MCH Block Grant FY22 Application & FY20 Report

 

NPM-3: Percent of very low birth weight (VLBW) infants born in a hospital with a Level III+ Neonatal Intensive Care Unit (NICU).

 

This Measure will not be continued.

 

Annual Report FY20:

 

Program Activities:

 

The Performance Measure was achieved. The Performance Objective was 90.4% and the annual indicator was 90.6%.

 

The Utah 2019 results are higher than the Healthy People 2020 target of 83.7%. From 2015-2019, the average for this indicator was 90%. This continues to be above the HP2020 baseline of 75% and above the target of 83.7%. According to a 2010 review of very low birth weight (VLBW) infants delivered in risk-appropriate settings, the percentage of VLBW infants born in a hospital with a level III or higher neonatal intensive care unit (NICU), changed only slightly between 2000 and 2007. (74.2% to 74.7% respectively). According to the National Performance Measure 3 Risk Appropriate Perinatal Care Evidence Review, “Five States reported greater than 90% of VLBW births were delivered at level III or higher hospitals, a goal that may not be achievable in all states.”1,2
 

Utah has completed the CDC Levels of Care Assessment Tool (LOCATe). Utah contributed data to a multi-jurisdictional analysis to be conducted by the CDC. Facility groupings, by assessed levels of neonatal care, will be used to examine differences in neonatal and infant mortality between neonatal levels of care. Facility level characteristics reported on LOCATe, including volume of services, volume of high-risk deliveries, and specific availability of providers, will be assessed for relationships with neonatal mortality.

Accomplishments / Successes:

 

Utah has a rate of 1.07% of VLBW infants in 2019, with the national rate at 1.38%. The Utah rate was 29% lower than the national average. From 2015-2019, the average was 1.11%, which continues to be below the United States average. The VLBW HP2020 had a baseline of 1.5% and a U.S. Target of 1.4% and the VLBW in Utah has always remained below the HP2020 goal.
 

Utah successfully implemented the CDC LOCATe Assessment, providing the data to the CDC. This data will be combined with LOCATe data from other requesting jurisdictions, along with the birth and infant death cohort files for the corresponding years that LOCATe was implemented in each jurisdiction. The birth facility will be used as a key to link LOCATe data from each jurisdiction with the corresponding birth and infant death cohort files from that jurisdiction. The complex linking was completed by a data resource and is crucial to the multi-jurisdiction analysis.

A report was drafted on Very Low Birth Rates in Utah from 2014-2018. Some key findings included:

• The rate of VLBW births in Utah remained lower than the rate of VLBW births in the United States.
• VLBW infant birth rate was approximately 1,108 per 100,000 live births.
• The birth rate of VLBW infants (<1500 grams) did not display any significant changes during this time.
• There were no significant differences between VLBW birth rates across Local Health Districts.
• The VLBW birth rate among multiple births (9.53%) was significantly higher than the rate in singleton births (0.79%).

 

In 2015, a rule on VLBW reporting was implemented in Utah. This rule required hospitals to enter their VLBW data into a REDCap database. REDCap is a secure web application for building and managing online surveys and databases, which allows for robust data analysis and review. There has been decreased compliance with hospitals entering his information. Feedback was solicited from hospitals and they shared that the reporting requirements were difficult to implement for various reasons. These included having resources to compile and enter the data, the time that it was taking along with difficulties in pulling the data. Based on this feedback, the decision was made to sunset the rule.
 

Summary of successes and accomplishments on “Moving the Needle” in relation to NPM-3:

 

• The Data Resources Program completed the data linkages and de-identification needed for the CDC multi-jurisdictional analysis to explore maternal and neonatal risk-appropriate care from LOCATe data.

 

• Compiled a VLBW report with data from 2014-2018 that outlined various components of the VLBW birth rate in Utah, including how Utah compares to the United States, the rate among multiple births, the rate by maternal race/ethnicity, and mother’s residence in Utah’s Local Health Districts.

 

• The VLBW Reporting Rule was sunset due to feedback from hospitals on the burdensome requirements including the time that it takes to pull or enter the data and a lack of resources to compile the information.

 

Challenges / Gaps / Disparities Report:

 

Due to the continued success of this performance measure, it was determined that this will not be a state priority going forward. Between 2014-2018, the VLBW was higher in women who reported their ethnicity as Hispanic and in those who reported being non-Hispanic and non-white. The Utah Women and Newborns Quality Collaborative Maternal Committee began exploring a quality improvement project for the Latina Maternal population in FY21.

 

Agency Capacity / Collaboration Report:

 

Utah is one of the first states to provide LOCATe data to the CDC for the multi-jurisdiction exploration of maternal and neonatal risk-appropriate care. This is to evaluate practices and systems of risk-appropriate care to improve maternal, neonatal, and infant outcomes. Another key collaboration was listening to the feedback of hospitals to sunset a rule that was not working for them and had decreased compliance on hospitals entering the data. The hospitals were appreciative of the reduction in reporting requirements. The plan is to continue to use the results from the CDC LOCATe for discussions on how to improve health outcomes for women and infants.

 

Summary Progress Report of ESMs related to NPM-3:

 

ESM 3.1 VLBW REDCap Data: Percent of reporting by hospital facilities where VLBW infants were delivered.

 

Goal/Objective:

 

Increase the percentage of reporting by hospital facilities, where VLBW infants were delivered.

