In application year 2022, the infant and perinatal priority for the Bureau of Women’s and Children’s Health (BWCH) is to promote equitable and optimal care and protective factors for mothers and infants before, during, and after pregnancy. In meeting this priority, we will continue to remain focused on reducing infant mortality and morbidity, and reducing disparities in infant and maternal morbidity and mortality.

Arizona’s Title V Program works to address NPM 6: Developmental Screening through internal collaboration with the Office of Newborn Screening and through BWCH’s home visiting programs.

Arizona's early childhood home visiting programs provide support for new families to promote positive parenting and child development.  In 2022, the Maternal, Infant, and Early Childhood Home Visiting (MIECHV), Health Start and the High Risk Perinatal Program (HRPP) home visiting programs will continue to implement strategies that support services for mothers, infants, and families, including educating families about infant toddler development, mental health, the critical importance of bonding, injuries in the home, safe sleep, immunizations, and the effects of Adverse Childhood Experiences (ACEs).  In addition, continued professional development for home visitors and home visiting supervisors will be a priority.  More information on MIECHV and Health Start home visitation planned activities are included in the Children’s Health and Women’s Health 2022 Applications.

The High Risk Perinatal Program (HRPP) will continue to contract with medical transport companies to provide air and ground transport for high risk pregnant women and neonates in need of inter-facility transport to a higher level of care. Transport providers obtain authorization and administrative specialty program direction from a board-certified maternal fetal medicine specialist or neonatologist contracted with ADHS. HRPP provides financial assistance for qualifying maternal or neonatal transports and requires contracted transport companies to write off the remaining balances after the established family liability has been met.

In 2021, HRPP added a newly built hospital to the contract bringing the total to 27 hospitals.  HRPP contracts with all Level II, IIE and III hospitals certified by the Arizona Perinatal Trust (APT) to provide the appropriate level of neonatal care. HRPP also will continue to contract with neonatology groups to provide risk appropriate medical care to enrolled infants during hospitalization. HRPP provides limited financial assistance for families who have no other form of payment for inpatient services.

As a result of the increase in infants born with substance exposure, HRPP will continue to partner with 'SENSE' (Substance Exposed Newborn Safe Environment), led by the Arizona's Department of Child Safety (DCS). The primary goal of SENSE is to ensure substance exposed infants and their families are provided with a coordinated and comprehensive array of services once discharged from the hospital. HRPP also opened enrollment to allow all babies diagnosed with neonatal abstinence syndrome (NAS) to be automatically eligible regardless of the number of days in the newborn intensive care unit (NICU).  Beginning in July of 2021, HRPP will also collaborate/contract with Hushabye Nursery.  Hushabye Nursery opened its doors in November of 2020 and offers a safe and inclusive space where mothers, family members and babies from conception through childhood can receive integrative care and therapeutic support that offers each child the best possible life outcomes. Programs will include prenatal and postpartum support groups, inpatient nursery services and outpatient therapies. Hushabye is a free-standing, non-profit organization whose mission is to ‘embrace substance exposed babies and their caregivers with compassionate, evidence-based care that changes the course of their entire lives.’

HRPP contracts with eight agencies which cover the entire state and employ over 40  Community Health Nurses (CHN), who will provide support to families as they transition out of the Special Care Nursery or NICU to home. CHNs will continue to conduct developmental (i.e., Ages & Stages Questionnaire [ASQ]), physical and environmental assessments; the Edinburgh Postnatal Depression Scale (EPDS) screening; inter-conception education and support; and provide referrals to community services. HRPP will work with BWCH’s Children and Youth with Special Health Care Needs (CYSHCN) team to link families with services for children with special health care needs and work with the Newborn Screening Program (NBS) to ensure infants who require a second screening receive it. HRPP will continue to collaborate with MIECHV Strong Families Arizona Network to provide professional development for CHNs. HRPP home visiting is funded in part by State funds, MCH funds, and MIECHV funds.

HRPP plans to continue to offer virtual visits as an alternative to in-person visits (once the program does go back into homes). The virtual visits will be used as needed in between in-home visits.  In certain situations virtual visits act as a transition to the in-person home visit, allowing the nurse to establish a rapport with the family as some families seem comfortable initially doing virtual visits.

Currently, HRPP is in the beginning stages of researching the implementation of the evidence-based Maternal Early Childhood Sustained Home-visiting (MECSH) program. This program is implemented by nurses for families at risk of poor maternal and child health and development outcomes. It was developed as an effective intervention for vulnerable and at-risk mothers living in areas of socio-economic disadvantage.  MECSH draws together available evidence on the importance of the early years, children’s health and development, the types of support parents need, parent-infant interaction and holistic, ecological approaches to supporting families. MECSH uses a tiered service model, which encompasses the primary health care and more specialized services that families may need.

