The Kentucky (KY) Maternal and Child Health (MCH) Title V Program is committed to assuring the health and well-being of Kentucky’s mothers and their children. As defined in section 501(a)(1) of the Title V legislation, the purpose of the MCH Services Block Grant Program is to enable each state to:

• Provide and assure mothers and children have access to quality MCH services
• Reduce infant mortality and the incidence of preventable diseases and handicapping conditions among children
• Provide rehabilitation services for blind and disabled individuals under the age of 16 receiving benefits under Title XVI, to the extent medical assistance for such services are not provided under Title XIX
• Provide and promote family-centered, community-based, coordinated care for children with special health care needs (CSHCN) and facilitate the development of community-based systems of services for such children and their families

The KY Title V Program develops and supports the public health infrastructure and enabling services to meet these objectives. Title V Programs include the MCH and the CSHCN program. The KY Department for Public Health, as the MCH Title V Agency, contracts with the Office for Children with Special Health Care Needs (OCSHCN) to provide services for children with special health care needs. In addition to meeting the legislative intent of the funding, the Title V programmatic priorities are revised every 5 years based on a federally required comprehensive needs assessment for all 5 population domains. National Performance Measures (NPMs) are selected based upon the identified needs.

KY outcome measures are notably poorer in the eastern part of the state where residents have many social determinants such as problems accessing primary and specialty care, increased rates of substance use disorders, lack of providers, and transportation in areas where geographically large traveling distances for care and cultural difference exist.

Public policies have correlated with increasing numbers of those insured and a successful transition to the federal exchange (HealthCare.gov). The KY HEALTH 1115 Medicaid Waiver was not implemented secondary to federal rulings. Pregnant women and child benefits have not changed.

Women/Maternal Health Domain

The priority needs for KY is reduction of early elective deliveries (EEDs) and maternal morbidity/mortality. KY has selected the NPM #2: Percent of cesarean deliveries among low-risk first births. For 2020, KY added a SPM: Reduce by 10% the number of maternal deaths of KY residents associated with substance use disorder.

Reduction of EEDs included collaboration with a variety of stakeholders to strengthen or promote hard-stop policies at KY hospitals. Federally available data has shown a decrease of 3.2% since the 2009 inception of this plan.

The Health Access Nurturing Development Services (HANDS) home visitation program has proven to improve maternal and child outcomes of premature births, low birth weights, child abuse/neglect, pregnancy-induced hypertension, maternal complications and improved adequacy of prenatal care. The Federal Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program has improved performance measures in screenings, well child visits, depression referrals and other benchmarks.

Substance abuse is influencing all MCH populations in KY. The consequences of this epidemic in women include pregnancy complications, increased risks of relapse, and pregnancy associated deaths from overdose.

With an alarming increase in maternal deaths, half of which have substance use as a risk factor or cause, KY restructured the maternal mortality review process and established a 28-member multidisciplinary review team. Expansion of review scope included all causes of maternal death within one year of the end of pregnancy. Plans for 2020 include establishment of a Perinatal Quality Collaborative and application for Alliance for Innovation on Maternal Health status to utilize maternal safety bundles, potentially starting with “Obstetric Care for Women with Opioid Use Disorder”.

Smoking during pregnancy in KY is gradually decreasing over time, from 24.1% in 2009 to 16.9% in 2018; however, this is more than double the national rate of 7.2%. Activities promote smoking cessation among pregnant women and smoke-free policies. Continued emphasis on evidence-informed strategies has diminished impact, in recent years, in regards to the percent of women who smoke during pregnancy and the number of children who live in a household where someone smokes.

Perinatal/Infant Health Domain

Infant mortality is the single leading indicator of the overall health and well-being of a population. The 2017 infant mortality rate is 6.7 per 1,000 live births, an increase from  and rose from 6.3/1,000 live births in 2016. In the 2015 needs assessment, stakeholders identified neonatal abstinence syndrome, prematurity, and unsafe sleep as the priority issues. The chosen state priority need continues to be infant mortality. Evidence-based strategies recommended nationally for addressing infant mortality are regionalized perinatal care, safe sleep initiatives, and breastfeeding. KY targets two NPMs for this domain, NPM #4: A) Percent of infants who are ever breastfed, B) Percent of infants breastfed exclusively through 6 months and NPM #5: A) Percent of infants placed to sleep on their backs.

