PERINATAL/INFANT HEALTH DOMAIN

Nebraska Application for the 2019-2020 Year

 

In this section, Nebraska MCH Title V describes activities of the upcoming year, October 1, 2019 to September 30, 2020 for the Perinatal/Infant Health Domain.  Also discussed is the relevance of the activities and ESMs to priorities, as well as any updates in the priorities, evidence-based or evidence informed strategies, and performance measures. The numerical sequence of headings used below references the new narrative format found on pages 35-36 of the Title V MCH Services Block Grant to States Program: Guidance and Forms for the Title V Application/Annual Report, Eighth Edition.

The Nebraska Priorities in the Perinatal/Infant Domain are:

• Infant Mortality

NPM: Percent of infants: placed to sleep on their backs; placed on a separate sleep surface; placed to sleep without soft objects or loose bedding.

ESM: The number of birthing hospitals and pediatric clinics that become Champions of the Nebraska Safe Babies Campaign.

 

• Infant Abuse and Neglect

SPM: The rate per 1,000 infants of substantiated reports of child abuse or neglect.

ESM: none

 

• Breastfeeding of Infants

NPM: Percent of infants ever breastfed; and percent breastfed exclusively through six months of age.

ESM: The number of health providers participating in certified lactation counselor training who are minority women.

 

For the Perinatal/Infant Health Domain in 2019-2020, there are no changes in the population priority statements, the selected NPMs and SPM respectively.  The ESM for infant mortality is slightly revised, in order to add pediatric clinics to birthing hospitals as Champion sites in the Nebraska Safe Babies Campaign.   

 

1. Description of Planned Activities

Steady progress in this domain is projected to continue, with the leadership of Title V Maternal Infant Health team member Jackie Moline, growing the Nebraska Safe Babies campaign to include abusive head trauma as well as safe sleep; and to include pediatric and family practice clinics as well as hospitals as Champions in prevention. The steady growth and engagement of birthing hospitals as pledged and then Champions has expanded the visibility and the credibility of the Title V MCH program in Nebraska. 

 

Consumer Engagement in this domain:

Title V interacts with many “consumers” in this domain, not the least of which are the 50+ birthing hospitals that represent the necessary link to parent and caregiver education and preparation upon arrival of a newborn infant. Tapping into the communication and leadership styles of these organizations to mobilize their participation and follow-through as champion hospitals is no small feat once, yet many are returning for a second campaign.

 

A very important area where Title V, through relationship with N-MIECHV, comes even closer to consumers occurs through partnering to reach all N-MIECHV families with safe sleep environmental assessment, teaching, and support for safe sleep practices.  This interaction with at-risk families remains an anchor in the Title V action plan for this priority, even as systems-level action steps shift from focus on Nebraska Safe Babies to making better use of Pregnancy Risks Assessment Monitoring System (PRAMS) data.

 

The Power of Collaborative Partnerships

In addition to the state’s birthing hospitals, Nebraska Title V has many collaborative partnership in the population domain of Perinatal/Infant Health.  Discussed in the Women/Maternal Health population domain and equally relevant here are Title V staff participation: in the Community of Practice with tribal health departments; on prenatal care and breastfeeding; and Nebraska Title V involvement with the Nebraska Perinatal Quality Improvement Collaborative (N-PQIC) as board member, as member of the new Nebraska AIM (Alliance for Innovation on Maternal Health) Maternal Advisory group, and annual Summit planning committee member.  Title V staff also participate as planning committee members for the annual March of Dimes Prematurity Summit.

 

Title V has also sustained a long-time relationship with the Nebraska Breastfeeding Coalition, recently incorporated into the Nebraska Perinatal Quality Improvement collaborative.  Related to breastfeeding support and unique contributions of Title V is the expertise of the Maternal Infant Health nurse consultant on the topic of milk-soy protein intolerance, a frequently requested teaching and resource topic.

 

Priority: Reduce Infant Mortality

2019-2020 Objective and Strategies

 

• Objective P4a (new):  By 2020, ensure that existing PRAMS resources regarding infant mortality and its prevention are based on NE data, evidence-based practices, and CLAS standards.

