In 2019, BWCH's infant and perinatal priorities focused on reducing infant mortality and morbidity. To support NPM 4 (percent of infants who are ever breastfed and percent of infants breastfed exclusively through 6 months), BWCH partnered with the 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 (MIEHCV) Program, was able to provide ongoing training and support opportunities for 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.

Newborn Screening (NBS) is a coordinated system 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 many activities and initiatives. Title V funds are used to help support the work of the Newborn Screening Program. In 2019, NBS continued its efforts to partner with the High Risk Perinatal Program/Newborn Intensive Care Program (HRPP/NICP) Community Health Nurses (CHN). This partnership supported identifying infants who have either not returned for the second screen or who need a repeat screen due to an abnormal prior screening. Additionally, infants with newly diagnosed conditions were referred to the Community Health Nurses (CHNs) to provide the parents/caregivers with extra support in caring for their infant with a special healthcare need.  ONBS provided refresher training and resources to CHNs at the annual HRPP/NICP conference.

Laboratory analysis is a core function of the ONBS and the program provided data on blood spot and hearing screening to families and providers. ONBS and Office for Children with Special Healthcare Needs (OCSHCN) partnered with data sharing and outreach projects related to sickle cell disease and sickle cell trait. Additionally, the ONBS partnered with the OCSHCN 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 supported training and supplies needed to continue to offer this service.

The Title V program also supported the participation of ONBS staff at national conferences targeted at specific disorders identified through newborn screening, such as the annual National Cystic Fibrosis Conference.

The Bureau of Nutrition and Physical Activity (BNPA) did a number of activities in 2019 related to the promotion of breastfeeding. In 2019, LATCH-AZ conferences were held in Tucson and Phoenix to provide education and networking opportunities to breastfeeding promotion and support professionals. These sessions attracted 325 WIC staff, peer counselors, Strong Families home visitors, and community partners.  In addition, the International Board of Certified Lactation Consultants (IBCLCs) Mentoring Program provided five education sessions designed specifically for the candidates to prepare for the examination. A total of five 5-Day Breastfeeding Boot Camps were held to educate more individuals on breastfeeding.

In order to focus on the education of other community professionals, BNPA provided 2 lactation webinars targeting community educators in 2019. The implementation of the online breastfeeding courses for clinicians developed in 2017 and were completed in early 2019.  There are 15 courses available and outreach was conducted among hospital staff.  During 2019 there were approximately 1893 total online courses completed. Programs related to child care centers, health care providers, and workplace accommodation programs were limited in 2019; efforts continued but were not focused in this area. Additional funding has been applied for that would allow for continued and increased efforts in these areas.

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 2019, the 24-hour Breastfeeding Helpline provided breastfeeding support to 5478 calls.

In 2019, through a partnership with Maricopa Department of Public Health, BWCH has 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 implement the CDC worksite health scorecard which includes "Make It Work Arizona".  The “Making It Work Arizona” toolkit is a resource that 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 2019, 21 employers requested toolkits and reported implementing workplace policies supporting breastfeeding. 

BWCH continued to implement Pregnancy Risk Assessment Monitoring System (PRAMS). BWCH leveraged Title V and other federal and non-federal funds to further support its ongoing implementation. In 2019, PRAMS used data collected for calendar year 2017 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 2019 Annual Report and 2021 Application.

In 2019, the Maternal, Infant and Early Childhood Home Visiting Program (MIECHV) served 2,325 families completing 23,241 visits. MIECHV continued to support voluntary, evidence-based home visiting programs in at-risk communities and coordinate services across the early childhood system. ADHS provided evidence-based home visiting programs, including 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 four Native American Tribes: Cocopah, Gila River, Hualapai, and Navajo Nation). In addition, AZ MIECHV grant was approved to fund Arizona’s state-funded home visiting program, Health Start, as a promising approach.

MIECHV supported the 2019 Title V state priority needs by implementing various strategies. The strategies and outcomes for 2019 are included in the Children’s Health section of the application.

MIECHV continued to support training and education of home visitors at the annual Strong Families Conference. MIECHV-funded home visiting programs had 64 enrolled participants who indicated a referral was needed based on the assessment completed at enrollment. Of those that needed a referral, 56 (or 87.5%) received a referral.

During the Strong Families Home Visiting Conference, second-hand smoke and cessation resources were provided during a breakout session workshop. We do not have a specific number count of participants for the workshop as we do not have individuals pre-register and we do not count attendance. However, there were 33 workshop evaluations submitted indicating that at least 33 individuals attended the session.

