Perinatal/Infant Health

Plan for the Application Year: October 2021 - September 2022

The NPM for this domain is the percent of infants placed to sleep on their backs; percent of infants placed to sleep on a separate approved sleep surface; and the percent of infants placed to sleep without soft objects or loose bedding. Sudden Unexpected Infant Deaths (SUIDs) are a leading cause of infant mortality in Alaska and many of these deaths are related to the sleep environment.

Preventing SUID requires accurate information about the circumstances these deaths occur. Accordingly, the ESM for this domain is the percent of SUID cases reviewed by MCDR in prior year with scene reenactment, including photos, completed by the investigating agency.

Substance misuse was strongly selected by both public feedback and the domain leadership group during needs assessment and prioritization process. For this domain, the need specifically related to maternal substance use, particularly alcohol. The SPM, Percent of women (who delivered a live birth and were trying to get pregnant) who had one or more alcoholic drinks in an average week during the 3 months before pregnancy, is based on PRAMS data. Alaskans are thought to experience high rates of FAS/FAE, an outcome which would provide an excellent indicator for maternal alcohol use. However, there is no reliable data source because of the complexities of diagnosis and under diagnosis. Compounding efforts to better appreciate needs of individuals affected by FASDs is the fact that diagnosis is often made years after birth. Newly implemented SENI program data describes pregnant women’s report of alcohol use during the last month of their current pregnancy while they are under care for childbirth. In the coming year, SENI is expected to screen at least 25% of all pregnant women in Alaska for alcohol use during their current pregnancy using a validated tool that asks pregnant women how much alcohol they have used in the month prior to birth at the time when they are under care for birth of that infant. These data may help inform understanding of the number and portion of all pregnancies exposed to alcohol whether diagnosed as FASDs or not. SENI will compile an annual report of all its data and share that report widely during this period.

NPM Strategies:

5.1: Review all infant deaths through the Maternal Child Death Review, generate actionable recommendations for all preventable deaths and increase awareness about the MCDR program among the public, clinicians, and policymakers.

MCDR is significantly funded by Title V with partial grant funding and technical support for review and classification of SUID deaths. MCDR review panels engage in a multidisciplinary process to examine factors leading to infant mortality and to develop recommendations for prevention of future deaths from similar causes for each death that is determined to have been preventable. For SUIDs, the panels complete a categorization algorithm to determine whether and how the death was related to the sleep environment. For all cases, the panel utilizes all records gathered through the program’s extensive records collection process to examine social determinants of health, institutional factors including racism and poverty, access to services, trauma history, interpersonal violence dynamics, behavioral health conditions including substance misuse, and all other relevant stressors. The program aims to ensure proper representation of communities and cultures which are disproportionately impacted by infant mortality within each panel to generate recommendations that are culturally sensitive and relevant. Panels also include diverse expertise from multiple fields to ensure comprehensive understanding of multiple complex systems that are involved in an infant’s life and death. The MCDR Program Manager has prior experience as an infant death investigator, and she and the Health Program Associate both have prior experience in child welfare. Additionally, during the upcoming year, MCDR plans to work with a contracted case abstractor for SUID cases. The selected contractor is a board-certified neonatal nurse practitioner who has been a leader in comprehensive services for birthing people and infants impacted by substance use disorders. In addition to his clinical knowledge, the selected contractor’s ability to interpret complex social histories will be an important asset to the program.

MCDR monitors investigative quality for all cases, including SUIDs, which include a scene investigation. Despite progress with completion of SUIDI forms, the quality of investigations continues to pose challenges towards fully understanding each death, particularly involving thoroughness of interviews and evidence collection. The CDC-recommended best practice includes a scene reenactment completed by the investigating agency (typically law enforcement) with caregivers, appropriately using a weighted doll as an investigative tool, is a key component of the SUID investigation. It not only provides information essential to accurate SUID categorization but also reflects a level of effort and attention to the case that may not occur without a reenactment, even if a SUIDI form is filled out. When conducted according to best practice and using culturally appropriate communication and interpersonal behavior techniques, scene reenactments are not believed to be traumatic to families. Best practices require investigators to allow caregivers to decline a scene reenactment, but when presented appropriately, many caregivers find that going through this process affords an opportunity to have a role in finding the answers they seek. MCDR has assisted the field by providing investigative tools and connecting investigating agencies with training and support to conduct these types of investigations properly.