 

Summary of Proposed Strategies: Work with Pregnancy Risk Assessment Monitoring System (PRAMS) workgroups to update fact sheets, create new social media tools and otherwise put PRAMS data in use to reduce infant mortality.

 

• Objective P4b: By 2020, increase by 10% adoption of safe sleep practices among at-risk families.

 

Summary of Proposed Strategies: N-MIECHV will assemble materials to develop a toolkit for Home Visitors including information on safe sleep practices, abusive head trauma prevention, and other home safety topics.  N-MIECHV will disseminate toolkit to other home visiting programs statewide, and follow up at six months regarding utilization.

 

Discussion of Activities for this Priority

The strategies for this priority shift away from the successful Nebraska Safe Babies campaign, which will continue with core activities but for the most part is successfully implemented. In the spring of 2019, the PRAMS steering committee met and identified updating PRAMS fact sheets and other messaging approaches as an action priority, to put Nebraska PRAMS data to better use aligned with Title V priorities to reduce infant mortality.  The Title V action plan for the priority of Infant Mortality thus represents this shared alignment and the Title V reciprocal commitment to engage in the data and messaging update effort during 2019-2020.

 

As noted in the introduction to this section, a very important area where Title V, through relationship with N-MIECHV, has access to consumers is through the practice of home visitors.  This linkage with home visitors in the field and at-risk families remains an anchor in the Title V action plan for this priority, even as systems-level action steps shift from focus on Nebraska Safe Babies to making better use of PRAMS data.  In 2019-2020, Nebraska plans to take another step forward in performance measurement by reaching out to home visiting programs six months after launch of a resource toolkit on safe sleep and abusive head trauma prevention, to measure utilization by home visitors and impact on families.  

 

Results-based Accountability (RBA) for this Priority

Reflecting a trend in the team use of RBA measures in Title V, there are only four measures proposed for 2019-2020 compared to five in 2018-2019. The selected RBA measures focus on the effective relationship between Title V and N-MIECHV in Nebraska; increased intentionality to measure impact and significance of activities; and the capacity of N-MIECHV to set benchmark measures backed by a robust data system.

 

Results Based Accountability (RBA) measures Reduce Infant Mortality
	2018-2019	Proposed for 2019-2020
How much did we do?	How many safe sleep educational sessions provided?   Number and % of N-MIECHV homes with sleep environments assessed.	Number and % of N-MIECHV homes with sleep environments assessed.    How many home visiting programs or home visitors received the safe sleep toolkit.
How well did we do it?	How many hospitals became Safe Sleep champions?   Number and % of messages/materials produced/disseminated about safe sleep meeting CLAS and literacy standards.	After six months, the number and percent of home visitors stating they were aware of the toolkit and had used it.
Is anyone better off?	Number and % birthing hospitals providing feedback about the safe sleep activity.	Home visitors in N-MIECHV record environmental assessments and teaching for parent/caregiver 80% of the time (visiting a home with infant < 1 year)

 

Priority:  Reduce Infant Abuse and Neglect

2019-2020 Objectives and Strategies

 

• Objective P6b: Increase by 10% the percentage of community providers routinely screening for maternal depression in pregnant and postpartum women.

 

Summary of Proposed Strategies: Promote best practices in maternal depression screening/universal assessments at the annual Current Practices of Maternal Behavioral Health conference.

 

Discussion of Activities for this Priority

This priority area has been scaled back considerably for 2019-2020 to focus on the single intervention of delivering health provider education annually on maternal depressing including screening, at the annual Current Practices of Maternal Behavioral Health conference.  Previous activities and interventions resulting in the design, testing, and dissemination of the Crying Plan are considered complete and will not see new activity in 2019-2020.

 

Results-based Accountability (RBA) for this Priority

Reflecting a trend in the team use of RBA measures in Title V, there are only three measures proposed for 2019-2020 compared to five in 2018-2019. The selected RBA measures focus on the delivery of the annual Current Practices of Maternal Behavioral Health Conference, as a vehicle both to reach a relevant audience and to take measures from the audience in the form of program evaluations.

