Plan for the application year: Oct 2024 - Sept 2025
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.
SUID prevention is a multi-faceted practice area that includes three main areas: (1) to collect accurate data to inform prevention approaches, (2) to provide quality messaging through a variety of channels including individualized, culturally relevant interactions, and (3) to provide support and culturally tailored interventions for caregivers so safe sleep information is relatable and integrates meaningfully into their lives. The ESM for this domain, the percent of people who recently delivered a live birth who were screened for depression during a postpartum checkup, focuses on the last of these three pieces. Untreated perinatal depression can interfere with parent-infant interaction and attachment, difficulties in family function, problems with breastfeeding and infant development. Caregivers who face the barriers associated with perinatal depression may have difficulty receiving and understanding safe sleep messaging and integrating safe sleep practices into their everyday lives. Adequate screening and treatment of perinatal depression can enhance the wellbeing of children and families by reducing the risk of complications during birth and deterioration of core supports.
The need to address substance misuse was identified as a priority during the needs assessment and prioritization process. For this domain, the need 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. While there is not reliable data source due to the complexities of diagnosis and resulting under diagnosis, Alaskans are thought to experience high rates of FASD, an outcome which would provide an excellent indicator for maternal alcohol use. However. Compounding efforts to better appreciate needs of individuals affected by FASDs is the fact that diagnosis is often made years after birth. The Substance Exposed Newborns Initiative (SENI) program data describes pregnant people’s report of alcohol use during pregnancy. In the coming year, SENI is supporting health care facilities to screen 15% of all pregnant people in Alaska for alcohol use with the use of a validated tool. This data may help inform understanding of the number and portion of all pregnancies exposed to alcohol, whether diagnosed as FASDs or not. SENI data that includes report of alcohol use in the last month of pregnancy will be reported and shared widely during this period via the Alaska Perinatal Quality Collaborative (AKPQC) data dashboard.
NPM Strategies:
5.1: Leverage multi-sector partnerships to provide evidence-based and culturally appropriate safe sleep materials and education for families who experience high-risk factors for SUID, including caregiver tobacco use.
The Section will continue to work with partners to provide safe sleep materials and information that is culturally appropriate to families with risk factors for SUID. Currently the safe sleep program distributes safe sleep board books from Charlie’s Kids Foundation, an informational rack card, which was developed in partnership with Alaska Native Tribal Health Consortium (ANTHC), and a wallet-sized fold out card, “My Healthy Alaskan Baby,”. In the up-coming period, the “My Healthy Alaskan Baby” card, with information on childhood health resources is being updated. These publications are given to families via birthing facilities, pediatric clinics, and other social service organizations. Perinatal Nurse Consultants will review recent AAP guidance for consistency of messaging and any updates needed in current distributed materials.
In March 2022, the PRAMS program began mailing the safe sleep informational rack card to Phase 8 respondents who reported their infant was alive and living with them. In December 2023, the “My Healthy Alaskan Baby” cards were also added to the mailings. From August 2023 through April 2024, 730 birth parents across Alaska received safe sleep and other resource information with their thank you gift after responding to the PRAMS survey.
WCFH will continue to support the MIECHV Nurse Family Partnership home visiting program to engage pregnant people and new parents with materials and personalized safe sleep conversations. Based on the results of a prior continuous quality improvement project, the team of nurses continue to provide safe sleep messaging as early as possible during pregnancy. Alaska’s MIECHV program will build on these successes and extend safe sleep education, strategies, and resources to all of Alaska’s home visiting and Early Intervention program staff through a mix of professional development platforms. WCFH will continue to coordinate the Home Visiting ECHO series, which is another avenue to disseminate safe sleep messaging. Further information on safe sleep will be provided to home visitors throughout the year through the Home Visiting listserv. This active listserv shares trainings and resources to the field and has 294 subscribers from across the state.
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. Through the Alaska Perinatal Quality Collaborative, the Title V MCH Director will share this opportunity and recognition 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. WCFH will also look to partner with the Alaska State Hospital and Healthcare Association (AHHA) to engage hospitals on this certification.
The MCDR program will continue to conduct review of all infant deaths from SUID and enter categorization information and prevention recommendations into the national database. In addition to contributing to national surveillance and study of SUIDs, this process also helps to identify risk factors in Alaskan infant mortality, which are shared with partners through presentations, publications, professional consultation, and data requests. SUIDs are the most common cause of infant mortality in Alaska, and both infant mortality and SUID rates have recently increased. The review of these cases amounts to a substantial portion of MCDR activities, with more than 20 cases to review in typical years. During the upcoming year, there will be a backlog of cases to review due to recovery from delays in records returns and other barriers due to pandemic impacts and program staffing. This area of MCDR’s work has been supported in the past by a CDC grant which has been used to fund a case abstractor who prepares a portion of SUID cases for multidisciplinary review (funds are not able to cover this service for all cases) and a small percentage of MCDR staff time. MCH Epidemiology has been awarded funding to continue SUID prevention work for the next five years.