The COVID-19 pandemic caused MCDR to fall behind in its review of cases. This was primarily due to the transition to virtual review meetings, which was not appropriate for full-day review meetings as had been the practice. In light of this, the program intends to focus resources on the review of preventable deaths while completing an abbreviated review process for neonatal and infant deaths due to natural causes. At least one clinical expert will still review infant deaths that are determined not to have been preventable, capturing essential data points for future mortality analyses.

MCDR recommendations are released on a rolling basis in quarterly reports. The program’s dedicated Epidemiology Specialist will develop fact sheets and other materials related to infant mortality, particularly SUIDs. Program staff will also continue to respond to data requests from the public to help inform practices and service delivery and share information at public events as opportunities arise.

5.2: Leverage multi-sector partnerships to provide evidence-based and culturally appropriate safe sleep materials and education for high-risk families, including caregivers who use tobacco.

The Alaska safe sleep program will continue to work with partners to provide safe sleep materials and information that is culturally appropriate to high-risk families. Currently the safe sleep program distributes safe sleep board books from Charlie’s Kids Foundation and an informational rack card.

The safe sleep program will collaborate with partners to develop a training course for healthcare professionals regarding providing safe sleep education to parents and caregivers. This training will incorporate accurate and current information about safe sleep from accredited sources and Alaska’s SUID data as collected by MCDR. The training will be accessible via the website https://learn.dhss.alaska.gov/login/index.php.

Alaska DHSS safe sleep program intends to partner with Alaska Medicaid to distribute safe sleep materials to their beneficiaries, and with WIC to collaborate on providing safe sleep information to their clients. WCFH will continue to support the MIECHV Family Nurse Partnership home visiting program in their efforts to support pregnant women and new parents with materials and personalized safe sleep conversations. This year the MIECHV Nurse Family Partnership program has planned a continuous quality improvement (CQI) activity involving parent education and sleep sacks. The program has already developed training materials with assistance from the WCFH Nurse Consultant and Nurse Family Partnership National Service Office. The MIECHV Data Analyst will work with the program on designing, implementing, and evaluating this Plan/Do/Study/Act (PDSA) activity.

Alaska currently has one hospital that is certified as a safe sleep leader by Cribs for Kids. Cribs for Kids National Safe Sleep Hospital Certification program recognizes individual hospitals for their commitment to infant safe sleep. The WCFH Nurse Consultant will partner with other state hospitals to encourage achievement of certification by at least one other facility in this reporting period. WCFH will promote interest in certification achievement by hosting individual conversations with state hospitals and provide support in their development of the policies and staff trainings as required by the certification application. WCFH will also look to partner with the Alaska State Hospital and Nursing Home Association (ASNHA) to engage hospitals on this certification.

5.4: Partner with birth center clinical staff to effectively screen pregnant/post-partum people for substance use including tobacco, alcohol, marijuana and substances that may impair judgment, including prescribed medications, in order to identify infants at high risk for SUID.

In the upcoming year, SENI will continue to support current screeners to achieve a screening rate of at least 60% and work to increase the number of birth centers participating in SENI screening, while achieving screening of at least 25% of all families of newborns in Alaska. An online toolkit and training program for SENI screeners will continue to support this effort. SENI will continue to use questions about substance use as opportunity to provide a brief intervention and support to access appropriate treatment for those needing and accepting it. SENI strategies to reduce substance exposed pregnancies will continue to include promotion of:  (1) use of validated and best practice tools and process to identify pregnant people who are using nicotine, alcohol, marijuana and other substances, and offer resources and care aimed at reducing risk factors for SUIDs, including tobacco and alcohol use, and the course of providing clinical care, (2) of avoidance/reduction/treatment for harmful substances when pregnant in order to reduce adverse outcomes as much as possible. SENI will compile an annual report of all its data and share that report widely.

