Perinatal and Infant Health

Annual Report Year 2023

Priority Area: Decreasing perinatal and infant health disparities

Improving perinatal and infant health outcomes continues to be a priority within the District of Columbia and DC Health. Following a life course perspective, the health and well-being of pregnant mothers and their infants significantly impact the health status of the overall population. Infant mortality is a key indicator of population health as healthy mothers tend to give birth to healthy babies and are best positioned to fully nurture them. Health during infancy and early childhood establishes a positive trajectory for health throughout the life course.

In the District, adverse birth outcomes, including preterm births, low birth weight, and infant deaths, continue to disproportionately affect non-Hispanic Black mothers and residents in Wards 5, 7, and 8.  In 2019 to 2020, preterm births were significantly higher among non-Hispanic Black mothers (13.1%) compared to non-Hispanic White mothers (7.2%). Moreover, the infant mortality rate was three to five times higher among non-Hispanic Black infants compared to Hispanic and non-Hispanic White infants, respectively, from 2016 to 2020.

Yet, progress on addressing disparities has been stagnant in recent years and geographic areas of the city (Wards 5, 7, and 8), as well as racial groups (African Americans) continue to face higher mortality rates compared to the rest of the District. Across the eight wards, infant mortality rates during 2016-2020 were significantly higher in Wards 5, 7, and 8 at 6.0, 9.9, and 12.9 per 1000 live births, respectively compared to Wards 2 and 3 at 2.1 and 3.0 per 1000 live births, respectively.   Medicaid financed births reported more than triple the rate of infant mortality compared to those births financed by private insurance. More than half of all infant deaths (59%) occurred during the neonatal period. Reducing infant mortality depends in large part on promoting the health of women of childbearing age, promoting the health of women during pregnancy, reducing preterm birth, and reducing low birth weight.

Focus Area 1: Breastfeeding

Breastfeeding has many health benefits for both babies and mothers. Breast milk provides the ideal nutrition for infants and can help protect babies and mothers against certain illnesses and diseases. According to survey data from DC’s Pregnancy Risk Assessment Monitoring System (DC PRAMS), 93.3% of women ever breastfed during their current pregnancy in 2022. However, once stratified by race, clear disparities exist in breastfeeding rates among non-Hispanic Black women (89.3%) and non-Hispanic White women (97.2%) in the same year. DC Health strategically targets and supports pregnant women and new moms with breastfeeding through intentional programs and activities aimed at addressing the barriers that impact mothers’ intent to breastfeed, ability to initiate and maintain breastfeeding and/or continuing breastfeeding exclusively.

Performance Measures:

• National Performance Measure (NPM): Percent of infants who are ever breastfed
• NPM: Percent of infants breastfed exclusively through six months
• Evidence-based-or-informed Strategy Measure (ESM): Percent of women referred for breastfeeding peer counseling support
• ESM: Increase the percent of completed breastfeeding education training
• ESM: Percent of women provided with in-person or telephonic breastfeeding consults/support services

Objective 1: Increase rates of breastfeeding initiation among African American women from 63% to 75% by 2026.

Strategies:

• Educate pregnant women about the benefits and management of breastfeeding, with priority given to subpopulations with lower rates of breastfeeding initiation and duration.
• Refer and track referral completion of women to breastfeeding services

Activities:

In FY23, Title V continued to fund and provide technical assistance and program evaluation support to the DC Breastfeeding Coalition (DCBFC). DCBFC operates to increase breastfeeding initiation and continuation rates for all infants in the District of Columbia. Working in partnership with maternal and child health professionals, community health organizations, and mother-to-mother support groups, DCBFC seeks to promote, protect and support culturally sensitive programs and activities that build awareness and understanding of the preventive health benefits of breastfeeding. Through its breastfeeding research, advocacy, and educational activities, the Coalition seeks to reduce health disparities, particularly among families of color living in DC communities with fewer resources. “Creating a Breastfeeding-Friendly District of Columbia”, a project led by the DCBFC, aims to maintain access to culturally congruent peer and professional support for breastfeeding at the East of the River Lactation Support Center located in Anacostia (Ward 8) while expanding this capacity through evidence-based and evidence-informed strategies that have a high likelihood of sustainability. The target population for this project was WIC-eligible women living in Wards 5, 7, and 8 in the District, with a special focus on Black people, adolescents, and populations with historically lower rates of breastfeeding. DCBFC focuses on the following key objectives:

• ssTo increase basic breastfeeding knowledge and provision of supportive breastfeeding care by home visiting staff;
• To facilitate prenatal breastfeeding education classes for Mary’s Center’s Home Visiting Program, Community of Hope’s Home Visiting Program, and the United Planning Organization’s Early Learning Program;
• To increase breastfeeding support in the District; and
• To increase the number of International Board-Certified Lactation Consultant (IBCLC) candidates from underrepresented groups.

The DC Breastfeeding Coalition improves the capacity of home visitors and childcare staff to provide breastfeeding education and support to families. DCBFC hosted a series of breastfeeding trainings for the three designated community partners: Community of Hope, Mary’s Center, and United Planning Organization. The training focused on: Breastfeeding Basics, Hand Expression, Breastfeeding Positions and Latch, and Breastfeeding Barriers and Solutions. Enhancing breastfeeding training and education gave staff confidence and skills to better educate and support breastfeeding families. DCBFC also assists with virtual breastfeeding classes for families served by the three community partner organizations in both Spanish and English.

The DCBFC also leads professional development sessions for lactation professionals to become IBCLC’s. The Coalition improves access to professional lactation support, particularly among Black residents with low household incomes. DCBFC administered lactation support training (Lactation Certification Preparation Course, LCPC) to 11 participants in FY23 and achieved a 91% successful completion rate. Lactation Certification Prep Course (LCPC) is taught by a team of International Board-Certified Lactation Consultants (IBCLC) deeply rooted in the DC metro area. These practitioners provide professional breastfeeding support to some of the most underserved communities in DC. All the instructors are from underrepresented groups in the field of lactation; combined they have 34 years of certified lactation consultant experience. Several class participants self-identified as a member of one or more of the groups that are underrepresented in the lactation profession.