 

Significance of ESM 3.1:

 

Perinatal regionalization classifies hospitals at risk-appropriate levels in regards to care for both mothers and infants. This ensures that high-risk pregnancies and LBW, preterm or other at-risk infants have access to the most appropriate care. In Utah, hospitals self-designate their levels of care and because of this, there is no uniformity with Utah’s leveling. In an attempt to assure level designations in our facilities, a database has been created that all Utah hospitals report the outcomes of every VLBW infant either delivered or transferred to their facility. This data will allow Utah to have a more informed conversation about the importance of Perinatal Regionalization through the eyes of some of our most ill and vulnerable infants.

 

ESM 3.1 Progress Summary

 

Maternal and Infant Program staff worked with Utah's delivering facilities to ensure that morbidity data on 100% of very low birthweight babies (VLBW) were entered into the REDCap system in compliance with rule 433-1. The implementation of the rule has made it possible to collect the data from all facilities and birth certificate data were used to verify reporting by the delivering facility. Three years of data were collected, but due to the burdens of reporting on hospitals, it was decided to sunset the rule that required this reporting.

 

ESM 3.2 Standardized guidelines: Percent of hospitals facilities providing support to build a consensus based model of Utah Standardized Level of Care.

 

Goal/Objective:

 

Increase the number of hospitals facilities providing support to build a consensus-based model of Utah Standardized Level of Care to 100%.

 

Significance of ESM 3.2:

 

A survey carried out by the Maternal and Child Health (MCH) Bureau several years ago provided objective criteria that indicates Utah currently has ten hospitals that self-designate as Level III neonatal intensive care units (NICU) while the survey data collected indicate that number is much smaller based on the published Guidelines. Currently, Utah regulations that designate Levels of Care for Perinatal Services are imprecise and there is no regular oversight of NICU services by the Department.
Through collaboration, the MCH Bureau has worked on developing Utah specific Guidelines for Neonatal Care based on the 7th edition of Guidelines for Perinatal Care; however, these guidelines have remained in draft form for the last few years. With the collection of Utah specific data on VLBW infants, creation of these guidelines will be able to be re-approached.

 

ESM Progress Summary:

 

This involves collaboration with the CDC Levels of Care Assessment Tool (LOCATe), which helps to create standardized levels of neonatal care. The Neonatal area of LOCATe is based on the most recent guidelines and policy statements issued by the American Academy of Pediatrics. Utah collaborated with the CDC to assist with collection and interpretation of the data. The results were compiled and reported back to each delivering facility and a report was given to the Utah Women and Newborns Quality Collaborative.

 

NPM-4.1: Percent of infants who are ever breastfed.

The Performance Measure was achieved. The Performance Objective was 90.0% and the Annual Indicator was 91.8%.

 

NPM-4.2: Percent of infants’ breastfed exclusively through 6 months.

 

The Performance Measure was not achieved. The Performance Objective was 28.3% and the Annual Indicator was 26.3%.
 

Annual Report FY20:

 

Program Activities:
 

The policies, procedures, and practices of a birthing facility a new birthing parent encounters in the first hours and days after childbirth can help or hinder their future breastfeeding success. Implementing evidence-based strategies, like those described by the World Health Organization’s “Ten Steps to Successful Breastfeeding,” can significantly improve a person’s confidence in their ability to reach their breastfeeding/chestfeeding goals.

The Stepping Up for Utah Babies program is a free, Utah-centric program that works with birthing facilities to become certified as a “Breastfeeding Friendly Facility.” The Stepping Up program utilizes quality improvement methods to assist participating birthing centers in implementing “The Ten Steps to Successful Breastfeeding” through an incremental approach – implementing two steps at a time, with the goal of implementing all 10 steps.
 

During FY20, the Stepping Up for Utah Babies program staff continued to offer on-going technical assistance to participating birthing facilities. Assistance included but was not limited to additional training for staff on requirements for step certification, sharing up-to-date research and resources, and providing feedback and answering implementation questions as they arise.
 

Stepping Up staff also continued their efforts to recruit additional birthing facilities to participate in the program. Outreach included directly contacting nursing/lactation staff to discuss the program and sharing information about breastfeeding/chestfeeding at community health fairs. We reached approximately 1,100 people with messages about general health, nutrition, pregnancy, breastfeeding/chestfeeding, women’s health, maternal health, and infant health during those events. The community events were held prior to the COVID-19 pandemic.
 

The Utah WIC Program developed a statewide goal in FY19 to ensure that every pregnant and postpartum WIC participant receives at least one contact from the Utah WIC Peer Counseling Program. Breastfeeding peer counselor contacts are recorded in the WIC VISION computer system. Additional goals included that each local agency offers at least one training on breastfeeding to staff members; that lactation education courses for WIC staff, including breastfeeding peer counselors, be offered as funds allow; and that the Utah WIC Breastfeeding Peer Counseling Program continues to collaborate with the Utah Department of Health and community organizations.
 

In FY20, the Utah WIC program encouraged breastfeeding peer counselor contacts for prenatal and postpartum WIC participants in many ways. These included referring prenatal and postpartum WIC participants to the WIC breastfeeding peer-counseling program through the Nutrition Interview, Referrals, and Participant Care Plan screens in the Utah WIC VISION computer system; and through community program referrals by the Mother-To-Baby Utah (MTB UT) program. Furthermore, each local agency offered at least one training on breastfeeding, and many local agencies asked their peer counselors to participate in the trainings through sharing new breastfeeding research with other staff members. Finally, a 45-hour Lactation Education course was offered to all WIC staff members, including peer counselors, in FY19.