 

Results Based Accountability (RBA) measures Reduce Infant Abuse and Neglect
	2018-2019	Proposed for 2019-2020
How much did we do?	Number of participants at CPMBH conference and number of sessions on maternal depression screening.    Number and % of consumers in hospital survey providing feedback about Crying Plan.	Number of participants at CPMBH conference and number of sessions on maternal depression screening.
How well did we do it?	How many hospitals became AHT prevention champions?     Number and % of materials produced/disseminated about AHT prevention meeting CLAS and literacy standards.	CPMBH conference includes inequities and culture in presentations on maternal depression.
Is anyone better off?	% CPMBH participants identifying change in practice r/t maternal depression screening.	% CPMBH participants identifying change in practice r/t maternal depression screening.

 

Priority: Increase Breastfeeding of Infants

2019-2020 Objectives and Strategies

 

• Objective P5a: Increase by 10% the percentage of Nebraska birthing hospitals adopting breastfeeding friendly practices.

 

Summary of Proposed Strategies: The Maternal Infant Health program will collaborate with the Nebraska Perinatal Quality Improvement Collaborative to improve Nebraska's mPINC score (the maternal practices in infant nutrition and care survey of hospitals conducted by CDC).

 

• Objective P5b: Increase the number of African American and American Indian Women who are breastfeeding their babies any amount at 6 months of age.

 

Summary of Proposed Strategies: Repeat the LEARN (Lactation Education Across Rural Nebraska) project with a priority on recruitment of minority nurses or other providers working with minority women to become Certified Lactation Counselors. Monitor impact of new CLCs on serving minority mothers and evaluate past CLCs sustained impact with local mothers. Continue to facilitate the Tribal health Community of Practice, with periodic calls to discuss topics of shared interest, including breastfeeding initiation and longevity, and ways to improve outcomes.

 

Discussion of Activities for this Priority

As discussed earlier for this population domain, strong collaboration between Title V and the Nebraska Perinatal Quality Improvement Collaborative have proven fruitful, and extend to Title V joining an N-PQIC led project to improve Nebraska’s mPINC score, which at this time is assigned a “71” out of a possible score of 100, and landed 50th out of 53 states and jurisdictions in the rating. (Find the most recent report, from 2015: https://www.cdc.gov/breastfeeding/pdf/mpinc/states/2015/nebraska-2015-mpinc-report.pdf.)  More recent data is expected in 2019-2020.

 

In 2019-2020, the LEARN project will see another iteration, undertaken with collaborative partners and using Title V resources and influence to assure outreach and, if needed, scholarships and resources for nurses of minority group heritage, and/or nurses who work with disadvantaged populations. In addition to evaluation reports as have been produced for each LEARN project cohort, in 2019-2020 an overall project evaluation encompassing all cohorts will be planned and conducted.

 

As noted in the Maternal/Women’s Health Domain application discussion, the Tribal Health Department Community of Practice that has been led by Rayma Delaney of the Title V MCH team, with assistance from Jackie Moline, RN, Maternal Infant Health program coordinator, will continue.  The Community of Practice has evolved and is becoming a tool for Tribal staff to utilize as a means to learn from each other and share information.

 

Results-based Accountability (RBA) for this Priority

The RBA measures for this priority in 2019-2020 reflect shifts in program activities.  The Children’s Healthy Weight CoIIN has ended.  The Tribal Community of Practice is planned for continuation, addressing both the priority of Prenatal Care as well as Breastfeeding, however the RBA measures for the Tribal Community of Practice will in 2019-2020 appear only in the Prenatal Care priority area. For 2019-2020 RBA measures in the Breastfeeding domain will focus on the LEARN (Lactation Education Across Rural Nebraska) project, with another project iteration of (preferred) minority nurses participating in training to become Certified Lactation Counselors, and an evaluation activity of LEARN overall.

 

Results Based Accountability (RBA) measures Increase Breastfeeding of Infants
	2018-2019	Proposed for 2019-2020
How much did we do?	How many CHW CoIIN BF activities attended?   How many Tribal CoP activities attended?	An evaluation of LEARN is completed.
How well did we do it?	What % of participants in LEARN represent minority groups?    Number and % of materials produced/disseminated related to BF meeting CLAS and literacy standards.	What % of participants in LEARN represent minority groups?   How many LEARN participants passed the certification exam.
Is anyone better off?	How many LEARN participants passed the certification exam.	The monitoring project for LEARN participants measures the minority states of women served.

