In the application year 2024, 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. BWCH will continue to support NPM 4 and NPM 5 and utilize Title V Needs Assessment data to inform strategies. At the conclusion of this narrative Family Engagement projects will be shared.

In 2024, all activities under each priority will be assessed annually and categorized using Levels of Public Participation (Inform, Consult, Involve, Collaborate, Empower) to identify the appropriate level of public participation and engagement for each activity, as found in Appendix H. Levels of Public Participation. The Perinatal/Infant health population domain will continue implementing Health Equity and Family Engagement activities. The Health Equity activities are identified in italics throughout the report and the Family Engagement 2024 activities for each population domain are highlighted in the CYSHCN 2024 Action Plan narrative.

Arizona’s Title V Program works to address NPM 6: Developmental Screening 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 2024, 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). Arizona will be adding a new evidence-based nurse home-visiting model, the Maternal and Early Childhood Sustained Home-Visiting (MECSH) with the Oral Health Module in identified at-risk communities throughout the state. 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 2024 Action Plans.

The High-Risk Perinatal Program (HRPP), funded through Title V and state-appropriated funds, 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 the ADHS. HRPP provides financial assistance for emergency maternal and neonatal transports and requires contracted transport companies to write off the remaining balances after the established family liability has been met.

The HRPP contracts with all Level II, IIIA, IIIB, and IV hospitals certified by the Arizona Perinatal Trust (APT) to provide the appropriate level of neonatal care. In 2024, as the APT continues to recertify hospitals based on new standards of care, the HRPP will continue contracting with newly established Level II, IIIA, IIIB, and IV perinatal care centers to ensure program services are being offered to all eligible infants in Arizona. The HRPP also will continue to contract with neonatology groups to provide risk-appropriate medical care to enrolled infants during hospitalization.

The HRPP will coordinate with the Arizona Department of Child Safety (DCS) to determine how the program can support and partner with 'SENSE' (Substance Exposed Newborn Safe Environment). 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. The HRPP will continue to allow infants with a diagnosis of neonatal abstinence syndrome (NAS) to be automatically eligible regardless of the number of days in the newborn intensive care unit (NICU). The HRPP will continue to collaborate and contract with Hushabye Nursery and Jacob’s Hope, free-standing, non-profit organizations whose mission is to ‘embrace substance-exposed babies and their caregivers with compassionate, evidence-based care that changes the course of their entire lives’. The HRPP contracts with eight (8) Community Health Nursing (CHN) agencies that cover the entire state and employ over 40 CHNs, who will provide support to families as they transition out of the Special Care Nursery (SCN) or NICU to home. CHNs will continue to conduct developmental (e.g. 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. The HRPP will continue to work with the ADHS Newborn Screening Program (NBS) to ensure infants who require a second screening are identified promptly and administered a second screening. The HRPP will continue to collaborate with MIECHV Strong Families Arizona Network to provide professional development for CHNs.

HRPP plans to continue to offer virtual visits as an alternative to in-person visits. 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 socioeconomic disadvantage. MECSH draws together the 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 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 a 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 to ensure alignment in strategies to support home-visiting programs. The workgroup 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 Bureau of Assessment and Evaluation. This initiative aims 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.

Pregnancy Risk Assessment Monitoring System (PRAMS) is a joint research project between the Arizona Department of Health Services and the Centers for Disease Control and Prevention (CDC) that aims to find out why some babies are born healthy and others are not by asking new mothers in Arizona about their behaviors and experiences around the time of their pregnancy. Findings from AZ PRAMS guide infant health strategies. Housed within the ADHS Bureau of Assessment and Evaluation, AZ PRAMS is predominantly funded through the CDC but receives supplemental funding through the Justice Reinvestment Fund (state) and Title V to enhance program reach. AZ PRAMS asks infant health-related questions such as low birth weight, preterm birth, breastfeeding, newborn sick visits and well-baby check-ups, baby sleep location, and baby sleep positioning. Over the past year, AZ PRAMS saw an increase in response rates from June 2022 at 37.30% to June 2023 at 52.33%. AZ PRAMS surpassed the nationwide all-site average response rate by 4.27%. This notable improvement can be attributed to the creation of new positions and the hiring of three PRAMS staff members in 2023, resulting in response rates through phone interviews rising from 5.43% (June 2022) to 13.90% (June 2023). In 2024, AZ PRAMS will implement a new “Phase 9” survey that will be available in three (3) modes: web (new), paper, and interview. Following the launch of the PRAMS data dashboard, ongoing efforts will revolve around disseminating data and enhancing the turnaround time for data sharing and reporting. AZ PRAMS will continue to collaborate with the Navajo Nation, the Inter Tribal Council of Arizona, and the Preconception Health Alliance to distribute and translate data into actionable changes.

In 2024, 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 on the use of the Sudden Unexpected Infant Death (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 determining the cause and manner of death. These trainings are scheduled to occur every other year. The next training is scheduled for Spring 2024.