Healthy Living through Environment, Policy, and Improved Clinical Care (EPICC), in the Bureau of Health Promotion, successfully applied for funding from the Association of State and Territorial Health Officials (ASTHO) to help worksites improve or enhance their employee lactation accommodations. The award was received in January 2020. EPICC sent an RFA to worksites throughout the state inviting them to apply for funding using the ASTHO funds. Seventeen worksites were selected but work was not completed until FY21. EPICC’s lactation specialist created a worksite training video and several podcasts on lactation accommodations in the workplace. EPICC continued its work with local health departments asking them to reach out to worksites and provide technical assistance on lactation accommodations (Note that this work slowed substantially due to the demands of COVID-19 work). The EPICC worksite specialist continued his work assessing the number of worksites that have lactation policies and/or meet the criteria for the federal lactation accommodations through several surveys that included the CDC Scorecard, the EPICC mini-scorecard, and the Utah Worksite Wellness Recognition Award assessment.
 

Accomplishments / Successes:

 

From the inception of the program in 2015 to the end of FY20, a total of 23 (52%) Utah birthing centers have been trained on the Stepping Up program and had successfully implemented a combined total of 117 steps. During FY20, we saw five birthing facilities complete all ten steps and become designated as a Breastfeeding Friendly Facility. These five Breastfeeding Friendly Facilities and the one Baby-Friendly facility accounted for 24.4% of births in Utah. This is significant because research has shown that families exposed to The Ten Steps to Successful Breastfeeding used by the Stepping Up for Utah Babies program have improved breastfeeding/chestfeeding rates.
 

Much of this success is due to the ongoing partnership and support from the Intermountain Healthcare System. They continue to encourage their member birthing facilities to continue working on the steps and certify as a Breastfeeding Friendly Facility.

During FY20, one hospital (Bear River Valley Hospital) was trained in the Stepping Up program. Bear River is located in Box Elder County and is considered a rural area of Utah. Also, during FY20, 30 new steps were implemented by the participating birthing facilities.

In FY20, 7% of pregnant and postpartum participants received at least one contact from a WIC breastfeeding peer counselor, which was less than the goal of 12% for FY20. Additionally, the number of employed peer counselors decreased from 36 in FY19 to 32. The decreased number of peer counselors and peer counselor contacts may have affected the Utah WIC breastfeeding prevalence rates. Utah WIC’s ever breastfed prevalence rate was maintained at 88%, but all other breastfeeding prevalence rates, such as for breastfed at 6 months and 12 months, and exclusively breastfed at 3 months and 6 months decreased by 1 percentage point between FY19 and FY20.

Despite these challenges, there were several successes within the WIC Breastfeeding Peer Counseling Program. First, participants who were contacted by a breastfeeding peer counselor were often contacted at least 2 times, and sometimes 3 or more times prenatally and postpartum. This indicates that the participants who were contacted by peer counselors may have received improved quality of contacts. Additionally, breastfeeding peer counselors reported success while working from home and utilizing technology such as text messages, YouTube videos, and video calls to support participants in breastfeeding. Two local agencies successfully hosted virtual breastfeeding conferences in FY20 and reported having more participation than their past in-person conferences. Other local agencies worked with hospitals to provide outreach to their breastfeeding peer counseling programs, even though they were unable to complete hospital visits during COVID-19.

Sending out the call for proposals increased awareness of worksites of the importance of providing accommodations for lactating women. It also provided a way for EPICC to reach worksites and provide resources and educational materials. It provided the opportunity to let staff at local health departments know about worksites in their jurisdictions that may be interested in technical assistance. Worksites that received funding were transformed by their improved lactation accommodations. The considerable number of applications received indicated the interest and need for technical and financial assistance for improving lactation accommodations among worksites.
 

Summary of successes and accomplishments on “Moving the Needle” in relation to NPM-4:

 

• Stepping Up for Utah Babies program trained an additional hospital, oversaw the successful implementation of 33 steps, and designated 4 hospitals as a "Breastfeeding Friendly Facility."
   
• The Utah WIC Breastfeeding Peer Counseling Program contacted participants at least 2 times which led to an improved quality of contact. (December 31st, 1969 - December 31st, 1969)
   
• Two local WIC agencies hosted a virtual breastfeeding conference and had more participation than their past in-person conferences.
   
• EPICC received funding from the Association of State and Territorial Health Officials (ASTHO) that they released to worksites throughout the state. Seventeen funded worksites were provided technical assistance, resources, and education that improved their lactation accommodations.
   

Challenges / Gaps / Disparities Report:

An ongoing challenge to hospitals that have begun work on the Stepping Up for Utah Babies program is the amount of additional duties administrators, nurses, and educators must take on to accomplish the requirements set by the program. Furthermore, outreach to smaller and/or birthing facilities outside the two major health systems (Intermountain Healthcare and the University of Utah) has proven challenging. Communication attempts by Stepping Up for Utah Babies staff are often unreturned or directed to the incorrect person.

