Plan for the application year: Oct 2023 - Sept 2024
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.
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. 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. 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.
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. Alaskans are thought to experience high rates of FASD, 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. The Substance Exposed Newborns Initiative (SENI) program data describes pregnant people’s report of alcohol use during the last month of their current pregnancy while they are under care for childbirth but does not include data on intendedness. In the coming year, SENI is expected to screen at least 25% of all pregnant people in Alaska for alcohol use during their current pregnancy, using a validated tool that asks pregnant people 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 data that includes report of alcohol use in the last month of pregnancy will be reported and shared widely during this period via the 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 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. Perinatal Nurse Consultants will review recent AAP guidance for consistency of messaging and any updates needed in current distributed materials. Alaska DOH 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. Other opportunities such as potential PSAs and social media messaging are being explored. A new Perinatal Nurse Consultant will join the team in September 2023 which will bring back capacity to work more on safe sleep messaging and dissemination.
The PRAMS program mailed out the safe sleep informational rack card to all respondents to the Phase 8 survey from March 2022 through June 2023, reaching approximately 800 people across the state. Due to limitations of the customized CDC software used, mailing the safe sleep rack card to PRAMS Phase 9 respondents will be paused beginning in 2023 because it will not be possible to identify and refrain from sending materials to respondents who may be grieving the loss of their infant or whose infants are not residing with them. The team will work to identify and make necessary programming changes, if possible, so that this can be resumed.
WCFH will continue to support the MIECHV Nurse Family Partnership home visiting program in their efforts to support 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. Using American Rescue Plan funding, 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 use ARP2 MIECHV funding to support 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 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. The coming year will be the beginning of a new award cycle for this funding. As of the date of this submission, it is unknown whether funds will be awarded, although there is potential for funding in a larger amount than prior years.
During 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 with newborns in Alaska. The 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, 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. SENI will compile an annual report of all its data and share that report widely.
A focus over the next year will be to get SENI more upstream to the prenatal care level. Most screening happens at the time of delivery in the hospital. While the SENI tool has been implemented in some facilities providing prenatal care, more work needs to be done to expand during before the time of delivery. SENI will also focus on partnering with hospitals to better integrate the SENI form into hospital electronic health records (EHR). The current paper-based scantron format of SENI is not sustainable and must be better integrated with EHRs. The Alaska Native Medical Center was able to recently integrate this form into their EHR.
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 practice. The input of community-based partners echoes many MCDR recommendations for individually tailored safe sleep support that is culturally specific and trauma-informed, and which 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 other poor maternal health outcomes, including interpersonal violence and barriers to accessing behavioral health services. 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. At prior annual AKPQC Summits, there has been time allotted for patient stories to not lose that perspective. Historically, the AKPQC had engagement with two parents with lived experience but did not have the structure at that to support their participation. These two parents participated in the monthly AKPQC Steering Committee meetings to provide their perspective, particularly during the planning phase and during the first year of implementation. The parents represented both the urban and rural perspective, with one being from Anchorage and one being from Bethel. There were many lessons learned from this experience. The AKPQC learned about things such as power dynamics. Parents are not always empowered to speak up with a group of physicians. There needs to be multiple methods of receiving input to meet the needs of parents and their busy schedules. In addition to meetings, having a structure that allows feedback via email and phone calls is also important. Honoring parent time via stipends was also a lesson learned. It is important to recognize their time and input.
WCFH staff participated in two communities of learning related to patient engagement sponsored by Alliance for Innovation on Maternal Health (AIM) and led by MoMMA’s (Maternal Mortality and Morbidity Advocates) Voices. This led to requesting MoMMA’s Voices to provide a session on patient engagement at AKPQC/MCDR Joint Summit which will be reported in next year’s annual report. During fall of the upcoming year, WCFH staff plan to attend the MoMMA’s Voices Summit pending CDC grant funding. Through these opportunities, WCFH hopes to create an environment that fosters lived experience throughout work in the PQC 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 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 Birthworkers and other community-based doulas, taking their knowledge and experiences into consideration during the planning of quality initiative activities, provider training and program planning.
WCFH receives input from people with lived experience through a variety of formal and informal sources, including quotes from the PRAMS open-ended question, 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, providers and the public.
The adult ACEs survey (OARs) will be conducting “road shows” to collect qualitative data to provide context and meaning to the qualitative survey data by incorporating local community perspectives.
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 includes interventions including 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. Due to COVID-19 impact on hospitals, healthcare providers shortages, and the dense number of strategies in the change package, SAPI will continue in the upcoming year.
SENI will continue to work with the AKPQC to engage hospitals and birthing facilities in both SENI screening and offering of voluntary POSC services.
In the coming period, the AKPQC will continue to promote SENI screening as the optimal standard of care for birth center staff to use 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 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.
The SENI POSC Initiative will continue its focus on the Fairbanks, Mat-Su, and Juneau POSC community pilot sites 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 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 may 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 placement of infants on their backs for sleep in the same room as their caregiver(s).
The MCH Epidemiology Unit previously documented a rise in NAS in Alaska by analyzing medical billing ICD-10-CM codes using Medicaid or 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 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 Council of State and Territorial Epidemiologists (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 screening will continue to ask the question: “Do you want to become pregnant again in the coming year?” among all pregnant people 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 posting resources that have been collected towards the development of a toolkit and an online training program for SENI screeners on the Alaska Learning Management System. 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 work with partners to reduce barriers for Medicaid enrolled women of childbearing age to access IPP LARCs. SENI staff will continue to provide leadership in this area by sharing (deidentified) SENI data on substance use among pregnant people and the data describing desired timing of subsequent pregnancy, with both DHS and 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. This data brief will be finalized and disseminated in the upcoming months. 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 summits, and Perinatal ECHOs to share information and provide training related to SBIRT. Such activities have been ongoing during 2023 and will be reported during the next block grant cycle. 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.
In response to provider and hospital feedback, WCFH developed an on-demand, enduring continuing education activity specifically addressing Perinatal SBIRT that became available in 2022. SENI will continue to support the recorded introductory training to Perinatal SBIRT and will create an orientation to best practices in screening pregnant people for substance use. These “canned” sessions are posted on the DOH Learning System for provider use. Additional Perinatal SBIRT trainings that go into more depth and strengthen skills and methods for all screeners will be conducted. SENI staff will continue to collaborate with the DBH SBIRT expert trainers 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 AK PQC staff and MCH-Epidemiology Unit staff to manage the data. The Alaska Division of Behavioral Health (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 among pregnant people, and alcohol use among women of childbearing age.
PRAMS data has always been a mainstay when assessing the use of alcohol prior to and during pregnancy. 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 2023. The Phase 9 PRAMS survey, which began data collection with 2023 births, includes reformatted questions about drinking alcohol and binge drinking, with a focus on each trimester of pregnancy 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.
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. 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. This could be an area of effort for the new CSTE fellow.
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