PERINATAL-INFANT HEALTH DOMAIN

Nebraska Annual Report for the 2017-2018 Year

 

In this section, Nebraska MCH Title V reports on the accomplishments and activities in the Perinatal-Infant Domain for the period October 1, 2017 to September 30, 2018. The numerical sequence of headings used below references the new narrative format found on page 35 of the Title V MCH Services Block Grant to States Program: Guidance and Forms for the Title V Application/Annual Report, Eighth Edition.

 

The Nebraska Priorities in the Perinatal/Infant Health Domain with 2017-2018 NPM, SPM, and ESM statements are as follows:

• Reduce Infant Mortality.

NPM: Percent of Infants placed to sleep on back.

ESM: The percent of infants whose sleep environments are assessed, at least once, by six months of age.

• Reduce Infant Abuse and Neglect.

SPM: The rate per 1,000 infants of substantiated reports of child abuse and neglect.

ESM: None

• Increase Breastfeeding.

NPM: Percent of Infants ever breastfed and breast fed exclusively through 6 months.

ESM: The number of health providers participating in certified lactation counselor training who are minority women.

 

1. Context: the State of this Population Domain

The environment for addressing infant mortality and poor birth outcomes has been improving in Nebraska, with greater attention to maternal mortality as described in the Women/Maternal Health domain annual report, and in the July 2018 release of the DHHS Business Plan that includes Improving Birth Outcomes in Nebraska as a priority.  This has mobilized a cascade of partners, cross-sector awareness, and some resources to address four areas within the priority: Reducing Preterm Births, Reducing Infant Mortality, Increasing Breastfeeding Rates, and Implementing the Nebraska Safe Babies Campaign.  Alignment with Title V MCH in Nebraska has been resonant for many partners and stakeholders. In addition to this emerging effort, partnerships and collaborations are interwoven throughout efforts to address Title V priorities.

 

Partnerships and Systems to Improve Safe Sleep: Responsibility for leading Title V safe sleep activities lies with Jackie Moline, BSN, RN, CLC, serving as program coordinator for the Title V Maternal Infant Health Program. Integral to the Nebraska Safe Babies – Safe Sleep campaign are Nebraska’s birthing hospitals and their associated organizations such as the Nebraska Hospital Association, the Nebraska Medical Association, and the Nebraska Perinatal Quality Improvement Collaborative.  The credibility and visibility established by the Maternal Infant Health Program, under Jackie Moline, RN, as a trusted and reliable source of resources and support for quality improvement has been an effective driver of this campaign.  Activities in this priority area also involve the leadership of Jennifer Auman, program manager for Nebraska’s evidence-based Maternal Infant Early Childhood Home Visiting (MIECHV) programs, both federally- and state-funded.  Personal and organizational partnerships established through the CoIIN Safe Sleep learning network are projected to continue, particularly those involving local health departments, with the Nebraska Perinatal Quality Improvement Collaborative, and the Nebraska Chapter of the American Academy of Pediatrics.  Important to developing approaches to reach all of Nebraska’s increasing diverse populations are the DHHS Office of Health Disparities and Health Equity, and the Refugee Health Program. 

 

Partnerships and Systems to Reduce Infant Abuse and Neglect: The Maternal Infant Health Program, in collaboration with the Child Safety CoIIN partners, leads the development and planned dissemination of the Crying Plan.  Numerous partners were included in testing methods to finalize the Crying Plan.  Medicaid Managed Care Organizations, the Nebraska Family Helpline, cultural community organizations, WIC clinics, community action agencies were all part of dissemination.  Many partners have been engaged with messaging about the relationship between parental stress and frustration about infant crying and risk for abusive head trauma.  The Current Practices of Maternal Behavioral Health conference planning committee includes partners from the Division of Behavioral Health, the Women’s Health Initiative, and the University of Nebraska Medical Center, Behavioral Health Education Center of Nebraska. The Nebraska Perinatal Quality Improvement Collaborative is a regular partner of the Maternal Infant Health Program. 

