NPM #3 Perinatal Regionalization – Ensure risk appropriate care for high-risk infants to reduce infant mortality / morbidity.

 

Similar to national trends, infant mortality rates (IMR) in Missouri have experienced a steady decline over the past two decades. Despite these significant declines, the racial disparities associated with IMR have remained steady and disproportionately affect African-Americans. The 2018 Missouri IMR was 6.3 per 1,000 live births (provisional data), still above the 2017 national IMR of 5.8 per 1,000 live births. The non-Hispanic African-American rate in MO (10.3 per 1,000 live births) continues to be twice the non-Hispanic White rate (5.4 per 1,000 live births). While IMR have decreased across all racial/ethnic groups, the racial disparity associated with them has effectively remained unchanged for the past 50 years – African American infants are twice more likely to die than white infants within the first year. Approximately 50% of infant deaths occur among preterm and very low birthweight (VLBW) infants, and transferring these babies in a timely manner to level appropriate care facilities has been shown to significantly reduce the risk of infant death among these high risk infants. Perinatal regionalization is a standardized mechanism where hospitals are assigned levels of care (Level I, II, III and IV) based on their neonatal intensive care unit capabilities. In 2018 (provisional data), 87.1% of Missouri VLBW babies were delivered at level III or higher facilities. This assessment was based on data analysis from a survey completed by hospitals in conjunction with vital statistics data. VLBW babies delivered at Level III or NICU facilities were highest among Non-Hispanic Black women (91.5%), followed by Hispanic women (91.3%) and Non-Hispanic White women (84.9%). Overall, 8.8% of Missouri infants were born at low birth weight (less than 2500 grams); with non-Hispanic Black low birth weight rate being the highest (15.6%) and about 2 times that of Non-Hispanic Whites (7.4%) and Hispanics (7.3%). Efforts to reduce infant mortality addressed methods for risk-appropriate care, utilization of 17 Alpha-hydroxyprogesterone caproate (17P), and collaborative initiatives.

 

Risk-appropriate Care

The March of Dimes (MOD) Preterm Labor Assessment Toolkit (PLAT) was developed to enable the standardized identification of women in preterm labor by medical providers and hospitals. The goal is to ensure timely and appropriate interventions for improved neonatal outcomes. Preliminary results from the 2018 Annual Licensing Survey of Missouri Hospitals indicated 11 hospitals had implemented PLAT.

 

During the 2017 legislative session, Senate Bill 50 (SB50) was passed which requires birthing facilities to annually report their neonatal and maternal levels of care to the Missouri Department of Health and Senior Services (DHSS) starting January 1, 2019. SB50 also required DHSS to hold multiple public hearings in diverse geographic regions of the state to seek stakeholder input, and after receiving input, establish criteria for levels of neonatal and maternal care designations. To schedule these hearings, DHSS collaborated with the Missouri Hospital Association in order to hold the meetings at hospitals to make it easier for clinicians to attend. Six public hearings were scheduled for November 2017 to present state data on neonatal and maternal morbidity/mortality as well as discuss the SB50 legislation. Approximately 63 birthing facilities will need to report their levels of care each year. During the public hearings, DHSS staff took notes on any comments, questions and/or concerns so that stakeholder input would be considered during the rule making process. Discussions were also had between DHSS epidemiology staff and the Centers for Disease Control and Prevention in regards to the Levels of Care Assessment Tool (LOCATe) and how to best support our facilities during completion of the survey. 

 

Collaborative Initiatives

The SHFY has a full-time public health consultant nurse position that provides coordination for infant mortality initiatives. This role serves as the expert in infant mortality, fields legislative questions, and disseminates information to the MCH team. This position is actively involved in internal efforts as well as informed about activities throughout the state and takes the lead in representing DHSS when working with MCH stakeholders.

 

DHSS committed to reducing infant mortality and prematurity as identified in the Department’s strategic plan. In the fall of 2018, a new strategic initiatives team assembled with the goal to put together a department dashboard for measuring, monitoring, and managing performance more efficiently. The team included representatives from each division and office within the Department. The dashboard included four department themes: reduce opioid misuse, improve the health and safety of Missourians most in need, enhance access to care, and foster a sustainable, high-performing department. Improving the health and safety of Missourians most in need includes initiatives to address chronic disease and infant mortality.

 

The Prematurity & Infant Mortality Subcommittee under the Children’s Services Commission, which voted in summer of 2017 to no longer meet, brought forth legislation during the 2018 session to disband. Several Subcommittee members voiced concern that infant mortality efforts within the state would suffer without the existence of the Subcommittee. Despite the Prematurity & Infant Mortality Subcommittee no longer in existence, efforts to implement SB 50 continued within the DHSS.

 

Collaboration continued with several local and regional initiatives to reduce infant mortality. Efforts included two Healthy Start grantees, the Maternal Child Health Coalition in Kansas City and Bootheel Babies and Families in the southeast region. FLOURISH St. Louis, a collective impact initiative working in coordination with Generate Health, also worked to address infant mortality. FLOURISH continued to work within their priority focus areas including infant health, prenatal care access, transportation, health communication and navigation, and behavioral health. The five action teams that were formed to head the work within the focus areas prioritized strategies for each of the focus areas and began their work. For example, the infant health action team hosted a webinar training over safe sleep practices that targeted providers, community members and hospital staff. Furthermore, the transportation action team sought innovative ways to improve access for mothers and families through BUILD 2.0. BUILD is a national program designed to support partnerships between community-based organizations, hospitals/health systems, and health departments that are working to address important health issues in their community. Through the BUILD Health Challenge, Flourish and the transportation action team worked with cross-sector partners in managed care, Metro Transit, medical transportation, and policy advocacy to improve transportation access which is key to healthier outcomes and addressing racial disparities in infant mortality. In addition, FLOURISH continued to be part of CityMatch’s Institute for Equity in Birth Outcomes. This three-year partnership addresses designing and implementing strategies that focus on racial equity. FLOURISH focused on how housing conditions and the lack of quality housing for low-income families impact the health of pregnant moms and babies. They raised awareness of the housing conditions, including broken heat and rodent infestations, and identified potential solutions that would help families. Another collaboration, the Infant Mortality Reduction Initiative (IMRI), funded by the Missouri Foundation for Health, serves two areas, St. Louis and the six county region of the Bootheel in the southeast corner of the state. The purpose of collaborating with the Maternal Child Health Coalition, Bootheel Babies & Families, FLOURISH, and IMRI was to connect local and state efforts and to be a resource to accelerate positive changes.

