For Perinatal and Infant Health (PIH), New York’s Title V Program selected NPM 3: Percent of very low birth weight (VLBW) infants born in a hospital with a Level III+ Neonatal Intensive Care Unit (NICU). This National Performance Measure (NPM) was selected because of its relevance to quality and systems of care for high-risk and vulnerable infants. While NPM 3 specifically measures site of delivery for very low birth weight infants as one critical indicator of care, the NYS Title V program views this indicator more broadly as part of a continuum of supports, services, and systems of care for infants, people who are pregnant, people who recently gave birth, parent/caregivers, families, and service providers. This broader approach aligns with several priorities voiced by families in NYS’s needs assessment, including awareness of community resources and services, enhancing supports for families, improving people’s health care experiences, and fostering community engagement and empowerment.

In addition, New York’s Title V Program established one State Performance Measure (SPM) for this domain, state-wide improvement from 74.34% to greater than 85% of newborn bloodspot samples received at the lab within 48 hours of collection. This SPM was developed to reflect the state’s continued commitment to ensure that every newborn in the state receives newborn bloodspot screening as a public health service to identify and support infants with a wide range of medical conditions. As a population-based program, the Newborn Bloodspot Screening program is an integral part of the state’s public health system for supporting the health and lifelong well-being of newborns and their families.

A focus on improving services and outcomes for infants is supported by other measures assessing the perinatal period. The proportions of low birth weight (8.2%) and preterm (9.2%) births in NYS have not changed for years; racial and ethnic disparities continue. Non-Hispanic Black infants represent significantly more low birth weight births (13.3%) and preterm births (13.3%) than non-Hispanic white infants (6.3% and 7.7%, respectively). NYS has improved the proportion of pregnant people entering prenatal care during the first trimester to 80.6%, but disparities persist with only 71.8% of non-Hispanic Black and 74.7% of Hispanic pregnant people beginning early prenatal care compared to 85.7% of non-Hispanic White pregnant people. In Title V led community forums, community members expressed that they do not “feel heard” by their health care providers, that their concerns and treatment preferences are not taken seriously, and that providers do not care about them or understand of what they are going through. They indicated people avoid seeking care and services because they feel judged or anticipate being treated poorly. Participants indicated that people would be more likely to visit a provider who shows compassion, has been trained about bias and cultural competence, and who is relatable (i.e., from the community and speaks their language).

During the forums, many families expressed the need to raise awareness about available community resources and services, especially for postpartum depression, and to increase the availability and scope of services to support families in the postpartum period, including postpartum doulas, home visitors, community health workers, and breastfeeding support. According to the 2020 Pregnancy Risk Assessment Monitoring System Report, 10.0% of NYS women reported experiencing depressive symptoms after giving birth.

NYS historically has been a leader in establishing systems of perinatal regionalization, with consistently high performance in this measure. Building on that success, the NYS Title V Program is currently engaged in a multi-year effort to expand and update perinatal regionalization standards and designations for the state’s birthing hospitals and centers. As this work progresses, it is essential to closely monitor NPM-3 and other related measures to ensure that quality of care and key health outcomes are maintained or improved.

Both NPM-3 and SPM-1 align with the NYS Prevention Agenda goal to reduce infant mortality and morbidity.

Three specific objectives were established to align with this performance measure:

Objective PIH-1: Increase or maintain the percent of very low birth weight infants born in a hospital with a Level III+ NICU by 2.4%, from the 2017 level of 91.2% to 93.4% by 2022. (NYS Vital Statistics Birth Data)

Objective PIH-2: Decrease the infant mortality rate by 2.6%, from 4.6 deaths per 1,000 live births in 2017 to 4.49 deaths per 1,000 live births in 2022 (NVSS).

Objective PIH-3: Improve the timeliness of Newborn Blood Spot samples received at the NYSDOH Wadsworth Laboratory from 74.3% to greater than 85% of samples received within 48 hours of collection by September 2023. (Newborn Bloodspot Screening program data)

Five strategic public health approaches were identified to accomplish these objectives over the next five years. These are presented in the State Action Plan Table, and each is described in more detail here, with specific program and policy activities that will be implemented to advance the broader strategic approach in the upcoming year.