To conduct individual face-to-face or telephonic breastfeeding consults, East of the River Lactation Support Center (ERLSC) continues to operate within the Children’s National Anacostia primary care pediatric clinic. Breastfeeding families are provided education and lactation support during their pediatric visit which is an optimal standard of care. This model of lactation care provides an opportunity for breastfeeding families to receive services without having to travel outside their medical home. Breastfeeding families from all Children’s National primary care locations, DC WIC clinics, and the DC community at large are seen at the ERLSC. Breastfeeding families seeking lactation support find ERLSC through various points of contact, including the DC Breastfeeding Coalition website, social media outlets, their WIC clinic, and by word of mouth. In FY23, DCBFC conducted 421 unique breastfeeding consults.

To facilitate the provision of IBCLC support to DC WIC families during FY23, five DC WIC clinics (Unity-Parkside, Unity-East of the River, Unity-Anacostia, Unity-Upper Cardozo and Children’s Health Center- MLK), were served by two DCBFC IBCLCs. 302 WIC families received support from DCBFC provided IBCLCs, 87 of which were seen during their prenatal period. Moreover, IBCLCs provided direct preceptorship to four (4) WIC peer counselors to increase staff capacity.

FY23 also included the development and implementation of a Breastfeeding Learning Collaborative for primary care pediatricians at Children’s National Hospital (CNH). This project, implemented between February to July 2023, aimed to improve evidence-based primary care practice surrounding breastfeeding assessment for pediatric patients from birth to 6 months of age. The overarching goal of the project was to improve the rate of patients who needed assistance with breastfeeding that receive assistance or a referral for services to 70%. Participants were recruited from the faculty and pediatric residents with continuity clinic at one of the five community-based primary care sites owned and operated by CNH. The project goal of having 10 registered participants was met and exceeded with 34 total registrations (20 faculty, 14 residents) received. Participants received monthly education topics related to the assessment, management and support of breastfeeding. At the onset of the project, 46% of patients with an identified and documented problem breastfeeding had no documentation regarding any intervention. At the conclusion of the project, 91% of patients with a documented problem breastfeeding received assistance during the visit or a referral for lactation support services. 

Finally, DCBFC engaged in creative and innovative methods to increase public awareness and community engagement around breastfeeding. In FY23, five (5) breastfeeding mothers/families and one (1) pregnant woman participated in the Breastfeeding & Baby Bump Beautiful Photo Shoot, a campaign promoting positive images around pregnancy and breastfeeding. DCBFC also published the American Sign Language (ASL) Breastfeeding video series that features education and information specifically targeting the Deaf and Hard-of-Hearing (DHH) community. Videos are only available in sign language with closed captioning and the production team is comprised of 80% of individuals who are DHH.

In FY23 Title V continued to provide Subject Matter expertise (SME) and program evaluation guidance to DC Women, Infants, and Children (DCWIC). WIC aims to improve birth outcomes, breastfeeding rates, infant feeding practices, immunization rates, and more. The mission of WIC is to safeguard the health of low-income (185% of the federal poverty line or below) women, infants, and children up to age 5 who are at nutrition risk by providing nutritious foods to supplement diets, information on healthy eating, and referrals to health care. DC WIC provides District families access to free, healthy food, breastfeeding resources and support, nutrition education, referrals to community organizations, and immunization screening. Four Local Agency organizations (Children’s National Hospital, Unity Health Care Inc., Mary’s Center, and Community of Hope) provide WIC services in the District, and DC Health serves as the State Agency.

DC Health aims to increase the District’s WIC coverage rate from 48% to 65% by 2026 and increase the percentage of mothers who breastfeed their infant. To simplify the enrollment process and reach all eligible families, DC Health and the DC Department of Human Services executed a data sharing agreement to share client level Temporary Assistance for Needy Families (TANF) and WIC data in FY22. Next steps for FY2023 included finalizing a data matching protocol to identify TANF families eligible for WIC but not participating and carrying out quarterly WIC outreach for enrollment. DC WIC uses multiple strategies to increase the percent of participants who breastfeed. DC WIC partners with Pacify to provide access to live and on-demand breastfeeding support services. Pacify performs services via an app that allows participants to video chat with an International Board-Certified Lactation Consultant (IBCLC). This partnership contributes towards achieving DC WIC’s FY2022 breastfeeding goal of increasing breastfeeding initiation and duration rates by implementing evidence and practice-based breastfeeding promotion and support activities. In FY23, 401 WIC participants enrolled in Pacify. Pacify IBCLC’s made 365 contacts with WIC participants, providing breastfeeding support. In addition, DC WIC works with the DCBFC through the East of the River Lactation Center to provide access to IBCLCs for WIC families mostly residing in Wards 7 and 8. These WIC sites were chosen based on the high enrollment of Black women and disparate breastfeeding rates seen at these sites. In FY2023 IBCLC’s provided 71 high-risk lactation services.

The goal of the DC Healthy Start (DCHS) Program is to improve health outcomes before, during, and after pregnancy, and reduce racial/ethnic differences in rates of infant death and adverse perinatal outcomes within the District of Columbia. The Healthy Start Program supports the Title V objective of increasing the rate of breastfeeding among women by 2026 by adopting and implementing set breastfeeding support strategies at program enrollment and throughout the perinatal period, including support breastfeeding policies and training for staff. These strategies include introducing and educating participants about breastfeeding at program enrollment. To improve perinatal health outcomes and close the disparity gaps based on race and place in the District, DCHS leverages patient-centered medical homes in areas with disparate perinatal health outcomes to implement the enhanced case management program. Community of Hope and Mary’s Center are community health centers that serve as medical homes for program participants, while also providing comprehensive case management and care coordination through DCHS. Additionally, to work toward more equitable birth outcomes and target women who are at high risk for adverse perinatal outcomes, DCHS increases social supports in the perinatal period by using group prenatal care (Centering Pregnancy) and community-based doula models.  