A partnership between the MCDR program and WCFH staff will enable continued implementation of MCDR’s OASH award for the prevention of maternal mortality from violence. The funding will support workforce development for doulas, with an emphasis on doulas culturally matched to populations who experience violence and mortality disparities. A partnership with the University of Alaska-Anchorage (UAA) Department of Population Health research team focuses on an evaluation of a previous year’s direct service provision by the doula pilot project and this coming year will build on the evaluation results to support doula and perinatal community health worker training. Full spectrum doula care encompasses prenatal, birthing, and postpartum support and includes education on culturally appropriate safe sleep strategies and harm reduction as part of the core curriculum.
During the upcoming year, SENI will continue to support current screeners to achieve a screening rate of at least 80% and work to increase the number of birth centers participating in SENI screening, while achieving screening of at least 15% of all families with newborns in Alaska. SENI will continue to pay the licensing fee and printing costs for the 4 Ps Plus, a substance use screening tool which is validated for use during pregnancy. An online SBIRT training program by the Division of Behavioral Health for health care staff was developed to support this effort and will continue to be offered to health care staff around the state. SENI will continue to use screening for 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 processes 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 through the course of providing clinical care, and (2) of avoidance/reduction/treatment for harmful substances when pregnant in order to reduce adverse outcomes as much as possible.
A continuing focus will be to get universal verbal screening for substance use to the prenatal care level. Most screening currently occurs at the time of delivery in the hospital and discussions are progressing with several prenatal clinics to implement screening during the prenatal period. SENI will also continue partnering with hospitals to better integrate a validated substance use screening form into hospital electronic health records (EHR) and linked to referrals when indicated. To incentivize and provide resource support to SENI facilities, the Section is currently doing a procurement for an agency to administer stipends to help cover the costs of sustaining or implementing SENI screening. These stipend funds could be used to pay for staff training, EHR enhancements, or whatever costs may be creating a barrier to screening. This will be done via federal funds received from the Division of Behavioral Health.
5.3: Identify opportunities to meaningfully engage lived experience perspectives.
SUID prevention, especially safe sleep, is a complex topic that cuts across many maternal and infant public health practices. The input of community-based partners echoes many MCDR recommendations for individually tailored safe sleep support that is culturally specific, trauma-informed, and considers basic needs and stressors faced by caregivers. Safe sleep promotion requires collaboration and integration across systems, as many common factors have been identified for SUIDs and poor maternal health outcomes. Addressing these challenging problems requires engagement and openness to the insights of those with firsthand experience.
The AKPQC plans to create a Patient Advisory Council within the next year. The Patient Advisory Council will meet periodically to provide input on AKPQC activities and initiatives. WCFH has placed an emphasis on and values the input of lived experience from families. Parents have been part of advisory committees for such programs as newborn screening, home visiting, and children and youth with special health care needs. The AKPQC also values the input of families and follows the philosophy of “Nothing about us, without us.” Historically, the AKPQC had engagement with two parents with lived experience but did not have the structure at that time to support their participation. These two parents were members of the AKPQC Steering Committee meetings and provided their perspective during the monthly meetings, particularly during the planning phase and during the first year of implementation. There were many lessons learned from this experience. The AKPQC team realized that due to power dynamics, parents are not always empowered to speak up in a group of physicians and other providers. Additionally, there needs to be multiple methods of receiving input to accommodate the needs of parents and their busy schedules. Having a structure that allows feedback via email and phone calls is also important. The AKPQC also learned the importance of compensating parents for their time and input to enable their sustained engagement.
During fall of the upcoming year, a person with lived experience and a WCFH staff member plan to attend the MoMMA’s Voices Summit, pending CDC grant funding. Through this opportunity, WCFH hopes to create an environment that fosters lived experience throughout work in the AKPQC as well as other areas of the section.
WCFH will continue to build on the partnership with the Alaska Native Birthworkers Community (ANBC) that was fostered through participation in the Association of Maternal and Child Health Programs (AMCHP) Health Beginnings Cohort, which focused on dismantling racism to eliminate inequities in pre-term birth. As opportunities arise, WCFH will continue to engage with ANBC and other community-based doulas, taking their knowledge and experiences into consideration during the planning of quality initiative activities, provider training, and program planning.