Breastfeeding outcomes improved. Mothers initiating breastfeeding prior to hospital discharge increased from 52.7% to 70.9% (2005-2017). Duration rates for 6 months are much lower at 21.1%. Gap filling surveys are underway as contracted with Coffective®, through the Women, Infant and Children (WIC) program. Ninety-five percent of birthing hospitals have implemented kangaroo care.

MCH developed an educational safe sleep campaign, which included social media. Messaging included the ABCDs of safe sleep, (alone, back to sleep, crib use, danger – be aware, not impaired/distracted). In 2016, the Sudden Unexpected Infant Death (SUID) registry identified 103 SUID cases moving SUID to the second leading cause of death for KY’s infants with 95% having at least one unsafe sleep risk factor. While rates appear to be decreasing, messaging continues. To address this issue, additional information on infant sleep positioning and unsafe sleep will continue to be collected in the Pregnancy Risk Assessment Monitoring System (PRAMS), a CDC funded grant that conducts surveillance of women who have recently had a live birth. The percentage of surveys returned for a recently awarded PRAMS state was higher than averages reported across other states.

Substance use during pregnancy has additional consequences of neonatal abstinence syndrome (NAS), infant deaths from unsafe sleep practices (bed sharing, and impaired caretaker) and deaths from abusive head trauma. KY focused on SPM #1: Reduce by 5% the rate of NAS among KY resident live births. Rates of NAS have increased more than 20-fold in the last decade in KY. NAS surveillance continues and MCH has completed three NAS annual reports. MCH continues to collaborate with the Department for Behavioral Health, Developmental and Intellectual Disabilities (DBHDID); the OCSHC; and the Department for Community Based Services (DCBS) to develop and implement a Plan of Safe Care for infants discharged from the hospital who are substance exposed or diagnosed with NAS. One example, of an innovative and integrated program is the Healing, Empowering, and Actively Recovering Together (HEART) model describe in this report. To address ongoing needs about adequacy of care for infants with NAS, MCH is working with local coalitions, local health departments (LHD), and community and state partners to develop a sustainable plan of safe care and to maintain mental and physical health for mothers and their children.

Birth defects and congenital disorders are one of the leading causes of infant mortality. The MCH program continues to provide metabolic screening referral and linkage to specialty providers for 57 disorders as recommended per the Recommended Uniform Screening Panel (RUSP). X-linked adrenoleukodystrophy (X-ALD), another devastating disorder, was added to this panel in 2018. Many of the metabolic disorders can be effectively treated with metabolic foods and formulas (reimbursable by Medicaid). As a payor of last resort, KY operates a Metabolic Foods and Formula program at no cost for KY resident’s requiring metabolic foods and formula.

Child Health Domain

Injury is the leading cause of death among KY children over the age of one, and a priority need identified in 2015. Child maltreatment is the highest priority with child passenger safety and teen driving concerns also raised by the participants. For this domain, KY selected NPM #7.1: Rate of hospitalization for non-fatal injury per 100,000 children, ages 0 through 9 and adolescents ages 10-19. Hospitalizations for child maltreatment are part of the reported rate for this measure. Education for identification and reduction of pediatric abusive head trauma (PAHT) is ongoing. In 2018, an innovative curriculum was developed to educate high school students on PAHT and safe sleep.

KY continues to work on projects with the KY Safety Prevention and Alignment Network (KSPAN), the Division of Pediatric Forensic Medicine at the University of Louisville (UL), Prevent Child Abuse Kentucky, the KY Chapter of the American Academy of Pediatrics (AAP), and local health departments (LHDs).

The Child Fatality Review and Prevention program (CFR) revitalization and restructuring continued during 2018 with the number of review teams locally expanded from six teams in 2017 to 104 as of 2019. These teams conduce comprehensive, quality reviews and develop interventions for prevention programs at the local level. Mentoring, training and technical support are provided to the state coroners, and local team members. The MCH director and CFR coordinator are members of the Child Fatality and Near Fatality External Review Panel (conducted under the auspices of the Department of Justice), allowing for referral of review by the External Panel for cases in which suspected abuse or neglect has led to a child’s death.