 

The MCH Services Program contracted with 113 Local Public Health Agencies (LPHAs) to support a leadership role for LPHAs within coalitions and partnerships at the local level to build MCH systems and expand the resources those systems use to respond to priority maternal child health issues, including the prevention and reduction of adverse birth outcomes. One specific example is the Atchison County Health Department, which employed a women’s health nurse practitioner, screened each Women's Health Clinic patient for prenatal health issues, screened each pregnant WIC client for perinatal health issues, and provided assessment, education and intervention or referral as indicated to prevent preterm labor and promote risk-appropriate perinatal care.

 

DHSS began a partnership with Healthy Birth Day, Inc. on the Count the Kicks project, a proven stillbirth prevention public health campaign. According to the Centers for Disease Control and Prevention, Missouri has the 21st highest stillbirth rate in the country. Missouri vital statistics show that 458 stillborn babies are born each year in our state. The introduction of Count the Kicks in Missouri has the potential to save 119 babies every year if Missouri’s stillbirth rate decreases by 26 percent, as has happened in neighboring Iowa where the campaign began. Count the Kicks teaches the method for and importance of tracking fetal movement in the third trimester of pregnancy. Scientific studies show that expectant moms should track their baby’s movements once a day in the third trimester and learn how long it normally takes their baby to get to 10 movements. Moms will start to notice a pattern, a normal amount of time it takes their baby to get to 10. If "normal" changes during the third trimester, this could be a sign of potential problems and an indication to call their provider. Particular efforts will be made to eliminate racial disparities while lowering the overall stillbirth rate. Nationally and across Missouri, African American women are more than twice as likely to lose a baby to stillbirth as the general population of pregnant women.

 

Through a public health awareness campaign launched 6/1/2018 through 10/6/2018:

• over 67,000 pieces of Count the Kicks educational materials were distributed to Missouri birthing hospitals, obstetrical offices, midwives, county health departments, and WIC offices. 
• More than 5,000 Missourians visited the Count the Kicks website with more than 10,000 page views. 
• Nearly 500 Missourians “liked” Count the Kicks on Facebook and engaged in educational videos.
• Nearly 400 expectant mothers downloaded and started using the free Count the Kicks app. 

 

Through a continued partnership with Healthy Birth Day, Inc., DHSS contracts with the organization to ensure Missouri health care providers will continue to be able to order Count the Kicks educational materials free of charge.

 

17P

DHSS and MOD continued to receive periodic updates from OPTUM regarding their expansion progress with Mekena/17 Alpha-hydroxyprogesterone caproate (17P) services, specifically in the Bootheel region of the state. OPTUM continued to have discussions and data presentations with the managed care organizations and providers located in St. Louis and the Bootheel.

 

The Newborn Health Program contracted with Voxiva to supply free text messages to pregnant women and new mothers up to their child’s first birthday. This Text4baby service had three customized messages that were sent weekly. These messages were customized to Missouri specific phone numbers and websites. Since women who have had a preterm birth can increase their chances of having a full-term birth by taking 17P, early in their pregnancy, enrollees received a message discussing 17P and whether they had a prior preterm birth.

 

Genetics and Healthy Childhood (GHC) funded home visiting services offered in 26 counties and served 940 families through the Missouri Building Blocks (BB), Healthy Families Missouri Home Visiting (HFMoHV) and the Maternal, Infant and Early Childhood Home Visiting (MIECHV) programs. These programs implemented the following evidence-based models:

• Nurse Family Partnership model;

• Healthy Families America model;

• Parents as Teachers model; and

• Early Head Start Home Based Option model. 

 

Home Visitors are knowledgeable about the risks for preterm birth and share education with women enrolled prenatally when appropriate. Data from FY18 indicated that 15% of infants (29/196) were born preterm among mothers who enrolled in home visiting prenatally before 37 weeks gestation. Home Visitors actively encouraged clients to maintain adequate prenatal care once enrolled in the program and continually monitor expectant mothers for potential complications that may affect maternal and infant outcomes such as very low birth weight. 

 

The Home Visiting Program shared the following resources with DHSS contracted home visitors through the Missouri Home Visiting Gateway Weekly Update during 2018:

• 10/27/17 - March of Dimes offers a variety of resources at a low cost about preterm labor, pregnancy and health, 17P, and other pregnancy and maternal health located at this link: https://www.marchofdimes.org/catalog/
• 6/29/18 - March of Dimes research article - Blood test may identify risk of premature birth

 

Resources

The Newborn Health program distributed 32,584 Pregnancy and Beyond booklets in FFY18. These booklets were distributed to hospitals, doctor’s offices, LPHA’s, birthing centers, and other partners throughout the state. New OB patients were given the booklet to be used as a reference for a wide range of information concerning pregnancy and a child’s first five years of life. Lutheran Family and Children Services stated, “The Pregnancy and Beyond book is very helpful for families and our teen moms that are pregnant. What a great tool to help understand each step of pregnancy and beyond!” The Pregnancy and Beyond booklet also includes sections on perinatal and infant health.