 

Partnerships and Systems to Improve Breastfeeding:  Primarily responsible for Title V efforts in this priority area is Jackie Moline, program coordinator for the Maternal Infant Health Program.  Breastfeeding advocates within the NE DHHS include WIC and the Women’s Health Initiative.  Significant collaborative partners include the Nebraska Breastfeeding Coalition and the Nebraska Perinatal Quality Improvement Collaborative.  Partnership with the DHHS Office of Health Disparities and Health Equity provides a resource for performance measurement, as well as cultural insights, in the experiences of breastfeeding women among minority groups in Nebraska.  The PRAMS (Prenatal Risk Assessment and Monitoring System), under new and energetic leadership of Jessica Seberger also is emerging as a significant partner in interpretation of data measures and messaging efforts to translate data into action.  Rayma Delaney, Title V Planning and Support, is the lead liaison with tribal health departments for subaward agreements and subrecipient monitoring. 

 

Summary of programmatic efforts and use of EBP to address each priority need

 

Priority: Reduce Infant Mortality

2018.  Objectives and Strategies

 

• P4a.  By 2020, increase by 10% hospital safe sleep policies and practices among Nebraska’s birthing hospitals.

 

Summary of programmatic efforts: The Title V Maternal Infant Health program continued implementation of Nebraska Safe Babies campaign with birthing hospitals statewide. Champion recognition has yielded high visibility for project and for local hospitals, contributing to significant success in implementing the campaign.  Planning began to implement the next phase of the Nebraska Safe Babies campaign, with addition of abusive head trauma education materials and training. Web-based campaign launched July 9, 2018.

 

• P4b. By 2020, increase by 10% adoption of safe sleep practices among at-risk N-MIECHV families.

 

Summary of programmatic efforts:  The Maternal Infant Health Program collaborated with N-MIECHV to implement the safe sleep environmental checklist, and measure utilization and impact. By February 2018, 100% of N-MIECHV sites (7 in all) were consistently implementing the safe sleep checklist.  One site, Lincoln-Lancaster County Health Department (LLCHD), produced a before-and after- report on an educational safety campaign with clients, which included safe sleep environments and practices.  In the report, safe sleep practices were listed as one of 10 top areas of home safety improvement, with findings of 80.4% of homes practicing safe sleep on the initial visit, increasing to 92.4% of homes on 6-month follow-up.  (The entire report of summary results of the LLCHD project is available on request.

 

• P4c. By 2020, increase by 10% adoption of safe sleep practices among licensed child care providers.

 

Summary of programmatic efforts: The Maternal Infant Health Program provided education to staff in the DHHS child care licensing section on safe sleep practices and use of the safe sleep environmental checklist. However, there was relatively little measured uptake of the tool in child care inspections, in education offered by child care licensing staff to care givers, or to care giver use of the tool. Challenges to uptake included a need to change state regulations on education requirements for child care workers, as well as a potential need for resources to update the educational materials currently in use.

 

• P4d.  By 2020, increase by 10% adoption of safe sleep practices among families receiving interventions from Children and Family Services.

 

Summary of programmatic efforts: The Maternal Infant Health Program provided education to staff in the Division of Children and Family Services on safe sleep practices and use of the safe sleep environmental checklist. In this arena, interest was sustained to the extent of incorporating safe sleep education for new child welfare workers, and drafting policy documents to detail how the education was to be disseminated.

 

Use of Evidence-based Practice in this Priority Area:

At the site, www.mchevidence.org, the summary of evidence for safe sleep (5/21/2019) shows, “The following trends emerged from analysis of peer- reviewed evidence (Note: this review focused only on sleep position). These findings may serve as ideas to expand your ESM in the future.

• Interventions targeting caregivers only appear to be somewhat effective.
• Interventions implemented at the caregiver, health care provider, and hospital levels without quality improvement initiatives appear to be effective.
• Interventions implemented at the caregiver, health care provider, and hospital levels with quality improvement appear to be somewhat effective.
• National campaigns appear to be effective.
• Due to the limited scope of included studies, there is less clear evidence of the effectiveness for interventions focusing on health care providers or child care providers only.”

In Nebraska, the Title V Maternal Infant Health Program works with the additional lever for influencing birthing hospital practice and policy as a result of statutory requirements that DHHS provide resources and materials and birthing hospitals comply.

Priority: Decrease Infant Abuse and Neglect

2017-2018 Objectives and Strategies

 

• P6a.  By 2020, increase by 10% the percentage of community providers recommending and helping expectant parents develop a Crying Plan. 