During FY20, the COVID-19 pandemic proved to be a significant disrupter of program activities. Birthing facilities were forced to react to the rapidly changing health directives and policies enacted by federal, state, local, and birthing facility officials. Quality improvement projects surrounding the implementation of the Stepping Up for Utah Babies program were halted in order for birthing facility staff to focus on protecting their patients from this novel virus. Additionally, due to social distancing requirements, restrictions on group gatherings and travel, and safeguarding birthing facility staff, and Stepping Up staff's overall safety, all training and in-person meetings were canceled.
The primary challenge in FY20 was the COVID-19 pandemic. The pandemic interrupted the operations of WIC clinics due to the policy changes required to ensure staff members’ and participants’ safety, such as not seeing participants in person. Additionally, many peer counseling staff members were asked to help with local agency COVID-19 tasks, which may have affected their time management for contacting prenatal and postpartum WIC participants. Furthermore, there were mixed messages about the safety of breastfeeding during the pandemic, which may have influenced WIC participants to choose not to breastfeed during this time. Finally, WIC agencies stated that because of the pandemic, they were unable to hire more peer counselors during FY20. Each of these challenges may have played a role in the decreased number of peer counselor contacts and the slight decline in the Utah WIC Breastfeeding Prevalence rates.

Many challenges occurred during 2020 due to the COVID-19 pandemic. Staff were redirected from their regular activities to COVID-19 work and were unable to give their time and energy to focus on breastfeeding. A webinar designed to help worksites understand lactation accommodations as well as an award program was delayed. Many businesses were also completely overwhelmed with contact tracing and staff shortages and were unresponsive to opportunities. We also had hoped for more responses to our women’s survey. We anticipated having at least 40 women complete the survey about lactation accommodations in the workplace; however, many worksites were closed during the time the survey was conducted and we received only seven valid responses (despite the small number, the respondents provided insight into things that were important to them).

Emerging Issues:

Breastfeeding peer counselor recruitment and retention remains an ongoing concern within the Utah WIC Breastfeeding Peer Counseling Program. Additionally, despite improved collaboration with health care provider offices for the WIC Breastfeeding Peer Counseling program, some agencies have reported a lack of support from local hospitals who are not breastfeeding friendly and are unwilling to collaborate with WIC and promote breastfeeding.

The COVID-19 pandemic opened doors for more people to work at home on a more permanent basis and women with infants may be able to breastfeed at home in the future; therefore, work on lactation accommodations in the workplace may become less urgent than it has been in the past.
 

Agency Capacity / Collaboration Report:

 

The success of the Stepping Up for Utah Babies program would not be possible without our many partners. Our most important partners are the staff and administration that do the work to implement the Ten Steps to Successful Breastfeeding in their facilities. Their commitment and dedication to the program positively impact our breastfeeding rates. Second, partnerships with the Women, Infants, and Children (WIC) and the Healthy Living through Environment, Policy, and Improved Clinical Care (EPICC) programs provide Stepping Up staff with expert advice and additional tools that can be shared with participating birthing facilities that assist in the implementation of the steps. We also share an ongoing and beneficial partnership with the two most prominent healthcare systems in the state, Intermountain and the University of Utah. Intermountain Healthcare strongly encourages all of its member hospitals to participate in the Stepping Up for Utah Babies program, tracks their progress, and recognizes their achievements and certifications. The University of Utah is our only Baby-Friendly Facility in the state; however, they are supportive of the Stepping Up for Utah Babies program and have also received a designation of being a “Breastfeeding Friendly Facility.”

The Utah WIC Program partners with several organizations. This includes MTB UT, local hospitals, local health care provider offices, local universities, La Leche League, Head Start, Community Health Clinics, Nurse Family Partnership programs, Parents as Teachers programs, Baby Your Baby, Early Intervention, Welcome Baby, the Mountain Mother’s Milk Bank, and local doulas, local health educators, and local IBCLCs.
 

EPICC partnered with local health departments and shared names of worksites that applied but did not receive funding so that their staff could still follow up with them and offer assistance. In addition, EPICC established an internal workgroup comprised of EPICC staff who chaired or could speak on behalf of prominent statewide organizations (Utah Worksite Wellness Council, the Childhood Obesity Prevention Workgroup, and the Utah Association of Local Health Departments). EPICC contacted a private furniture sales industry to secure discounts on comfortable chairs for breastfeeding mothers for all worksites that applied, whether they were funded or not.

 

Summary Progress Report of ESMs related to NPM-4.1 and 4.2:

 

ESM 4.1 - Stepping Up for Utah Babies: Number of Utah hospitals, that deliver babies, that have implemented some of WHO's evidence based 10 Steps to Breastfeeding Success.

 

Goal/Objective:

Increase the number of steps being implemented in Utah delivering hospitals.

 

Significance of ESM 4.1:

Advantages of breastfeeding are indisputable. The American Academy of Pediatrics recommends all infants (including premature and sick newborns) exclusively breastfeed for about six months as human milk supports optimal growth and development by providing all required nutrients during that time. Breastfeeding strengthens the immune system, improves normal immune response to certain vaccines, offers possible protection from allergies, and reduces probability of SIDS. Research demonstrates breastfed children may be less likely to develop juvenile diabetes, may have a lower risk of developing childhood obesity and asthma, and tend to have fewer dental cavities throughout life.

The bond of a nursing mother and child is stronger than any other human contact. A woman's ability to meet her child’s nutritional needs improves confidence and bonding with the baby and reduces feelings of anxiety and postnatal depression. Increased release of oxytocin while breastfeeding, leads to a reduction in postpartum hemorrhage and quicker return to a normal sized uterus over time. Mothers who breastfeed may be less likely to develop breast, uterine, and ovarian cancer, and have a reduced risk of developing osteoporosis.