Furthermore, BWCH will continue to convene an internal home visiting workgroup to support the goals of shared vision for home visitation within the Bureau, improve communication and coordination among Bureau home visiting programs, and identify opportunities for collaboration and alignment of strategies where applicable. The BWCH Home Visiting Workgroup will continue to monitor trends and impacts of COVID-19 to ensure alignment in strategies to support home visiting programs.

BWCH will continue to support statewide participation in the home visiting database management system for all of its home visiting programs. This initiative will continue to be a partnership between home visiting programs housed within BWCH (Health Start, MIECHV, and HRPP CHN) and the Office of Assessment and Evaluation. The aim of this initiative is to consolidate measures; identify rich data sources; reduce unnecessary data collection; and provide consistency to data collection tools and methods at the field level that will provide instant feedback to evaluate programmatic performance and outcomes of each of their programs.

BWCH will continue to implement the Pregnancy Risk Assessment Monitoring System (PRAMS). BWCH will leverage Title V and other federal and non-federal funds to further support its ongoing implementation.  If PRAMS meets the 2020 CDC threshold of at least a 50% response rate, 2020 data will be shared in 2021 to describe the maternal and infant populations in Arizona and to assess possible associations between perinatal health outcomes and maternal characteristics. Additional information regarding PRAMS is mentioned in the Women's Health 2019 Annual Report and 2022 Application.

In 2022, the Arizona's Child Fatality Review (CFR) program will offer additional training to law enforcement agencies, medical examiners, and other first responders.  These trainings aim to increase awareness and understanding of the Arizona Child Fatality Review Program as well as the associated Arizona State Statutes; increase understanding the use of the SUID Investigation Reporting Form and basic Sudden Unexpected Infant Death Investigation (SUIDI) concepts; demonstrate how to perform a doll re-enactment for a SUIDI; and teach first responders the importance of the doll re-enactment for the SUIDI in regards to determination of cause and manner of death. These trainings are scheduled to occur every other year (offset with the pause of the 2021 training due to the COVID-19 pandemic); the next training is scheduled for February 2022.

Arizona Revised Statute 36-3506 requires law enforcement to utilize the Infant Death Investigation Checklist as a part of their investigations involving infants. In 2019, the CFR program adopted the Centers for Disease Control’s Sudden Unexpected Infant Death Investigation Reporting Form (SUIDIRF) for all investigations surrounding Sudden Unexpected Infant Death (SUID). Additional training on the use of SUID doll reenactments is also provided to better assist agencies with understanding the manner and cause of an infant's death. Additional proposed 2022 activities for Arizona's CFR program are included in the Children's Health 2022 Application (with exception of the Safe Sleep and SUID efforts listed here).

Safe Sleep priorities for 2022 will focus on the following strategies. The Safe Sleep Task Force will continue to partner with key community stakeholder from around the state to accelerate improvements that prevent and reduce infant deaths through collaborative learning, quality improvement, and innovation.  Arizona plans to reduce unsafe sleep related deaths by improving safe sleep practices to decrease the SUID mortality rate caused by unsafe sleeping conditions by 5%.  Arizona also plans to work toward the reduction of disparities between White and Non-Hispanic Black and American Indian/Alaska natives by 3%. Arizona continues to focus on three key partnerships to promote safe sleep practices: birthing hospitals, home visiting, and licensed and unlicensed child care. Arizona's activities to address primary drivers of safe sleep include:

• Adding safe sleep modeling to annual skills training as part of the Strong Families AZ Learning Festival;
• Using Safe Sleep Crib Cards as visual reminders for hospital staff staff that would like to participate in the distribution and education of safe sleep;
• Standardizing safe sleep messages for all home visiting programs;
• Standardizing education and training for home visitors on current AAP guidelines;
• Developing standardized safe sleep message with input from community partners;
• Support local county health department Safe Sleep initiatives through the Healthy Arizona Families Intergovernmental Agreement (MCH HAF IGA); 
• Engaging grandparents and caregivers on the recommended AAP guidelines; and
• Providing training for nursing and medical schools to help hospitals establish policies.
• Maternal Health Innovation Program to coordinate efforts to train doulas serving tribal communities.

Through this collaborative partnership there was a consensus that it be recommended that all birthing hospitals participating in the distribution of the crib cards develop a safe sleep policy to further educate staff and ensure the same standard of care.  Besides the crib cards education and distribution Title V funding will also continue purchase pack ‘n plays and provide technical assistance on distribution to our county partners, including tribal communities, as funding allows. The goal is that 75% of all birthing hospitals participate in the distribution of and education of patients using the crib cards. In 2022, the Safe Sleep Task Force will continue to support birthing facilities in developing and implementing safe sleep policies for their patients. In addition, ADHS’s Child Fatality Review program will continue to partner with the Maricopa Medical Examiner’s Office to provide training and continued education on the use of Sudden Unexpected Infant Death doll reenactments to law enforcement and providers all around the state.  Lastly, current local Arizona American Academy Pediatrics (AzAAP) providers are developing a Cognitive Behavior Therapy (CBT) on Safe Sleep for pediatricians to improve their professional practice that will help providers earn credit for Maintenance of Care (MOC) part 4.

