Vermont implements the DULCE model in six pediatric offices in Vermont. DULCE is an innovative national demonstration project, sponsored by the CSSP, through which pediatric primary care clinical sites proactively address social determinants of health and other needs, including substance use disorder (SUD), to promote the healthy development of infants from birth to six months of age and provide support to their parents. A key feature of the DULCE intervention is a Family Specialist, employed by the local Parent Child Center, who is a member of the pediatric team, and connects families to resources based on parents’ needs and priorities. DULCE employs the Medical-Legal Partnership model to provide families with more intensive assistance in obtaining concrete support when needed. The DULCE intervention incorporates a Strengthening Families Protective Factors approach and provides optional home visits. This universal program for all babies is accepted by most families in the pediatric practice. DULCE sites participate in monthly (new sites) or quarterly (established sites) continuous quality improvement and data management activities with VCHIP to review data and implement PDSA cycles.

In 2023, Vermont was awarded a Transforming Pediatrics for Early Childhood (TPEC) grant from HRSA. This funding will allow us to expand DULCE to three new pediatric practices in Vermont. Also, in 2023, the Vermont legislature authorized a two-year pilot to utilize Medicaid funding through the Blueprint for Health to support approximately 70% of the cost of implementing a DULCE site at six practices in Vermont. The other 30% of DULCE’s cost for these sites is covered with TPEC funding. If successful, the legislature has indicated potential interest in further expanding the pilot to include additional sites in 2025. Vermont is hopeful that this may be a sustainable funding source for the existing six DULCE sites as well as the three sites funded by TPEC.

 

Family engagement is integral to the DULCE approach. Utilizing a continuous quality improvement framework with VCHIP, in 2023, Vermont developed a Family Advisory Team structure currently with five family representatives who come together monthly to provide feedback and expertise on DULCE implementation and adaptations. Centralizing the group ensures that all sites benefit from family engagement and feedback even if they are new and/or still recruiting families for participation. Feedback from the group has been integral to:

• Developing and fielding successful exit surveys
• Implementing screening
• Learning about the family experience of the program
• Integrating data collection

 

Touchpoints

Brazelton’s Touchpoints is an evidence-based approach to building strong family-child relationships (prenatal through age five) and a key Title V program. Vermont’s Touchpoints Center is at the Vermont Child Health Improvement Program (VCHIP) and has expanded Touchpoints training opportunities this year.  Supported by Vermont’s Preschool Development Renewal Grant Birth-to-Five (PDG B-5), Touchpoints is a key PDG B-5 strategy to promote early relational health and advance equity by building early educator professional capacity to deliver culturally and linguistically responsive care to Vermont’s most vulnerable families. Highlights include:

 

• The new Touchpoints Learning Management System (LMS) was approved through the UVM Brightspace and is being utilized to increase early educator access to asynchronous training. Touchpoints training is available for continuing education credit through the Northern Lights Professional Development Center.
• Four Touchpoints training sessions were offered to 68 professionals
• Pre- and post-training assessments showed participants’ relational and developmental knowledge and skills increased. Participants reported that the training met their expectations in some way, with 87% reporting the training was very well or excellent at meeting their expectations.
• A multidisciplinary Touchpoints strategic planning team continues to meet monthly.

 

Help Me Grow Vermont: Call to Action for Health Communications Campaigns

To increase the use of our Help Me Grow information and referral hub, Vermont’s go-to resource for connecting families to services and supports, we have strategically leveraged HelpMeGrowVT.org as the call to action for:
 