During enrollment into Mary Center’s Healthy Start program, participants are asked about their intent to breastfeed in addition to receiving breastfeeding education and resources to support their decision to breastfeed. Community of Hope offers a monthly “Making Milk 101” group education class to provide anticipatory guidance to pregnant patients about lactation and infant feeding. The groups are open to the community and foster a safe environment for pregnant people to feel empowered, supported, and enlightened as they learn about feeding in the first 24 hours, myths, benefits of skin-to-skin, the art of breastfeeding, positioning, latching, and how partners can help provide support. Overall DCHS provides Women’s Health Consultation as a telehealth appointment, that includes breastfeeding consultation and during the postpartum, DCHS tracks participants’ initiation of breastfeeding, participants who breastfed at least once, and participants who breastfed until 6 months.

DCHS works to increase participants’ access to lactation services in the postpartum period. These lactation services include continued home visits, where Community Health Workers (CHW) provide support through breastfeeding education and access to lactation services. In addition, DCHS’s participants are connected to Pacify, an app that offers 24/7 teleconference-style pediatric and breastfeeding consultation and connects families to a nationwide pool of experts— including lactation consultants, registered nurses, and doulas. Following enrollment to Pacify, the CHWs support families to ensure ease of future use by running a “test call” where they are connected to an expert on the other end. The Healthy Start Program also promotes WIC breastfeeding support groups and encourages engagement with WIC Breastfeeding Peer Counselors. Healthy Start ensures the coverage of breastfeeding education as part of Centering sessions. In FY23, DCHS held virtual Centering group care sessions in Spanish hosted by the Healthy Start clinical provider and facilitated by two CHWs. In these sessions, the prenatal groups can ask about breastfeeding, debunk myths and misconceptions, and seek the Centering community’s support in making decisions about breastfeeding. Healthy Start offers integrated doula services in its program model. In FY23, Mary Center continued the Supplemental Doula Program to provide contracted doula support to participants during the prenatal and postpartum periods. With this service, Healthy Start participants can opt-in to receive support from a doula. A doula conducts a postpartum visit 4-10 days after birth to process the birth story, ensure normal recovery, and offer support for breastfeeding. Community of Hope also offers the Meet the Doulas program, a 6 session education series facilitated by the Healthy Start Doula Team focusing on perinatal education. Healthy Start also works to increase access to breast pumps by connecting participants to a breast pump through their insurance services. In addition, the Mary’s Center clinic offers breast pumps directly as an initiative to reduce the administrative burden on participants and make the device readily available. DCHS ensures the training of staff to offer breastfeeding support. As part of their education, our Healthy Start CHWs are trained as Certified Lactation Counselors (CLC). As CLCs, DCHS CHWs can provide direct lactation support services when issues or concerns regarding breastfeeding arise.

Focus Area 2: Risk Appropriate Perinatal Care

Perinatal health is the health and well-being of mothers and babies before, during, and after childbirth. During the prenatal period, early initiation to care during the first trimester is imperative. Several studies have suggested that poor prenatal care utilization is associated with poor birth outcomes including but not limited to infant mortality, low-birth-weight babies, and prematurity, especially for Black women. Compared with infants born to mothers who received prenatal care, infants whose mothers did not receive prenatal care are three times more likely to have a low birth weight and are five times more likely to die in infancy. Women who do not receive prenatal care are also three to four times more likely to die from pregnancy-related complications than those who do receive care. Establishing early prenatal care and continuation until the time of delivery is one of the most effective interventions to improve birth outcomes due to the three major components of prenatal care: risk identification, treatment of medical conditions/risk reduction, and education. Quality prenatal care adequately and promptly identifies women who are at high risk for preterm birth and coordinates access to high-risk providers to address preventable pregnancy-related complications.

The District’s maternal mortality rate and pregnancy-related mortality rate can exceed the U.S. rates, respectively. Black women constitute about half of all births in the District but account for 90% of all pregnancy-related death. In contrast, White women in the District represent 30% of all births experience and no pregnancy-related deaths. Geographically, a large portion of pregnancy-associated deaths occur in Wards 7 and 8 of the District with a predominantly Black population and a shortage of birthing hospitals. Recognizing the importance of the health of mothers and children to the District of Columbia, DC Health developed and is implementing a focused strategy to improve and eliminate disparities in perinatal health outcomes. DC Health is driven to implement effective strategies to improve perinatal care quality and increase early initiation into prenatal care among all DC residents to improve birth outcomes.

Performance Measures:

• State Performance Measure (SPM) 6: Risk appropriate perinatal care – Decrease the proportion of Medicaid beneficiaries who a deliver a low-birthweight infant

Objective 2: Increase percent of pregnant women who initiate prenatal care in the first trimester from 68% to 75% by 2026

Strategies:

• Enhance capacity to provide a space for women to engage in early and continuous prenatal care to prevent maternal complications.
• Enhance health information technology systems.
• Increase identification of women at risk for preterm delivery and offer access to effective treatment to prevent preterm birth and referral to Maternal Fetal Medicine specialists.
• Increase the identification of effective approaches for improving birth outcomes such as group prenatal care (e.g., Centering Pregnancy) that provides a space to engage the target population through health education sessions to increase knowledge to encourage positive pregnancy health outcomes.
• Improve access to preconception care services, including screening, health promotion, and interventions that enable individuals to achieve high levels of wellness, minimize risks, and enter pregnancy in optimal health.

Activities:

In FY23, DC Health’s Community Health Administration (CHA) implemented year 2 of the Preterm Birth Reduction Initiative.  Four organizations (Community of Hope, Medstar Washington Hospital Center, Howard University Hospital, and Unity Healthcare, Inc.) implemented evidence-based strategies to reduce the occurrence of preterm birth and improve health outcomes. As described in DC Health’s Framework to Improve Community Health, the Preterm Birth Reduction Initiative supports the Maternal and Reproductive Health Services objective to reduce preterm births among Black women from 13.6% to 11.4% by 2026. Programmatic efforts targeted pregnant women at risk for preterm birth, prioritizing women with Medicaid and residing in Wards 5, 7, and 8.