5.5: Partner with the Office of Children’s Services to conduct evaluation of Plans of Safe Care.

The Office of Children’s Services (OCS) Plans of Safe Care Initiative (POSC) suffered multiple setbacks during the past year, many related to COVID. As a result, only one community launched a POSC pilot in April 2021. In the coming year, SENI will support the POSC by taking on the role of receiver of the federal notification data that OCS is required to submit to its federal funders. WCFH is hopeful that reporting the data to public health will create less stigma and normalize this support for at-risk families. In support of this new role, SENI will incorporate the required notification data into its existing data collection tool. SENI will work with its data management contractor, NTI Upstream, to provide report out of the notification data for OCS and the POSC community.   SENI will continue to support the POSC screeners with training, tracking and ongoing quality assurance for accurate collection and submission of these data.

5.6: In partnership with the Alaska Perinatal Quality Collaborative, engage hospitals and birthing facilities in data-driven, collaborative quality improvement focused on improving care and outcomes for newborns and families affected by substance use.

The Alaska Perinatal Quality Collaborative (AKPQC) launched in January 2019 with a long-term goal to eliminate preventable maternal and neonatal morbidity and mortality in Alaska. The AKPQC’s first maternal initiative, focused on improving care for pregnant and birthing people with severe hypertension, recently concluded and moved to sustainability. As a result of this initiative and efforts of participating hospitals, the AKPQC exceeded its primary goal by reducing the rate of severe maternal morbidity (SMM) among birthing people with preeclampsia by 28% from 2018 to 2020.

Harnessing the momentum from this first successful initiative, the AKPQC is planning its next initiative focused on improving care for pregnant people and newborns affected by substances. This dyad-centered initiative will engage Alaska hospitals in collaborative quality improvement following the Institute for Healthcare Improvement Breakthrough Series model. Participating hospitals will implement evidence-based interventions that improve the identification, clinical care, and discharge and follow-up for pregnant people, newborns, and families impacted by harmful substances. Specific newborn interventions include developing guidelines and processes for non-discriminatory and risk-based toxicology testing, implementation of the Eat, Sleep, and Console model of care, and promoting safe discharge plans, including safe sleep information and warm handoffs to community supports for newborns and families impacted by substances.

SENI will continue to work with the Alaska Perinatal Quality Collaborative (AKPQC) to engage hospitals and birthing facilities in both SENI screening and offering of voluntary POSC services.  WCFH is hopeful that that Title V funded PQC will help to launch POSC in more Alaskan communities. Because POSC in Alaska is still evolving and happening in only one pilot community, details about the nature of SENI’s support is an evolving process.  However, one element that was funded for this coming year is the Facilitated Attuned Interactions (FAN) trainings for one POSC community that hopes to launch its project soon.  FAN is a conceptual model and practical tool for attunement in relationships, communication, and reflective practice. FAN promotes family engagement and practitioner/parent collaboration to help develop family resilience and healthy goal setting in a range of service modalities, including home visiting program staff, primary care, early intervention, and child welfare. In the coming year, at least 40 community-based staff from community-based organizations that serve families with substance use issues will receive training in FAN.  Currently, Alaska has no certified FAN trainers. By the end of this time period, two Alaskan infant mental health experts will become certified in FAN and be qualified to conduct FAN trainings for Alaskan organization staff who deliver various family services statewide. SENI staff will collaborate with the Alaska Mental Health Trust, DPH, Division of Behavioral Health (DBH), the Child Welfare Academy (OCS training center) and other partners to plan for further growth and dissemination of FAN in the coming year.