 

ESM Progress Summary:

 

The policies, procedures, and practices of a birthing facility a new birthing parent encounters in the first hours and days after childbirth can help or hinder their future breastfeeding success. Implementing evidence-based strategies, like those described by the World Health Organization’s “Ten Steps to Successful Breastfeeding,” can significantly improve a person’s confidence in their ability to reach their breastfeeding/chestfeeding goals.

The Stepping Up for Utah Babies program is a free, Utah-centric program that works with birthing facilities to become certified as a “Breastfeeding Friendly Facility.” The Stepping Up program utilizes quality improvement methods to assist participating birthing centers in implementing “The Ten Steps to Successful Breastfeeding” through an incremental approach – implementing two steps at a time with the goal of implementing all 10 steps.

From the inception of the program in 2015 to the end of FY20, a total of 20 (45%) Utah birthing centers have been trained on the program and had successfully implemented a combined total of 35 steps. Specifically, during FY20, Stepping Up program staff trained three new birthing facilities: Central Valley Medical Center (rural area), St. George Regional Hospital (the hospital is located in an urban city in a rural county), and Salt Lake Regional Medical Center (urban area) and oversaw the certification of 13 steps.
Moving forward, Stepping Up for Utah Babies program staff will continue recruiting birthing facilities to be trained and begin the work required to become a certified Breastfeeding Friendly Facility. Stepping Up staff remains committed to providing technical assistance and recognition to participating birthing facilities for those facilities already trained. Furthermore, Stepping Up staff plan to create increased educational opportunities by providing short, on-demand training videos that will be available on the Stepping Up for Utah Babies website https://mihp.utah.gov/stepping-up-for-utah-babies. These training videos are currently being created and will be released at a later date.

A challenge of this program has been the training of smaller, rural birthing facilities. The staff has tried traditional contact methods, including calling and emailing birthing facility staff, which has been unsuccessful due to contacting the incorrect person or the emails/calls not being returned. Stepping Up staff is looking at other ways to reach these facilities. For example, surveys asking for more information about the implementation resources Stepping Up staff could provide that will help them succeed in becoming a recognized Breastfeeding Friendly Facility and looking for and working with community partners with pre-existing relationships with the birthing facilities.

The success of the Stepping Up for Utah Babies program would not be possible without our many partners. Our most important partners are the staff and administration that do the work to implement the Ten Steps to Successful Breastfeeding in their facilities. Their commitment and dedication to the program positively impact our breastfeeding/chestfeeding rates. Second, partnerships with the Women, Infants, and Children (WIC) and the Healthy Living through Environment, Policy, and Improved Clinical Care (EPICC) programs provide Stepping Up staff with expert advice and additional tools that can be shared with participating birthing facilities that assist in the implementation of the steps. We also share an ongoing and beneficial partnership with the two most prominent healthcare systems in the state, Intermountain and the University of Utah. Intermountain Healthcare strongly encourages all of its member hospitals to participate in the Stepping Up for Utah Babies program, tracks their progress, and recognizes their achievements and certifications. The University of Utah is our only Baby-Friendly Facility in the state; however, they are supportive of the Stepping Up for Utah Babies program and have also received a designation of being a “Breastfeeding Friendly Facility.

 

ESM 4.2 - Worksite lactation policy: Number of worksites that have created a lactation policy that complies with federal standards:
 

Goal/Objective:

Increase the number of worksites that create or revise a lactation policy or formal communication.

Significance of ESM 4.2:

For infants not breastfeeding, there is an associated increased risk of infant morbidity and mortality, and significantly higher risk of many diseases including diabetes, obesity, leukemia, SIDS, NEC, etc.

Duration rates are greatly affected by mothers returning to work to businesses that are not meeting the federal workplace accommodation law. Policies must be in place and implemented to provide an environment that is conducive to supporting breastfeeding women.

ESM 4.2 Progress Report:
 

During FY20, the EPICC program continued to reach out to, and collaborate with Utah worksites to create lactation policies that comply with federal and state laws. During FY20, eighty-three worksites completed either the CDC Worksite Health Scorecard, Healthy Worksite Award, or EPICC Mini-Scorecard. Of those, 61% of worksites currently have an existing breastfeeding policy in place that complies with federal standards. Sixteen worksites have created a new policy, formal communication, or revised and updated a policy for breastfeeding/lactation support for employees and 84% of the worksites provide private space and provided paid or unpaid break time for expressing breast milk. EPICC staff and LHDs provided technical assistance and breastfeeding support materials to worksites that do not have policies or are not compliant with lactation accommodation law.
 

The 2020 survey of women who use lactation rooms and are affected by worksite policies was intended to be a one-time event but EPICC has obtained additional funds and is considering conducting another survey of women who use worksite accommodations.

In 2020, with funding from ASTHO, EPICC began the Workplace Lactation Accommodations Project, focusing on worksites with high concentrations of women earning $15.00 an hour or less. Funds were provided to 17 worksites to use on improving their lactation accommodations and ensuring that policies were in place. Women who used the improved accommodations were asked to take a survey to provide feedback about how they benefited from the changes along with challenges they faced. Because we asked employers to send the link to the women’s worksite lactation accommodations survey to their employees, we have no knowledge of who received it and we cannot determine the exact number that it was sent to. Our results indicate that a minimum of 36 individuals received and at least initiated the survey. Filter questions were used to eliminate unqualified respondents. Respondents were disqualified if they were not female, if they had not had a baby within the past 18 months, if they were not currently using their employer’s lactation accommodations. Responses were also not included if we could not confirm that respondents were 18 or over. We are using 36 as our denominator. Only seven surveys were determined to be complete and valid, yielding a response rate of 19.4% (7 of 36). Please note that the small sample is likely due to the low number of women who qualified to complete the survey as well as the impact that COVID-19 had on opportunities to work at home, therefore reducing the need for breastfeeding women to use their employers’ accommodations.

