Perinatal/Infant Health, Application Year FY 2022

The 2020 needs assessment process resulted in a strong and leading identification of infant mortality and birth outcomes as a priority health need. The number of Ohio infants who died before their first birthdays dropped to 929 in 2019 from 938 in 2018, marking a third straight year of decline (2019 is Ohio’s most recent infant mortality data released in December 2020). Nine more families were able to celebrate their babies’ first birthdays than in the previous year. Ohio’s infant mortality rate remains at 6.9 per 1,000 live births, consistent with the 2018 rate. Unfortunately, the racial disparities gap continues to widen. Black infants are 2.8 times more likely to die than white infants. There were 356 Black infant deaths in 2019, an increase of 17 from 2018; while we recorded the lowest number of white infant deaths (518) during the past 10 years. The needs assessment process identified poverty, housing, transportation, employment, income, and family and social support as leading social determinants of health needs associated with poor birth outcomes. The Action Group continues to prioritize care coordination and access to health care and social services as opportunities within existing health care and social service systems to improve birth outcomes. Opportunities identified for changes at the systems level included: improve collaboration and coordination among community programs and among state agencies; identify women and families most in need; and improve data sharing and outcome tracking.

 

Emerging Issues

Calendar year 2020 and the first half of 2021 have highlighted a myriad of challenges for Ohio’s mothers, fathers, infants, children, and families related to the global COVID-19 pandemic. These challenges further validate the importance and urgency of systems-level change. The COVID-19 pandemic exposed and amplified the health disparities and inequities facing Ohioans of color. At the same time, Ohio, and the rest of the nation are grappling with instances of unjust use of violence and the lives of people of color taken too soon. This led to widespread recognition that racism must be addressed in our state and communities. The events of recent months present a unique opportunity to shine the spotlight on the challenges faced by Ohioans of color and propel policy action toward change. Ohio can combat this crisis by taking a comprehensive and systemic approach.

 

Priority: Support healthy pregnancies and improve birth and infant outcomes

 

Measures

• NOM: Infant mortality rate per 1,000 live births
• NOM 9.2: Neonatal mortality rate per 1,000 live births
• SOM: Black infant mortality rate per 1,000 live births

• NPM 4: Percent of infants ever breastfed, and percent breastfed exclusively through 6 months.
• NPM 5: Percent of infants placed to sleep on their back, alone on separate approved sleep surface, without soft objects or loose bedding

• ESM: Percent of birthing hospitals receiving recognition from Ohio First Steps for Healthy Babies
• ESM: Number of families provided with a crib and safe sleep education through Cribs for Kids

 

Addressing the disparity in birth and infant outcomes will be measured through the SOM. Both NPMs improve infant outcomes and the ESMs will measure progress in improving both.

 

Objective: By 2025, increase the percent of infants who are ever breastfed to 90.8% and percent of infants who are breastfeed exclusively through 6 months to 31.2%.

 

Strategies:

1. Continue implementation and expand promotion of the statewide 24/7 breastfeeding hotline and virtual lactation consultants.
2. Continue to build upon breastfeeding initiatives in hospitals, worksites, and childcare facilities.
3. Improve breastfeeding continuity of care with statewide partners.

 

In March 2021, Professional Data Analysts, Inc. (PDA) created two reports, Breastfeeding Experiences of Black or African American Women in Ohio and Breastfeeding Experiences of Appalachian Women in Ohio, based on quantitative and qualitative data from focus groups. PDA also identified future collaborations, topics for discussion, and strategies to implement to improve breastfeeding initiation and duration, particularly focusing on African American and Appalachian women. ODH will engage partners to identify new strategies and activities as well as improve and enhance current activities.

 

ODH extended the contract with Appalachian Breastfeeding Network to continue 24/7 breastfeeding support throughout FY 22. Data will continue to be collected and reported monthly.

 

The Ohio First Steps for Healthy Babies hospital initiative will include an optional Father/Partner engagement award. Hospitals that apply will be recognized for their inclusion of fathers and partners as they implement the Ten Steps to Successful Breastfeeding. First Steps will continue with quarterly applications and recognition. Continuing education webinars will also be planned.