Strategy PIH-1: Integrate specific activities across all relevant Title V funded programs to promote access to early prenatal care, birthing facilities appropriate to one’s needs, postpartum care, and infant care.

Consistent with a life course perspective, improving birth outcomes for infants requires attention to health and health care services for infants, parents/caregivers, and people of reproductive age (see MWH above for additional discussion). NYS has made significant strides to reduce infant mortality and morbidity yet work remains. Timely and comprehensive prenatal and postpartum medical visits are essential to providing prevention education and anticipatory guidance, screening for risk factors that may negatively affect the health of the neonate, managing chronic conditions and pregnancy complications, and connecting families with a wide array of community services and social supports to holistically address the health and wellness needs of pregnant people, neonates, and new families. 

Several Title V funded programs, including Maternal and Infant Community Heath Collaboratives (MICHC) (ended 6/30/22); Perinatal and Infant Community Health Collaboratives (PICHC; began 7/1/22); and the NYS Perinatal Quality Collaborative (NYSPQC), play a direct role in promoting comprehensive health and wellness of neonates through population-based systems, public health interventions, and delivering or linking people to health care services. Additionally, Title V-funded staff provide oversight of several programs and initiatives relevant to the strategies of this domain, including the Newborn Screening Program (NSP) and Regional Perinatal Centers (RPCs). The RPC grant program was funded by Title V until April 2022, when a state appropriation was passed in the 2022-23 state budget.

The Title V Program will lead the following specific program and policy activities to advance this strategy over the upcoming 2022-23 year:

• Activity PIH-1.1: Across all Title V funded programs, enhance promotion of the NYS Growing Up Healthy Hotline to increase awareness of available community resources, supports, and services including Supplemental Nutritional Programs for Women, Infants and Children (WIC) Program, Medicaid, family planning, home visiting, prenatal care, and the NYS Early Intervention Program.
• Activity PIH-1.2: Through the PICHC and Maternal, Infant, and Early Childhood Home Visiting (MIECHV) programs, integrate use of a birth plan including a discussion of appropriate Level of care (LoC) (high risk = higher LoC) for childbirth.
• Activity PIH-1.3: In collaboration with OPCHSM, review and approve applications to establish midwifery-led and physician-led birth centers across New York State (see Domain 1 Women and Maternal Health (WMH) for details).
• Activity PIH-1.4: Support new and ongoing messaging, educational, and social marketing campaigns to promote perinatal and infant health, such as messages related to the safety of birthing hospitals, maternity care options (levels of care and types of care providers), perinatal mood and anxiety disorders, and vaccine promotion tailored to individuals who are pregnant, neonates/infants, their parents/caregivers, and families.
• Activity PIH-1.5: Through the Regional Perinatal Centers (RPCs) and networks of affiliate birthing hospitals, support and enhance capacity to provide high quality perinatal telehealth services and perinatal subspecialty providers, particularly to rural communities and communities with disproportionate access to such services. Title V staff will collaborate with OPCHSM on the oversight of $5M in state capital funding earmarked to support perinatal telehealth (see Activity WMH-1.2 for additional details).
• Activity PIH-1.6: Through the PICHC and MIECHV programs, integrate use of virtual home visiting services to increase acceptance and support of services for hard-to-reach families (See Activity WMH-1.3 for details).
• Activity PIH-1.7: Through the PICHC and MIECHV programs, support community health workers (CHWs) to engage high-risk pregnant and postpartum families in consistent, comprehensive preventive and primary care services, including newborn care, screening, and assisting families in enrolling in health insurance, and providing families with social support to enhance health literacy and use of health care (See Activity WMH-1.4 for additional details).

Strategy PIH-2: Implement updated perinatal regionalization standards, designations, and structured clinical quality improvement initiatives in birthing hospitals and centers.

