Perinatal & Infant Health: Annual Report

FY 2019 Annual Report

In 2018, there were 21,794 infants under the age of one residing in Idaho. For the same year, there were 21,406 live births in the state. The percent of preterm infants was 9.1%, and the infant mortality rate was 5.1 per 1,000 live births, a 10.9% increase from 4.6 deaths per 1,000 births in 2017. About 35% of Idaho births are covered by Medicaid. Idaho’s cesarean rate was 24 per 100 births, which is much lower than the national rate of 31.9. In 2018, 4.5% of total births were non-medically indicated early elective deliveries, compared with 4.4% of births in 2017[1]. About 3.8% of births occur in a non-hospital setting.

For the Perinatal and Infant Health domain, two national priority areas were selected to align with the state’s priority needs: “NPM 4: Breastfeeding” and “NPM 5: Safe Sleep.” State Performance Measure (SPM) 3: Injury Prevention was developed to capture the state’s dedication to reducing perinatal morbidity and mortality. The needs assessment identified perinatal nutrition, specifically breastfeeding and supporting a healthy home environment, including injury prevention and healthy parenting practices, as state priority needs. The MCH Program developed three objectives to address the state’s priority needs of improving breastfeeding rates and to support services, programs, and activities that promote safe and healthy family functioning. These objectives include: 1) Increase the percentage of infants breastfeeding at six months of age; 2) Reduce sleep-related infant deaths by improving safe sleep practices; and 3) Fund injury and disease prevention activities to reduce morbidity and mortality rates among pregnant women and young children. Strategies to address these objectives and NPMs are discussed below.

Breastfeeding

For FY 2019, strategies discussed in the FY 2018 annual report for breastfeeding were continued by Idaho Title V, WIC, and MIECHV. Key strategies included training for home visitors, sponsoring the Idaho Breastfeeding Summit, membership on the Idaho Breastfeeding Coalition board of directors, and WIC’s peer counselor program.

In 2019, the WIC program focused on the implementation and roll-out of eWIC, allowing participants to receive their nutritional benefits through an electronic benefits transaction (EBT) card. The implementation process involved coordinating the changes with contractors, local agency staff, and vendors. The implementation was done in phases to ensure a smooth rollout and paper checks were completely phased out after December 31, 2019.

The WIC Peer Counseling Program continues to evaluate its effectiveness by utilizing exit surveys and adapting to their participants’ needs based on the responses. The focus has been to increase communication and exchange of breastfeeding information and support.

The Idaho MCH Program planned to build on the existing collaboration with the MIECHV and WIC Programs to deliver another training event focused on teaching best practices to home visitors to support breastfeeding moms. However, due to WIC’s eWIC launch last fall and MIECHV’s Safe Infant Sleep CQI project with MCH, the training did not occur. See the Infant and Perinatal Health Application Report for FY2021 activities.

In March of 2018, the MCH Section Manager became a member of the Idaho Breastfeeding Coalition’s board of directors. Since then, the breastfeeding coalition mapped out various activities to be carried out in 2019-2020. Of the activities discussed, the following were conducted:

The 3rd annual Idaho Breastfeeding Summit was held in June 2019, with a total of 74 attendees in Fort Hall, Idaho (ESM 4.2). The sessions included a panel from the Fort Hall Reservation speaking about their breastfeeding experiences. In addition to the networking opportunity the event provided, a coalition building activity was included. This allowed attendees throughout the state to come together and brainstorm how to improve their local landscape for breastfeeding resources. Participants also received updates on Idaho’s breastfeeding policy, and learned about a nationally recognized, Idaho-specific WIC-hospital partnership. The Idaho Title V Program will continue to sponsor the Breastfeeding Summit as a strategy to further promote breastfeeding education for professionals and families. The 4th annual Idaho Breastfeeding Summit is scheduled to occur October 8-9, 2020, in Boise, Idaho.

Safe and Healthy Family Functioning

Safe Sleep

Strategies to promote safe sleep education and practice was shifted to allow Title V to take the lead on implementation, rather than relying solely on community partners.