The OASH grant to reduce maternal mortality and violence highlights the role of culturally matched doulas. The evaluation process currently in progress by UAA research team seeks to elucidate the experience of doulas and their perspectives in the provision of care to families experiencing risk factors. This grant will continue to support community perinatal health worker and doula workforce development with an iterative process of doula training curriculum provision, evaluation, and refinement.
In addition to the above strategies, the WCFH Unit will continue to receive input from people with lived experience through a variety of formal and informal sources, including quotes from PRAMS margin and back page comments from respondents, input from MCDR committee members and community-based contractors, narrative stories from the field as shared by MIECHV home visitors, Title V Public Input responses, and many others. WCFH also receives input through more formal qualitative studies, such as the Northwest Arctic Breastfeeding Needs Assessment which was facilitated through a partnership between WCFH and the Section of Chronic Disease and Health Promotion and conducted by International Data Systems (a Kijik Tribal Corporation subsidiary), and the Anchorage Pacific Islander Maternal Health Needs Assessment, which was completed by a UAA MPH Intern in partnership with MCDR. Each of these sources has unique questions and opportunities and WCFH staff will continue to consult with community members, peer jurisdictions and national partners to determine the most impactful and ethical methods of sharing the information gained with internal partners, health care providers, and the public.
SPM Strategies:
1.1: 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 AKPQC launched the Substance-Affected Pregnancies Initiative (SAPI) initiative in September 2021. For SAPI, a change package of evidence-based practices was created which included interventions such as: development of guidelines and processes for non-discriminatory and risk-based toxicology testing, implementation of the Eat, Sleep, and Console model of care, and promotion of safe discharge plans, including safe sleep information and warm handoffs to community supports for newborns and families impacted by substances. In December 2023, SAPI concluded data collection and is now in the sustainment phase, supporting the maintenance of practices which were implemented during the initiative.
Beginning in September 2023, a supplemental funding opportunity under the CDC Statewide Perinatal Quality Collaborative Cooperative agreement enabled WCFH to embark on implicit bias training with a specific focus on substance use disorder (SUD) in pregnancy. However, due to delays in the procurement process, this training is anticipated to occur within the upcoming year. Additionally, another supplemental opportunity concentrating on SUD in pregnancy has been announced, with the anticipated award beginning September 2024. Alaska has applied for this supplement, intending to allocate the funds towards procuring iPads for participating SENI sites, compensating doula speaker fees, enhancing the inclusion of SUD-related content within the Alaska Doula curriculum, supporting the Patient Advisory Council (PAC) of the AKPQC, and facilitating the above-mentioned learning opportunity for the AKPQC Program Coordinator and individuals with lived experiences.
In the coming period, the AKPQC will continue to promote universal verbal screening with a validated tool followed by brief intervention as the optimal standard of care for birth center staff to use to identify newborns and their families with risk factors. SENI will continue to work with the AKPQC to engage hospitals and birthing facilities in both universal verbal screening and offering of voluntary POSC services. POSC programs are supported through a partnership between WCFH and the Office of Children’s Services and provide tailored plans to address the needs of families experiencing risk factors for substance use and related social determinants of health.
SENI will keep its focus on the Juneau POSC community pilot site while working to expand to additional sites in order to move this work forward by: (1) increasing the number of pregnant people screened by SENI in those communities, (2) drafting POSCs tailored for use among families of newborns identified as experiencing risk factors and (3) identifying existing and needed resources necessary for effective implementation of POSC for these newborns and their families.
The MCH Epidemiology Unit previously documented a rise in Neonatal Abstinence Syndrome (NAS) in Alaska by analyzing medical billing ICD-10-CM codes using Medicaid and hospital discharge data. However, Medicaid data represent only a portion of the Alaska birth population, and hospital discharge data lack identifiers necessary for validation. In 2019, the Alaska Birth Defects Registry (ABDR) began tracking NAS-related ICD-10-CM codes for statewide NAS surveillance and case confirmation. Several epidemiologists in the Unit worked with the prior PHAP fellow and the current Council of State and Territorial Epidemiologists (CSTE) fellow to calculate a validated NAS prevalence estimate based on confirmed cases and evaluate the accuracy and completeness of two codes used to detect NAS. The CSTE adopted a new position statement on NAS surveillance in June 2023. The MCH Epi Unit plans to go back and re-classify the NAS cases from the prior sample to follow the new definition. This will allow MCH Epi to define "suspected" NAS and "confirmed" NAS. After this additional work is completed, the Unit will finalize a draft Epidemiology Bulletin that the CSTE fellow wrote in FY23 about the case confirmation study previously described.