NYS has been a longstanding national leader in implementing statewide systems of regionalized perinatal care. NYS’s regulations for perinatal regionalization and designation, as well as perinatal care services, were last updated in 2000 and 2005, respectively. It is imperative for NYS to ensure all perinatal hospitals are functioning in accordance with current standards of care for both obstetrical and neonatal outcomes. Since 2017, the Title V Program has worked to update these regulations to reflect current national standards of obstetrical and neonatal care and perinatal levels of care; changes in health care systems and reimbursements, as well as hospital restructuring and other corporate structural changes. As part of the regulation development process, Title V Program staff conducted an extensive review of current standards, in consultation with a 49-member multi-disciplinary Expert Panel and other topical expert consultants. Additionally, the proposed regulations further integrate recently established midwifery birth centers, along with physician-led birth centers, into the perinatal regional system, and place a greater emphasis on quality care and patient safety, particularly for obstetrical patients.

Current efforts to strengthen this public health system includes increased efforts to address maternal morbidity and mortality, integration of physician- and midwifery-led birth centers into the regional systems, and increased access to ancillary services such as alcohol and substance use and mental health services, directly and/or through referral and commensurate with the birthing facility’s level of care.

The NYSDOH submitted the regulatory package for approval in September 2020. In May 2021, a Midwifery Birth Center Accreditation bill was passed by both houses of the legislature and signed by Governor Hochul on December 30, 2021. A subsequent Chapter Amendment to incorporate accreditation into the Certificate of Need process and require additional perinatal regionalization-related requirements beyond the scope of birth center accreditation was passed by both houses and signed by Governor Hochul in early March 2022. This bill caused unanticipated delays as adoption as written would have affected the regulatory package’s MBC section significantly. At time of writing, the full regulatory package has been resubmitted for NYSDOH and external approval and submission for publication in the State Register (anticipated Summer 2022) and anticipates adoption of regulations by December 2022.

Working within this statewide system of perinatal regionalization, NYS’s Title V Program implements the NYSPQC, which aims to provide the best, safest, and most equitable care for pregnant and birthing people and infants in NYS by collaborating with birthing hospitals, perinatal care providers, and other key stakeholders to prevent and minimize harm through the translation of evidence-based guidelines to clinical practice. The NYSPQC has adapted the Institute for Healthcare Improvement (IHI) model for Idealized Perinatal Care and Breakthrough Series Methodology as a framework to guide improvement. Key NYSPQC activities include:

• embedding evidence-based guidelines into practice
• strengthening collaboration and communication within and among neonatal and obstetric providers, administrators, and organizations
• fostering prepared and proactive care teams
• assessing, conducting, and sharing surveillance and performance data on maternal and neonatal health indicators
• evaluating and measuring performance continuously
• setting priorities and implementing a comprehensive strategy for benchmarking and data driven quality improvement (QI) activities
• providing topic-specific, intensive QI supportive activities, trainings and toolkits that are all-inclusive packages to facilitate improved clinical outcomes, excellent patient care and efficient resource allocation
• researching best practices
• reassessing outcomes of performance improvement interventions continually.

Specific priorities set by the NYSPQC are implemented by all participating NYS birthing hospitals and partners to improve outcomes for perinatal care. Analysis of NYSPQC project data provided by participating birthing hospitals helps to improve services and systems related to perinatal health care.

The NYS Title V Program will lead the following specific program and policy activities to advance this strategy over the upcoming 2022-23 year:

• Activity PIH-2.1: Establish regulations to require birthing hospitals to provide referral and support for ancillary services, including mental health, alcohol and substance use treatment and other services. (See also Activity WMH-2.1.)
• Activity PIH-2.2: Assess perinatal designation surveys and site visit findings, communicate with birthing hospital staff on identified issues, and issue final designations for perinatal levels of care.
• Activity PIH-2.3: To improve coordination and increase bilateral referrals between birthing hospitals and home visiting programs:

• 2.3a: Title V staff will continue to assist in connecting PICHC and MIECHV funded home visiting programs with their local birthing hospitals and support formal meetings where possible. Resources will be shared with programs and evaluation surveys conducted to determine use and effectiveness of resources.
• 2.3b: Title V staff will share promising and best practices from established home visiting-birthing hospital partnerships across the state to encourage collaboration (see Activity WMH-2.3 for additional details).
• 2.3c: Title V staff will also collaborate with PICHC, MIECHV, WIC and OCFS on the WIC Referral Project and the State MIECHV CQI project, to improve bi-directional referrals between local WIC sites and local MICHC and MIECHV home visiting programs.