 

Newborn Screening

The newborn screening program continues to distribute the newborn screening educational booklet free of charge to educate new and expectant parents. The booklets are ordered from the DHSS Literature Warehouse annually by birthing hospitals, LPHAs, pediatric clinics, WIC clinics, obstetrical clinics, independent birthing centers, midwives, Parents as Teachers, ParentLink, and family practice clinics. There were 50,974 newborn screening educational booklets distributed during FFY18.

 

The newborn screening program continues to distribute a quarterly newsletter, Behind the Screens. The intent of the newsletter is to help increase awareness and provide education about newborn screening, including hearing screening and critical congenital heart disease (CCHD) screening in addition to blood spot screening. The newsletter is distributed to “front-line staff,” individuals who are directly involved with the collection of newborn blood spot specimens and conducting hearing and CCHD screenings. The newsletter is emailed to over 150 individuals each quarter for them to read and distribute to their staff and co-workers. The newsletter is also posted on the newborn blood spot, hearing, and CCHD web pages. The “Behind the Screens” newsletter has received positive feedback from both front-line healthcare workers and laboratorians. Individuals have stated that they find the information useful in their day-to-day practices and enjoy seeing a more personal side to newborn screening through the Patient Spotlight articles. Newsletter recipients have also commented that they have learned something about newborn screening that they were not previously aware of. 

 

During the 2017 legislative session, a bill was passed that requires Missouri to screen for Spinal Muscular Atrophy (SMA) and Hunter Syndrome by January, 2019. Full pilot population screening for Hunter Syndrome began in late 2018 and SMA began in January 2019.

 

The newborn screening follow-up nurses continued to serve as liaisons for both professional and lay midwives, helping to ensure families have access to newborn screening. Continued outreach, education, and open communication has helped to foster a positive relationship between the Missouri Newborn Screening Program and the home birth community.

 

Neonatal Abstinence Syndrome

In February 2018, Missouri was one of five states chosen to participate in the National Governors Association’s (NGA) Learning Lab on Addressing Maternal Opioid Use Disorder to Prevent and Reduce the Effects of Neonatal Abstinence Syndrome (NAS). Since the launch of the project in March, the team of leaders from the Division of Behavioral Health, Division of Community and Public Health, Department of Social Services, and MO HealthNet Division have made great strides toward their goals.

The team attended a kick-off meeting in Columbus, Ohio where they learned best practices from Ohio’s Maternal Opiate Medical Support (MOMS) program. After the meeting, the team finalized and began executing a plan to coordinate and implement programs and services to prevent neonatal abstinence syndrome, to connect individuals to treatment, and to strengthen families. Several of the important outcomes of these efforts are detailed below:

• Established the NAS stakeholder group and held the first meeting in July 2018, which included state agencies, medical providers and health plans, state trade associations, and community providers.
• Coordinating with the Department of Social Services, Children’s Division on implementing Families First legislation in the women’s treatment program.
• Speaking at a State Emergency Management Agency conference on working together among state agencies to serve pregnant/parenting women with substance use disorder (SUD).
• Integrating programs that benefit pregnant/parenting women with SUD into State Opioid Response (SOR) and State Targeted Response to the Opioid (STR) grants.

Working with the Missouri American College of Obstetricians and Gynecologists and the Missouri Primary Care Association to identify waivered treatment providers for women and create a robust map of treatment resources for women.

 

SPM #1 Breastfeeding – Improve health outcomes for Missouri mothers and infants by increasing breastfeeding initiation and duration rates.

 

According to the 2016-2017 National Immunization Survey, 82.3% of Missouri infants were ever breastfed compared to 83.2% nationally, and exceeding the HP2020 goal of 81.9%. Over half of Missouri mothers were still breastfeeding at 6 months (57.8%) and fewer were exclusively breastfeeding at 6 months (31.3%). Based on (PRAMS 2017), 85.0% infants were ever breastfed compared to 82.1% in 2014.

 

This success may be attributed to the implementation of the MO “Show-Me 5” hospital initiative that is based on the Baby Friendly Initiative, launched in 1991 by UNICEF and the World Health Organization (WHO) to ensure that hospitals become centers of breastfeeding support. Based on (PRAMS 2017), Missouri mothers reported that hospitals provided breastfeeding information (97.7%), allowed “rooming in” or staying with baby in same room during hospital stay (89.3%) and a few Missouri infants were not given a pacifier while in the hospital (39.6%).

 

Employment has been identified as a barrier to breastfeeding duration, but relatively easy supports can be put in place to help new mothers reach their breastfeeding goals when returning to work. Supplementation with infant formula for non-medical needs has also been identified as a barrier to breastfeeding duration. Based on the 2018 CDC’s breastfeeding report card, 14.0% of breastfed infants received formula before they were two days old, an increase from 10.9% in 2016.

 

The American Academy of Pediatrics (AAP) continues to reaffirm its recommendation of exclusive breastfeeding for the first six months of a baby’s life. This recommendation is supported by positive health outcomes, as well as social and economic advantages for mothers and children, making it a public health issue and not only a lifestyle choice. Families require an enabling environment to achieve optimal breastfeeding. Multiple methods across different venues were used in Missouri to increase support for breastfeeding.