1. Support Delivered communications campaign to raise awareness around the prevalence of perinatal mood and anxiety disorders (PMADs) and bridge connections between expecting and new parents and statewide perinatal mental health resources. As the call to action, HMGVT:
   • Maintains a real-time database with information on mental health services and support to better connect families.
   • Provided 171 referrals to therapists and support groups specializing in perinatal mood and anxiety disorders.
2. One More Conversation campaign to help Vermonters understand that there is no known safe amount of substance use for a healthy pregnancy and help health care professionals continue the conversation with their patients.  
3. Strong Families Vermont Home Visiting where families can directly connect with HMGVT staff to ensure connection to home visiting services. Designed to raise awareness and normalize home visiting for young families, this social marketing campaign offers:
   • Digital social media advertisements, print materials, and five videos of a family and home visitor for ongoing promotion of home visiting.
   • Print and digital materials have been disseminated to obstetric and pediatric practices, Federally Qualified Health Centers (FQHCs), Planned Parenthood of Northern New England, birthing hospitals, and a variety of community and social service agencies.
   • A promotional postcard was mailed to ~14,000 Vermont Medicaid beneficiaries who were pregnant and with children under four years of age.
   • Referrals to HMGVT for home visiting services have increased. HMGVT has made 31 referrals for nurse home visiting and four for family support home visiting, a 91% increase over the prior reporting period.

 

Read more about HMGVT in the Child Health Report section.

 

Strong Families Vermont Home Visiting

Home Visiting continues to be a foundational strategy to promote optimal perinatal and infant health and development. Vermont is close to completing six years of implementation of the Maternal Early Childhood Sustained Home Visiting (MECSH) model under the Maternal, Infant Early Childhood Home Visiting (MIECHV) funding and continues to ensure a comprehensive statewide and local early childhood home visiting system. Evidence-based home visiting has been fully integrated into Children’s Integrated Services (CIS) as one of four core, specialized services. This integration ensures that participants are directed to the most appropriate service and care is well coordinated across the early child services system.  Performance highlights of the MIECHV program over this reporting period include:

 

• 94% of caregivers were screened for depression within 3 months of enrollment and 61% with positive screens were connected with mental health services.
• 80% of caregivers received a postpartum visit with a healthcare provider within 8 weeks of delivery.
• 97% of children received well-child visits according to the American Academy of Pediatrics (AAP) schedule.
• 91% of children had a caregiver who read, told stories, and/or sang songs with the child daily.
• 45% of infants were breastfed any amount at 6 months of age.  

 

Additional highlights over the reporting period include extensive training efforts for home-visiting staff. Vermont’s American Academy of Pediatrics (AAP) Chair, met with all MECSH nurse home visitors to provide interactive training on safe sleep and shared the toolkit for pediatric providers written following the American Academy of Pediatrics (AAP) guidelines and banned sleep products.

This was incredibly useful to help support the practice of home visiting staff in their roles with families assessing safe sleep and providing education to Vermont families.

 

Over this past year, FCH’s home visiting team and injury and violence prevention staff supported a two-day training, Connected Parents Connected Kids, for home visitors, domestic violence advocates, child welfare staff, and other professionals working with perinatal families. The curriculum is designed to support home visitors, health care professionals, domestic violence experts, survivors, and policymakers at all levels as they improve health care’s response to domestic violence.

 

The Connected Parents Connected Kids curriculum presents an evidence-based intervention, CUES, which stands for Confidentiality, Universal Education, Empowerment, and Support. The universal education approach is not disclosure driven. This ensures that all clients receive information on healthy and unhealthy relationships and resources for addressing IPV and warm lines to help prevent child abuse regardless of whether a client discloses that they are experiencing violence. This is an important way to promote health equity—CUES also prompts providers to share their power by not requiring disclosure for the patient to receive these educational brochures that have safer planning and information on domestic hotlines and chat lines for support.  The training also covered strategies for responding to disclosures, including how to seek insight into the client’s perspectives and priorities, and how to work collaboratively with the client to strengthen their ‘safer’ plan.

 

As part of this effort, Vermont’s MIECHV home visiting program also provided training and support on the implementation of a new validated IPV tool, (WAST 8) Women Abuse Screening tool, which was a preferred validated tool more in line with Connected Parents Connected Kids curriculum and is no longer using the former IPV tool, HITS (Hit, Insult, Threaten or Scream).  MECSH Home Visitors have been well supported with ongoing technical assistance to support the utilization of the Connected Parents Connected Kids curriculum in the WAST –8 as the new evidence-based tools required by MIECHV IPV screening.