 

ODH will enter Year 4 of the CDC State Physical Activity and Nutrition (SPAN) Cooperative Agreement. Activities planned include developing and implementing a Breastfeeding Worksite Award. The 17 counties receiving funding to educate local businesses and assist with development of lactation policies and accommodations in FY 21 will continue their work and expand to new worksites.

 

The ECE Breastfeeding Friendly Child Care Award remains available for ECE providers who completed a required training and application depicting their implementation of breastfeeding-friendly practices. Outreach to all licensed childcare centers and family providers will continue. Recognized providers will also be eligible for the up-and-coming Breastfeeding Worksite Award.

 

ODH will continue to improve breastfeeding continuity of care by reaching out to new statewide partners as well as enhancing collaboration with current partners. The Coffective initiative, with the WIC program, will continue to link local WIC projects with hospitals and community organizations.

 

Objective: By 2025, increase the percent of infants placed to sleep on their back to 93%, alone on separate approved sleep surface to 53.1%, and without soft objects or loose bedding to 76.5%.

 

Strategies:

1. Continue implementation of the Cribs for Kids Program to provide safe sleep education and safety-approved cribs to families; including improved data collection by race.
2. Continue implementation of the annual safe sleep campaign to provide consistent messaging on safe sleep practices to families.
3. Partner with local infant mortality collaboratives to tailor statewide safe sleep messaging to better reflect experiences of communities of color.

 

Ohio is participating in the HRSA-funded CityMatCH Alignment for Action Cohort (AAC) with a local government partner on safe sleep messaging for Black women and families. Information was collected through focus groups for Black women about their sources of safe sleep information, sleeping behaviors, and how mothers think and communicate about safe sleep. This information will serve as the foundation of activity design between the local partner and State Title V during FY 22.

 

Objective: By 2022, develop plan for enhancing coordination of pregnancy and post-partum supports and messaging.

 

Strategies:

1. Enhance partnerships with state agencies, local organizations, and stakeholders to improve coordination of pregnancy and post-partum services.
2. Enhance partnerships with state agencies to improve coordination of state funding for local MCH activities.
3. Explore coordination of safe sleep, breastfeeding, and smoking cessation messaging.

 

The Ohio Council to Advance Maternal Health (OH-CAMH) is coordinating with 79 member organizations to develop a statewide strategic plan. Partner organizations include local organizations, state organizations, national organizations, Title V staff, and patients/families. The Council will work to refine and prioritize strategies and identify or develop evaluation metrics for each strategy through the development of a strategic plan. Multidisciplinary collaboration, racial/ethnic diversity, and inclusion of those with lived experience in decision making processes are some of the core values and expectations that OH-CAMH indicated were important in the OH-CAMH Charter. Assessing the diversity of the workgroup membership list will occur before starting the strategic planning process.

 

A cohort of seven Ohio communities represented by seven of the nine Ohio Equity Institute counties (more information in the next objective) will join for technical assistance and training around the Queens Village model developed by Cradle Cincinnati. Queens Village is a supportive community of powerful Black women who come together to relax, repower, and take care of themselves and each other. Queens Village is an initiative of Cradle Cincinnati, a collective impact organization that fights high rates of infant mortality that disproportionately affect Black women in Cincinnati and beyond. They center Black women’s voices on changing not just racial disparities in birth outcomes but also the conditions that drive inequity in maternal and infant health. The cohort will seek to train community-based organizations to provide a safe space for Black mothers to support and be supported by their peers, to connect, to relieve stress, to process trauma, and to build a better world together for themselves and their children.

 

The Ohio Department of Health will leverage Governor Mike DeWine’s Cross-Agency Leadership Team as a planning resource to better coordinate state funding for MCH activities. As well as continue strategic planning for infant mortality investments with partners at the Ohio Department of Medicaid through managed care plan community dollars prioritizing the needs of Black pregnant women.