 

Summary of programmatic efforts: The Crying Plan has been developed and disseminated as planned, with versions available in both English and Spanish.  Collaboration with the Nebraska Medicaid Managed Care Organizations and the DHHS Division of Children and Family Services has increased dissemination of the Crying Plan in interactions with expectant parents.  In 2018, a plan was developed with partner birthing hospitals to include questions about the Crying Plan when contacting new parents post-discharge, in order to assess the impact of education given in the hospital as well as use of the Crying Plan with new parents.  The evaluation activity will be completed in 2019. In addition, community providers were educated about the Crying Plan at the annual Current Practices of Maternal Behavioral Health conference, April 2018, in a TEDtalk style presentation. 

 

The Title V Maternal Infant Health Program and N-MIECHV staff participated in the Child Safety CoIIN in 2017-2018, developing materials and resources to expand the Nebraska Safe Babies campaign to include abusive head trauma as well as safe sleep. 

Four hospital partners participated in testing the hospital toolkit for AHT policies and parent communication.  The completed toolkit is found here: http://dhhs.ne.gov/Pages/Abusive-Head-Trauma-Campaign-Toolbox.aspx

 

P6b.  By 2020, increase by 10% community providers routinely screening for maternal depression in pregnant and postpartum women.

 

Summary of programmatic efforts: The Maternal Infant Health Program contributed to a PRAMS project for providers on screening pregnant women for mental and behavioral health issues, including depression.  The resource is entitled, “Prenatal Visits are Critical Opportunities for Mental Health Screenings and Referrals,” and is available here: http://dhhs.ne.gov/PRAMS%20Documents/PRAMS%20Screening%20Resource%202018.pdf  In April 2018, Dr. Leslie Butterfield spoke at the Current Practices of Maternal Behavioral Health about depression in pregnancy and traumatic stress in childbirth, to an audience of 201 physicians, advance practice registered nurses, nurses, Licensed Independent Mental Health Practitioners, Clinical Social Workers, and Certified Lactation Counselors.

 

Use of Evidence-based Practice in this Priority Area:

There is no national performance measure about reducing infant abuse and neglect, and as a result no ready guidance available at www.mchevidence.org.  While not the results of extensive root cause analysis, the connection is borne out of life experience and the overwhelming frustration of not being able to stop the baby crying that can lead to the events of shaking or injuring infants.

 

Priority: Increase Breastfeeding

2017-2018 Objectives and Strategies

 

• P5a. By 2020, increase by 10% the percentage of Nebraska birthing hospitals adopting 6 or more standards of Baby Friendly hospitals. 

 

Summary of programmatic efforts: The Maternal Infant Health Program has been collaborating with the Nebraska Perinatal Quality Improvement Collaborative to improve Nebraska’s mPINC score (the maternal practices in infant nutrition and care survey of hospitals by CDC).  Twenty-three hospitals across Nebraska are implementing one or more of the Ten Steps to Successful Breastfeeding, including policy change and education of personnel.

 

P5b.  By 2020, increase by 10% the percentage of African American women, and American Indian women, who are breastfeeding their infants exclusively at 6 months of age.

 

Summary of programmatic efforts: The successful LEARN (Lactation Education Across Rural Nebraska) project was repeated.  In this instance a partner organization, CHI Health, funded a training course for 75 Certified Lactation Counselors, and collaborated with the Maternal Infant Health Program and the NE Breastfeeding Coalition on plans to survey participants for impact on practice over the year following training, as well as introduce a community project portion as an expectation of receiving a scholarship to attend the course.

 

LEARN recruitment launched in August for CLC course in Arvada CO in October.  The focus of the LEARN project is to increase the number of Certified Lactation Counselors in Nebraska who are of diverse racial and ethnic backgrounds. Eight participants attended the week-long education course in October, 2018 provided by the Center for Breastfeeding, Healthy Children’s Project Inc.  Each new CLC will participate in a year-long evaluation to determine the impact of the CLC training on practice, and will complete a community project to promote breastfeeding awareness.  

 

The maternal infant health program lead, Jackie Moline, collaborated with Medicaid Managed Care Organizations and tribal health subrecipients to assess the use of incentives in increasing initiation and breastfeeding longevity. In 2017, with the NE WIC program public health nutritionist in the lead, Nebraska Title V staff joined in the national Children’s Healthy Weight CoIIN breastfeeding workstream.