The Preterm Birth Reduction Initiative supports the implementation of evidence-based strategies to reduce maternal risk factors and the occurrence of preterm births among high-risk District residents. DC Health is funding partners to implement quality improvement initiatives to reduce preterm birth, with a focus on institutionalizing best practices in screening and referral processes, medication therapy, management of risk factors, and coordination of support services. In FY23, $1,375,158.89 was distributed to grantees to implement services to prevent preterm births.

Services provided through the Preterm Birth Reduction Grant include: Centering Pregnancy; perinatal navigation and coordination services; doula and midwife support; parental care; behavioral improved connectivity using designated Connectivity Coordinators and use of applications such as Mahmee and BabyScripts; referral to high-risk specialty care (Maternal Fetal Medicine); behavioral health and substance use screenings and referrals; social determinant of health screening and assessment and referral (i.e., WIC, housing, transportation), and postpartum resources. Training and education on delivery of care, screening and assessment, service coordination, and quality improvement are also provided to providers and staff.

Every month, grantees identify women who are at high risk for preterm deliveries and enroll them into appropriate services to help reduce the risk of poor outcomes.  The services include Centering Programs, referrals to Maternal Fetal Medicine Clinics, providing educational material, or pharmaceutical therapy when applicable.  Over 5,000 women have utilized the services.

 

Additional funds are being utilized to improve connectivity and address data capacity to improve data reporting, such as patient-level outcomes (i.e., interventions to delivered to high-risk patients, number of women who delivered preterm, and referral tracking).

 

The Maternal Health Learning Collaborative provides an opportunity for grantees to receive collective technical assistance and support, including training opportunities and sharing of progress and lessons learned to improve collaboration.  

 

Preterm Birth Reduction Initiative (FY23)
Grantee	Number of People Served
Community of Hope	351
Medstar Washington Hospital Center	300
Howard University	882
Unity Health Care	3,199

 

Overall, the Preterm Birth Reduction Initiative Grantees successfully engaged community stakeholders, connected patients to tailored nurse navigation, provided preterm birth education and implemented Centering Pregnancy. However, staffing challenges affected the overall implementation of some activities. DC Health provided technical assistance to grantees to help mitigate challenges and implement innovative strategies.

In FY23 the District’s Title V program continued to fund two Well Woman Projects: Unity Healthcare, Well Woman Project (Unity), and  La Clínica del Pueblo’s Mujeres Saludables (Well-Women) Project ( La Clínica) which are discussed in further detail in the Women/Maternal Health Domain. Both grantees implemented evidence-based promotion strategies to expand access to interception care, preconception care, quality prenatal care, and health care over the life course to improve equity of birth outcomes in the District. While both projects focused primarily on well-woman interventions, they also implemented strategies directly aligned with Title V’s goal of improving risk-appropriate perinatal care. Their objectives focus on increasing the percentage of pregnant women who initiate prenatal care in the first trimester from 68% to 75% by 2026.

 

Unity serves a majority Black population. It is incredibly important to support the efforts to improve their workflow and ability to improve early entry into prenatal care. Unity reported in FY23 using the Uniform Data System (UDS) clinical quality measure showing that 70% of pregnant women entered prenatal care during the first trimester. To engage women in early prenatal care, Unity hired a Registered Nurse Obstetric Intake Coordinator (RN OB Coordinator) to coordinate efforts in increasing early entry into prenatal care rates. All patients with confirmed pregnancies who desired to continue their care at Unity were navigated to the RN OB Coordinator. The intake visits allowed the OB RN Coordinator to conduct a comprehensive assessment of the patient’s history. This information supported the clinical care teams to develop a care plan for the entire pregnancy based on the risks and needs identified during the assessment. In FY23 Unity was able to conduct 698 obstetric intake visits with the RN OB Coordinator once the workflow was finalized.

 

One of La Clínica’s project goals involved the enhancement of access and quality of comprehensive prenatal care for immigrant and low-income Latina pregnant women.  The key indicator to measure the success of the project was ensuring at least 65% of prenatal patients entered prenatal care during their first trimester. To achieve this goal, La Clínica enhanced its capacity to provide prenatal care through quality improvement activities such as its Prenatal Clinical Champions program. The Prenatal Clinical Champions program convened healthcare professionals with clinical expertise, leadership skills, and passion to improve their overall prenatal care capacity, staff training in Spanish provided by Planned Parenthood covering Women’s Sexual and Reproductive Rights and Family Planning Methods, group-based health education sessions, individual health educations sessions, and community health promotion activities to engage the community. In FY23, the total number of unique prenatal patients reached via the Title V Grant was 21, a significant increase from the prior years of grant implementation. Of the 21 unique patients served, 11 (52%), were engaged in the first trimester.  La Clínica’s providers prioritized women further along in their pregnancy since they had been without care for more time were thus at higher risk of worse outcomes. This strategy aligned perfectly with La Clínica’s mission: “To build a healthy Latino community through culturally appropriate health services, focusing on those most in need.”

 

The District of Columbia Hospital Association (DCHA) established the District of Columbia Perinatal Quality Collaborative (DCPQC) in collaboration with DC Health. The DCPQC serves as the Healthy Start Community Action Network (CAN) for the District of Columbia and continued to be funded through the District’s Title V program. The DCPQC/CAN serves as the District’s champion for reducing maternal mortality, improving maternal and infant health outcomes, and narrowing racial and place-based disparities in maternal health. The DCPQC convenes a team of perinatal care providers from across the care continuum including a focus on DC birthing hospitals, public health professionals, and other multi-sectoral stakeholders, to improve health outcomes for women and newborns through continuous quality improvement. Overarching programmatic goals are to reduce pregnancy-related morbidity and mortality among women in the District, reduce racial, geographic, and socio-economic disparities, and to work with participating hospitals to reduce impacts of national policies and practices that reflect systemic racism by January 2026.