• Activity PIH-2.4: Continue collaboration with other NYSDOH units to support the programmatic review to establish midwifery-led birthing centers through national accreditation and streamlined Certificate of Need application, and support integration of these facilities into the regional perinatal system as a critical foundation for obstetrical and neonatal patients who are at low risk.

• 2.4a: Collaborate with OPCHSM and the Division of Legal Affairs to review, update and promulgate MBC-specific regulations following enactment of New York’s MBC Accreditation Law (anticipated March 2022). These regulations or guidelines are separate from the perinatal regionalization and perinatal services regulations mentioned previously, although they encompass overlapping parts of regulation.

• Activity PIH-2.5: Collaborate with stakeholders to educate OB/GYN and family practice providers about changes to local birthing hospitals’ level of perinatal care designation.

Strategy PIH-3:  Apply public health surveillance and data analysis findings to improve services and systems related to perinatal and infant health care.

Data-driven, evidence-based, or informed practice is essential to achieving public health goals for Maternal and Child Health (MCH). Across all Title V funded programs, continuous effort is needed to enhance the collection, analysis, and sharing of data to inform the planning and implementation of MCH programs and policy work. Sharing data with stakeholders, including providers and community members, is critical to raise awareness, empower community action, and facilitate quality improvement efforts at all levels.

The NYS Title V Program will lead the following specific program and policy activities to advance this strategy over the upcoming 2022-23 year:

• Activity PIH-3.1: Collaborate with the Office of Children and Family Services, PICHC, MIECHV and local WIC programs on the WIC Referral Project and the State MIECHV CQI project, to improve bi-directional referrals between local WIC sites and local home visiting programs (see Activity WMH 2.3c for additional details).
• Activity PIH-3.2: Lead quality improvement projects through the NYSPQC, with birthing hospital teams and community-based organizations, with a focus on:

• 3.2a: Reducing maternal morbidity and mortality by improving the assessment, identification, and management of care for pregnant and postpartum people with OUD (see Activity WMH 3.4 for additional details).
• 3.2b: Improving the identification, standardization of therapy, and coordination of aftercare for infants with NAS.
• 3.2c: Improving infant outcomes, with a focus on those in the NICU, by improving equity and increasing the practice of family-centered care.
• 3.2d: Improving outcomes for all NYS birthing people by focusing on racial justice and birth equity (see Activity WMH 3.5 for additional details).
• 3.2e: Increasing provider knowledge and birthing hospital protocols related to the COVID-19 vaccination for the perinatal population and their families.
• Activity PIH-3.3: Summarize, share, and discuss findings and recommendations of the Maternal Mortality Review Board (MMRB) with key stakeholders, including the Maternal Mortality and Morbidity Advisory Council (MMMAC) and American College of Obstetricians and Gynecologists District II of New York (ACOG-NY), to inform statewide prevention strategies to improve maternal outcomes. This will include the development of issue briefs webinars, quality improvement projects through the NYSPQC, and a maternal mortality report and an Executive summary document. (See Strategy WMH-3 and Activities WMH-3.1, 3.2 and 3.3 for additional information.)
• Activity PIH-3.4: Establish a comprehensive perinatal data warehouse of perinatal outcomes to make data available in a timely way to birthing hospitals and support quality improvement activities.
• Activity PIH-3.5: Collaborate with NYSDOH AIDS Institute and the New York City Department of Health and Mental Hygiene on efforts to address significant increases in the number and rate of infectious (primary, secondary and early latent (P/S/EL)) syphilis among New York State females of childbearing age, and number and rate of congenital syphilis (CS) cases.
• 3.5a: Support the develop a statewide CS Strategic Plan and support the implementation of priority activities.
• 3.5b: Support distribution of NYSDOH-issued locally tailored and statewide health advisories to alert health care professionals of P/S/EL syphilis and CS surveillance trends, screening requirements and recommendations, and appropriate treatment regimens.
• 3.5c: Promote clinical education opportunities to birthing hospital staff, provided through the NYSDOH-supported Clinical Education Initiative and other CDC-funded provider training initiatives.
• 3.5d: Provide periodic updates and resources for community-based providers that engage with pregnant clients, to promote awareness of STIs that can affect pregnancy, fertility and the health of a fetus or newborn.