Women who completed the survey reported challenges that included distance between women’s workspace and the accommodations, distance to a bathroom or drinking fountain, the lack of extra chairs, sinks, or diaper-changing station, Also, the lactation room may not be “toddler friendly” for times that women need to have their older children with them. They appreciated having a specific place to pump and the educational materials on breastfeeding and postpartum depression in the lactation rooms. Women offered recommendations that included having accommodations closer to their workspace; providing comfortable chairs and refrigerators; ensuring that accommodations can support more than one woman at a time; and having paid breaks. This information can help employers target their lactation resources towards the things that are important to women who are breastfeeding. Note that the 17 worksites are not counted in the outcomes for this funding period as the work was not completed until October 2020.

The EPICC program and LHDs continue to have difficulty with worksites not following up after initial contact has been made. Worksites often mention that they are not interested in working on breastfeeding policies, as other issues may have a higher priority. Worksites may not have employees who breastfeed or pump and there is no need for a policy. There is also confusion over the actual lactation accommodation law, the requirements, and what is considered to be “private space” and “reasonable break time.”

ESM 4.3 - Breastfeeding Peer Counselor Program (BFPCP): Number of WIC-eligible clients that are referred to the Breastfeeding Peer Counselor Program:
 

Goal/Objective:

Increase the percentage of eligible pregnant and postpartum WIC participants who received at least one contact from a WIC Breastfeeding Peer Counselor.
 

Significance of ESM 4.3:

Breastfeeding is the normative standard for infant feeding and nutrition and can result in improved infant and maternal health outcomes. Mothers who receive help and support when they need it are more likely to reach their breastfeeding goals and meet their infant’s complete nutritional needs. A mother’s ability to begin and continue breastfeeding can be influenced by a host of community factors, and programs like WICs breastfeeding peer counselors can provide important coaching to enable and sustain breastfeeding efforts in WIC clients. Peer counseling interventions greatly improve breastfeeding initiation, duration, and exclusivity.

ESM 4.3 Progress Report:

The Utah WIC Program is a breastfeeding support program that serves approximately 2% of Utah's population. The participants that Utah WIC serves includes approximately 9200 prenatal and postpartum women who receive education and support in reaching their breastfeeding goals. Research shows that peer counseling programs are effective in improving breastfeeding initiation and duration rates. Therefore, the Utah WIC Program's Breastfeeding Peer Counseling Program is helping the State of Utah meet its breastfeeding initiation and duration goals.

In FY20, the Utah WIC Program measured the number of referrals to its breastfeeding peer counseling program. While overall referrals from WIC staff members and community partners decreased, WIC's breastfeeding prevalence rates mostly stayed consistent with the previous years. Utah WIC collaborated with the MTB UT program, which provided concrete examples of referrals they had provided to the WIC breastfeeding peer counseling program and how these referrals benefitted participants. Additionally, in FY20, three local agency breastfeeding peer counseling programs were awarded national awards from USDA. Furthermore, local agencies were finding ways to expand their breastfeeding outreach through collaboration with health care providers and hospitals, community groups, creating community breastfeeding groups, and implementing evidence-based breastfeeding screening tools.

Since FY20, local agencies have continued to search for and implement innovative ways to improve breastfeeding outreach within the community. This includes furthering relationships with health care providers and hospitals, community organizations, health department and local agency organizations, and private practice health care professionals within their communities. Additionally, local agencies have hosted events, such as breastfeeding conferences and breastfeeding fairs to encourage community members and organizations to learn more about WIC and breastfeeding. During each fiscal year, WIC has obtained adequate funding to provide lactation continuing education courses to staff members, including peer counselors, to help them improve their breastfeeding promotion and support skills.

The primary challenge experienced by the Utah WIC Breastfeeding Peer Counseling Program is retention and recruitment of WIC breastfeeding peer counselors. Breastfeeding peer counselors sometimes have high turnover because of the hours, pay rate, or other personal needs, such as taking care of family or going back to school. Local agencies are working to find ways to promote improved recruitment and retention of breastfeeding peer counselors.
 

SPM-1: Percent of live births occurring before 37 completed weeks of gestation.

Annual Report FY20: 

The Performance Measure was not achieved. The Performance Objective was 9.4% and the Annual Indicator was 9.7%.

Program Activities:

The Preterm Birth Rate was 9.7%. This rate is below the 2019 U.S. preterm birth rate of 10.2% and is a bit above the Healthy People 2020 goal of 9.4%.
 