 

Hospitals

During this reporting period, three Missouri hospitals were recognized as Missouri “Show-Me 5” hospitals. Hospitals seeking this recognition have implemented five out of the Ten Steps to Successful Breastfeeding, a set of evidence-based measures developed by the WHO and adopted by the Baby Friendly Hospital Initiative (BFHI). The MO Department of Health and Senior Services (DHSS) course titled “Fundamentals of Breastfeeding: an 18 Hour Course” was offered at two sites in the state. This training brings together health care providers from hospitals, health departments and the Women, Infants and Children (WIC) program to learn basic information on breastfeeding. Attending this course can assist hospitals in getting the staff training necessary to meet the standards of the BFHI. DHSS was unable to provide a 45-hour exam preparatory course at no cost to potential International Board Certified Lactation Consultants during this period. The WIC program does allow agencies to use WIC funding to pay for the 45-hour course, which some agencies were able to do. The Bureau of Community Health and Wellness (CHW) wrote for and was awarded a CDC grant which will provide funds to have a 45-hour course offered in the state once per year for the next five years.

 

Additionally, DHSS partnered with the Missouri Breastfeeding Coalition to hold the Third Annual MotherBaby Summit to promote the Missouri “Show-Me 5” and the Baby Friendly Hospital Initiatives to hospital stakeholders, including hospital administrators and labor and delivery nurse managers. A total of 128 maternity leaders from 37 of the state’s 63 maternity facilities attended the one-day event, which was an increase from the previous year with 100 attendees from 26 hospitals. This event not only provided education for hospital staff, it also served to provide networking opportunities. There was no need (during this reporting period) to contract with physicians or nurses to provide training at hospitals on “Show-Me 5” steps. The MotherBaby Summit was generously funded by Dr. Bobbi Philipp of Boston Medical Center, through her grant with the W.K. Kellogg Foundation. The 2019 event will be funded in part by the Kellogg Foundation, and in part by the grant from the CDC. 

 

Local Public Health Agencies

One hundred nine of the 114 Local Public Health Agencies (LPHA) reported active promotion of breastfeeding initiation at birth and the continuation of breastfeeding through the first six months of life, and of those, 52 LPHAs reported working with community partners to promote breastfeeding. The MCH Services Program contracted with 113 LPHAs to improve health outcomes for Missouri infants, and many LPHAs are intentionally focused on improving health outcomes for Missouri mothers and infants by increasing breastfeeding initiation and duration rates. The LPHAs promoted breastfeeding initiation and continuation through encouraging increased community participation related to the support of breastfeeding in local breastfeeding and obesity prevention coalitions and ongoing educational efforts to increase awareness and knowledge of the benefits of breastfeeding.

 

Specific areas of LPHA activities worth highlighting include:

Breastfeeding Peer Counselor/Support/ International Board Certified Lactation Consultant (IBCLC)

• Monroe County Health Department provided breastfeeding counseling to mothers who were seen with their infant at newborn follow-up visits.
• Callaway County Health Department’s breastfeeding peer counselor continued to promote breastfeeding friendly worksites.  
• Laclede County Health Department supported breastfeeding and provided education and support through the WIC program, lactation consultation, a breastfeeding support group, and breastfeeding peer counseling.
• Morgan County Health Center has an IBCLC and breastfeeding peer counselor that hold a monthly Breastfeeding Q&A on Facebook Live, and the health department offers lactation consultation and education through WIC. The health department continued to educate local businesses on becoming Breastfeeding Friendly Worksites and presented awards to several businesses for their efforts.
• The Phelps/Maries County Health Department was acknowledged as a Breastfeeding Friendly WIC Clinic, supported one nurse to obtain IBCLC certification, and began the process to form a breastfeeding support group.
• Cass County Health Department provided Breastfeeding Basics classes and a breastfeeding encouragement group.
• Sullivan County Health Department’s breastfeeding peer counselor provided breastfeeding support and hosted a monthly MOMS (Moms Offering Moms Support) group on a wide variety of topics. 
• Andrew County Health Department provided lactation support with a qualified lactation specialist during business hours and an after-hours phone line until 10:00 pm every evening to provide consultation and support to breastfeeding mothers.

Breast Pump Lending Programs/Resources

• Knox and Scotland county health departments offered a breast pump lending program.
• Carroll County Health Department loaned breast pumps to WIC and non-WIC mothers and maintained a lending library of educational materials related to breastfeeding.
• Andrew County Health Department purchased a multi-user hospital grade breast pump and hosted a community lactation room.
• Ray County Health Department hosted a community breastfeeding room.

Baby Fair/Community Wide Baby Shower

• Callaway County Health Department held their third annual public Baby Fair.
• Miller and Morgan county health centers held Community Baby Shower events.
• Phelps-Maries County Health Department held their third annual Breastfeeding Walk with 157 participants.

 

Breastfeeding Friendly Sites

Efforts to promote worksite lactation support have continued through the Missouri Breastfeeding Friendly Worksite Program. A total of 87 new worksites were recognized during this reporting period, covering a total of 14,576 employees. This brought the total number of Breastfeeding Friendly Worksites to 539. DHSS continued to collaborate with the Missouri Breastfeeding Coalition on hospital, worksite and childcare initiatives. Bimonthly conference calls were held with attendance from DHSS, local health departments, local breastfeeding coalitions, hospital nurses and other breastfeeding professionals. DHSS also provided lactation rooms to support state employees who were pumping breast milk at work for their infants.

 

CHW, with funding from the CDC 1305 grant, contracted with 4 LPHAs to provide workplace lactation support to local employers and child care facilities. LPHAs in the counties of Washington, Callaway, Pike, and Scott were awarded $3,000 each in funds. Their staff approached businesses to explain the importance of lactation support and the benefits to the employer and employees. The goal of the contracts was to have worksites recognized as a Breastfeeding Friendly Worksite or Breastfeeding Friendly Child Care. LPHA staff provided education and acted as a resource to 33 employers and 8 child care providers.