 

The Title V team will conduct an environmental scan of other states’ safe sleep, breastfeeding, and smoking cessation messaging. We will explore the use of existing infant mortality collaboratives throughout the state to develop a collective, statewide strategy for messaging.

 

Objective: By 2025, reduce Black infant mortality rate to 6.0 per 1,000 live births.

 

Strategies:

1. Increase access to clinical and social services through outreach and identification of Black pregnant women.
2. Increase use of social support services among high-risk Black pregnant women to address social determinants of health.
3. Support local community-driven policy and practice change addressing social determinants of health that impact poor birth outcomes.
4. Improve access to basic needs resources for pregnant and postpartum women (e.g., Cribs for Kids).
5. Data to examine variations in cause of infant death by race and ethnicity to inform data to action.

 

Last year, Healthy People 2030 developed new goals for our country’s infant mortality rates. While Ohio has long achieved the Healthy People goal for white infants, we have not reached the same goal for Black infants. Ohio Governor Mike DeWine has tasked the Eliminating Racial Disparities in Infant Mortality Task Force with developing recommendations to achieve this goal for all infants by 2030. The Task Force’s recommendation must acknowledge the events that unfolded in 2020 and also create a bold roadmap for change in actionable, practical, but ambitious recommendations that accelerate the rate of change we need to overcome decades of disparities in birth outcomes. Recommendations will be founded on the experiences and recommendations of Ohio’s Black families.

 

The Ohio Equity Institute (OEI) will serve as an implementation mechanism for recommendations designed by the Eliminating Racial Disparities in Infant Mortality Task Force. The Ohio Equity Institute (OEI): Working to Achieve Equity in Birth Outcomes is a grant-funded collaboration between the Ohio Department of Health and local partners created in 2012 to address the racial inequities in birth outcomes. Each OEI community will also receive technical assistance through a cohort-model to develop and implement Black women-led community engagement. This equity and community strategy will center Black women’s voices on changing not just racial disparities in birth outcomes but also the conditions that drive inequity in maternal and infant health.

 

Four subgrantees supported through the Disparities in Maternal Health Community Grant Program will design innovative and culturally humble initiatives to address racial/ethnic and/or geographic health disparities related to maternal health in Ohio. Projects will uplift the voices of the communities most likely to experience disparities in maternal mortality/morbidity and support existing and/or new interventions in these communities; as well as fund solutions identified by communities to address unmet needs through a disparity-focused, equity lens.

 

The Action Group will define “basic needs resources” and the scope of this strategy as well as expand the prescription produce program for pregnant and postpartum women in five priority counties.

 

Perinatal Periods of Risk (PPOR) Phases 1 and 2 will be completed. Results of this analysis will inform the design of activities aligned with workplan strategies. A brief focused on racial disparities in infant mortality and maternal experiences before, during, and after pregnancy is under development and will be disseminated to key partners to inform strategy development.

 

Contributing program scorecards for infant mortality will be created in Clear Impact. ODH has adopted the Results Based Accountability (RBA) framework for performance management and invested in the Clear Impact platform as the data collection system to manage performance objectives and track progress over time. ODH has started implementation of RBA and use of Clear Impact with the State Health Improvement Plan (SHIP) indicators, which include infant mortality. Each program in the Bureau of Maternal Child and Family Health (BMCFH) that contributes to addressing infant mortality is creating a program scorecard to track key performance measures, share data with program partners and the public, and have conversations that drive change and improve outcomes. To ensure the scorecards are useful as we strive to eliminate the Black infant mortality disparity, programs are including disaggregated measures.

 

Objective: By 2022, assess need for and explore opportunities to improve infant outcomes through enhancing screenings and education provided during well-baby visit.

 

Strategies:

1. Assess need for and explore opportunities to educate/train providers on enhanced screenings and education during well-baby visit (Bright Futures, including lead, hearing, vision, oral health, immunizations, safe sleep.)
2. Explore cross-program support opportunities through partnership with ODH Immunizations program.

