Perinatal/Infant Health

Plan for the application year: Oct 2020 - Sept 2021

Alaska continues to be among the states with the highest rate of SUID deaths (preceded by Alabama, Arkansas and Mississippi) with a rate of 159.8/100,000 live births during 2014-2018. There are signs of progress, with lower rates in recent years and a predicted rate of 126.7/100,000 live births for the 2015-2019 period. Of 33 SUID deaths reviewed by the maternal child death review (MCDR) during 2018-2019, the committee found that caregiver substance use was a factor in 18% of cases. The previously established NPM continues to be appropriate for this domain (Percent of infants placed to sleep on their backs; Percent of infants placed to sleep on a separate approved sleep surface; Percent of infants placed to sleep without soft objects or loose bedding).

It essential to understand the exact circumstances in which each SUID death occurs to engage in targeted prevention efforts. 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. A scene reenactment 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. Accordingly, the ESM selected 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 pregnant 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 Strategy 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. In collaboration with external partners and experts from within the Committee, MCDR will be leading an effort to provide training and tools to the field to improve SUID investigation. The new MCDR Program Manager brings prior experience in child death investigation, and she is working to strengthen partnerships with law enforcement agencies, increase awareness of the MCDR program and recruit investigators who can participate as committee members. This will improve the relevance and actionability of MCDR recommendations related to SUID deaths, particularly for investigative agencies. In addition to sleep-related deaths, MCDR also conducts multidisciplinary review of all other deaths among neonates and infants. Similar to improvements being made related to MCDR in other domains, the committee is implementing an effort to ensure that all recommendations are specific (including a “who, what and when” component), and actionable above the individual level.

MCDR publishes quarterly reports including case information and recommendations. 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 related to research and grant funding requests and share information at public events as opportunities arise.

NPM Strategy 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 education that is culturally appropriate to high risk families.

The safe sleep program will collaborate with partners to develop a comprehensive safe sleep website that may be used by all Alaskan families and health and social service organizations. The website will include links to nationally accredited websites that follow AAP guidelines for safe sleep of infants. This website will also include culturally competent information and risk mitigation strategies for safe sleep. Currently the safe sleep program distributes safe sleep board books from Charlie’s Kids Foundation and an informational rack card. The intent of the website is to provide a place for a place for all Alaskans to receive accurate and current information about safe sleep and Alaska’s SUID data as collected by MCDR.

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 education 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 will be accomplished by having the safe sleep program manager provide a train the trainer safe sleep presentation to the home visiting nurses at least once during the reporting period and additional trainings as requested by the partnership. The train the trainer presentation includes recent statewide SUID data sharing, lecture on the AAP guidelines, and group discussion on risk mitigation strategies. This will also be offered to other statewide home visiting programs.

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.

NPM Strategy 5.3: Partner with other agencies to integrate tailored safe sleep messaging into Plans of Safe Care.

Beginning in 2017, with leadership from Alaska’s Office of Children’s Services (OCS), the Alaska Division of Behavioral Health (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, experience withdrawal symptoms, or have fetal alcohol spectrum disorders (FASD). 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 2020, the Alaska Perinatal Quality Collaborative (PQC) is promoting 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 POSC 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 is working to inventory and develop needed resources for families.

During the October 2020 - September 2021 time period, the POSC Initiative will 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 POSC 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.

NPM Strategy 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.

During the October 2020 - September 2021 time period, 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. Support for these activities will include development of a toolkit and an online training program for SENI screeners. 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 that. The SENI strategy to reduce substance exposed pregnancies is to promote: (1) use of validated tools and process to identify women, especially pregnant women who are using alcohol, to describe and act on their desire regarding becoming pregnant (again) in the coming year by supporting and training health care workers to ask about this during any routine health visit and while in care for childbirth, (2) early identification of pregnancy, (3) 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. SENI will compile an annual report of all its data and share that report widely.

SPM Strategy 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.

During the October 2020 - September 2021 period, 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 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 the Governor’s Council on Disabilities & Special Education FASD Committee to advocate for be-bundling of LARCs from the maternity care bundle as well as to reduce other existing barriers for Medicaid enrolled women of childbearing age to access LARCs. SENI staff will continue to provide leadership, including serving as co-chair of the FASDs Committee’s Primary Prevention Working Group.

Also during the October 2020 - September 2021 time period, SENI will investigate screening instruments validated for use among the general population of women of childbearing age, and assess integration of the question: “Do you want to become pregnant in the coming year?” into that tool. A trial use of such a draft tool will be planned with at least one clinic serving women of childbearing age.

SENI will compile an annual report of all its data and share that report widely during this period.

SPM Strategy 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 implement a more complete and frequent training in SBIRT skills and methods for all screeners under a contract with a new organization, Alaska Center for Substance Use in Pregnancy and the Newborn, Inc. (ACSUPN). ACSUPN trainer William Trawick is a well-known neonatal nurse practitioner whose prior work includes establishing the Alaska Neonatal Abstinence Evaluation Support & Treatment (NEST) Program at Alaska Regional Hospital. The program is the only one of its kind in Alaska for treating Neonatal Abstinence Syndrome (NAS). Addressing health care worker discrimination towards pregnant women who use substances, especially alcohol, will be one focus of the SBIRT trainings. Trainings will all be conducted by distance due to COVID-19 impacts. Training is recognized as 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.

SENI aims to increase the number of birth centers from 5 to 6 and outpatient clinics from 1 to 6. Orientation trainings will help facilitate this growth as would an increase in SENI staffing. The Alaska Division of Behavioral Health continues to fully fund SENI and has tripled SENI’s funding since 2016.

SPM Strategy 1.3: Collect, analyze and disseminate data related to alcohol use among pregnant women.

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.

SPM Strategy 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.

WCFH will include 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. SENI staff will work with BRFSS to develop the text and placement of the question within the BRFSS survey.