Strategy PIH-4: Apply a health equity lens to Title V activities that addresses social determinants and reduces disparities identified by surveillance, research, and community members that impact infant health and use of perinatal and infant health care and support services.

As noted in other domains, perinatal and infant health outcomes are impacted by the social determinants of health (SDOH), or the conditions in which people are born, live, work, play, learn, and age. SDOH include factors like socioeconomic status, education, community environment, employment, social supports, and access to health care services. Systematic differences in the distribution of power and resources due to racism and other biases are root causes of inequities in access, availability of services, and quality of care. All ten priorities that emerged from community members' input during the Title V Needs Assessment revolve around SDOH and inequities. These factors and inequities impact the health outcomes of both individuals and entire communities.

Efforts to improve infant health outcomes must focus directly on addressing longstanding and persistent racial and ethnic disparities in infant health. This persistence of disparities in most of our major health indicators clearly shows that while evidence-based interventions can affect positive change, they alone are not enough to address the larger issues contributing to health inequities. NYS’s Title V Program thus seeks to combine the strength of data-driven, evidence-based, or evidence-informed programs and interventions with authentic community engagement opportunities across all Title V funded programs that address perinatal and infant health, including discussions and actions related to racial justice, as well as strengthening community-based and clinical/provider relationships, to increase equity in access to health care and social support services. Title V funded programs seek to engage and empower individuals, families, and communities by increasing awareness of available community resources and supports; working with community stakeholders to improve delivery of care and services; and enhancing social support, health literacy, and self-care and advocacy skills for pregnant and parenting families.

The Title V Program will lead the following specific program and policy activities to advance this strategy over the upcoming 2022-23 year:

• Activity PIH-4.1: Title V staff will distribute a Parent Portal resources flyer, developed by the NYS Council on Children and Families to birthing hospital/center obstetrical, neonatal, and social work/patient discharge planning teams. Evaluation will include development of follow-up to assess usage of the resource by institutions, as well as monitoring referrals from birthing hospitals to PICHC as reported via the DMIS.
• Activity PIH-4.2: Through the PICHC program, work with diverse community stakeholders including community residents to identify and collaboratively address issues and barriers impacting maternal and infant health outcomes at the community level (see Activity WMH-4.1 for further detail).
• Activity PIH-4.3: Through the PICHC and MIECHV programs, provide supports to individual clients and their families to address social determinants of health outcomes. Provide information on community resources, screen and assist families in enrolling in health insurance and health care, work directly with families to strengthen health literacy, self-care, and advocacy skills, and provide and enroll families in enhanced social supports and educational opportunities (see Activity WMH-4.2 for further detail).
• Activity PIH-4.4: Through the NYSPQC, continue to develop and lead a new quality improvement project with birthing hospital teams and community-based organizations, to improve outcomes for all infants admitted to Neonatal Intensive Care Units (NICUs) and their families by focusing on racial justice and birth equity.

Strategy PIH-5: Maintain and strengthen a robust statewide population-based Newborn Bloodspot Screening Program (NBSP).