 

The Title V Maternal Infant health Program also participated in a PRAMS-initiated collaboration with the Nebraska Breastfeeding Coalition and CHI Health to produce and implement a resource on using evidence-based practices to increase breastfeeding in Nebraska, through increasing awareness of breastfeeding rates; strategies that have been shown effective in increasing breastfeeding rates; and best practices in grant writing.  The resource is geared towards organizations and professionals who want to increase breastfeeding rates by starting local projects. The resource is located here: http://dhhs.ne.gov/PRAMS%20Documents/Breastfeeding%20Resource_Full2.pdf

 

Use of Evidence-based Practice in this Priority Area:

At www.mchevidence.org, the following trends emerged from analysis of peer- reviewed evidence.

• Lactation consultant interventions and home visits provided by professionals (other than lactation consultants or peer counselors) appear to be effective for increasing both breastfeeding initiation and exclusivity at 6 months.
• Peer counselor interventions appear to be effective and are more likely to influence initiation than exclusivity at 6 months.
• There is less clear evidence to support the WIC food package change, group education, or hospital policies.

Emerging evidence was described as follows:

• There is emerging evidence that an intensive, hospital-based quality improvement and technical assistance intervention to improve compliance with the Ten Steps to Successful Breastfeeding program appears to be effective through the following: skin-to-skin care after cesarean delivery was significantly associated with increased breastfeeding initiation and exclusivity in all races; rooming in was significantly associated with increased exclusive breastfeeding in African American infants only.

 

Nebraska’s innovation to increase the number of Certified Lactation Counselors who are minority women is addressed to the disparity Nebraska sees between white majority and non-white minority women. Breastfeeding is beneficial to almost all mothers and infants, but the benefits may be significantly greater for minority women.  Minority women are disproportionately affected by adverse health outcomes, which may improve with breastfeeding.  Relative to white women in the U.S., African-American and Hispanic women have increased rates of obesity, diabetes, and cardiovascular disease.  Research suggests that breastfeeding may reduce a mother’s risk of hypertension, hyperlipidemia, and cardiovascular disease. 

 

2. Alignment of NPMs, ESMs, SPMs, SOMS with priority needs

 

Priority:  Reduce infant mortality.

NPM 5: Percent of infants placed to sleep on their backs.

ESM5.1: The percentage of infants whose sleep environments are assessed, at least once, by six months of age.

 

The NPM and ESM are aligned with the priority of reducing infant mortality.  The ESM makes use of the opportunity to work with N-MIECHV local implementing agencies as practice sites with the means for accurate measurement of practice.

 

For the state priority of decreasing infant mortality, Nebraska has adopted the National Performance Measure (NPM) of the percent of infants placed to sleep on their backs (NPM5).  The source of the data is the Pregnancy Risk Assessment Monitoring System (PRAMS).  Nationally in 2007, 77.1% of infants were placed to sleep on their backs, and in 2013, 80.9% were placed on their backs, showing improvement.  Least likely to place their infants to sleep on their backs are women on Medicaid, young mothers under age 20 years, non-Hispanic Black mothers, and mothers who participate in WIC. 

 

The ESM for this priority is drawn from N-MIECHV experience and data. The ESM selected for this priority is the percent infants whose sleep environments are assessed, at least once, by 6 months of age.  Data for 2016 provide a baseline for this ESM.  The indicator objective for 2017 is 70%.  Safe sleep environments and practicing Back to Sleep reduce the risk of Sudden Infant Death Syndrome (SIDS) and other sleep-related causes of infant death.

 

Priority Need: Decrease infant abuse and neglect.

SPM2: The rate per 1,000 infants of substantiated reports of child abuse and neglect.

 

An area of improvement has been in the rate of substantiated reports of abuse and neglect – Nebraska’s rate per 1,000 infants in 2017 dropped significantly as compared to 2016: from 19.7 to 17.6.  The SPM is highly relevant to stakeholders, and strongly aligned with the priority.

 

Priority Need: Increase breastfeeding of infants.

NPM 4: Percent of infants ever breastfed and percent of infants breastfed exclusively through 6 months of age.

ESM4.1: The percentage of health providers participating in certified lactation counselor training who are minority women.