In application year 2022, Arizona will support efforts to address Neonatal Abstinence Syndrome (NAS) and newborns exposed prenatally by tobacco, alcohol, and other drugs that are harmful to the newborn. Arizona will attend meetings and collaborate with stakeholders to discuss ideas and next steps around care coordination processes for newborns exposed prenatally and their mothers and families. Arizona will continue to monitor the progress of achieving the goals and priority action steps that were developed in the 2018 Arizona National Governors Association NAS Action Plan, which was sunsetted in conjunction with other key state agencies’ and stakeholders’ strategic plans and implementation efforts.  Arizona will continue to distribute the NAS provider and patient/client informational flyers through the county health departments to reach local medical providers and the communities.  Arizona will also continue to work with the Arizona Statewide Task Force on Preventing Prenatal Exposure to Alcohol and Other Drugs to increase awareness of Substance Exposed Newborn (SEN) best practices at the hospital setting and to support universal screening of prenatal and postpartum mothers and newborns.

Arizona will continue to monitor the incidence of NAS and other substance exposures, but strategies will be focused on the larger universe of the opioid epidemic. In application year 2022, ADHS will continue to implement the CDC Overdose Data To Action (OD2A) and SAMHSA's State Opioid Response (SOR) grants that focus on the prevention of opioid drug misuse, abuse, and overdose fatalities. As part of these grants, ADHS works in collaboration with various state agencies, county health departments, local substance abuse coalitions, and other key partners on the implementation of the state's opioid action plan.

ADHS will continue to provide technical assistance to ten (10) county health departments on the implementation of local overdose fatality review (OFR) teams; analyze and disseminate overdose data; increase the capacity of county health departments to deploy and distribute Naloxone; provide support and training on linkages to care; and enhance public access and application of data from multiple sources. This includes providing assistance with increasing public awareness related to prescription drug  and illicit substance misuse and abuse; encouraging the adoption of safe opioid prescribing practices by healthcare providers; and distributing and encouraging the use of the Arizona Opioid Prescribing Guidelines, the Guidelines for Identifying Substance Exposed Newborns, and the online continuing medical education course on safe opioid prescribing practices.

In 2022, BWCH will continue to explore the opportunity to combine the People of Color, Infant Mortality workgroup with the Maternal Mortality Task Force with the intent of aligning maternal and infant mortality and morbidity strategies in Arizona. The goal of the group would be to convene a combined group of stakeholders with a vested interest in addressing the underlying factors associated with health disparities in infant mortality rates among American Indians, Hispanic/Latinos and African Americans in Arizona. BWCH, through the Office of Assessment and Evaluation, completed the Perinatal Periods of Risk (PPOR) analysis to inform the workgroup strategies.  Based on the analysis, the workgroup has identified areas to implement prevention efforts to address the highest risk factors for high-risk populations including: inadequate weight gain, no prenatal care, multiple gestation, and previous preterm birth. Additionally, focused intervention efforts will be aimed at addressing unsafe sleep environments as excess deaths in the infant health period were attributed to an unsafe sleep environment.   Therefore, BWCH will continue to partner with the Maternal Mortality Task Force to focus efforts and build out a plan that aligns with the Maternal Mortality Action Plan; exploring the opportunity to develop a Maternal and Infant Mortality Action Plan.  Planned activities for 2022 include: coordinating efforts with the Maternal Mortality Task Force, strategic planning, and continuing to fund a Maternal and Infant Mortality Summit. 

To support NPM 4: Breastfeeding, BWCH, in partnership with the Bureau of Nutrition and Physical Activity (BNPA), will continue to support breastfeeding initiatives through training, technical assistance, policy and procedures, and direct support services. In addition, BNPA, through the Maternal, Infant, and Early Childhood Home Visiting (MIEHCV) grant, will provide training and support for home visitors to become International Board Certified Lactation Consultant (IBCLC) certified or receive in-depth breastfeeding education and training.

The Bureau of Nutrition and Physical Activity (BNPA) has a number of planned activities for 2022 related to the promotion of breastfeeding as funds are available. The LATCH-AZ conferences will be scheduled twice yearly as education and networking sessions.  These sessions will aim to attract at least 300 WIC staff, peer counselors, Strong Families AZ home visitors, and community partners.  In addition, the International Board of Certified Lactation Consultants (IBCLCs) Mentoring Program will provide at least four education sessions designed specifically for the candidates to prepare for the examination.  A minimum of four 5-day-long Breastfeeding Boot Camps will be held. At least one of the four sessions will be virtual and one will be held in Tucson; the remaining sessions will be hosted in Phoenix.