In previous years, the MCH Program struggled to find their place in the delivery of safe sleep education. In April 2019, the MCH Program received technical assistance (TA) from the MCH Evidence Center at Georgetown University and worked with John Richards and his team. During a three-part, web-based meeting, the MCH Director and staff completed a “Turn the Curve” activity which was instrumental in brainstorming safe sleep activities and initiatives for Idaho. During the facilitated activity, the program used SUID’s related death and other Idaho-specific information to make decisions on which areas of the state need the most support and education around safe sleep. With a focus on bolstering activities surrounding safe sleep, the MCH Program undertook various activities in 2019:

In 2019, the MCH program used a three-prong approach to addressing safe sleep in the state of Idaho. The first approach was collaborating with the MIECHV program. The data collected in 2019 showed that only 37% of infants under the age of one enrolled in the program reported they “never shared a bed,” while 44% reported “they always place the baby to sleep without soft bedding,” and 80% reported “they always place the baby on their backs to sleep.” The data findings were instrumental in MIECHV’s decision to tailor their annual continuous quality improvement (CQI) project around safe sleep. Home visitors were also receptive and interested in the CQI project as well. The MCH Program assisted in the development of data collection tools for home visitors to assess parent/caregiver knowledge on best safe sleep practices, and provided incentive items for participants such as swaddle sacks, parent pledge magnets, educational materials, and Cribs for Kids Cribettes for families in need of a safe sleep surface.

The second approach was redesigning the Department infant safe sleep webpage. The webpage had been neglected for several years with very little useful information for the public. The MCH program dedicated staff time to develop a comprehensive webpage with evidence-based information from local and national resources for parents/ caregivers, childcare providers, and health care professionals. Along with the redesign of the webpage, an educational brochure was developed with an area of focus on “room-sharing, not bed-sharing.” This approach was intentional as MIECHV, PRATS, and the Child Fatality Review Committee data has demonstrated that bed-sharing is of the most concern when it comes to safe sleep in Idaho.

The third approach to bolstering safe sleep education in Idaho was the development of a social media campaign ad that ran in October 2019 for safe sleep awareness month. The MCH Program worked with the Department media vendor on the creation of a thirty-second, animated PSA educating on the AAP recommended safe sleep guidelines. The video is filmed from the perspective of the infant as he is laying in his empty crib on his back. He begins to remind the viewers about the importance of following the ABC’s of Safe Sleep, while finishing his narrative by encouraging views to visit the Department safe sleep webpage at nbs.dhw.idaho.gov. In conjunction with the media development, a logo for the safe sleep program was created with the messaging “Alone. Back. Crib. Every Nap. Every Night.” that was used throughout the video PSA and printed on the educational brochures and swaddle sacks. The animated PSA ran on YouTube and Facebook ads for the entire month of October. As another avenue to promote the redesign of the webpage and increase views of the PSA, the MCH Program also supported the use of a Google Paid Search ad. Whenever certain keywords such as “SIDS” or “safe sleep” were searched in the Google search engine, the Department safe sleep webpage would appear at the top of the screen with the intent for users to be more inclined to click on our webpage. The table below is a summary of the total views of the animated PSA and the number of “clicks” to the Department safe sleep webpage:

Figure 1 - Safe Sleep Program Logo

The MCH Program established a MOU with Ada County Paramedics in 2017 to offer safe sleep classes for new parents and community members, and in return, the MCH Program supplied them with a number of Cribs for Kids crib sets (including a crib, sheet, sleep sack, pacifier, and educational materials) and sleep sacks. Since then, Ada County Paramedics has continued to partner with the MCH Program. In September of 2019, Battalion Chief Bart Buckendorf lead a safe sleep awareness campaign in which he walked 600 miles within 3 weeks from Pocatello (southern region) to Coeur d’Alene (norther region) while making stops along this journey in 30 towns across the state to teach safe sleep classes to community members. The MCH program provided Bart with 1000 sleep sacks as incentives for class participants. Overall in 2019, Ada County Paramedics offered 23 classes to their community with 100 participants (ESM 5.1).