 

CHW continued to recognize child care providers supporting breastfeeding families. A team of DHSS staff began development of an online training about breastfeeding support for child care providers, however the training was not approved by the end of the grant year. CHW recognized 20 child care providers as a Breastfeeding Friendly Child Care during FY18 with a total of 87 providers recognized since the start of the program. The Missouri Breastfeeding Coalition and local breastfeeding coalitions, newsletters and emails from the Child and Adult Care Food Program, Child Care Health Consultants, and Division of Regulation and Licensure promoted the DHSS recognition programs. Trainings provided by LPHAs also promoted these programs.

 

Mini grant funding ($500 each) was awarded to 44 businesses to create or improve lactation rooms, all of which were then designated a MO Breastfeeding Friendly Worksite. Other collaboration included partnering with the Missouri Council for Activity and Nutrition, Missouri Chamber of Commerce, and the Missouri Chapter of Society of Human Resource Managers to educate employers on the Affordable Care Act (ACA) provision for employers to provide workplace accommodations that enable breastfeeding employees to express breast milk.  

 

Health Equity

Collaboration also continued with the University of Missouri on research to determine barriers and needed interventions to improve racial and socio-economic disparities related to breastfeeding. The State Breastfeeding Coordinator attended the 2018 United States Breastfeeding Coalitions Convening, a conference aimed at assisting breastfeeding coalitions to grow their work. The subject of the 2018 conference was reducing disparities in breastfeeding and lactation work, applying a racial equity focus to projects aimed at breastfeeding promotion and support, and showcasing programs that are succeeding in this work. Two members of the Missouri Breastfeeding Coalition also attended the conference with the generous support of the United States Breastfeeding Committee. Attending this conference helped to increase understanding of both current disparities and ways to reduce these disparities with intentional program planning. Governor Michael Parson signed a proclamation declaring the importance of breastfeeding to Missouri and designating August 2018 as Missouri Breastfeeding Month. DHSS promoted Missouri Breastfeeding Month through a social media campaign and provided campaign messages to local agencies. The Missouri WIC program continued to provide the Breastfeeding Peer Counseling Program in 88 local agencies, with more than 130 Peer Counselors providing lactation support to WIC families. Peer Counselors are chosen from and are representative of the community in which they practice, which improves culturally appropriate lactation support. Statewide peer counseling training and meetings took place throughout the year, improving the skills of the peer counselors. Local WIC professional staff also continued to be trained on breastfeeding. Forty-six local WIC agencies received designation and additional funding as a Breastfeeding Friendly WIC Clinic, which is a Missouri designation that recognizes WIC local agencies that provide exemplary breastfeeding support. WIC is an important partner with MCH, because the two programs serve the same or similar participants. In many rural communities, WIC staff members are the only lactation support providers. Each WIC office also provides a lactation room that can be used by employees, participants, or other members of the community. WIC staff members, including peer counselors, are encouraged to participate in community breastfeeding coalitions and to partner with their local health care providers and hospitals to increase the continuity of breastfeeding support.

 

Additional Resources

Child Care Providers

In FFY2018, the Child Care Health Consultation (CCHC) Program updated three breastfeeding sessions available for use by LPHAS for continuing education credits for child care providers. These sessions included information specific to: the benefits of breastfeeding, proper care of breast milk, how to support a breastfeeding mother, and how to become a breastfeeding friendly child care facility. Seven hours of continuing education credits and 1.5 hours of specialized consultation were provided through LPHAs regarding breastfeeding questions, concerns, and policy development. By offering these services, more families and child care providers supported and promoted breastfeeding.

 

Home Visiting

The Bureau of Genetics and Healthy Childhood (GHC) evidence-based home visiting programs promoted breastfeeding prenatally and encouraged sustained breastfeeding postnatally. Among mothers who enrolled in home visiting prenatally, data from FY18 indicated that 36% of infants (51/140) who were breastfed continued to receive any amount of breast milk at 6 months of age. 

 

To support the home visitors as they support new mothers to breastfeed, the 4th quarter CQI newsletter, Quality Outlook, provided information by World Alliance for Breastfeeding promoting National Breastfeeding Month and World Breastfeeding Week (August 1-7, 2018) http://worldbreastfeedingweek.org/. Additionally, GHC Home visiting shared the following resources with all home visiting programs through the Missouri Home Visiting Gateway Weekly Update in 2018:

• 2/2/18 - A statewide 1-2-day training offered by the DHSS WIC and Nutrition Services Program on education to support breastfeeding, Using Loving Support to Grow and Glow
• 6/22/18 – NICHQ article - Build Resiliency in Teen Moms to Improve Breastfeeding and Save Babies
• 8/3/18 – NICHQ article - Bridge the Breastfeeding Gap
• 8/23/18 - NICHQ survey about experiences supporting mothers, with results to be used in a webinar
• 11/7/18- Webinar: Improving Our Approach: Better Conversations About Breastfeeding

 

Women enrolled in DHSS supported home visiting are encouraged by Home Visitors to enroll and participate in the supplemental nutrition program for WIC early in their pregnancy, if they are not already enrolled, and are encouraged to meet with WIC peer counselors to receive information and additional support regarding the benefits of breastfeeding. The DHSS Home Visiting program specifically collects breastfeeding data on the zero age form to determine whether the mother breastfed the new baby after delivery, even for a short period of time (includes pumped breast milk and donor milk) and on the 6 month age form if the child is breastfed any amount at 6 months of age (includes pumped breast milk and donor milk). The data collected on the 6 month age form is the reported data. For FY18, 36% of children were still receiving breastmilk at age 6 months. 