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.

According to the 2022 Child Fatality Review Report, there were 65 SUIDs in Arizona in 2021 and unsafe sleep environments were identified in 95% (62/65) of them. Arizona’s Title V Program works to address NPM 5: Safe Sleep through the following strategies.

The Safe Sleep Task Force will continue to partner with key community stakeholders from around the state to accelerate improvements that prevent and reduce infant deaths through collaborative learning, quality improvement, and innovation. Key stakeholders include the Department of Child Safety, Safe Kids Coalitions, county health departments, March of Dimes, AzAAP, Arizona Perinatal Trust, Health Start, Tribal Injury Prevention, Indian Health Services, First Things First, and many others. 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 programs, 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;
• Distribute Safe Sleep Crib Cards, which hospital staff can share with families to teach them about Safe Sleep environments and practices, to birthing hospitals;
• Standardizing safe sleep messages for all home visiting programs;
• Standardizing education and training for home visitors on current AAP guidelines;
• Developing standardized safe sleep messages 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;
• Providing training for nursing and medical schools to help hospitals establish policies; and
• Coordinating efforts to train doulas serving tribal communities through the Maternal Health Innovation Program.

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 across hospitals. The goal is that 75% of all birthing hospitals participate in the distribution of and education of patients using crib cards. In 2024, 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 AzAAP providers also developed Cognitive Behavior Therapy (CBT) on Safe Sleep for pediatricians to improve their professional practice which will help providers earn credit for Maintenance of Care (MOC) part 4.

Title V funding will also continue to be used to purchase cribs (Pack ‘n Plays) that are provided to families without a safe sleep environment at home in conjunction with safe sleep education for the family. The ADHS Injury Prevention Program Manager will continue to provide technical assistance on the distribution of Pack ‘n Plays to our local partners, including county partners and tribal communities, as funding allows.

The All Babies Cry model empowers new mothers and fathers with practical demonstrations of infant soothing and clear strategies for managing normal stress in parenting. In 2024, ADHS Injury Prevention Manager will continue to work with Prevent Child Abuse of Arizona and participating hospitals Mount Graham, Yavapai Regional Birthing Center, Banner Gateway, Banner Desert, Carondelet St. Joseph's, Tucson Medical Center, and Kingman Regional Center. ADHS will pause onboarding additional hospitals as The Children's Trust of Massachusetts is currently undergoing leadership changes.

In the application year 2024, Arizona will support efforts to address Neonatal Abstinence Syndrome (NAS) and newborns exposed prenatally to 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 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 in 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 exposure and will continue its work to improve the NAS and substance exposure surveillance system to enhance the reporting system to ensure all cases are captured in the data collection.

Strategies will be focused on the larger universe of the opioid epidemic and addressing women and substance use and overdose risk. In the application year 2024, 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 collaborates with various state agencies including, county health departments, local substance abuse coalitions, and other key partners implementing 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 assisting 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 2024, BWCH will continue efforts to carry out the Fetal-Infant Mortality Action Plan (FIMAP) through the BWCH and BAE-led Fetal-Infant Mortality Workgroup. The goal is to convene internal team members with a vested interest in addressing the underlying factors associated with health disparities in infant mortality rates among American Indians, Hispanics/Latinos, and African Americans in Arizona. The purpose will be to carry out the Fetal-Infant Mortality Action Plan (FIMAP) and the long-term goal is the alignment of maternal and infant mortality and morbidity strategies in Arizona. BWCH in partnership with BAE will co-lead these efforts and will be responsible for leading all aspects of the FIMAP. Planned activities for 2024 include: carrying out the Fetal-Infant Mortality Action Plan (FIMAP); the formation of an Infant Health Task Force (IHTF); and the development of a Fetal-Infant Mortality Review (FIMR) team. BWCH will utilize Title V funds to support the facilitation of the workgroup and task force activities. BWCH will need to seek additional funding to support the development of an FMIR team. The goals of the FIMAP are based on the top areas of fetal-infant mortality needs: 1) Reduce prematurity/preterm births; 2) Prevent birth defects; 3) Strengthen systems of care for mothers and infants; 4) Diversity and strengthen the workforce; 5) Improve surveillance of fetal-infant morbidities and deaths; and 6) Promote optimal fetal-infant health. The goals of the FIMAP will be accomplished through activities implemented by the Infant Health Task Force that will be formed as part of this program. The Infant Health Task Force will be composed of members of the current Maternal Health Task Force, which will include representatives from ADHS and SPHS AIM, along with members from the South Phoenix Alliance for Maternal Health Coalition. Additionally, ADHS will recruit family advisors and key infant-perinatal health partners, with an emphasis on recruiting members that represent the specific population to be served (Black/African American, Native American, and Hispanic current or future parents from at-risk communities), to join the IHTF.

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.

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 several planned activities for 2024 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 six (6) 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.