 

The NPM is specific to the priority statement, and thus strongly aligned.  The ESM is project specific, and is developed to measure Title V efforts to address the reality of disparities in breastfeeding rates in Nebraska among minority groups.  The ESM reflects the interests of stakeholders that Title V is attentive to disadvantaged groups in Nebraska.  As a systems-level, workforce development approach, the growth of Nebraska’s assets in breastfeeding advocates and supports statewide has been enhanced by addition of additional, and more diverse, Certified Lactation Counselors.

 

3. Progress in achieving established performance measure targets along with other programmatic impact.

Nebraska Title V is implementing a results based accountability (RBA) framework for many of the objectives and strategies of the Title V action plan.  The period 2017-2018 represents the second year of reporting out on RBA measures. 

 

The RBA table for Reducing Infant Mortality captures the focus on engaging birthing hospitals as Champions as well as N-MIECHV, in the Safe Babies campaign, and early efforts to measure progress on CLAS and literacy development.  Seven measures were initially identified, and only two produced measures or statements of progress for the period. There were no new materials developed on safe sleep during the period, resulting in three measures unavailable.  Measures on birth data will not be available until 2020.  One measure is available due to lack of a plan to repeat the environmental safe sleep assessment in the N-MIECHV safe sleep project.

 

2017-2018 Results Based Accountability (RBA) measures Reduce Infant Mortality
	Planned for 2017-2018	Achieved 2017-2018
How much did we do?	# and % Nebraska birthing hospitals achieving Champion status.        # and % Nebraska home visiting programs routinely applying safe sleep environmental checklist.    # new health-literate and # newly translated resources developed.	As of May 2019 38 of the 54 birthing hospitals in NE became safe sleep champions, and 2 AHT Prevention Champions.   7 N-MIECHV sites (100%) are using safe sleep checklist.     No new safe sleep materials.
How well did we do it?	When new materials are reviewed: # and % reviewers from minority groups.    # testing iterations before materials are considered in final form.	N/A     N/A
Is anyone better off?	# and % total births occurring in Champion hospitals.    # and % environmental checklists in home visiting showing improvement at six months compared to baseline.	Birth data for 2018 not available until 2020   N/A – no repeat or followup process planned.

 

The RBA table for Reducing Infant Abuse and Neglect speak to development and dissemination of the Crying Plan.  Ten measures were initially identified, eight produced measures or statements of progress for the period. No follow up with dissemination partners has been planned for The Crying Plan. Race/ethnicity has not been made a part of the Current Practices of Maternal Behavioral Health registration process as yet.

 

2017-2018 Results Based Accountability (RBA) measures Reduce Infant Abuse and Neglect
	Planned for 2017-2018	Achieved 2017-2018
How much did we do?	# review and testing cycles completed on Crying Plan.      # of individuals participating in testing methods.      # organizations receiving Crying Plan for dissemination.    # participants in Current Practices of Maternal Behavioral Health.    # agenda activities related to maternal depression.	2 Health-literate and 2 newly translated resources developed: 1-2-3 Don’t Shake Me and The Crying Plan.   Total reviewers not known.  Reviewed by 4 pilot sites, committee members, and several N-MIECHV locations   54 birthing hospitals, 17 health departments, 7 FQHCs   201     2 on maternal depression and 1 on paternal depression.
How well did we do it?	# and % reviewers of Crying Plan from minority groups.    # participants, presenters, and planning committee members from minority groups participating in Current Practices of Maternal Behavioral Health conference.    # organizations participating in dissemination of Crying Plan who serve low income participants, are cultural organizations, or serve high proportion of minority clients.	Not measured     0 presenters, 2 planning committee members, unknown for participants.         Dissemination limited to birthing hospitals, health departments and FQHCs.
Is anyone better off?	# and % favorable responses in evaluations returned for Current Practices of Maternal Behavioral Health conference.    Survey results asking organizations who disseminate crying plan for their feedback on client response and overall usefulness and appeal.	131 evaluations received from 201 participants, very favorable.       Follow up survey to dissemination partners not done.

