In application year 2021, 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. 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 IBCLC certified or receive in-depth breastfeeding education and training. Newborn Screening (NBS) efforts, through the partnership between the NBS office and High Risk Perinatal Program (HRPP) Community Health Nurses (CHN), will continue to place emphasis on follow-up screens.  This partnership will continue to support efforts to identify infants who have either not returned for the second screen or who need a repeat screen due to an abnormal prior screening.  Early childhood home visiting programs will continue to educate 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).  To augment reduction of infant mortality and morbidity, BWCH will implement the activities for the upcoming application year outlined under each of the program areas:

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 2021, NBS will continue 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 have either not returned for the second screen or who need a repeat screen 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. In 2021, a planning team made up of 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 screen or repeat screen.

Laboratory analysis remains a core function of the ONBS and the program will continue to provide data on blood spot and early hearing screening. ONBS and Office of Children’s Health, Children with Special Healthcare Needs (CSHCN) 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 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. The program will support training and supplies needed to continue to offer this service. The Title V program will also support the participation of ONBS staff at national conferences targeted at specific disorders identified through newborn screening, such as the annual National Cystic Fibrosis Conference and the annual Early Hearing Detection & Intervention (EHDI) Conference.

The Bureau of Nutrition and Physical Activity (BNPA) has a number of planned activities for 2021 related to the promotion of breastfeeding as funds are available. The LATCH-AZ conferences will be scheduled biannually as education and networking sessions.  These sessions will aim to attract at least 300 WIC staff, peer counselors, Strong Families 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 (4) five-day long Breastfeeding Boot Camps will be held. At least one of the four sessions will be virtual and one will be held in Tuscon; 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 two in-depth sessions targeting community educators.  The implementation of the online breastfeeding courses for clinicians developed in 2017 will continue to be supported and promoted as lactation education virtually is in high demand.  Programs related to child care centers, health care providers, and workplace accommodation programs will be limited in 2021; efforts will be continued but will not be focused in this area.  Additional funding has been applied for that would allow for continued and increased efforts in these areas.

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 Breastfeeding; Women's, Infant, and Children (WIC) Program; and Children Information Center Helplines.  Information is provided in English, Spanish and Telecommunications Device for the Deaf (TDD). Additional information about Children’s Information Helpline can be found in the Children’s Health 2021 Application.  The Breastfeeding Helpline will continue to provide 24-hour breastfeeding support in 2021.  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.

BWCH will continue to implement Pregnancy Risk Assessment Monitoring System (PRAMS). BWCH will leverage Title V and other federal and non-federal funds to further support its ongoing implementation.  PRAMS will use data collected for calendar years 2017 through 2019 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 2021 Application.

Arizona's early childhood home visiting programs provide support for new families to promote positive parenting and child development.  In 2021, 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.  In addition, continued professional development for home visitors and home visiting supervisors will be a priority.  Details for MIECHV and Health Start home visitation planned activities are included in the Children’s Health and Women’s Health 2021 Application.

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.

HRPP will continue to contract with 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.

Community Health Nurses (CHN) will continue to provide support to families through home visitation during the transition of the infant from the NICU to home. CHNs will continue to conduct developmental (Ages & Stages), physical and environmental assessments; the Edinburgh Postnatal Depression Scale (EPDS) screening; inter-conception education and support and make referrals to community services. HRPP will continue to work with BWCH’s Children with Special Health Care Needs (CSHCN) Team to link families with services for children with special health care needs and the Newborn Screening Program (NBS) for infants who require a second screening. 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.

As a result of the increase in infants born with substance exposure, HRPP will continue partnership 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) as automatically eligible regardless of the number of days in the NICU.

MIECHV, Health Start and HRPP home visiting programs, will continue to support and inform the Title V state priority need to increase early identification and treatment of developmental delays and NPM 6 (percent of children, ages 10-17 months, receiving a developmental screening using a parent completed screening tool) by implementing the following measures.  Furthermore, BWCH will continue to convene internal home visiting workgroups 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.