SENI participating facilities will continue to ask the question: “Do you want to become pregnant again in the coming year?” among all pregnant people screened with the 4P’s Plus tool. SENI will support current SENI screeners to achieve a screening rate of at least 80% and work to increase the number of birth centers participating in SENI screening to achieve a screening rate of at least 15% of all families of newborns in Alaska. Support for these activities will include promotion of an online SBIRT training program developed by DBH on the Alaska DOH Learning Management System. SENI staff will continue to provide leadership in this area by sharing (de-identified) SENI data describing desired timing of subsequent pregnancy on the AKPQC ArcGIS data hub and with community-based partners.
The Alaska PRAMS Phase 9 survey includes a core question related to pregnancy planning: whether a healthcare provider talked to them about their desire to have or not have children during any healthcare visit in the 12 months before they got pregnant. The first birth year to collect these data is 2023. Over the upcoming year, PRAMS staff will work with other Title V staff to consider ways the new PRAMS data could be used to support this strategy. 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. Results from 2021 data collection became available in fall 2022 and a data brief describing the results has been drafted and is in the editing phase. Findings from the question may also be included in the women’s health data book described as a strategy in the Women’s domain. WCFH plans to repeat the question in the 2024 BRFSS survey to support evaluation of activities promoting provider discussions with patients about pregnancy intention in the upcoming year.
WCFH will utilize opportunities including the AKPQC/MCDR joint summit and Perinatal ECHOs to share information and provide training related to SBIRT. Data related to substance use and experiences of mental health symptoms and interpersonal violence among women of childbearing age and pregnant individuals is consulted in the planning of trainings. It is anticipated that similar activities will continue into the next Block Grant year as the data continue to support the need for provider training related to identification and response to IPV and maternal mental health. Using Maternal Infant Early Childhood Home Visiting (MIECHV) American Rescue Plan (ARP) funding, a new ECHO for Alaska home visitors was launched in 2022 and is expected to continue through 2024 based on available funds. It is the first MIECHV funded ECHO in the country. This ECHO includes home visiting and Early Intervention staff and administration from all of Alaska’s home visiting models located in large and small public, non-profit, and tribal programs across the state. The Alaska Home Visiting ECHO focuses on topics such as maternal depression and intimate partner violence (IPV) screening. It also includes emergency preparedness, resiliency, and improving virtual visits.
WCFH SENI program partnered with the Division of Behavioral Health to develop and promote an on-demand SBIRT training posted on the DOH Learning System for health care provider use. DBH is working to identify a new contractor for additional in-person Perinatal SBIRT trainings that go into more depth and strengthen skills and methods for all screeners. SENI staff will continue to collaborate with the incoming DBH SBIRT expert trainers when they are selected to develop and conduct all trainings.
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 integrated into the AKPQC data dashboard.
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 AKPQC staff and MCH-Epidemiology Unit staff to manage the data. DBH continues to fully fund SENI and has increased SENI’s funding level by ten-fold since 2016. DBH also provides the Perinatal SBIRT training team in support of SENI and at no cost to SENI.
1.5: Collect, analyze, and disseminate data related to alcohol-affected pregnancies, alcohol use during pregnancy, and alcohol use among women of childbearing age.
PRAMS data is the traditional data mainstay for assessing the use of alcohol prior to and during pregnancy and trends and estimates from PRAMS will continue to be disseminated by the PRAMS Program Manager. An Epidemiology Bulletin describing key findings from PRAMS and recommendations for providers is planned for the second half of 2024 that will include all Phase 8 (2016-2022) data. The Phase 9 PRAMS survey, which began data collection with 2023 births, includes reformatted questions about drinking alcohol and binge drinking during pregnancy, with a focus on each trimester rather than only the last 3 months of pregnancy. Of note is that the first trimester of pregnancy also includes “the time before knowing” they were pregnant. Having data summarized with the Phase 8 question format will be important since the transition to the Phase 9 format will start a new trend line.
As SENI screening rates increase to approximate universal screening, these data may also become useful for surveillance in the future. Screening rates at participating facilities are over 70% and the goal for the upcoming measurement period it to improve them to over 80% at participating facilities. SENI program staff will explore ways to improve reporting, including through electronic reporting mechanisms that can be incorporated into the facility electronic health record.
The Alaska Birth Defects Registry will continue to collect reports of Fetal Alcohol Syndrome (FAS) and update the online condition-specific report for FAS.
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