 

Text4Baby

The Text4Baby program provided pregnant women and new mothers five breastfeeding text messages during pregnancy and three during the first year after baby’s birth. Approximately 15,449 expectant and new mothers received messages pertaining to breastfeeding in FY18. Messages sent during pregnancy included:

• Week 9 – “If you qualify, WIC provides healthy foods, healthcare referrals, nutrition education, & breastfeeding support. Call 800-392-8209 & ask for WIC. If you need help getting food, call the National Hunger Hotline at 800-548-6479.
• Week 25 – “Are you thinking about breastfeeding? Breast milk is the best food for babies. To learn more about breastfeeding, visit text4b.org/028.”
• Week 26 – “Did you know that if you qualify, WIC can help you with breastfeeding? To find a local WIC office, call 800-392-8209 or visit text4b.org/060.”
• Week 33 – “Premature babies need extra help with breastfeeding. Even if your baby can’t breastfeed at first, she can still be fed your pumped milk.”
• Week 39 – “Help protect your baby from illnesses like the flu. Breastfeed right after baby’s born. Your milk can help fight disease & protect your baby. Have questions or concerns about breastfeeding? Call 800-994-9662 for help before pregnancy and once you start nursing baby.”

Messages sent postpartum included:

• Week 4 – “WIC supports Moms with healthy foods, referrals, nutrition education & breastfeeding support. Call 800-392-8209 or visit text4b.org/018. Want to check the safety of your medicines during breastfeeding or pumping? Ask your Dr. and search here: toxnet.nlm.nih.gov/newtoxnet/lactmed.htm.”
• Week 8 – “Back to work? You can pump milk at work to save for later. Breastfeeding helps you & your baby re-connect at the end of each work day. Medicine you take while breastfeeding may enter your milk. Ask Dr. /midwife (CNM/CM) or lactation consultant before taking any meds. Or call 866-626-6847.
• Week 24 – “Even if you get sick, you can keep breastfeeding your baby. Worried? Call your Dr., midwife (CNM/CM) or lactation consultant.”

 

SPM #2 Safe Sleep – Percent of infants placed to sleep on their backs.

 

According to the American Academy of Pediatrics (AAP), throughout the first year of life, sleeping babies have died accidentally from: suffocation; smothering; wedging; being trapped under someone else while sharing a bed; being placed to sleep on a sleep surface not intended for an infant; and from Sudden Infant Death Syndrome (SIDS). Infant deaths due to unsafe sleep practices continue to be a significant contributor to infant deaths in the US and Missouri. The AAP has issued evidence-based recommendations for a safe infant sleep environment. The recommendations are based on epidemiologic case-control studies of infants up to one year of age. Even though Safe Sleep was not selected as a top priority during our needs assessment process, Missouri selected the percent of infants placed to sleep on their backs as a State Performance Measure. According to Pregnancy Risk Assessment Monitoring System (PRAMS) data 2017, a 6.4% increase of Missouri mothers (81.9%) placed their infants on their backs to sleep from 2014. This is slightly higher than the U.S. rate of 79.8% (2017) and the Missouri rate exceeded the HP2020 goal of 75.9%. Although women under 20 years old (80.7%) were less likely to place their babies on their backs to sleep compared to their counterparts aged 20-24 years old (86.1%), and 35 years old and over (84.0%), they did so more frequently than their national counterparts (72.3%). Non-Hispanic Blacks (72.1%) also less frequently placed their babies on their back to sleep than non-Hispanic Whites (84.4%), however, this was a 10.2% increase from 2016. The frequency in Missouri was greater than their national counterparts for non-Hispanic Blacks (66.2%), but was lower for non-Hispanic Whites (85.2%). College graduates were the highest proportion of Missouri mothers who laid their infant on their back (90.2%). In Missouri, those with private insurance had a higher percentage of infants placed to sleep on their backs (86.5%) than those on Medicaid (77.1%). Continued education and outreach is needed to increase the awareness of the mothers and caregivers who are not practicing safe sleep.

 

Cribs

Safe Cribs for Missouri

The Safe Cribs for Missouri program provides portable cribs and safe sleep education to low-income families who have no other resources for obtaining a crib. The program utilizes both Title V and state funding from the Children’s Trust Fund. Implementation of the program includes partnering with multiple Local Public Health Agencies (LPHA). The overall goal of the program is to support families and reduce the risk of sleep-related infant deaths. Eligibility criteria include participation in two educational sessions using the evidence-based AAP guidelines on the topic of safe sleep. The initial one-on-one education session utilizes a 10-item checklist of safe sleep teaching points. The client and educator both initial each item on the checklist to document that the item was covered. If additional caregivers participate in the education, they also sign the checklist. Brochures on safe sleep, secondhand smoke, and car safety for pregnant women and infants are also utilized. Newborn t-shirts with “This Side Up While Sleeping” printed on the front are also provided. In addition, each participant views the 12-minute Never Shake & Safe Sleep for Your Baby video. The educator demonstrates how to set up the crib, and the client then practices the set-up. The follow-up education session is conducted in the home approximately 4-6 weeks after the crib is received, or when the infant is 4-6 weeks old. The educator observes the infant’s sleep environment, answers questions, addresses any barriers and provides additional education as needed. Pre and post-surveys are used to measure learning and implementation of safe sleep practices.

 

A total of 406 cribs were distributed and 667 one-on-one educational sessions were provided. Interesting to note is that mothers/families who are scheduled to participate in the program will often call prior to the session to indicate that they unexpectedly received a crib. This may have occurred through a baby shower or gift from a family member. This then allows the program to provide that crib to another family in need.