In February 2019, the MCH Program leveraged the existing collaboration with the MIECHV Program to offer Cribs for Kids® crib sets, sleep sacks, and fitted sheets to the Parents as Teachers and Nurse-Family Partnership programs throughout the seven health districts. Home visitors provided safe sleep education to families when they received their safe sleep products and gave crib sets to families who did not have a safe sleep surface for their baby. The following Cribs for Kids® materials were distributed through the MIECHV Program:

The Idaho Child Fatality Review Team (CFRT) was formed by the Governor’s Task Force for Children At-Risk, under an Executive Order, to review deaths to children under the age of 18 using a comprehensive and multidisciplinary process. Between April 2019 and November 2019, the CFRT conducted case reviews of child deaths occurring in 2017. The CFRT utilizes information gathered by coroners, law enforcement, medical personnel, and state government agencies in their reviews. The CFRT is tasked with identifying opportunities for increased awareness and education around sleep-related deaths. In the most recent annual report, which is a report of findings and recommendations for child deaths occurring in 2017, there were 99 full-reviews of child deaths (187 total child deaths). These deaths were due to an external cause, were unexplained, or were due to a cause with identified risk factors. Of these, 9 were categorized as Sudden Unexpected Infant Death (SUID), 1 death was of undetermined cause, and 4 were accidental deaths to infants or toddlers in the sleeping environment. Unsafe sleep environments were noted in 6 of the 9 SUID/unexplained infant deaths and more than 1-in-3 of the 2017 SUID deaths involved co-sleeping with an obese adult. The CFRT encouraged parents, caretakers, and health care providers to follow the 2016 American Academy of Pediatrics recommendations for safe sleep guidelines for infants up to one year of age. Additional recommendations were offered to coroners to have training on guidelines for coding and detailing findings on a death certificate and to law enforcement to encourage more agency cooperation to help identify at-risk children and prevent additional tragedies.

During the 2020 Idaho legislation session, the Idaho Child Care Program (ICCP) presented House Bill 549 that would require all licensed childcare facilities in the state to have safe sleep policies and practice safe sleep behaviors when caring for infants. Specifically, the bill addresses infants “being alone, on their back, in a crib.” In addition to safe sleep, the legislation adds criminal history requirements. The bill passed in both the House and Senate and became law on July 1, 2020.

Injury and Disease Prevention

In FY 2019, strategies discussed in the FY 2018 annual report for injury and disease prevention were continued by the MCH Program. Key strategies included funding the Idaho Poison Control Center, funding the Epidemiology Program, funding and managing the Idaho Newborn Screening Program, distribution of CMV education materials, and collaboration with the Child Fatality Review Team. New strategies and important changes are highlighted below.

During FY 2019, the Bureau of Communicable Disease Prevention (BCDP) Epidemiology Section, Surveillance Program, and Immunization Program continued to partner to prevent the transmission of hepatitis B virus from infected mothers to their infants through surveillance and case-finding activities. BCDP surveillance staff monitor incoming electronic laboratory reports (ELRs) daily to identify any laboratory result that indicates a positive hepatitis B virus result in a woman of childbearing age. Routine follow up of these reports occurs by epidemiologists in each of Idaho’s seven public health districts to inquire whether the hepatitis B-infected woman is currently pregnant, plans to become pregnant, or has children. If the woman is not currently pregnant, education is provided regarding behaviors to reduce the risk of transmitting hepatitis B virus to household members, including children. If the woman is planning to become pregnant, additional education is provided regarding the necessity of prenatal care and vaccination of the newborn with the HBV vaccine and HBIG after delivery and the woman is referred for case management through the Immunization Perinatal Hepatitis B Program. 

ELRs are monitored for pregnancy status, reason for testing, and ordering provider. If the pregnancy status indicates the patient was pregnant when the test was ordered, the reason for testing was prenatal screening or indicates pregnancy, or the ordering provider is an OB/GYN, the Immunization Perinatal Hepatitis B program is notified as well as the public health district epidemiologist to ensure the woman is placed in case management if she has not already been referred for case management.

Idaho also uses a similar method to identify pregnant women who have laboratory results indicating infection with syphilis, HIV, chlamydia, gonorrhea, Zika virus, and the other hepatitis viruses.

Idaho implemented an interface between the immunization registry and the disease surveillance system that allows for direct import of immunization records into disease investigations. This new interface eliminates the need to access the registry and then manually enter immunization information into disease investigations of vaccine preventable diseases and decreases the probability of data errors. This functionality has been used during the investigation of pertussis, measles, meningococcal disease, mumps, and Hib among children in 2019. This assists epidemiologists with making targeted education efforts as well as to recommend prophylaxis.