The NYS NBSP is a population-based program and public health system that identifies infants who may have a rare, but treatable disease through bloodspot screening shortly after birth. Within NYSDOH, the NBSP is housed and administered by the Wadsworth Center, NYS’s public health laboratory, with direct support from Title V and several other state and federal funding sources. The NBSP currently performs laboratory testing for 50 diseases, following national recommendations for NBS programs. The program ensures that every newborn in the state receives newborn bloodspot screening as a public health service, with no fee for testing. The program also performs follow-up case management to ensure newborns with a positive screening result receive appropriate diagnostic testing and treatment. Specialty Care Centers are certified and monitored to ensure newborns have access to specialty care for disease-specific testing and management. In addition, the NBSP contracts with each of the state’s 10 Inherited Metabolic Disease (IMD) Specialty Care Centers to enroll patients with an IMD diagnosis identified by newborn screening in the NYS Newborn Screening Patient Registry. These IMD Specialty Care Centers are responsible for entering and tracking for consented patients annually and for attending an annual meeting to discuss long-term follow-up data. Patients are monitored until age 18, when the individual must consent to continue participation until age 21. In 2021, the program screened 211,203 infants, 99.97% of all NYS resident infants born that year (See Form 4 for further details).

NBSP practices continuous quality improvement using LEAN principles, with a focus on improving overall efficiencies, reducing false positives, and improving timeliness in newborn screening for time-critical conditions. The program also strives to promote the growth of the field of NBS by promoting the development of its staff, participating in national committees, conducting pilot studies, and training other state newborn screening programs. The NBSP collaborates with other public health programs to support mutual goals. For example, the NBSP collaborated with the state’s Early Hearing Detection and Intervention (EHDI) program on a project to send letters to primary care providers regarding newborns requiring follow-up for failed newborn hearing screening. The NBSP has identified a need for continued education for primary care providers on newborn screening and genetics.

COVID-19 presented unique challenges and barriers to the NBSP, including challenges related to site visits at hospitals during this public health emergency, as well as system-wide delays in shipping that affected the ability to meet the state performance measures of samples being received within 48 hours of collection. To address and reduce the impact of these barriers, the NBS program continued to use established protocols for conducting virtual site visits developed in early 2020, to conduct virtual site visits. Despite these challenges, the NBSP anticipates that these issues will not affect the 2022-23 program year and has identified several activities to continue to support efforts to meet the SPM.

The Title V Program will collaborate with the NBS program on the following activities to advance this strategy over the upcoming 2022-23 year:

• Activity PIH-5.1: NBSP staff will continue to conduct virtual site visits and in-person visits when appropriate with birthing facilities and hospitals to provide education to the hospital staff about Part 69-1, newborn screening regulation and compliance. The site visits are part of a birth hospital Continuous Quality Improvement (CQI) initiative supported by the Association of Public Health Laboratories to improve pre-analytic turnaround times (from collection of newborn dried blood specimens to receipt of specimens by the Program).
• Activity PIH-5.2: Continue implementation and evaluation of a hospital late collection (>120hr) follow-up process with birth hospitals, to ensure timely collection and mitigate any risks of hospital staff oversight.
• Activity PIH-5.3: Continue supporting the ongoing CQI initiative at the 10 Inherited Metabolic Disease (IMD) Centers for Short-term Follow-up compliance. Individual quality reports with the following outcome measures will be provided to each of the 10 IMD Center Directors: total number of referrals for center, percentage/number of referrals closed more than 90 days, percentage/number of referrals lost-to follow-up, and the NYS overall averages in each category. Standard operating procedures for follow-up practices at the Centers will be requested and reviewed. A similar project was completed with the Endocrine Specialty Care Centers in the past (2019-2020).

The NYS Title V Program established one Evidence-Based Strategy Measure (ESM) to track the programmatic investments and inputs designed to impact NPM-3:

ESM PIH-1: Percent of birthing hospitals with final level of perinatal care designation, in accordance with updated regulations and standards.

Data for this measure will come from hospital surveys and site visit reports from the NYSDOH subrecipient (IPRO) and NYSDOH staff. The baseline value for this measure will be determined after regulations are adopted. The program has set a goal to update designations for 50% of hospitals within one year post-adoption and 100% within three years of adoption.