In FY23, the DCPQC implemented specific program goals aimed at moving the needle addressing objective 2: Reduce the percent of women who reported implicit bias and discrimination while receiving healthcare services by 2026. In FY23 the DCPQC executed a racial equity and respectful care education and engagement series. The three-part series is offered to each hospital team as a group to encourage group collaboration and action in follow up to each session. The DCPQC built on activities for FY23 with all hospitals in hospital specific respectful care training for nurses and providers. The percent of nursing staff who completed the respectful care training over the course of FY23 increased from 65% to 81% while providers who completed respectful care training over the course of the year increased from 58% to 78%. The DCPQC also held regular monthly hospital technical assistance meetings to check-in on how hospitals included equity in their quality improvement work. Through this work, hospitals began incorporating race and ethnicity in their data collection and reporting. Hospitals used this information to examine differences in performance, such as unnecessary procedures and delays to target improvements aimed at certain populations.  One hospital noted collaborating with all clinical staff across their Women and Infant Services and Emergency Departments to help ensure proper access and review of new policies focused on equitable care. By tracking timely treatment improvement efforts by race and ethnicity, hospitals observed disparities in the first quarter of FY23 with delivery of timely treatment for non-Hispanic Black women of 55.6% and 61.9% for non-Hispanic White women. By the fourth quarter of FY23, performance on timely treatment following quality improvement efforts improved and the disparity was addressed with 86.1% and 81.5% improving timely treatment for non-Hispanic Black women and non-Hispanic White women respectively. 

 

Clinical Implementation Workgroups were provided with patient education training and preeclampsia patient education resources by the Preeclampsia Foundation. Each patient education kit included 200 symptom tear sheets, 200 postpartum tear sheets, 25 symptom magnets, four clinic posters (two in English and two in Spanish), 100 subject-specific brochures, and 25 rubber bracelets. The workgroups added these resources to the patient's discharge packets and distributed them to all patients with severe hypertension/ preeclampsia. In FY23, the DCPQC/CAN, submitted hospital discharge data to the AIM data center, and hospitals registered to access the AIM data center.  Additional patient representatives were recruited, and racial equity and respectful care training were scheduled and implemented.  Hospitals entered data into the AIM data center and participated in the Preeclampsia Foundation training and educational resources. Clinical Implementation Workgroups met monthly to discuss successes, challenges, and barriers regarding AIM projects. Technical assistance was provided to the team to troubleshoot any issues that may arise. Looking forward, the DCPQC continues to explore ways to further engage patient and family representatives directly in the Clinical Implementation Workgroups and activities of the DCPQC/CAN. Enhancing the availability of data and data reports to support the work of the DCPQC will help to ensure that the members are able to make informed decisions and monitor progress effectively. In addition, developing mechanisms to engage Clinical Implementation Workgroups in improvement efforts as they work to meet staffing shortages will also be critical to enabling the DCPQC to successfully implement the current AIM bundle and expand the capacity of the DCPQC efforts to improve outcomes.

Objective 3: Reduce the infant mortality disparity ratio among non-Hispanic Black infants from 3.5 to 2.6 by 2026

Performance Measures:

• SPM 6: Risk appropriate perinatal care – Decrease the proportion of Medicaid beneficiaries who a deliver a low-birthweight infant

Strategies:

• Provide support to newborn screening programs to assist with early diagnosis and connection to intervention services.
• Incorporate safe sleep education into hospital discharge regulations at birthing facilities in the District.
• Support home visiting programs, pre-term birth reduction programs, and case management for high-risk women.
• Preconception and prenatal nutrition education to help lower the risk of congenital malformations.
• Refer and track referral completion of infants needing additional screening and specialty follow-up.

Activities:

DC Title V program funded and provided evidence-based programmatic support to the District of Columbia’s Universal Newborn Hearing Screening Program, also known as the DC Early Hearing Detection and Intervention (DC EHDI) Program. Newborn hearing screening checks infants’ hearing shortly after birth. This screening process helps detect a possible hearing loss within the first months of an infant’s life. The overarching goal of the DC EHDI program is to ensure children who are deaf or hard of hearing (DHH) are identified through appropriate newborn, infant, and early childhood hearing screenings for diagnosis and early intervention (EI). EI works to optimize language, literacy, and cognitive, social, and emotional development. DC EHDI adheres to the national hearing loss intervention guidelines of 1-3-6. Every newborn will receive a hearing screening by one month of age; every infant that does not pass the initial hearing screening and rescreening will have completed a diagnostic audiological exam by three months of age, and all infants confirmed as DHH will be enrolled into EI services by six months of age. During FY23, 11,284 babies were born in the District of Columbia. Of those infants, 11,183 received a newborn hearing screening. The DC EHDI Program supports Title V goals of decreasing perinatal and infant health disparities by increasing the percentage of infants with newborn hearing screening test results outside normal limits that receive prompt and appropriate follow-up testing. The DC EHDI program continued to implement a multifaceted plan for addressing timely diagnosis, referrals to EI services, enrollment in EI services, and family support for the program. This plan focused on: (1) Collaborating with birthing hospitals, outpatient screening providers, and other health care professionals to ensure timely newborn screenings; (2) Engaging DC’s EHDI partners, stakeholders, and families in learning communities; (3) Developing and fostering collaborative partnerships with EI programs and (4) Addressing the importance and engagement of families within the EHDI system.