The Reduce Preterm Birth Committee of the Utah Women and Newborns Quality Collaborative (UWNQC) did a data audit to compare birth certificate to hospital data. They reviewed 179 cases and found a 94% rate of offering 17 alpha-hydroxyprogesterone caproate (17P) to women with a previous preterm birth. Also, 80% of women who have a spontaneous preterm birth (PTB) did not have a history of PTB. The committee invited a 17-P patient to share her experience at a committee meeting including the process of receiving 17-P. A Cervical Length Project grant in rural areas of Utah was awarded. Family Planning Elevated at the University of Utah collaborated with ACOG to offer Preconception Care Awareness training in southern Utah. The committee members continued to share facility specific data at staff meetings, along with the resources developed to address Spontaneous Preterm Birth available at https://mihp.utah.gov/uwnqc/reduce-preterm-birth including the Preterm Birth Prevention Video Series, the Utah Screening and Progesterone treatment process and care protocol, What to Do to Prevent a Preterm Birth: 17P (Progesterone) Guide for Providers; 17P for Preventing Preterm Birth Fact Sheet (English and Spanish), What to Do After a Preterm Birth Guide for Families (English and Spanish). The resource also outlines how to implement changes and track improvement at hospitals.  

COVID-19 resources were provided to clinicians. Family Planning Elevated provided Provider and Clinic Recommendations on contraceptive access during the pandemic.

 

Accomplishments / Successes:

In 2019, Vital Records staff presented to providers statewide on the importance of accurately reporting prior preterm births on the birth certificate. This included packets of information with UWNQC resources such as a 17P for Preventing Preterm Birth for Providers. Having the collaboration of Vital Records for our data collection and training providers has been a helpful resource. One of our contacts at Vital Records serves on one of our UWNQC committees which allows her to see our activities and understand why capturing the data is important.

The University of Utah, one of our major Health Systems, created a spontaneous PTB section in their Electronic Medical Record (EMR) EPIC which captures patient history of spontaneous preterm birth, whether 17P was offered, if the patient took 17P injections and if so, when they were started. This data will help to establish a baseline and identify potential barriers to optimal treatment.

Multiple births are a factor in the preterm birth rate. In 2019, 3.6% of total births were multiples (twins, triplets, quadruplets or higher), and this represented 23.1% of the total Preterm Births. The UWNQC committee has been focused on spontaneous singleton births.  

Preterm Birth Risk factors included: Women who have had 3 or more previous live births (11.6%) PTB rate, age: 18-19 year olds (12.97%), 35-39 year olds (11.47%) and 40-44 year olds (15.03%). Education is a preventive factor, with the more education that a woman has, the lower the PTB rate.

Although the Medicaid rate of Preterm Births hit 10.87%, the gap between mothers who were and were not enrolled in Medicaid reduced by 13% in 2019. Of the 12 Utah counties that had PTB rates over 10%, 10 of them are in rural or frontier counties. Rural or frontier counties account for 18% of all births and 19.24% of the PTB's. There are currently some telehealth programs in place that offer resources specific to rural residents.

Reviewing the rates of Preterm Birth by race and ethnicity, all races went up in comparison with 2018. The PTB rate for Hispanic/Latina did go down from 11.16% in 2018 to 10.42% in 2019. The highest rate for the past five years is among Native Hawaiian or Other Pacific Islanders (NHPI). Since 2012, The Utah Office of Health Disparities (OHD) in collaboration with public health and health care professionals and community partners has been working to address this issue, along with infant mortality. A final product of these efforts is the It Takes a Village: Giving our babies the best chance (ITAV) project. It Takes a Village raises awareness and educates NHPI families and community members about maternal and infant health in the context of Pacific Islander cultural beliefs and practices. ITAV is one of the outcomes of a birth outcomes disparities project that was originally rooted in the theoretical framework from the National Partnership for Action to End Health Disparities.  The curriculum includes discussing topics such as birth spacing which can reduce the risk for Preterm Births.

MotherToBaby Utah provided information about exposures in pregnancy to help reduce untreated conditions, prevent exposures that increase risks for birth defects, and prevent other adverse pregnancy outcomes including preterm birth and low birth weight.
 

Summary of successes and accomplishments on “Moving the Needle” in relation to SPM-1:

 

• The Reduce Preterm Birth Committee of the Utah Women and Newborns Quality Collaborative (UWNQC) completed a data audit to compare the birth certificate to hospital data.  
   

• Tracked 17P usage data via run charts for UWNQC hospitals. This data, along with Preterm Birth reduction resources, were provided to various hospitals statewide and at staff meetings.
   
• Family Planning Elevated at the University of Utah collaborated with ACOG to offer Preconception Care Awareness training in southern Utah.

Challenges / Gaps / Disparities Report:
 

An ongoing challenge is limited evidence-informed interventions to reduce preterm birth. With the U.S. Food and Drug Administration advisory committee recommending in October 2019 that the standard treatment to prevent women from having another preterm birth, Makena, be withdrawn from the market following a public hearing. That decision raised various concerns in the committee about prescribing 17-P and the SMFM and ACOG guidelines/statement were consulted. Due to COVID-19, meetings from March 2020-June 2020 were postponed. Based on the comprehensive Needs Assessment, Preterm Birth was determined to not be one of the MCH priorities for the next 5 years.
 

Agency Capacity / Collaboration Report:
 

Stakeholders from the key major health systems in Utah: Intermountain Healthcare, MountainStar (HCA), Steward Health and the University of Utah work with the UWNQC board and committees. This collaboration helps us to educate providers, collect preterm birth data and implement statewide standard protocols and algorithms. Another partnership is with the University of Utah Family Planning Elevated team. They worked with ACOG to provide Preconception Care Awareness training for southern Utah clinicians. Government collaborations include working with Local Health Departments statewide and with hotlines such as the Utah Tobacco Quit Line, state resource center, Baby Your Baby and Mother-To-Baby. Social Media efforts include public education about how to be healthy prior to pregnancy on the Power Your Life website, along with offering various resources on the UWNQC for providers and the public. The collaboration with the Office of Vital Records is key in obtaining and analyzing 17P data utilization.