The Health Start Program continued to support ESM 6.1 (number of home visitors trained to provide ASQ3 and SE2 training over the next five years) by meeting the annual objective of 10 home visitors trained in 2019. Health Start will continue to provide developmental screening for children ages 10-17 months to increase early identification and treatment of developmental delays. In 2019, Health Start provided at least one Ages and Stages Questionnaire screening to 212 children ( 54% of enrolled children) twelve (12) months of age or younger.  In 2019, Health Start provided enhanced education on emergency preparedness as part of the Emergency Preparedness and Response Action Learning Collaborative led by AMCHP and education and interventions addressing sexually transmitted disease testing during pregnancy. Health Start continued to implement an evidence-based home visiting model, Family Spirit, in four (4) sites.  Health Start worked in collaboration with the Bureau of Chronic Disease and Health Promotion to provide tobacco cessation training and referrals and with the Office of Environmental Health to continue the Childhood Lead Poisoning Prevention testing education program to increase lead testing of children in the program. Health Start, in 2019, continued working with the Office of Epidemiology and Disease Control to mitigate the syphilis outbreak among women and babies through the promotion of increased testing. The Health Start Impact Evaluation paper highlighting the evaluation protocol was published open access in the British Medical Journal (Appendix S).  Additional planned activities can be found in the Women’s Health section of the report.

The High Risk Perinatal Program (HRPP) is Arizona's oldest home visiting program. HRPP's purpose is to reduce maternal and infant morbidity and mortality through a statewide regionalized system of coordinated perinatal care. HRPP is a primarily state-funded program that leverages Title V funds to increase access and enhance services.  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. 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 section, in 2019 over 3,300 infants were enrolled in HRPP; Community Health Nurses made 7,451 visits to medically fragile infants and their families after they were discharged from the NICU; and 886 critically ill pregnant women and 861 critically ill newborns were transported to the appropriate level of care hospital as determined by program contracted physicians.

In 2019, HRPP home visiting nurses completed 143 initial ASQ developmental assessments with parents and 89% of these assessments were completed within 1 year of enrollment. Between July 1, 2019 and May 31, 2020, HRPP community health nurses assisted new mothers in completing 1,781 Edinburgh Postnatal Depression Scale surveys. Of these, 289 new moms scored greater than 9 leading them to be referred to mental health services. Twenty-four (24) new moms declined to complete the Edinburgh screen.

As a continuous quality improvement (CQI) measure, HRPP required six hours of training annually for 30 community health nurses. The nurses are required to complete a minimum of one-hour training in the following categories: Adverse Childhood Experiences (ACEs), Neonatal Abstinence Syndrome (NAS), and Perinatal Mood and Anxiety Disorders (PMAD). The remaining three training hours can be on topics of their choice.

In 2019, BWCH continued work to identify programmatic measures and indicators that apply to all BWCH home visiting programs (MIECHV, Health Start and 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 2019, ETO was expanded to include state-funded Healthy Families Arizona (HFA) and Nurse Family Partnership (NFP) programs, High Risk Perinatal Health, and Health Start home visiting programs. A coordinated home visitation management system will enhance future MCH assessments and evaluation with home visiting populations in at-risk communities similar to those identified in the MIECHV at-risk communities.

In addition to ETO, BWCH home visiting programs introduced the Children with Special Health Care Needs Screening Tool and utilized the ASHLine active referral form to improve tobacco cessation referrals. Each BWCH home visiting program has provided an update on implementation of the screening tools.

Health Start implemented the Arizona Survey on Children’s Health (ASCH) in February 2019 at all 14 sites.  There were 388 ASCH surveys completed with families with children ages 11-13 months. Health Start screened 767 prenatal women for substance use, of which 63 were using tobacco. Of those, only 4 accepted active referrals to the Arizona ASHline for cessation services.             

HRPP began implementing the Children’s Health Survey and ASHLine referrals in July 2019. The Children’s Health Survey and ASHLine information was utilized to improve referrals for children and caregivers interested in cessation services.  Between July 1, 2019, and May 31, 2020, 214 Children’s Health Surveys were completed with 27 of those children qualifying as Children and Youth with Special Health Care Needs. Seventeen (17) referrals were made to the ASHLine for tobacco cessation services.

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.

Safe Sleep priorities for 2019 focused on the following strategies. The Safe Sleep Task Force continued to partner with the Collaborative Improvement and Innovation Network (CoIIN) to accelerate improvements that prevent and reduce infant deaths through collaborative learning, quality improvement, and innovation. In 2019, the Safe Sleep Task Force met on a quarterly basis.  Partners included DES, AzAAP, AHCCCS, 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, and Prevent Child Abuse and Association for Supportive Child Care. Goals focused on reduction of infant deaths by promoting safe sleep practices to decrease the sudden unexpected infant death (SUID) mortality rate by 5%. The Task Force worked toward reducing disparities by 3% for SUID between White and Non-Hispanic Black and American Indian/Alaska natives. Arizona continues to work with birthing hospitals, home visitors, and licensed and unlicensed child care facilities to address this issue. Through the CoIIN initiative and the partnerships there was a consensus that it be recommended that all birthing hospitals participating in the distribution of the crib cards develop a safe sleep policy to further educate staff and ensure the same standard of care. In 2019, 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. Lastly, current local AAP providers developed a CBT on Safe Sleep for pediatricians to improve professional practice that will help providers earn credit for Maintenance of Care (MOC) part 4 and plan to be rolling out within the next couple of months.