DC EHDI continued to work closely with and provide technical assistance to staff at the five District birthing hospitals, one birthing facility, Children’s National Hospital (CNH), Gallaudet Hearing and Speech Clinic, Kaiser Permanente, and other service providers to improve data quality, accuracy and timeliness of hearing screening and treatment/care plans reporting. The DC EHDI system continued to use the OZ e-SCREENERPLUS (eSP) Database to track newborn hearing screening results for all infants born in the District and District infants born in other jurisdictions. This system captures and documents initial and repeat screenings, referrals, and diagnoses. All providers (hospital providers and diagnostic audiologists) are required to maintain up-to-date records of all infants screened. Staff are required to adhere to the standard operating procedures for entry and management of all data entered in OZ eSP. All screening results are extracted on a continuous basis and reviewed for accuracy and completeness. When there were errors or incomplete information found in reporting, DC EHDI reached out to providers to obtain more information to ensure OZ is updated and accurate.

In addition, DC EHDI continued to contract services from Maryland/DC Hands and Voices (MD/DC Hands and Voices) to support families with children who are DHH, without bias around communication modes or methodology. They provide parents with resources, networks, and information they need to improve communication access and educational outcomes for their children. MD/DC Hands and Voices operates a program called “Guide By Your Side”. The Guide By Your Side program provides support and mentorship to parents of children newly identified as DHH through “guides.” The guides are parents of children that are DHH and may also be DHH. DC EHDI also continued to work in collaboration with the District’s neighboring states of Maryland (MD) and Virginia (VA) to ensure that infants receive appropriate care and follow-up. DC EHDI has established protocols with MD and VA’s EHDI Programs to securely exchange newborn hearing screening details for one another’s tracking systems. DC EHDI also collaborates with other state EHDI coordinators to learn about the successful implementation of evidence-based practices and novel approaches to improve the EHDI system and families’ interaction within the system.

DC EHDI also continued to fund an educational audiologist that collaborates with the Office of the State Superintendent of Education (OSSE) Part C/Early Intervention Strong Start Program. The educational audiologist assists the families that have been referred to Strong Start in their decision-making process regarding communication opportunities, hearing technology, early intervention, and additional services as needed until the child ages out of the program at the age of three.

In FY23, DC EHDI also continued to partner with the Office of the State Superintendent of Education (OSSE), Part C/Early Intervention (EI) agency and operator of the Strong Start (EI/Part C program) to ensure that children identified as DHH were entered into EI services. DC EHDI worked with Strong Start to continue to review a recently drafted data use agreement that will allow DC Health to have shared access to data, along with OSSE, to aid both entities in thoroughly following and tracking babies who are DHH and qualify for EI services from the referral stage to the admission and participation stages. Currently, the drafted data use agreement is being reviewed and accessed for expansion due to HRSA’s EHDI language acquisition data focus. After it is updated, it will need to go through both legal teams for DC Health and OSSE prior to implementation. Throughout the project period, DC EHDI has focused on the entry of newborn hearing screening data by hospital/birth facility staff and additional outpatient screening and service providers. Inconsistent data reporting from the hospitals continues to be a challenge for the DC EHDI Program. Although there have been major improvements, there are still challenges with reporting included missed/no screen outcomes results for birth and OP screenings and little to no notes indicating status on transfers, referrals, newborn’s medical home, and/or notes on newborn’s case to aid follow-up. This reporting greatly impacted the program’s ability to accurately conduct surveillance. Duplication of profiles has also been problematic. In addition, due to last year’s assessment of the continuous pattern of infants not receiving quality birth hearing screenings, DC EHDI and providers are prioritizing implementing Quality Improvement (QI) process solutions. Finding a solution is imperative to ensure accurate data is being reported in OZ eSP Database, including the number of profiles (aligning with an accurate number of births in DC) and infant profiles that have no follow-ups/listed as in process due to being a duplicate. DC EHDI also continues to actively address reporting and other issues through a variety of QI mechanisms, including the establishment of protocols around the timeliness of reporting screening results, recording of upcoming appointments and medical home information, providing updates on newborns (e.g., inpatient/NICU status, transfers to other hospitals, etc.), and on-going communication with birthing facilities and CNH to resolve issues that arise.

All five DC birthing hospitals and CNH have either begun to explore and/or have completed implementation of the OZ NANI (Newborn Admission Notification Information) software that interfaces between a hospital’s EHR (Electronic Health Record) and OZ SP Database to create an automatic case entry from the birth file. NANI is a secure set of software tools that assist newborn screening programs in gathering timely, basic newborn admission information to establish an accurate denominator of hospital births and eliminate potential manual entry errors. It also helps to ensure OZ has demographic and other appropriate updates, including discharge and transfer information, and updated patient names, all in real-time. Four out of the five birthing hospitals have completed implementation and the last one is moving towards implementation. In FY23, DC EHDI partnered with OZ and birthing hospitals to identify why data elements such as race, and ethnicity that are missing and not transferring over to OZ NANI seamlessly. There appears to be a disconnect when linking the hospital’s electronic health record to NANI. DC EHDI is working diligently with the DC OZ eSP Database HL7 Coordinator and hospital IT staff to determine where the connection is lost in the transfer of patient records and/or updates and how to improve this feature. Additionally, DC EHDI has begun attending the Interagency Coordinating Council (ICC) meetings. The ICC advises and assists OSSE and the Division of Early Learning in the performance of its responsibilities, including the identification of fiscal and other supports specifically for early intervention programs; the promotion of methods for intra- and inter-agency collaboration regarding child find, monitoring, financial responsibility, and the provision of early intervention services; the transition of toddlers with disabilities to preschool and other appropriate services; and preparation and submission of annual report on the status of early intervention programs for infants and toddlers with disabilities and their families. DC EHDI has at least one representative join their quarterly meetings as we work closely with the Part C Strong Start team for DHH children in the District. DC EHDI hosts numerous meetings with the DHH community in the District. The program has encountered barriers in accessing interpretive services through DC Health. Although the EHDI coordinator requests services promptly, interpreters are not typically assigned until the day before a scheduled meeting. In some instances, the quality of the interpreters has been poor due to timeliness, lightning, and proper translations. DC EHDI will work with leadership to determine the best ways to address this challenge and provide equitable language access for the District’s DHH community.