The MCH Program and the Idaho Bureau of EMS and Preparedness shared the cost of poison control activities through a contract with the Nebraska Poison Center. For 2019, calls from Idaho resulted in 13,160 unique interactions with the Nebraska Poison Center. The goal for the Nebraska Poison Center is to quickly and accurately handle all calls originating in Idaho, which increases the public education about poisonings, as well as, reduces the burden on our health care system by giving callers advice on whether they should be seen by an emergency department. These services include pill identification, human and animal exposures, and chemical poisonings. In 2019, the Nebraska Poison Center received 49 Idaho calls regarding pregnant women and 48.5% of the calls made to the poison center were for children under five years of age. The MCH Program purchased a variety of educational materials for distribution to the Idaho 2-1-1 Careline, through which partners, schools, and community members can request such materials.

Title V funds the personnel and operation costs for the Idaho Newborn Screening (NBS) Program, which is managed under the MCH Section. The NBS Program screens for 47 different conditions using dried blood spots and requires universal screening for critical congenital heart defects (CCHD). In 2019, 99.5% (21,661/21,765) of live births occurring in the state had at least one metabolic newborn screen completed, with a 97% CCHD screening rate (21,194/21,765). There are limitations to the CCHD screening data as newborns admitted to the NICU do not receive a screening since the newborn’s pulse oximetry is being monitored as standard of care. This is a likely cause for the lower screening rate. A total of 21 NBS conditions were diagnosed, received follow up and/or treatment after being detected through the NBS Program, saving lives and financial resources for both affected families and the State of Idaho. The Idaho NBS team regularly attends meetings and conferences that have a focus on improving program operations and decreasing the number of conditions not caught on the screens. These include the Idaho Sound Beginnings Advisory Council, Northwest Regional Newborn Screening Meeting, Newborn Screening and Genetic Testing Symposium, Western States Regional Genetics Network Summit, and the AMCHP Annual Conference.

The NBS Clinical Coordinator presented at the Idaho Perinatal Project Nurse Leadership Summit in Boise. The presentation focused on CCHD and newborn dried blood spot screening and collection. Additionally, the Program Manager and Clinical Coordinator provided in-service trainings at multiple facilities which included hospitals, birth centers, and clinics across Health Districts 1 and 2 in northern Idaho. The team was able to focus on each facility’s challenges and provide customized education to nursing staff and managers. A similar in-service was provided at a clinic in Caldwell, Idaho, whose nurse manager requested specific dried blood spot collection and shipment training for her clinical and laboratory staff. After each of these educational sessions, the teams verbalized appreciation knowing more about the program, best practices and screening techniques, and who to contact with questions about Newborn Screening in Idaho. In addition to in-person educational efforts, the Clinical Coordinator assembled educational materials to create two toolkits to be used to train staff on CCHD screening and newborn metabolic screening. Since increasing educational outreach, the NBS Program has noticed a marked decrease in several types of errors that were targeted during the educational sessions.

The Idaho NBS Program has continued to meet on a quarterly basis with NBS stakeholders, which includes Dr. Fleming, clinical geneticist, Dr. Brown, pediatric CF specialist and co-founder of St. Luke’s Cystic Fibrosis Center of Idaho, and Dr. Lundgren, pediatric infectious disease specialist. In 2019, three additional members were added to the committee group: Dr. Daniel Flynn, Pediatric Endocrinologist, Dr. Matt Hansen, Pediatric Hematologist-Oncologist, and Angela Lindig, Executive Director of the Family2Family Center, Idaho Parents Unlimited, LLC, and parent of children with special health care needs. The convening of this small group has been vital in the exploration of new public health NBS laboratories that will meet Idaho’s needs.

In 2019, the NBS team focused its efforts on streamlining CCHD screening data for follow up and quality assurance purposes. Previously, the data was being reported as a raw dataset, making it more time consuming to identify which cases need follow-up for education. The MCH Data Analytics Unit created an exception report that will be generated on a weekly basis and will flag cases that are in need of follow-up. A screenshot of the report is provided below. The report includes the following:

• Screenings not documented
• Error in following screening algorithm (e.g. deemed a pass, when a fail)
• Missing values (either hand or foot)
• Hours of life >24 hours
• Consecutive screening values not input, if failed first or second screen
• # of hours between consecutive screening <1 hour
• Data entry errors

Figure 2 - Example Exception Report

The program will continue to provide technical assistance and training on CCHD screening best practices. Information about future best practice trainings is provided in the Application Report. The NBS Clinical Coordinator has been an asset to the implementation of CCHD screening since she has firsthand experience conducting CCHD screening in birth facilities as a certified maternal newborn nurse. Her expertise has been essential in developing follow-up policies and procedures and providing education to health care providers. The NBS Program will explore non-mandated, voluntary CCHD diagnosis reporting with physicians since there is currently no mechanism for collecting diagnosis data.