 

Safe Kids

The Bureau of Community Health and Wellness serves as the state lead for Safe Kids Worldwide to implement and facilitate accomplishment of common goals and objectives concerning childhood injury prevention. Nine Safe Kids coalitions cover 53 counties in Missouri. Through this network, more than 700 cribs were provided along with AAP safe sleep education and training. In addition, over 180 safe sleep events were held to help reduce the risk of injury and death of infants due to unsafe sleep environments. These events involved more than 4,000 participants such as expectant parents, parents, caregivers, relatives, grandparents and foster parents. These activities were accomplished with support from the MCH Block Grant and alternative sources of funds.

 

Local Public Health Agencies

Specific local agency efforts included the following:

• Camden, Clay, Daviess, Harrison, Henry, Jackson, Linn, Macon, Miller, Morgan Ozark, and TriCounty county health departments provided a Safe Crib Program with safe sleep education and distribution of portable cribs. Ozark County provides Pack-n-play cribs for free through the Safe Sleep for Babies program.

• Springfield-Greene County Health Department collaborated with Safe Kids Springfield, hospitals, and other organizations to sustain safe crib distribution and education programs for providers and families.
• Monroe County provided a safe cribs program and conducted home visits for newborns as needed.

 

Child Care Providers

Section for Child Care Regulation (SCCR) provides technical assistance to potential child care providers who seek to become licensed. In Missouri, licensed child care providers who care for children younger than twelve months of age are required to have a safe sleep policy in accordance with the American Academy of Pediatrics. As the policies are developed, SCCR staff provide technical assistance and resources to assist child care providers in developing and implementing their policy. After they receive a license to care for children under the age of 12 months, regular inspections are conducted to ensure that compliance is met.

 

During FFY18 SCCR cited 1,807 violations relating to infant safe sleep policies and practices during initial licensing inspections and ongoing compliance inspections throughout the state. When violations are cited, SCCR staff provide technical assistance to the provider to educate them on the rules so they can achieve and maintain compliance with the rules regarding infant safe sleep. SCCR cited 1,259 fewer violations in FFY18 than FFY17. This information shows that while we have made a significant step in the right direction, there is still more work to be done to ensure that every infant in Missouri is cared for in a safe environment with properly trained caregivers.

 

Infant Safe Sleep training that is in accordance with AAP guidelines is delivered statewide and is required of all child care providers who work in facilities licensed to care for infants. In FFY18 12,160 child care providers successfully completed the online/on-demand training offered by SCCR. Approved infant safe sleep training must be completed when an individual begins employment and must be repeated every three years.

 

In FFY2018, the Child Care Health Consultation (CCHC) Program updated four continuing education trainings available to the LPHAs for use in providing education to child care providers. The CCHC Program offered 45 hours of continuing education trainings for child care providers, 5.5 hours of specialized consultation, and 1 technical consultation regarding safe sleep, including policy development. The CCHC Program’s goal through offering these services was to support and promote safe sleep practices in childcare, decrease the number of children exposed to unsafe sleep practices, and increase policy development in the child care setting. 

 

Outreach

Text4baby

There are five customized texts related to safe sleep available from Text4baby, which sends free text messages with health information and helpful tips during pregnancy and until a baby turns one. Participants enrolled in the program received the following messages:

• Week 2 of infancy message "In the crib, use only a firm crib mattress & fitted sheet. Do not use crib bumpers because baby can suffocate. Info at healthychildren.org/safesleep. Blankets can cause baby to suffocate. Have baby sleep in infant pajamas with feet or sleep sacks to keep baby safe & warm: text4b.org/106."
• Week 3 of infancy message "Babies should always sleep on their back in a crib. Even for naps. Keep baby in the room with you but not in your bed. No stuffed animals, blankets or pillows in the crib. Soft things can go back in baby's bed at age 1, but right now they could cause baby to suffocate."
• Week 10 of infancy message "Share with anyone caring for baby the safest way for baby to sleep is on their back, in a crib, with no stuffed animals, blankets or pillows. Smoke raises risk of sickness or death from SIDS. Protect baby & don't let anyone smoke near baby at home or in the car. Info: text4b.org/010."
• Week 16 of infancy message "At this age, many moms have questions about baby's food and sleep. Visit text4b.org/004 for info on feeding. Checking on baby at night? Keep baby in a crib near your bed to help you see he's safe. Safe sleep info: 800-505-2742 or visit text4b.org/106."
• Week 20 of infancy message "The safest way for baby to sleep is alone in a crib on her back. Never put baby to sleep on sofa or pillow. Tell this to everyone who cares for baby."

 

Two messages are also sent prior to the birth of the baby during the 32nd and 38th weeks of pregnancy. These messages reinforce the importance of having a crib, placing baby on their back to sleep, and nothing in the crib while baby sleeps. In FY18 an average of 1,287 participants were enrolled in the Text4baby program each month.

 

Media

In collaboration with the State Safe Sleep Coalition, consistent safe sleep messages were developed to provide to all partners working with families with young children. This included 33 safe sleep social media messages, E-newsletter articles, and several presentations/webinars. 

 

Birth Certificate project

The majority of birth certificates issued for children less than one year of age come directly from the LPHAs. The MCH Services Program partnered with 36 LPHAs to provide the Safe to Sleep brochure and information on local safe sleep resources, including sources for free cribs, when the LPHAs issue or mail birth certificates for children less than one year of age.