DC Title V program continues to support the DC Health Safe Sleep Program (DC SSP) to educate and empower parents, caregivers, and partnering agencies with information on Sudden Infant Death Syndrome (SIDS), Sudden Unexpected Infant Death (SUID), and safe sleep practices guided by the American Academy of Pediatrics Safe Infant Sleep recommendations. Unexpected deaths that cannot be explained are referred to as either sudden unexplained infant death, SIDS, or deaths of undetermined cause. Ensuring babies are sleeping safely greatly reduces a baby's risk of SIDS and other sleep-related causes of infant death. To lower the risk of sleep-related deaths, it is vital for all parents and caregivers of a baby to learn and understand infant-safe sleep practices. DC SSP has built and operationalized strong community capacity, by collaborating and sustaining robust working relationships with over 35 organizations (including local hospitals, daycare centers, short-term family shelters, and community organizations) that serve pregnant women and families in the District. Primarily using a “Train the Trainer Model”, the SSP Coordinator trains and provides technical assistance to staff at partner organizations, as well as providers at childcare settings, across the District that predominantly work in communities at higher risk for poor pregnancy outcomes.

One noteworthy partnership involves DC Help Me Grow (HMG) Program where HMG provides safe sleep education to DC residents and local agency staff. HMG also supports the SSP’s expansion by increasing engagement with Spanish-speaking families. The program has also maintained an important relationship with the Office of the State Superintendent of Education (OSSE), providing training to licensed childcare center staff in the District, as well as groups with the DC Child and Family Services Agency, Child Protective Service (CPS). During the onset of the COVID pandemic, DC SSP shifted from in-person training to all virtual training. This approach has become the program’s new training model and continued to be a very effective and accommodating way of reaching more partners and their program staff. The program targets infants, birth to twelve months in all DC Wards, to ensure all neighborhoods have access to the program with a special emphasis on partner agencies serving families in Wards 5, 7 8, which historically have had the highest rates of infant mortality in the District.

The DC SSP program is one part of the District’s efforts to provide infant safe sleep education and contribute to the saturation of messaging from various angles and venues. The program aligns with Title V’s priority of decreasing perinatal and infant health disparities. In FY23, 11,581 parents/caregivers were educated on infant-safe sleep practices. To support the program’s long-term sustainability, the DC SSP continues to take steps to ensure partners are educated and infant-safe sleep resources are embedded within the community. Additionally, the DC SSP virtual training is reaching significantly more participants each year. This shift has increased convenience for District residents and allowed DC Health to provide more community partners with technical assistance and program oversight. Looking forward, the program will increase partner site visits to strengthen partnerships as well as ensure partners comply with program responsibilities and portable cribs are stored properly.

The DC Newborn Metabolic Screening (DC NMS) Program, supported by Title V funding, ensures all newborn infants born in the District of Columbia receive timely metabolic and genetic screening for core and secondary health disorders that are treatable by diet, vitamins, and/or medication, or by anticipatory measures to prevent adverse reactions. The DC NMS Program collaborates with all the District’s pediatric providers, birthing hospitals and facilities to follow-up on abnormal screening results based on laboratory recommendations. This includes repeat screenings and referrals for genetic counseling and education, clinical evaluation and management, diagnostic (lab) testing, or other follow-up specialty care services as indicated. Metabolic and genetic disorders are rare, but can be serious, conditions that can lead to severe health and developmental problems or even result in death, if not identified and treated early. The overall goal of the DC NMS Program is to ensure that every infant born in the District is screened for 45 inherited disorders via a dried blood spot test prior to discharge. Our DC NMS Program aims to link every infant identified with abnormal screening results to a primary medical home and to ensure they receive timely and appropriate follow-up for medical referrals and connection to early intervention services. The DC NMS Program supports the achievement of Title V measures by decreasing perinatal and infant health disparities through the increase of the percentage of infants with newborn screening test results outside normal limits for a newborn screening disorder that receive prompt and appropriate follow-up testing.

In FY23, the DC NMS Program continued activities to enhance quality improvement and existing surveillance systems and Long-Term Follow-up (LTFU). The DC NMS Program maintained the program’s tracking systems and ensured appropriate follow-up information was shared regarding all abnormal labs and rescreening results for both immediate Short-Term Follow-up (STFU) and LTFU in coordination with key players involved in the program. This includes all the DC birthing facilities and hospitals, PerkinElmer Genetics Laboratory, primary care providers (PCPs), and specialty care providers. STFU regarding abnormal results begins immediately within the first days of an infant's life and continues as necessary to connect the newborn to additional testing and specialty follow-up if required. Once a diagnosis is made regarding a condition, a treatment plan regimen is generated and placed into action. DC NMS continued tracking the newborn in the LTFU phase along with both Primary Care Provider (PCP) at the newborn’s medical home and any specialists providing care to the newborn. This follow-through helps to ensure the coordination of care, delivery of treatment, and continuation of support services in place to provide the best clinical management for the newborn with a shared goal of healthy and therapeutic outcomes.

The DC NMS Program also continued to support the activities and partnerships with participation in the DC Fetus and Newborn Committee of the District of Columbia Chapter of the American Academy of Pediatrics. These engagements yielded valuable participant communication through stakeholder meetings and email interactions and discussions with essential health personnel from hospitals, clinics, government, and private entities. These collaborative efforts led to best practices in coordinating the inputs of stakeholders and partners into strategic planning for the program. There will also soon be a new District Sub-Committee on Metabolic Disorders/Newborn Screening.