Beginning in 2017, with leadership from Alaska’s OCS, the Alaska DBH, Tribal and non-tribal health partners, the Palmer Family, Infant, Toddler (FIT) Court, the National Center of Substance Abuse and Child Welfare’s Center for Children and Family Futures (CFF), and WCFH Substance-Exposed Newborns Initiative (SENI) staff collaborated to establish Alaska’s Plans of Safe Care (POSC) Initiative. Alaska’s POSC initiative’s goal is to fulfill the federal mandates set forth in the 2016 amended Child Abuse Prevention and Treatment Act (CAPTA) regarding infants and their families. Requirements were added to emphasize that POSC address the needs of infants who are identified as affected by substance abuse. Development of a services plan for the infant and their family/caregiver is stipulated. Because a substantial portion of infant deaths occurring in the sleep environment are associated with use of nicotine products and parent or caregiver impairment due to substance use, POSC will play a significant role in Alaska’s plans to prevent and reduce infant death in the sleep environment by designing a cohesive system to identify at risk newborns prior to hospital discharge and provide wraparound services that help keep babies safe and families healthy.

In the coming period, the AKPQC will continue to promote SENI screening as the optimal standard of care for birth center staff to identify at-risk newborns and their families and assure that specialized POSC are established and supported by community health and social care systems. Specialized POSCs will provide for tailored plans to address families using THC, tobacco, alcohol, opioids, and other harmful substances. While current state resources for such interventions, such as evidence-based maternal-infant home visiting services, are inadequate, the POSC Initiative will continue to work on conducting an inventory or needs and resources and develop needed resources for families. For example, integrations of the resources available from the State of Alaska Tobacco program, the WCFH Safe Sleep program, WIC, and the Alaska Breastfeeding Initiative will be employed and coordinated to increase effectively tailored safer sleep parenting practices. 

During the next year, the SENI POSC Initiative will continue its focus on the Mat-Su and Juneau POSC community pilot sites to move this work forward by: (1) increasing the number of pregnant women screened by SENI in those communities, (2) drafting POSCs tailored for use among families of newborns identified as using THC and nicotine prior to and during pregnancy of that newborn, and (3) identifying existing and needed resources necessary for effective implementation of POSC for these newborns and their families. Plans include making pack-n-plays available to families who need them, helping families to reduce infant exposure to nicotine and THC smoke and residues, and promoting placing infants on their backs for sleep in the same room as their parent(s).

5.7: Enhance surveillance of substance-exposed newborns using available data from birth defects registry, hospital discharge, and Medicaid data.

ABDR regulations were updated in 2019 to include requirements for health care providers and third-party payers to report additional conditions to the registry, including substance-exposed newborns and those with Neonatal Abstinence Syndrome (NAS). ABDR provides statewide surveillance coverage and thus can be utilized to generate population-level estimates of NAS. However, further examination is necessary to determine the validity of ICD-10 codes used to identify and report NAS to ABDR. Furthermore, the ABDR system is subject to reporting delays, so it is necessary to examine the coverage of the hospital discharge data surveillance system which may continue to be used to generate Alaska NAS rates that are nationally comparable.

During 2021, the MCH Epidemiology Unit will be conducting case confirmation studies of infants reported to the registry with neonatal withdrawal symptoms from maternal use of drugs of addiction, and newborns (suspected to be) affected by maternal use of other drugs of addiction (based on ICD-10 billing codes). This project will include identifying cases, selecting a certain percentage for medical records review for case confirmation, and calculating weights to apply to all reported cases to determine an adjusted number of “confirmed” cases. The project will also include probability matching of cases with hospital discharge data and matching with Medicaid to better understand how cases within each of these systems overlap and the extent to which some systems may under-represent or over-represent cases from certain populations. The CDC PHAP assigned to MCH Epi will lead this project, with support from the partially Title V funded Senior Epidemiologist, the MCH Epi Unit Manager, and the ABDR Epidemiologist.

SPM Strategies:

1.1: Promote provider use of the question, “Do you want to be pregnant in the coming year?” among all women of childbearing age, and the question, “Do you want to become pregnant again in the coming year?” among women who are in the last trimester of pregnancy.