Training on the 5-2-1-0 program (5 fruits and vegetables per day, no more than 2 hours of screen time per day, 1hour of physical activity per day, and no (0) sugary beverages) continues as part of early childhood education opportunities, and coordinated school health efforts. This program is a family friendly tool for improving nutrition and physical activity. MCH provides technical support tor development and implementation of model policies for childcare centers around nutrition and physical activity.

A statewide 100% Tobacco Free School (TFS) bill became law in 2019. This new law will prohibit the use of tobacco products on school property beginning in the 2020-21 school year. A smoke free environment is now enjoyed by 34.7% of Kentuckians secondary to community initiatives, and local ordinances.

To increase the number of preventive dental visits and measure ongoing progress, KY selected NPM #13.2: Percent of children, ages 1 through 17, who had a preventive dental visit in the past year. In 2018, 77.6% of Kentucky children had a preventive dental visit in the past year. The KY Oral Health Program (KOHP) trains public health nurses to provide fluoride varnish treatments to children through the fifth grade. Public health dental hygiene programs housed in LHDs serve 34 KY counties and perform screenings, apply sealants and link children to an oral health home.

Adolescent Health Domain

The priority need chosen from the needs assessment for this domain is obesity/overweight. Per state obesity information, obesity among high school students has increased from 16.5% in 2011 to 20.2% in 2017. For this domain, KY chose NPM #8.1: Percent of children, ages 6 through 11, who are physically active at least 60 minutes per day and NPM #8.2: Percent of adolescents, ages 12 through 17, who are physically active at least 60 minutes per day.

Addressing obesity requires a multi-level approach, and necessitates implementation of education and modeling positive behaviors across the lifespan. MCH works intensively on obesity prevention in early education centers/child care centers, and school settings through the Coordinated School Health (CSH) Program.

Suicide was identified in 2017 as an emerging need for this population the number of KY child/teen deaths from suicide continue to rise with some as young as age 10. With 75% of the deaths for children, age 15-17 occurring by suicide, active intervention with school districts and communities was ongoing with trainings provided to teachers and some district electing to contract with outside mental health supports.

Tobacco efforts have also focused on adolescents. By March 2018, the number of school districts with 100% TFS policies has grown to 40% of school districts or 70 in the state, covering 721 individual schools and protecting 56% of students in the state.

Children and Youth with Special Health Care Needs (CYSHCN) Domain

KY’s CYSHCN agency (OCSHCN) is addressing the challenges associated with reaching a larger percentage of its CYSHCN population. According to the 2016 National Survey of Children’s Health, KY’s rate of CYSHCN is the highest in the country. OCSHCN believes in working with partners, including families, on new initiatives to develop and promote a more robust system of care. It is the OCSHCN’s belief that such collaborations will ensure more of KY’s CYSHCN will have access to the care they need. OCSHCN believes that further developing the expertise to properly collect, measure, and evaluate data will ensure meaningful progress is made. To that end, OCSHCN continues to make progress on its Data Action Plan, which is designed to address the needs for proper measurement and evaluations.

CYSHCN priorities, identified through the Needs Assessment process, are linked to State Performance Measures (access to care, improved data capacity, and adequate insurance coverage). OCSHCN has leveraged available technical assistance and collaborated with other agencies to plan, strengthen, and better integrate the overall system of care. Nationally available data, including data from the National Survey of Children’s Health (NSCH), is examined along with internal data to determine needs in KY’s CYSHCN population. While NSCH provides a wealth of information, OCSHCN conducts in-state data collection for the purposes of obtaining more KY specific data. The KY specific data assist in tailoring program evaluation, needs assessment, and program planning and development towards KY’s CYSHCN population.

Cross-Cutting/Systems Building Domain

The state recognizes substance use disorder, tobacco use/exposure, oral health, and insurance adequacy affects multiple domains. Activities in these crosscutting domains are embedded in the five aforementioned selected national domains.