Arizona's Child Fatality Review (CFR) program is included in the Children's Health 2019 Annual Report and Children's Health 2021 Application with exception to the Safe Sleep and Sudden Unexpected Infant Death (SUID) efforts listed here. This upcoming application year, the CFR program will offer additional trainings to law enforcement agencies, medical examiners, and other first responders.  These trainings are scheduled to occur every other year. Arizona Revised Statute 36-3506 requires law enforcement to utilize the Infant Death Investigation Checklist as a part of their investigations involving infants. 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.

Safe Sleep priorities for 2021 will focus on the following strategies. The Safe Sleep Task Force will continue to partner with the Collaborative Improvement and Innovation Networks (CoIIN) 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;
• Using safe sleep bassinet 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;
• Standardizing education and training for home visitors on current AAP guidelines;
• Developing standardized safe sleep message with input from community partners;
• Partnering with community tribal elders on AAP guideline;
• Engaging grandparents and caregivers on the recommended AAP guidelines; and
• Providing training for nursing and medical schools to help hospitals establish policies.

Through the CoIIN initiative and the partnerships 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.  The goal is that 75% of all birthing hospitals participate in the distribution of and education of patients using the crib cards. The Safe Sleep Task Force continues to support birthing facilities in developing and implementing safe sleep policies for their patients. In addition, ADHS Child Fatality Review program partnered 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 providers are developing a Cognitive Behavior Therapy (CBT) on Safe Sleep for pediatricians to improve professional practice that will help providers earn credit for Maintenance of Care (MOC) part 4.

In application year 2021, 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 action steps that were developed in the Arizona National Governors Association NAS Action Plan 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 2021, 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 eleven (11) 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 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.

As part of this initiative, local communities are also encouraged to practice safe prescription drug disposal practices. This includes increasing the public's awareness of available resources, such as the state's DumpTheDrugs website that contains the location of more than 150 sites where people can take their unused medications to be properly disposed.

Moving forward in application year 2021, ADHS will continue to work collaboratively with key partners to monitor the implementation of the Overdose Data To Action strategies, Arizona Department of Health Services Opioid Action Plan, and the State Opioid Response.

In 2021, BWCH will continue to convene the People of Color, Infant Mortality workgroup.  The internal workgroup is currently composed of the Bureau Chief/MCH Director, the MCH Block Grant Manager, and representatives from the Offices of Women’s Health, Children’s Health, Injury Prevention, Assessment and Evaluation, and Children with Special Healthcare Needs.  The goal of the group is to convene a 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) to inform the workgroup strategies.  The PPOR Analysis identified Black/African American and American Indian/Alaska Natives as highest risk populations.  In addition, the highest periods of risk identified in Arizona, per the framework of the PPOR analysis, include maternal health/prematurity and infant health periods. Based on the analysis, the workgroup has identified areas to implement prevention efforts to address the highest risk factors for both high-risk populations including: inadequate weight gain, no prenatal care, multiple gestation, and previous preterm birth. Additionally, focused intervention efforts will be aimed on addressing unsafe sleep environments as excess deaths in the infant health period were attributed to an unsafe sleep environment. 

As a result of the PPOR analysis conducted, Arizona’s highest periods of risk are maternal health/prematurity and infant health periods.  The well-being of mothers and infants determines the health of families and community at-large. Moreover, in addressing maternal health, birth outcomes and early identification and treatment of health conditions among infants are improved and can prevent death or disability and enable children to reach their full potential.  Therefore, BWCH will 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 2021 include: developing an action plan, coordinating efforts with Maternal Mortality Task Force, inviting partners to join the workgroup, presenting PPOR findings to external stakeholders at a virtual Infant Mortality Summit and promoting collective action to address infant mortality; reducing the number of fetal/infant deaths amongst Black/African Americans and American Indian/Alaska Natives.