In order to focus on the education of other community professionals, BNPA will continue to provide lactation partnership meetings with a minimum of regional community forums, to identify goals and objectives in order to extend exclusivity in breastfeeding. The implementation of the virtual support groups and breastfeeding courses for families throughout Arizona were identified to be a need in 2021 and will be expanded to statewide services in 2022. Programs related to child care centers, health care providers, and workplace accommodation programs will continue to be supported but not a focus for 2022.  BNPA has applied for additional funding that would allow for continued and increased efforts in these areas; as well as increased awareness and education around safe breastfeeding and trauma-informed approaches.

To support families, children and parents with newborns, BWCH and BNPA will continue to coordinate efforts to maintain the Title V toll-free MCH Helplines. The dedicated service includes three helplines: 1. Breastfeeding; 2. Women's, Infant, and Children (WIC) Program; and 3. Children’s Information Center.  Information is provided in English, Spanish and Telecommunications Device for the Deaf (TDD). The Breastfeeding Helpline will continue to provide 24-hour breastfeeding support in 2022.  BNPA will use information gathered from these calls to guide the development of additional training and educational materials.  The website will be evaluated to provide the most updated resources that align with the American Academy of Pediatrics (AAP) and other relevant guidelines recommended by national subject matter authorities as an ongoing effort to maintain up to date information and user friendly resources. Additional information about the Children’s Information Helpline can be found in the Children’s Health 2022 Application. 

Newborn Screening (NBS) is a coordinated system with partners who collaborate to ensure every newborn receives a screening as well as the appropriate follow-up services, care, and intervention.  In 2022, as COVID-19 restrictions are lifted, the NBS Program will reintroduce its efforts to partner with the High Risk Perinatal Program (HRPP), Community Health Nurses (CHN).  This partnership will continue to support efforts to identify infants who need a repeat screening due to an abnormal prior screening and ensure that those infants receive appropriate screening. Additionally, infants with newly diagnosed conditions will be referred to the CHNs for extra support for the parents/caregivers in caring for their infant with special healthcare needs. The Office of Newborn Screening (ONBS) will continue to provide refresher training and resources to CHNs at the annual HRPP conference, as needed. In 2022, a planning team made up of the BWCH Home Visiting Workgroup (HRPP, Health Start and MIECHV funded home visitation programs) and NBS will explore opportunities to improve follow-up services and intervention strategies. The goal will be to identify gaps and strategies and map out a process for how home visitation programs can support families whose infants require a second screening or repeat screening.

Laboratory analysis remains a core function of the ONBS and the program will continue to provide data on blood spot and newborn hearing screening. ONBS and Office of Children’s Health, Children with Special Healthcare Needs (CSHCN) Program, will continue to partner with data sharing and outreach projects related to sickle cell disease and sickle cell trait. Additionally, the ONBS will continue to partner with the CSHCN Program on a project to lend out otoacoustic emissions (OAE) hearing screening equipment to midwives in the community to ensure that hearing screening is available to those newborns who are born outside of a hospital. Over the past several years, and especially since COVID-19, there has been an increase in babies born outside of a hospital (see data in the Infant Health 2020 Annual Report).  This has increased the need for additional screening equipment available to loan to midwives around the state, especially in more rural areas where access to loaner equipment is lacking.

The NBS program will support the purchase of additional screening equipment, training, calibration and supplies needed to continue to offer this service.

The Title V Program will continue to support staff time (a little under .5 FTE) within the Arizona Birth Defects Monitoring Program (ABDMP), housed within ADHS’ Office of Public Health Statistics, to collect and analyze information on children with reportable birth defects diagnosed within the first year of life and coordinate with other Title V-funded efforts to prevent birth defects (e.g., Preconception Health Alliance) and referral to services (e.g., through home visiting programs), to ensure children and families affected by birth defects have access to appropriate services. ABDMP will continue to provide annual data to BNPA to guide and support the state’s folic acid distribution program, PowerMeA2Z. More information about the ABDMP can be found in the Infant/Perinatal Health 2020 Annual Report and the CSHCN domain of this application.

BWCH will partner with Count the Kicks to plan a full campaign and training in Arizona.   Establishing a partnership with Count the Kicks will help build awareness among women in their third trimester and decrease stillbirths in Arizona. According to Count the Kicks Arizona profile, Arizona loses, on average, 489 babies a year due to stillbirth and, on average, 158 babies could be saved every year.  Participating states have shown a significant decrease in stillbirth rates after a five-year investment. More information can be found in the Women’s Health 2022 Action Plan.