Over the past year, the NBS Program increased its efforts to provide educational outreach to nursing staff and managers across the state. These efforts included presentations, in-service trainings, and the development of training toolkits when an in-person educational modality was not feasible. Rates in algorithm errors (not following the CDCs recommended algorithm) and documentation errors all decreased in 2019. The following errors were documented and improved upon in the last year:

• Algorithm error rates: birth with at least 1 error dropped from 1.74% (2018Q2) to 0.50% (2019Q4)
• Error rates for screenings incorrectly coded as “pass” dropped from 1.74% (2018Q2) to 0.38% (2019Q4)
• The number of failed screenings without documented follow-up dropped from 20 (2018Q3) to 0 (2019Q4)
• The number of births with incomplete screening data documented dropped from 287 (2018Q3) to 2 (2019Q4)

During the past year, the CMV workgroup and parent advocates met quarterly to determine next steps, and decided the focus would be outreach and education. The MCH Program targeted education efforts to pregnancy care providers, and mailed over 400 hard copies of CMV brochures, posters, and fact sheets for distribution.

As of 2018, the MCH Program developed and distributed two CMV fact sheets: one for pregnancy care providers, and one for pediatric providers. The MCH Program also developed, printed, and translated into Spanish a poster and brochure; purchased and distributed hand sanitizers with the messaging “Help Reduce the Spread of CMV;” and published the Department-hosted CMV webpage, cmv.dhw.idaho.gov. The poster and brochure were made available for order on the webpage, and notification of these resources was sent out in an email blast to childcare providers, schools, and churches. Nearly 3,000 email addresses were included in the email blast. Other distribution efforts included: distributing materials as exhibitors at the 2018 Idaho Perinatal Conference, Early Years Conference, and the Shot Smarts Immunization Conference; providing Spanish CMV materials to the ten Migrant and Seasonal Head Start Centers throughout the state; and sharing the poster and brochure with the Idaho CMV Advocacy Project for inclusion in their own outreach efforts.

In 2019, the MCH Program built upon the foundation laid in 2018 and sought ways to further disseminate CMV materials. The MCH Program translated the brochure into Spanish and made all CMV materials available on another website, healthtools.dhw.idaho.gov. This website is managed by Division of Public Health for public convenience. Health Tools is a Shopify site on which many of the Division’s programs post education materials and incentive items for external visitors to digitally download and/or place orders for free physical materials.

The MCH Program also expanded upon outreach efforts by celebrating CMV Awareness Month. An informational banner for the Department’s home page and Facebook posts were created, published, and drove visitors to cmv.dhw.idaho.gov. Meanwhile, the workgroup brainstormed more outreach activities and developed a plan to send OB/GYNs, pediatricians, and family medicine doctors throughout the state Provider Packets in 2020. Packets included posters in English and Spanish, brochures in English and Spanish, copies of the Pregnancy Care and Pediatric Care fact sheets, a letter from the Department about CMV, and included where providers can learn more about the virus and digitally access materials or order free copies. Furthermore, the MCH Program continued to supply hand sanitizers to the Idaho CMV Advocacy Project for their outreach efforts, which have proven to be extremely popular and attention grabbing.

In 2019, the MCH Program increased its presence and visibility as a vendor at relevant conferences and events. The program displayed and provided educational materials developed for safe sleep, CMV, newborn screening, poison control, and CCHD.  These conferences and events included the annual Idaho Perinatal Winter Conference, Shot Smarts Immunization Conference, Babypalooza, and via our Maternal, Infant, and Early Childhood Home Visiting (MIECHV) partners at the 2nd Annual Idaho Community Health Worker Learning Collaborative.

[1] Non-medically indicated early elective deliveries are based on singleton births at 37-38 weeks completed gestation that were non-medically indicated early elective inductions of labor or cesarean deliveries without attempt of labor. 

[2] Impressions are defined as the total number of times the safe sleep content was displayed on a unique persons newsfeed.