Better Access for Babies to Integrated Equitable Services Act of 2020 (BABIES Bill) provided legislation to create updated DC hospital discharge regulations. It will standardize newborn screening procedures, including for metabolic and genetic disorders, at birth facilities and ensure the provision of comprehensive newborn education across birthing hospitals and facilities. The new regulations will be key in streamlining congruency and accuracy across all systems. The DC NMS and Perinatal and Infant Heath Division (PIHD) has been leading the effort in drafting the new regulations. They are still in review but getting closer to proposing the rulemaking. The DC NMS Program encountered a few challenges in FY23, including access to updated contact information to assist with coordinating care between birthing hospitals, pediatricians, and families. Low staff capacity across birthing hospitals and delays in implementing evaluation and QA/QI activities has impacted these outcomes. Looking forward, the DC NMS Program will continue to focus on PCP's communication regarding follow-ups on repeat screenings and tests, referrals, and next steps in coordinating care for their patients, transition to a more expansive and streamlined data tracking system (OZ systems which house newborn hearing screening data), vital records collaboration with data sharing, quality assurance and quality improvement strategies, data utilization, and interoperability and overall providing seamless coordination across the newborn metabolic screening system.

As mentioned earlier in the domain narrative, DC Healthy Start aims to improve health outcomes before, during, and after pregnancy, and reduce racial/ethnic differences in rates of infant death and adverse perinatal outcomes within the District of Columbia. The program targets residents of Wards 5, 7, and 8 to ensure the identification and management of high-risk pregnancies. DCHS provides services and support for mothers, infants up to 18 months, and their families (fathers/partners) through comprehensive case management and care coordination to address health and social service needs. Two community health centers serve as medical homes for program participants. During the initial perinatal assessment and throughout the prenatal period, DCHS participants are assessed for medical risk factors that are indicative of a high-risk pregnancy, such as high blood pressure, history of smoking, history of opioid use, and domestic violence. Participants designated as high-risk pregnancies participate in more prenatal visits with their medical provider in addition to the increased in-person and remote home visits from DCHS community health workers (CHW). DCHS provides screening for risks to the fetus and newborn. Using the 4Ps Screening tool, CHWs assess participants in four domains: Partners, Parents, Past, and Pregnancy. With the screening tool, DCHS CHWs can detect drug and alcohol use and other factors that could pose a risk to the developing fetus and newborn. Positive screens are connected to the appropriate resources within the medical home.

As mentioned earlier in this domain narrative, the Preterm Birth Reduction Initiative aims to reduce the occurrence of preterm birth among at-risk District residents. The Preterm Birth Reduction Initiative supports the Title V objective of reducing the infant mortality disparity ratio among non-Hispanic Black infants by ensuring that all subcontracted organizations (Medstar Washington Hospital Center, Unity Health Center, Community of Hope, and Howard University Hospital) provide services to at-risk communities serving high proportions of women with pre-term births, Medicaid-insured and residing in Wards 5,7, and 8. Organizations focus on developing screening tools and/or procedures to help identify women at risk for preterm birth; managing associated risk factors for those at risk for preterm birth; and improving linkages to care, including prenatal care, labor and delivery options, social services, and community programs.

 

Objective 4: Decrease the percentage of low-birthweight infants with Medicaid insurance from 60% to 40% by 2025

Performance Measures:

• SPM 6: Risk appropriate perinatal care - Decrease the proportion of Medicaid beneficiaries who a deliver a low-birthweight infant

Strategies:

• Enhance the capacity to provide a space for women to engage in early and continuous prenatal care to prevent maternal complications.
• Enhance health information technology systems.
• Increase identification of women at risk for preterm delivery and offer access to effective treatment to prevent preterm birth and referral to Maternal Fetal Medicine specialists.
• Increase the identification of effective approaches for improving birth outcomes, such as group prenatal care (e.g., Centering Pregnancy) that provides a space to engage the target population through health education sessions to increase knowledge to encourage positive pregnancy health outcomes.
• Improve access to preconception care services, including screening, health promotion, and interventions that enable individuals to achieve high levels of wellness, minimize risks, and enter pregnancy in optimal health.
• Increase prenatal care within the first trimester

The percentage of low birthweight births in the District significantly decreased from 2011 to 2020 from 10.5% to 9.6%. The percentage of low birthweight births among all Medicaid financed births in the District was 12.6%, which was significantly higher than the percentage of low birthweight births financed by private insurance (7.2%) and CHAMPUS/TRICARE (4.8%). Mothers whose births were Medicaid financed were almost two times more likely than mothers with private insurance to have a low birthweight infant.

Activities:

As mentioned earlier in this domain narrative, the Preterm Birth Reduction Initiative aims to reduce the occurrence of preterm birth among at-risk District residents. The Preterm Birth Reduction Initiative supports the Title V objective of decreasing the percentage of low-birth-weight infants with Medicaid Insurance by ensuring that all subcontracted organizations (Medstar Washington Hospital Center, Unity Health Center, Community of Hope, and Howard University Hospital) provide services to at-risk communities serving high proportions of women with pre-term births, Medicaid-insured and residing in Wards 5,7, and 8. Organizations focus on developing screening tools and/or procedures to help identify women at risk for preterm birth; managing associated risk factors for those at risk for preterm birth; and improving linkages to care, including prenatal care, labor and delivery options, social services, and community programs.

DC Healthy Start supports the Title V objective of decreasing the percentage of low-birth-weight infants through programming and support, including referring participants to Women’s Health Consultation, Centering, and doula care, and providing clinical support to CHWs through the clinical provider. DCHS provides Women’s Health Consultation, offered by a Healthy Start Clinical Provider as a telehealth appointment. The Women’s Health Consultation visit was instituted as an adjunct to regular medical services and targets participants throughout the perinatal period. The Women’s Health Consultation covers various areas as needed, including (i) reproductive life planning, supporting participants with short and long-term reproductive goals, including preparing for pregnancy or accessing contraception; (ii) postpartum consultation, discussing and providing support related to postpartum recovery, postpartum depression, breastfeeding and more; (iii) inter-conception care, including linkage to primary care services for chronic illness, immunization support, mental health assessment, and risk assessment for STI prevention and interpersonal violence. This service aims to create a space for participants to engage in early and continued care to prevent complications and improve outcomes for mothers and their newborns and infants. DCHS also offers the integration of supplemental doula services. DCHS continued a supplemental doula program that started in FY22 that provides a contracted doula to birthing participants during the perinatal period and offers live or virtual support.