 

Another highlight of the reporting period includes a variety of efforts to reduce health disparities and eliminate structural barriers. Our completed CQI project on family retention at 12 months looked at disparities in retention data a found that people who were discharged early from the program had slightly higher rates of history of child abuse, history of substance abuse, unemployment, and homelessness. We will continue to assess the satisfaction of people in the program and encourage feedback from marginalized families to improve access and engagement.  Furthermore, training to advance health equity and the provision of culturally responsive services culminated in the completion of a training series on these topics for all MECSH Home Visiting staff:

 

• Resilience and Self-Care (completed)
• Antiracism and Allyship (completed)
• Intersectionality (completed)
• CLAS Standards (completed in March 2024)

 

The FCH Home Visiting team has worked with the VDH Policy Unit over the past year on the updated Vermont Home Visiting Rule, first established in 2013. As part of this work, the Vermont Home Visiting Manual has been completely updated as well, to reflect and expand on the Home Visiting Rule, standards, and guidance for all family and early childhood home visiting services in Vermont.

 

Lastly, our FCH home visiting team has been successful in developing infrastructure to expand evidence-based home visiting using Global Commitment Medicaid funds to implement Parents as Teachers (PAT).  Our team has worked in partnership with Vermont Medicaid to develop a per member per month (PMPM) case rate for reimbursement of Parents as Teachers and is now supporting the implementation of this new program.

Injury and Violence Prevention-Infant Safe Sleep

Title V FCH injury and violence prevention continues to support its existing Infant Safe Sleep programming. Vermont prioritizes the reduction of sudden unexplained infant death (SUID) rates. In Vermont, surveillance data shows families of lower socioeconomic status have higher rates of unsafe sleep practices. Data from the Pregnancy Risk Assessment Monitoring System (PRAMS) reports that families with Medicaid insurance have lower rates of placing their baby to bed on a separate approved sleep surface. Data from WIC supports the need for equitable healthcare through data reports on families participating in WIC having lower rates of putting their infants to bed without soft, loose bedding. From this data, FCH has developed evidence-based methods to address the social determinants of health to reduce infant safe sleep and fatality disparities. These include the development of infant safe sleep brochures, flyers, and posters for Vermont family education and a toolkit for pediatric providers:

• The family-focused materials were written following the American Academy of Pediatrics (AAP) guidelines and banned sleep products.
• The materials were written in plain language to help with ease of understanding at most reading levels and were translated into a variety of languages before being disseminated widely throughout the community.
• The content focuses on practical tips to improve sleep for caregivers and babies, guidance on products to avoid, and realigns expectations around what is infant safe sleep.
• The FCH led Infant Safe Sleep Committee is a statewide committee with representation from the Department for Children and Families, University of Vermont Medical Center, Vermont Child Health Improvement Project, Safe Kids Vermont, Prevent Child Abuse Vermont, and home health agencies. The committee developed a Pediatrician Toolkit for Vermont providers that will be distributed by FCH nurse coordinators (FCHCs).

 

The Child Fatality Review Team reviews all incidents of unsafe sleep related fatalities and makes recommendations to the legislature through an annual report. The Child Fatality Review Team reviewed SUID fatalities during the reporting period and recommended investing in a targeted qualitative research study to increase the understanding of sleep practices among families at risk for unsafe sleep related fatalities so that education and resources are targeted more effectively. The Team recommended increased economic support for families in the first six months after birth so that families are more easily able to adhere to safe sleep guidelines. Following this recommendation, the co-chairs presented at the Safe Kids Worldwide Childhood Injury Prevention Convention (PrevCon) on infant safe sleep. The presentation focused on the importance of the social determinants of health and the need for increased economic support for families with infant children.  In 2023, the Vermont Department of Health was awarded a five-year grant from the Centers for Disease Control and Prevention to participate in the Sudden Unexpected Infant Death Case Registry. Participation in the Registry gives access to the Child Fatality Review Team to input Vermont’s child fatality data into the National Center for Fatality Review and Prevention’s Case Reporting System allowing the Child Fatality Review Team to compare national trends with Vermont data. More information regarding this system is in the application year plan.

 

Newborn Screening and Early Hearing (see the CSHN report for information on these programs)