 

Collaborative Initiatives

The MCH Services Program Manager served on the Generate Health/FLOURISH St. Louis Infant Health Action Team, which focused its efforts on the promotion of safe sleep practices. The MCH Services Program Manager and District Nurse Consultants also served on regional coalitions promoting safe sleep practices, including the Maternal Child Health Coalition of Kansas City, Kansas City Metro Safe Sleep Initiative, Kansas City Health Commission on Women, Infants and Children's Health workgroup, Bootheel Healthy Start, Bootheel Babies & Families, Generate Health St. Louis Regional Health Initiative, St. Louis Prenatal Care and Infant Wellness Collaborative, and Safe Kids state and regional coalitions. As a result of these collaborations, the MCH Services Program staff build relationships with regional and state partners, resources, networks, and service providers and gain valuable information regarding specific topics, resources, and initiatives. They are then able to share the information gained with the LPHAs and other Department of Health and Senior Services (DHSS) programs, make connections between the LPHAs and the regional and state partners, resources, networks, and service providers, and share DHSS initiatives and priorities with the regional and state coalitions/teams.

 

Specific local agency efforts included:

• Scott, Mississippi, Dunklin, Stoddard, and New Madrid county health departments provided safe sleep education to their communities and were involved with collaborative efforts to promote safe sleep through Bootheel Babies and Families.
• Platte County provided SIDS and safe sleep practice education in all community CPR/First Aid trainings.

 

Policies & Practices

Hospitals

A survey was created to gather information about the safe sleep policies and practices of Missouri’s 64 birthing and children’s hospitals. The survey was sent to the hospitals in October 2017, and the survey results were shared with Infant Loss Resources, Inc. (ILR). The Bureau of Genetics and Healthy Childhood is working with ILR and Generate Health St. Louis to provide safe sleep education and technical assistance to hospitals.  The goal is to increase the number of Missouri hospitals certified by the Cribs for Kids Safe Sleep Hospital Certification Program.  

 

Local Public Health Agencies

Through the MCH Services Program contracts, 104 LPHAs reported active promotion of safe sleep practices, and 57 LPHAs reported working with community partners to promote safe sleep practices. LPHA activities to promote safe sleep included promotion of safe sleep policies and practices, safe sleep education, referral to pregnancy and parenting resources, and provision of free portable cribs with accompanying safe sleep education and follow-up in-home assessment of safe sleep practices.

 

Home Visiting

GHC funded home visiting services offered in 26 counties and served 940 families through the Missouri Building Blocks (BB), Healthy Families Missouri Home Visiting (HFMoHV) and the Maternal, Infant and Early Childhood Home Visiting (MIECHV) programs. These programs implemented the following evidence-based models:

• Nurse Family Partnership model;

• Healthy Families America model;

• Parents as Teachers model; and

• Early Head Start Home Based Option model. 

All GHC Home Visiting supported home visitors actively promote and provide resources on the ABCs (Alone, on their Back, in a Crib) of Safe Sleep. Home visitors also promote safe sleep in obtaining portable cribs for families who do not have and cannot afford a crib for their infant through the Safe Cribs for Missouri program or other local resources. Safe sleep practices are tracked on the DHSS Child Age Forms at age zero, and follow-up continues on the 0, 2, 3, 6, 9, and age 12 month forms. Data from FY18 indicated that 80% of infants (175/218) less than age 12 months enrolled in GHC funded home visiting programs were always placed to sleep on their backs, without bed-sharing or soft bedding. 

 

Additional supports provided to all home visiting local implementing agencies included:

• October 2017 - SIDS Awareness Month was highlighted to all local implementing agencies through the 1st quarter CQI Newsletter, Quality Outlook, by providing safe sleep tips and a link to Children’s Trust Fund to see the Never Shake & Safe Sleep for your Baby DVD https://ctf4kids.org/never-shake-safe-sleep-for-your-baby-dvd/. Safe to Sleep® Campaign website also included a helpful FAQ page and safe sleep videos for grandparents.
• March 2018, Annual Home Visiting Summit - samples of newly released materials promoting safe sleep practices and order forms.

 

Through the Missouri Home Visiting Gateway Weekly Update the following resources were shared:

• 10/27/17 - Children’s Trust Fund offers free resources on safe sleep, shaken baby syndrome, and many other resources located at this link: http://ctf4kids.org/order-form/.
• 11/10/17 - SAFE SLEEP: The links provided below are about safe sleep that can be shared with families:
  • An Ohio Dept. of Health physician talks about safe sleep at http://www.odh.ohio.gov/safesleep/. She promotes the ABCs of safe sleep - Alone, Back, Crib.
  • Video featuring three grandmothers talking about the ABCs of safe sleep: From Healthy Babies Baltimore website at https://www.youtube.com/watch?v=iVMn1B87UGA. No exceptions to baby sleeping alone, on his or her back, in an empty crib.
  • AAP rationale for room sharing can be found at: https://www.aap.org/en-us/about-the-aap/Committees-Councils-Sections/Child-Death-Review/Pages/Safe-Sleep.aspx1/19/18 - Safe Sleep Issue of CDC's Vital Signs.

• 3/2/18 - Infant Safe Sleep article from National Institute for Children’s Health Quality (NICHQ).
• 3/23/18 - Ignoring Safe Sleep Progress Risks Increasing Safe Sleep Deaths – NICHQ article.
• 3/30/18 - NICHQ webinar - Straight Talk About Infant Safe Sleep: Strategies for Helping Families Adopt Safe Sleep Habits.
• 4/20/18 - NICHQ article - Bedsharing, Breastfeeding and Babies Dying.
• 5/4/18 - NICHQ webinar - Improving Infant Safe Sleep Conversations: Strategies for Helping Families Adopt Safe Sleep Habits.
• 7/13/18 – NICHQ article - New Safe Sleep Teaching Tool.
• 8/10/18 – NICHQ article - Support Safe Sleep for All.
• 8/31/18 – NICHQ article - Creating a Safe Sleep City.
• 9/14/18 – NICHQ article - Improve Education, Change Outcomes – includes NICHQ Quiz “How Safe Sleep Savvy Are You?”