The Bureau supported the final activities of the Border Health CoIIN initiative by providing technical guidance and support to Mariposa Community Health Center in Santa Cruz County and participating in inter-statewide meetings in our efforts to increase by 10% the utilization of early and adequate prenatal care amongst Latina women on the US-Mexico Border.

In 2019 Arizona completed the NAS Prevention Toolkit (Appendix T), the Substance Exposed Newborn/NAS on-line training for home visitors and the NAS Provider Video Series as educational interventions to prevent substance exposed newborns and to increase awareness among stakeholders and the community. 

In 2020, Arizona will support Neonatal Abstinence Syndrome (NAS) and Substance Exposed Newborn prevention efforts through various collaborative efforts. Arizona will attend meetings and collaborate with stakeholders to discuss ideas and next steps around care coordination processes for substance exposed newborns and their mothers. Arizona will continue to implement the 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. Arizona will distribute the revised NAS Provider and patient/client informational flyers through the county health departments to reach local medical providers and the communities. Arizona will also continue to work with the Arizona Statewide Task Force on Preventing Prenatal Exposure to Alcohol and Other Drugs to provide guidance to medical providers on NAS (Appendix U). Arizona will continue to monitor the incidence of NAS and work with child welfare and other state and local county agencies on collaborative strategies to prevent and reduce opioid use and stigma reduction as part of the larger universe of the Opioid epidemic. Funding became available in 2020, and Arizona will proceed with the development of a stigma reduction media campaign addressing pregnant and parenting women with substance use disorders and the continuum of care by health and behavioral health treatment providers.

ADHS is implementing the Prescription for States grant from the CDC focused on the prescription drug abuse crisis. As part of this grant, ADHS works in collaboration with various state agencies, county health departments, local substance abuse coalitions, and other key partners on the implementation of the state's Prescription Drug Misuse and Abuse Initiative.

ADHS will continue to provide technical assistance to six county health departments on the implementation of this initiative through the use of a toolkit that contains an assortment of program materials. This includes providing assistance with increasing public awareness related to prescription drug misuse and abuse, encouraging the adoption of safe opioid prescribing practices by healthcare providers, distributing and encouraging the use of the Arizona Opioid Prescribing Guidelines, the Guidelines for Identifying Substance Exposed Newborns (Appendix V), and the online continuing medical education course on safe opioid prescribing practices.

As part of this initiative, local communities are also encouraged to practice safe prescription drug disposal practices. This includes increasing the public's awareness of available resources, such as the state's DumpTheDrugs website that contains the location of more than 150 sites where people take their unused medications to be properly disposed.

Moving forward, ADHS will continue to work collaboratively with key partners to monitor the implementation of the Rx Misuse and Abuse Initiative, as well as continue making updates to the materials included in the initiative's toolkit.

BWCH, through the Office of Assessment and Evaluation, completed the Perinatal Periods of Risk (PPOR) to inform the People of Color Infant Mortality workgroup strategies.  While infant mortality has been declining over the past several decades, certain sub-populations continued to experience infant mortality at higher rates. To allow communities to focus intervention efforts and have the greatest impact, a Perinatal Periods of Risk (PPOR) analysis was conducted (Appendix W). The PPOR analysis explored fetal (>24 weeks gestation) and infant (birth to 364 days) deaths across four main periods of risk: maternal health/prematurity, maternal care, newborn care, and infant health. Feto-infant deaths were categorized into these four main periods of risk based on birth weight (500-1499 g or 1500 g or more) and age at death (fetal, neonatal, and post-neonatal). The priority populations were determined based on the excess number of deaths compared to a reference population. This analysis was performed for Arizona based on vital records data from 2014-2018. The overall state reference population had a fetal-infant mortality rate of 5.7 per 1,000 live births plus fetal deaths. There were 3,092 fetal-infant deaths of which, 693 were deemed excess deaths; that is, if those in the target population(s) had equal outcomes as those in the reference population, there would have been 693 fewer deaths. Native American and Black infants were disproportionately affected compared to the reference population with a death rate of 11.8 and 11.7 per 1,000 live births plus fetal deaths, respectively. Most fetal-infant deaths were classified in the maternal health/prematurity period of risk. At its core, the PPOR analysis is a health equity analysis.