 

2. Alignment of Planned Activities with priority needs.

 

Priority: Reduce Infant Mortality

As a data set, the Pregnancy Risk Assessment Monitoring System (PRAMS) was developed in 1987 to reduce infant morbidity and mortality by influencing maternal behaviors before, during, and following pregnancy.  It is the only surveillance system that provides data about pregnancy and the first few months after birth. Title V support of the PRAMS goal to move data to action informs the evidence base and assists partners and stakeholders in identifying strategies to reduce infant mortality that are grounding in Nebraska-specific data. The home visiting universe is open to Title V through a close relationship with N-MIECHV, and as a result continuing to channel safe sleep messaging and environmental assessment through evidence-based home visiting is an effective and durable strategy.

 

Priority:  Reduce Infant Abuse and Neglect

One of the core innovations of Title V during the current five-year cycle is The Crying Plan.  While not represented in the 2019-2020 strategies, hopefully some impact evaluation might yet occur. The single strategy represented in the priority domain for 2019-2020 is the promotion of maternal depression screening at the annual Current Practices of Maternal Behavioral Conference. Unfortunately, without greater context, this might be taken to suggest that depressed moms are the primary source of infant abuse and neglect in Nebraska.  

 

Priority: Increase Breastfeeding of Infants

Nebraska identifies three key activities to improve breastfeeding initiation and longevity in Nebraska, and address disparities in breastfeeding between ethnic/racial groups of women. These are: a collaboration to improve breastfeeding support in birthing hospitals, efforts to improve diversity among Certified Lactation Counselors, and the Tribal Health Department Community of Practice.  All three are aligned with the priority.

 

3. Have new priorities emerged, taking precedence over established needs?

Strongly reinforcing to Title V priorities is the addition, in 2018, of Improving Birth Outcomes to the DHHS Business Plan. Having this MCH-inspired priority in the department business plan raises visibility to stakeholders, leaders, and policy makers, as well as serving as a new platform for engagement by partners.

 

SNAPSHOT: PUBLIC INPUT

In June 2019, Title V conducted a public input activity for stakeholders on the proposed 2019-2020 action plan. There were 32 unique respondents.  Comments were contributed as Concerns, Needs, and Suggestions.

In the section “Concerns” twenty comments were recorded for the Perinatal Infant domain. Eight identified concerns about access to quality child care.  Six comments named access to health care.  Three comments named maternal drug use and drug-exposed infants.  Three comments were about improved parental supports including education. Also included were remarks about social determinants of health, including transportation, language barriers, housing, education, poverty. (Abstracted 7/10/2019 KKRN)

 

4. Relevance of current ESMs for a selected NPM and determine if new ESM needs to be established.

 

Priority: Infant Mortality

NPM: Percent of infants: placed to sleep on their backs; placed on a separate sleep surface; placed to sleep without soft objects or loose bedding.

ESM: The number of birthing hospitals and pediatric clinics that become Champions of the Nebraska Safe Babies Campaign.

 

ESM changes:  In 2017-2018: The percent of infants whose sleep environments are assessed (in N-MIECHV) at least once by 6 months of age. In 2018-2019: The number of birthing hospitals that become Champions.  In 2019-2020: The number of birthing hospitals and pediatric clinics that become Champions in the Nebraska Safe Babies Campaign.  This progress over time represents the growing stages and phases of the Nebraska Safe Babies Campaign.  In 2018-2019, the Maternal Infant Health Program and collaborators began collaborating with a large local pediatric clinic to test adaptions of the campaign for the outpatient pediatric and primary care clinic setting.  In 2019-2020, the Campaign for clinic sites will be expanded.

Priority: Infant Abuse and Neglect

SPM: The rate per 1,000 infants of substantiated reports of child abuse or neglect.

ESM: None.

 

Priority: Breastfeeding of Infants.

NPM: A) Percent of infants who are ever breastfed B) Percent of infants breastfed exclusively through 6 months.

ESM: The number of health providers participating in certified lactation counselors training who are minority women.