 

The RBA table for Increasing Breastfeeding related primarily to the LEARN project and N-PQIC, both real time, boots on the ground activities for staff engagement, collaborations, and programmatic contributions. Six RBA measures were initially identified for this priority.  Only limited information was obtained, however, in terms of measures or statements of progress for the period.  No new materials on breastfeeding were produced, or reviewed.  In the 2017 LEARN project, four participants were of minority cultures.  This information was not obtained for the 2018 cohort.  Instead, the group of 65 CLCs of unknown racial/ethnic background reported they serve or interact with populations in the following proportions: 18% African American/black; 12% Arabic/Sudanese; 13% Asian Pacific Islander; 25% Caucasian/White; 22% Hispanic/Latino; 9% Native American; 1% other.

 

2017-2018 Results Based Accountability (RBA) measures Increase Breastfeeding
	Planned for 2017-2018	Achieved 2017-2018
How much did we do?	# new CLCs trained in Nebraska through Title V.      # new health-literate and # newly translated resources developed and disseminated to support breastfeeding.	2017 – 4 CLCs 2018 – 65 CLCs in collaboration with CHI Health providing funding    None
How well did we do it?	When new materials are reviewed: # and % reviewers from minority groups.    # CLCs trained and certified who are from minority cultures.	N/A     2017 – 4 2018 - Information not obtained.
Is anyone better off?	N-PQIC measures on quality improvement in hospital based practices on breastfeeding; # and % of women giving birth in hospitals that provide “ideal responses” on mPINC measures.    CLC data reports showing improvements on measures.	N/A.  mPINC survey was not released to hospitals until December of 2018.         Participant data from the 2017 cohort were reported in late 2018.  Reported practice changes by participants include: more likely to encourage breastfeeding on demand and within one hour of birth; more likely to join local breastfeeding support coalition; increased awareness of signs of abuse in women uncomfortable with breastfeeding; educating on benefits of breast over bottle. All 2017 participants providing education in community and/or organization

 

Learning from RBAs

Overall, the RBA framework provides a constructive way for staff to set and deliver achievement goals in priority areas of the Title V block grant, and feel the satisfaction of a results-based framework for success.  In the Perinatal-Infant domain, a total of 23 RBA measurements were planned for the period 2017-2018, and eleven (49%) produced some statements of results.  The team is learning that many RBA measures are not needed to reflect and measure significant performance, but a few key RBA measures are useful for keeping focus on the intent of the strategy.  (For example, to prioritize minority CLCs and diversity in the Current Practices audience, but not ask race/ethnicity status on enrollment or registration is an easy course correction.)  RBA measures stated in a meaningful way are needed so designated reporters readily understand, remember, count, and record results.  

 

4. Challenges and Emerging Issues

Nebraska has launched more than one innovation in this domain, including the LEARN project and the Crying Plan.  Quality improvement perspectives were useful in developing the approaches so as to insure effective implementation.  What is needed now is a structured approach to understanding impact in these innovation areas.  Allocating sufficient resources and time to such impact evaluation in a small state however, is doubly challenging in that the evaluation should not supersede or replace actual implementation, but rather supplement efforts to document progress towards outcome goals.  

 

Understanding at the systems level, in an accurate and authentic way, the barriers to breastfeeding faced by minority women is a formidable task. Moving the needle on breastfeeding initiation and longevity requires the voices of minority women sharing first-hand experience and advocating change.

 

5. Overall Effectiveness of Strategies and Approaches: Addressing Needs and Promoting CQI. 

 

Nebraska’s Infant Mortality Rate (IMR) in 2016 rose to 6.2, an increase from 5.8 in 2015.  Racial disparities remain, as shown by a SUIDS (Sudden Unexplained Infant Deaths) rate for African American infants occurring anywhere from 1.5 to 4.6 times greater than that of Caucasian infants (2014-2016 NE Vital Records).

 

While the mPINC score (a CDC measure of infant feeding care practices, policies, and staffing expectations within hospitals that provide maternity services) in Nebraska has been steadily rising – from 60 in 2009 to 71 in 2015 – there is still much room for improvement.  Various sources show that while many new mothers initiate breastfeeding, fewer sustain the practice for 6 to 12 months or longer. 

 

In these priorities and strategies, Title V has continued leadership in serving as a convener, collaborator and partner in addressing infant mortality, infant abuse and neglect, and improving breastfeeding rates, especially among minority or disadvantaged women.   Community leaders and groups have been involved in all three priorities to some extent in 2016-2017, particularly in methods to test messages under development.