 

The Title V team will continue to engage partners and collaborate on identifying gaps in screening and education. As we continue to plan, we are revisiting the intended goal of this objective. Our Epidemiologist is currently working on PPOR Phase 2 data. This data will allow us to investigate the opportunity gaps to discover which risk and preventive factors are likely to have the largest effect on improving our state’s infant mortality rate and also provide additional information to better direct intervention prevention planning. As we gain more insight from this process, we plan to align and refine our strategies and activities.

 

Other Efforts Supported by Title V MCH

The majority of MCH programs serving the Infant population are represented within the above application narrative. Several program summaries are included below to highlight additional relevant programs and a complete list of programs serving the Infant population is available in the Program Map (section V. Supporting Documents).

 

Ohio Connection for Children with Special Needs – Birth Defects Surveillance Program

Ohio Connections for Children with Special Needs (OCCSN) is Ohio’s statewide population-based birth defects surveillance program. The Ohio Revised Code 3705.30 authorizes the state director of health to require hospitals, physicians, and freestanding birthing centers to report children from birth to 5 years of age with certain reportable birth defects to the Ohio Department of Health (ODH). Collection of birth defect data is important for public health action, including facilitating referrals to services such as early intervention and targeting prevention strategies. The Birth Defects program’s mission is to improve the lives of children through birth defects surveillance, referral to services, research, and prevention. The program uses cross-agency collaboration to elevate maternal and infant health and to better serve Ohio families.

 

OCCSN began surveillance of Neonatal Abstinence Syndrome (NAS) in January 2020. Suspected cases are reported through the OCCSN data system from hospitals and provides passive surveillance of cases reported. Comprehensive genetic centers conduct case review for suspected birth defect cases seen at their facilities. For cases with confirmed NAS, referrals are sent to Part C Early Intervention for services and are automatically eligible for enrollment. OCCSN is also involved in the Pathways to Community Plans of Safe Care initiative that is focused on cross-agency collaboration to elevate maternal and infant health and to better serve Ohio families through building infrastructure to provide plans of safe care for infants who have been exposed to NAS.

 

Comprehensive Genetics Services Program

The Genetics Services Program funds a network of eight genetic centers that provide comprehensive care and services to people affected with, or at risk for genetic disorders. The purpose of the program is to ensure availability of quality, comprehensive genetic services in Ohio. Genetic services include, but are not limited to genetic counseling, education, diagnosis, and treatment for genetic conditions and congenital abnormalities. Persons in Ohio who would like genetic counseling, or other genetic treatment services, may contact one of the Comprehensive Genetic Centers (CGC), or may be referred by their primary care physician. The goals of the Comprehensive Genetic Centers (CGCs) are to ensure that children and adults with, or at risk for birth defects or genetic disorders and their families receive quality, comprehensive genetic services that are available, accessible and culturally sensitive; and providers, the general public and policy makers are aware and knowledgeable about birth defects, genetic conditions, and genetic disease related services in Ohio.

 

Infant Hearing Program

The Ohio Department of Health Infant Hearing Program (IHP) is the state of Ohio’s Early Hearing Detection and Intervention (EHDI) Program. The national EHDI principles under the Joint Committee on Infant Hearing (JCIH) include screen for risk of hearing loss by 1 month of age; diagnose a suspected hearing loss by 3 months of age; and begin provision of early intervention by 6 months of age. National averages indicate that about three infants per 1,000 births are identified with a hearing loss. The IHP has several goals that align with the national EHDI principles. These include ensuring that all infants who do not pass their hospital hearing screening receive no more than two screenings prior to hospital discharge. The IHP also provides follow-up coordination for tracking and monitoring of infants who need diagnostic hearing evaluations after non-pass hospital hearing screening results. In addition, the IHP refers families for home-based, early intervention services to help with the development of communication and language in infants and toddlers with hearing loss in order to help them build the best possible skills during the developmental stages for communications skills.