 

The ESM is relevant to the NPM and to Nebraska’s priorities by measuring a strategy to increase the diversity of Certified Lactation Counselors in Nebraska, as a means to address the differential measured in breastfeeding initiation and longevity between racial and ethnic groups of women.

 

5. Are Changes needed in established SPMs and SOMs? 

 

Priority: Infant Abuse and Neglect

SPM: The rate per 1,000 infants of substantiated reports of child abuse and neglect.

 

This is the only SPM identified in the Perinatal-Infant Domain.  There are no changes planned for this SPM.

 

6. Updates to the five year action plan table that reflect new or revised priority needs, evidence-based or evidence-informed strategies or performance measures for driving improved performance.  

 

Priority: Infant Mortality

As compared to the 2018-2019 action plan for the Perinatal Infant Domain, changes in the action plan for Infant Mortality priority in 2019-2020 include:

• Continued implementation of the Nebraska Safe Babies campaign is removed from the action plan.  While the campaign itself will continue, it will no longer be a focus of the action plan.
• A new action plan strategy is for the PRAMS program, with Title V support from MCAH staff, MCH Epidemiology and others, to update fact sheets, create new social media tools and otherwise put PRAMS data to use to reduce infant mortality.
• Remaining of the original safe sleep promotion strategies in the Title V workplan is N-MIECHV developing and disseminating a toolkit on safe sleep practices to home visiting programs statewide, and conducting a followup activity regarding uptake and utilization.

 

At the website, www.mchevidence.org, the evidence analysis for promoting safe sleep position offers the following trends from peer-reviewed evidence:

• Interventions targeting caregivers only appear to be somewhat effective.
• Interventions implemented at the caregiver, health care provider, and hospital levels without quality improvement initiatives appear to be effective.
• Interventions implemented at the caregiver, health care provider, and hospital levels with quality improvement appear to be somewhat effective.
• National campaigns appear to be effective.
• Due to the limited scope of included studies, there is less clear evidence of the effectiveness for interventions focusing on health care providers or child care providers only.

 

Priority: Infant Abuse and Neglect

In the Infant Abuse and Neglect priority, changes in the 2019-2020 action plan, as compared to that of the previous year, include:

• Limiting the action plan to a single strategy, to promote best practices in maternal depression screening at the annual Current Practices of Maternal Behavioral Health.
• Removing from the action plan strategies about The Crying Plan and the Abusive Head Trauma aspect of the Nebraska Safe Babies campaign, launched in 2018-2019. This includes a strategy to introduce a depression screening tool into WIC clinics, and a mapping strategy related to tele-behavioral health.

 

For evidence supporting strategies to prevent child maltreatment, the website, www.mchevidence.org refers to the evidence collection of the Child Safety Network (https://www.childrenssafetynetwork.org/sites/childrenssafetynetwork.org/files/Evidence-Based%20Strategies%20FINAL.pdf) Here, two evidence-based interventions are offered one of which is pertinent to the Perinatal-Infant population:

• Early childhood home visitation programs effective in reducing reported child maltreatment; and
• School based child sexual abuse prevention programs effective in increasing knowledge and protective behaviors among elementary school students.

 

Priority: Breastfeeding of Infants.

In the Breastfeeding priority, the following changes appear in the action plan:

• Nebraska is no longer participating in the Children’s Healthy Weight CoIIN, Breastfeeding Workstream, so that strategy is removed.
• Other action steps remain unchanged.

 

For evidence supporting strategies to promote breastfeeding initiation and duration, the website www.mchevidence.org offers the following:

• Lactation consultant interventions and home visits provided by professionals (other than lactation consultants or peer counselors) appear to be effective for increasing both breastfeeding initiation and exclusivity at 6 months.
• Peer counselor interventions appear to be effective and are more likely to influence initiation than exclusivity at 6 months.
• There is less clear evidence to support the WIC food package change, group education, or hospital policies.

Additionally, emerging evidence is noted as follows:

• There is emerging evidence that an intensive, hospital-based quality improvement and technical assistance intervention to improve compliance with the Ten Steps to Successful Breastfeeding program appears to be effective through the following: skin-to-skin care after cesarean delivery was significantly associated with increased breastfeeding initiation and exclusivity in all races; rooming in was significantly associated with increased exclusive breastfeeding in African American infants only.