All SENI screening will continue to ask the question: “Do you want to become pregnant again in the coming year?” among all pregnant women screened. SENI will support current SENI screeners to achieve a screening rate of at least 60% and work to increase the number of birth centers participating in SENI screening while achieving screening of at least 25% of all families of newborns in Alaska. Support for these activities will include further development of a toolkit and an online training program for SENI screeners. The toolkit will include information about immediate postpartum long-acting reversible contraception (LARCs). SENI will continue to partner with community-based organizations who share the aim of reducing alcohol exposed pregnancies, including the Recover Alaska Alliance, and will advocate for de-bundling of LARCs from the maternity care bundle, as well as reduce other barriers for Medicaid enrolled women of childbearing age to access LARCs. SENI staff will continue to provide leadership in this area by sharing (deidentified) SENI data on substance use among pregnant people with both DHSS and community-based partners.

1.2: Promote provider use of Screening, Brief Intervention and Referral to Treatment (SBIRT) for all harmful substances among women of childbearing age, especially those who are pregnant. Screening includes seeking information about the co-factors of family violence and maternal depression.

SENI will continue to refine and update its SBIRT trainings to strengthen skills and methods for all screeners. SENI will continue to contract with the Alaska Center for Substance Use in Pregnancy and the Newborn, Inc. (ACSUPN). ACSUPN trainer William Trawick is a well-known neonatal nurse practitioner, and he will continue to focus on health care worker discrimination towards pregnant women who use substances, especially alcohol. Newly developed trainings on “Eat, Sleep, Console” (ESC) have been integrated into the programming. ESC is a therapeutic modality and a developing best practice for care of newborns experiencing withdrawal from opioids and other substances. ESC facilitates bringing the newborn’s mother onto the baby’s care team where she can be supported to safely participate in the care of her substance affected newborn with rooming-in, skin-to-skin, breastfeeding and other care elements. Newborns receiving ESC generally require much less medication during withdrawal and can be discharged from hospital sooner. All SENI trainings will continue to be conducted by distance due to funding constraints on travel and improved access for all geographic regions of the state when online venues are used. Training continues to be a critical component in increasing screening rates.

SENI will continue to include screening for family violence and maternal depression as these are both strongly associated with poor maternal and infant outcomes and substance use. Those with positive screening will be offered support to access resources tailored to meet their needs. SENI will continue to track availability of those resources both by monitoring state supported violence shelters and associated programs and behavioral and mental health programs statewide. Data on the co-factors of family violence and maternal depression will be compiled and reported in SENI’s annual program report along with all other SENI data.

COVID impacted SENI expansion efforts, with one birth center resigned from the program and other joining.  During this year, SENI aims to continue efforts to increase the number of birth centers and outpatient clinics. SENI staff includes one nurse at .75 FTE and valuable support from both the AK PQC staff and the WCFH PHAP fellow. The Alaska Division of Behavioral Health continues to fully fund SENI and has increased SENI’s funding level by ten-fold since 2016.

1.3: Collect, analyze, and disseminate data related to alcohol use among pregnant people and women of childbearing age.

PRAMS data has always been a mainstay when assessing Alaska women’s use of alcohol prior to and during pregnancy. PRAMS will continue to be disseminated by the PRAMS Program Manager. As SENI screening rates increase to approximate universal screening, these data may also become useful for surveillance in the future. SENI will continue to use its questions about substance use as opportunity to provide a brief intervention and support to access appropriate treatment for those needing and accepting that.

1.4: Include a question in the BRFSS about whether women of childbearing age who saw a provider in the past year were asked by their provider if they want to be pregnant in the coming year.

In 2021, WCFH included a question in the Alaska Behavioral Risk Factor Surveillance System (BRFSS) asking women of childbearing age who were seen by a health care provider for any reason, if they were asked about their desire to become pregnant in the coming year.  This was supported by Title V funding. When the 2021 data become available, WCFH staff will review, assess, and develop an appropriate action plan.  WCFH plans to evaluate their action plan by repeating the question in the 2024 BRFSS survey.