 

Newborn Screening for Critical Congenital Heart Disease

In 2014, the Ohio General Assembly enacted legislation requiring Critical Congenital Heart Disease (CCHD) screening, and the Ohio Department of Health (ODH) in partnership with hospitals and birthing centers developed standard screening guidelines and began to systematically collect CCHD screening results. ODH continues to monitor hospital reporting and offers guidance to newly appointed hospital screening coordinators. Pulse oximetry, the measure of the oxygenation levels in the blood, is used to screen and identify infants that may have CCHD. Low pulse oximetry readings may be used as a reliable indicator for the seven specific CCHDs targeted for identification in Ohio. These include hypoplastic left heart syndrome, pulmonary atresia, Tetralogy of Fallot, total anomalous pulmonary venous return, transposition of the great arteries, tricuspid atresia, and truncus arteriosus. Birth facilities and hospitals with access to vital statistics electronic birth records enter the CCHD screening results directly into the Integrated Perinatal Health Information System (IPHIS). Children’s hospitals without access to IPHIS, or other facilities where an infant may be transferred, provide ODH with paper reports of CCHD screening results upon discharge of the infants from their facilities.

 

Sickle Cell Services Program

The Ohio Department of Health (ODH) funds two grant initiatives under Sickle Cell Services Program related to sickle cell disease, sickle cell trait, and other hemoglobinopathies. These initiatives are the Sickle Cell Initiative and the Statewide Family Support Initiative. As a public health program, the Sickle Cell Services Program works to ensure and enhance the availability and accessibility of quality, comprehensive sickle cell services and care for newborns, children and adults; promote public, patient, consumer, family, and professional education to increase awareness and knowledge about sickle cell disease, sickle cell trait, and other hemoglobinopathies; and, increase strategies to maximize collaboration, coordination, and utilization of all sickle cell-related services and resources in Ohio.

 

 

 

Child Fatality Review

Child deaths are often regarded as indicators of the health of a community. While mortality data provide us with an overall picture of child deaths by number and cause, it is from a careful study of each child’s death that we can learn how best to respond to a death and how best to prevent future deaths. Recognizing the need to better understand why children die, Governor Bob Taft signed a bill in July 2000 mandating child fatality review (CFR) boards in each of Ohio’s counties to review the deaths of children under 18 years of age. For the complete law and administrative rules pertaining to CFR, refer to the Ohio Department of Health website at odh.ohio.gov/wps/portal/gov/odh/health-rules-laws-and-forms.

 

To accomplish this, it is expected that local review teams will: Promote cooperation, collaboration, and communication among all groups that serve families and children; maintain a database of all child deaths to develop an understanding of the causes and incidence of those deaths; and recommend and develop plans for implementing local service and program changes and advise ODH of data, trends, and patterns found in child deaths.

 

CFR boards must meet at least once a year to review all deaths of child residents of that county. The basic review process includes: The presentation of relevant information; the identification of contributing factors; and the development of data-driven recommendations. At the state level, we are re-establishing the CFR Advisory Board. The purpose of this advisory board is to review Ohio’s child mortality and CFR data to identify trends in child deaths, identify system responses to child deaths in Ohio, to make recommendations in law, policy, and practice to prevent future child deaths in Ohio, and to review and provide input for the annual CFR report.

 

 

Fetal/Infant Mortality Review

Fetal Infant Mortality Review (FIMR) is a multi-disciplinary, multi-agency, community-based program that identifies local infant mortality issues through the review of fetal and infant deaths and develops recommendations and initiatives to reduce infant deaths. Currently, there are active FIMR programs in all Ohio Equity Institute (OEI) counties.

 

The FIMR process includes:

• Identification of cases based on the infant mortality issues of the community.
• Collection of appropriate records from medical, social service, and other providers.
• Maternal interview.
• Abstraction of available records to produce a de-identified case summary.
• Presentation of de-identified case summary to review team.
• Development of data-driven recommendations.
• Implementation of recommendations to prevent future deaths.
• Case Review Team reviews case summaries and develops recommendation.
• Case Action Team reviews recommendations and develops a plan to implement interventions.