The collaboration between UWNQC and Family Planning Elevated at the University of Utah will continue as the House Bill 12 from the 2018 Legislative session provides a statewide, immediate Postpartum Long-Acting Reversible (LARC) Program. This includes offering a program that provides family planning services to low-income individuals, disseminating educational materials statewide, and training providers. The bill has provisions for family planning services within the state Medicaid program. It includes the Medicaid program reimbursing providers separately for the insertion of LARC immediately after childbirth, and providing family planning services to certain low-income individuals. Unintended pregnancy data will be tracked to determine if a reduction may help to move the needle in reducing preterm births.

 

SPM-01 was discontinued following the 2020 MCH Needs Assessment.

 

Other activities in the Perinatal/Infant Health domain that contribute to improvement in the National Outcome Measures: 

 

Utah works to adhere to the three-tier framework outlined in the MCH Block Grant guidance. While the focus of most activities is the ESM →NPM→ NOM framework, activities on improving NOMs outside of the NPMs transpires in parallel. The following programmatic activities also work to improve outcomes in this domain. 

 

National Outcome Measures (NOM):

NOM 4: Percent of low birthweight deliveries (<2,500) grams).
 

MotherToBaby Utah provided information about exposures in pregnancy to help reduce untreated conditions, prevent exposures that increase risks for birth defects, and prevent other adverse pregnancy outcomes including preterm birth and low birth weight.

NOM 8: Perinatal mortality rate per 1,000 live births plus fetal deaths.
 

MotherToBaby Utah provided information about exposures in pregnancy and breastfeeding to help prevent exposures that increase risks for birth defects, developmental delays, and fetal deaths.

Utah's Perinatal Mortality Review Program reviews deaths to infants due to perinatal conditions. Infant death cases are reviewed by a multidisciplinary committee which assesses preventability and makes recommendations for prevention.

The Study of the Associated Risks of Stillbirth (SOARS) is an ongoing, state-specific, population-based survey designed to collect information on maternal experiences and behaviors prior to, during, and immediately following pregnancy among mothers who have recently experienced a stillbirth. SOARS was initiated in 2018 in an effort to find out why stillbirths occur and how to prevent future fetal deaths. Using methodology similar to the Pregnancy Risk Assessment Monitoring System (PRAMS), Utah women who recently experienced a fetal death are mailed a survey. Utah continued SOARS data collection in FY20.

 

NOM 9: Infant Mortality Rate per 1,000 live births.
 

MotherToBaby Utah provided information about exposures in pregnancy and breastfeeding to help prevent exposures that increase risks for birth defects, developmental delays, and fetal deaths.
 

NOM 10: Percent of infants born with fetal alcohol exposure in the last 3 months of pregnancy.
 

MotherToBaby Utah provided information about alcohol exposure in pregnancy and breastfeeding to help prevent FASD which may include birth defects and developmental delays. MotherToBaby Utah is working with PRAMS to reinstate the question for alcohol use in the last 3 months of pregnancy.

 

NOM 11: The rate of infants born with neonatal abstinence syndrome per 1,000 hospital births.
 

MotherToBaby Utah provided information about exposures, including mood medications, in pregnancy and breastfeeding to help reduce untreated mood conditions, prevent exposures that increase risks for birth defects and developmental delays, prevent other adverse pregnancy outcomes, and increase breastfeeding rates. In FY 2020, MotherToBaby Utah provided information to 701 clients about mood conditions and, assuming those pregnant and breastfeeding individuals started, continued, or restarted their prescribed mood medications, MotherToBaby Utah saved Utah over $20 million based on a study that indicated that untreated mood conditions cost each mother-infant pair $31,800 over the first five years of the child’s life.
 

NOM 12: Percent of eligible newborns screened for heritable disorders with on time physician notification for out of range screens who are followed up in a timely manner.
 

The Child Health Advanced Records Management (CHARM) Program integrates data in real time from a variety of programs to present a consolidated record of newborn screening results such as newborn hearing, heel-stick (ranges are included) and critical congenital heart defect (CCHD) results. One way the CHARM system shares the integrated data is through its CHARM Web Portal (CWP). Authorized private and public health care providers continued to use the CWP to look up and view a child's health information/results from the above newborn screening tests to coordinate care, treatment, and follow-up in a timely manner. Providers were also able to access the Medical Home Portal through a link in the CWP to find diagnostic and treatment information for newborn disorders.  In addition, CHARM continued to collaborate on the “Birth Certificate Alert Project” with the Early Hearing Detection and Intervention (EHDI) and Vital Records (VR) Programs. Through CHARM's data integration with EHDI and VR, when parents apply for a birth certificate for their child at the state or local health department, a hearing screening alert is generated by CHARM if the child did not pass a hearing screening test, was not screened, or needs to complete the process. When the birth certificate clerk sees the alert in the VR OLIVER system, he/she prints out a letter informing the parents or guardians that their child needs a hearing screening follow-up, and instructs them to contact the EHDI Program. The CHARM Program also prepares a report of these children for the EHDI Program in case the parent/guardian does not contact EHDI. From July 1, 2019 – June 30, 2020, there were 637 hearing alerts generated for children by CHARM and received in the OLIVER system; 319 (50.1%) of those children went on to complete a hearing screening test after receiving the alert. This linkage has improved follow-up efforts and care coordination for children that are deaf or hard of hearing.