In 2021, the Arizona WIC Program and external community partners identified a need for more robust community-based lactation support for breastfeeding individuals and lactation support professionals. The Arizona WIC Program does not have the human or financial resources to provide all this support on its own, but they are connected to a rich statewide network of lactation professionals. WIC leveraged this network to bring lactation professionals from other programs and arenas together with community members to build a community-based circle of lactation support for moms and babies. These networks will continue to meet in 2024.

In 2022, virtual breastfeeding support groups were established throughout Arizona and will continue as a statewide service in 2024. Programs related to child care centers, health care providers, and workplace accommodation programs will continue to be supported but will not be a focus for 2024. BNPA continues to look for additional funding that would allow for sustained and increased efforts in these areas as well as increased awareness and education around 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 2024. 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 2024 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 2024, the Office of Newborn Screening (ONBS) looks to continue initiatives with the Title V program, including a successful hearing screening partnership with the CYSHCN Program to provide disposable (probe tips) to use with the otoacoustic emission (OAE) machines, on-loan to midwives or community partners, for an early hearing screening. The ONBS is also looking to return to the successful previous initiative that assists midwives in obtaining critical congenital heart disease (CCHD) screening equipment. This initiative will ensure that pulse oximetry screening is completed on every newborn in their care. These initiatives will increase partnerships with the midwife community as a whole to ensure access to timely newborn screening (bloodspot, hearing and CCHD) is available for all infants in Arizona.

The ONBS is looking to establish a long-term follow-up program to support newly identified infants and their families. The program will collaborate with the High-Risk Perinatal Program (HRPP) and Community Health Nurses (CHN) to ensure that these families receive the support needed in navigating a new diagnosis. 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 follow-up screening. The ONBS will continue to provide refresher training and resources to CHNs as needed. The ONBS will continue to provide NBS data to support the Title V Program.

In 2024, 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’ Business Intelligence Office. AMBDP will collect and analyze information on children with reportable birth defects diagnosed within the first year of life. ABDMP will coordinate with other Title V-funded efforts to work on birth defects prevention efforts (e.g., Preconception Health Alliance, PowerMeA2Z), and promote referrals to appropriate services (e.g., through home visiting programs) to ensure children and families affected by birth defects have access to appropriate care. In 2023-2024, ABDMP plans to pilot a new family support/referral effort for families of children with select birth defects. ABDMP will continue to provide annual data to BNPA to guide and support the state’s folic acid distribution program, PowerMeA2Z. ABDMP will work with ONBS to improve data collection and reporting around neonatal pulse oximetry/CCHD screening. Additionally, as previously discussed, ABDMP also oversees surveillance of Neonatal Abstinence Syndrome (NAS) and works with Title V-funded programs on in-depth analysis of NAS, as well as prevention and intervention projects. More information about the ABDMP can be found in the CYSHCN domain of this application.

BWCH will continue to partner with Count the Kicks into year three (3) activities. More information can be found in the Women’s Health 2024 Action Plan.

In 2024, the Office of Children’s Health will continue to support the Bureau-wide implementation of the Engaging Family and Young Adults Program by managing the contract within the Children and Youth with Special Health Care Needs (CYSHCN) Program awarded to Diverse Ability Inc. and Raising Special Kids. The CYSHCN Program is housed within the Office of Children’s Health and has two family advisors positioned within the program that currently provides insight and feedback based on their lived experience to support the program and offer support to other programs and offices as requested. For Perinatal/Infant Health, similarly to Child Health, the goal is to connect the CYSHCN Family advisors to more opportunities that impact the population served within this priority by connecting to programs like the High-Risk Perinatal Program, Safe Sleep, and Home Visiting. Through that intentional review of the program, a goal in 2024, will be to develop a family or young adult advisor role that will be able to collaborate with initiatives within the Perinatal/Infant domain, specifically to support the launch of the Fetal-Infant Mortality Action Plan and participate as a workgroup member.

Alongside the Perinatal/Infant Health activities and work that will be led by the Office of Children’s Health team and collaborators, the Primary Care Office (PCO), housed within BWCH, will continue their cross-cutting activities relating to Perinatal/Infant Health.

The Primary Care Office (PCO) will continue to lead efforts to improve access to care to all health services in Arizona’s rural and underserved communities through the Arizona State Loan Repayment Program (SLRP), the Behavioral Health Loan Repayment Program, the National Health Service Corps Loan Repayment Program (NHSC), the Nurse Corps, the Accelerated Nursing Programs, the Nursing Education Investment Pilot Program, the Preceptor Grant program, the Conrad 30 Waiver Program, and the National Interest Waiver Program. These programs utilize the Health Professional Shortage Areas of Arizona to prioritize and focus efforts on the recruitment and retention of providers who specialize in Women's Health or Obstetrics and Gynecology, Certified Nurse Midwives, and Pediatrics providers including the specialization in Pediatric Emergency, Pediatric Pulmonology, Pediatric Genetics, Pediatric Gastroenterology and Neonatology.