NPM #3 Perinatal Regionalization – Ensure risk appropriate care for high-risk infants to reduce infant mortality / morbidity.

Risk-appropriate Care

The Division of Community and Public Health and Division of Regulation and Licensure, within the Department of Health and Senior Services (DHSS), will work together to determine best ways to implement the provisions of Senate Bill 50 (SB50). SB50 was passed during the 2017 legislative session, requiring the DHSS to hold public hearings and establish criteria for levels of maternal care designations and neonatal care designations for birthing facilities. SB 50 also requires all birthing facilities to have their levels of care verified every three years by either the American Academy of Pediatrics (AAP), The American College of Obstetricians and Gynecologists (ACOG), or DHSS. As of January 1, 2019, any hospital with a birthing facility and any such hospital operated by a state university shall report to DHSS its appropriate level of maternal care and neonatal care designations.

When Missouri birthing facilities report their neonatal and maternal levels of care, the information is collected through the Centers for Disease Control and Prevention Levels of Care Assessment Tool (LOCATe). LOCATe will identify which facilities have no formal written transfer plan for complicated/maternal patients. The Section for Women’s Health (SWH) will collaborate with Missouri Hospital Association (MHA) to assist identified facilities with incorporating a formal written transfer plan for these high risk patients. Having a written formal transfer plan for complicated/maternal patients in all facilities will ensure a more standardized approach to caring for these high risk patients. This activity will also increase the likelihood of high-risk, very low birth weight babies being born at a level III+ facility, therefore, reducing infant morbidity and mortality. 

The DHSS will continue to participate in the Maternal and Child Learning and Action Network (MC LAN) to assist with implementation of infant morbidity/mortality reduction initiatives throughout the state. The DHSS will provide the neonatal MC LAN stakeholders with pertinent Missouri data and assist MC LAN members with choosing and implementing the first neonatal/infant mortality reduction project. Initial discussions are to complete a project to address the topic of safe sleep or neonatal abstinence syndrome. The goal of the MC LAN is to roll out a neonatal/infant mortality reduction project in year 2020, so working to recruit all hospitals that provide neonatal and children’s services will be important. Similar to the maternal projects through the MC LAN, participating hospitals will be required to submit data through MHA for progress and outcomes monitoring.  

The DHSS will continue to host the Neonatal Abstinence Syndrome (NAS) stakeholder workgroup with the goal of defining statewide resources and identifying gaps. This information will then be used to develop a new 5-year work plan.

17P

Coordinated efforts to promote the appropriate use of 17Alpha-hydroxprogeserone caproate (17P) will provide the unique opportunity to reduce the incidence of preterm births among eligible women. The SWH, along with the Missouri Chapter of the March of Dimes (MOD), will continue to collaborate with OPTUM, an obstetrical homecare service, to increase utilization of 17P to those individuals with a history of a singleton spontaneous preterm birth. Plans are to expand OPTUM services from the I-70 corridor to southern Missouri, specifically the Bootheel region, where prematurity, infant mortality, and disparity rates are the highest in the state. OPTUM will coordinate with physicians to provide weekly, in-person, home administration of 17P, maternal-fetal assessments, and education on risk factors and signs of preterm labor. A trained registered nurse will provide these services. Partnering with OPTUM will also help address the common social determinants of health seen in the Bootheel such as lack of transportation and access to healthcare.

Some barriers associated with the use of 17P include the cost, pain of injection, and its intensive series. At almost $700 per injection, the total cost for 18 to 20 injections is around $14,000 per pregnancy. The injection is also very painful, which decreases the likelihood of compliance for the full course. The 18 to 20 week series makes for a big commitment, especially if lack of transportation plays a part. Some women, especially in the Bootheel region where every county is a designated Health Professional Shortage Area, have to travel approximately 100 miles for high-risk care. This can mean traveling to another large city such as Cape Girardeau or out of the state to Memphis, Tennessee. This is largely due to hospital closures in the Bootheel. During the summer of 2018, Twin Rivers Regional Medical Center, located in Kennett, MO, closed. In an emergent situation, pregnant women may be forced to go to another hospital that does not provide OB services.  

The Newborn Health Program will continue to partner with doctor’s offices, health providers, clinics, Local Public Health Agencies (LPHA), Home Visiting programs, MOD, and other stakeholders to distribute literature to educate women on the benefits of 17P. The program will track the distribution of the resources and obtain feedback from its partners on how these materials were used.

Collaborative Initiatives

The SWH will continue to participate in, as well as be a resource for, the local and regional infant mortality initiatives, including: Generate Health and FLOURISH in St. Louis; the Mother & Child Health Coalition in Kansas City; and Missouri Bootheel Regional Consortium Bootheel Babies & Families initiative in the southeast region of the state. The Mother & Child Health Coalition and Missouri Bootheel Regional Consortium are also the two Healthy Start Grantees in Missouri.

• St. Louis: Generate Health’s initiatives will focus on five strategic priorities, including: health equity, maternal and infant health, perinatal behavioral health, immunizations, and making change happen. FLOURISH St. Louis works in coordination with Generate Health. FLOURISH is a collective impact initiative aimed at making St. Louis a place where healthy babies and families flourish. FLOURISH has five action teams that will focus on the following: prenatal care, infant health, health communication and navigation, transportation, and behavioral health.
• Kansas City: The Mother & Child Health Coalition’s focus is on traditionally low-income families who reside in hard to reach neighborhoods in Missouri and Kansas. They have a special emphasis on cultural competency and strive to help people of all racial, ethnic, and socio-economic backgrounds.
• Southeast Missouri: Bootheel Babies & Families has three key focus areas including healthcare, safe sleep habits, and substance misuse. Safe sleep is the primary cause of infant mortality in that region of the state. They will also continue to organize and host their annual low birth weight conference, which brings together community members, partners, organizations, as well as national speakers.

The Maternal Child Health Services Program will support LPHA and/or community partner efforts to implement education programs for women of childbearing age, pregnant women, families, and providers on the risk of preterm delivery and the need for risk appropriate care for high-risk infants.

In FFY18, the Newborn Health (NH) program partnered with Healthy Birth Day, Inc. to implement and operate a Count the Kicks Public Awareness Campaign program to support pregnant women in Missouri and reduce Missouri stillbirth rates. According to the Centers for Disease Control and Prevention, Missouri has the 21st highest stillbirth rate in the country. Missouri vital statistics show that there are approximately 458 stillborn births each year in the state. The introduction of Count the Kicks in Missouri has the potential to save 119 babies every year if Missouri’s stillbirth rate decreases by 26 percent, as has happened in neighboring Iowa where the campaign began. Count the Kicks teaches the method and importance of counting baby’s kicks in the third trimester of pregnancy. Free Educational materials can be ordered from Count the Kicks at https://www.countthekicks.org/order-materials/. The NH program will continue to partner with a wide range of community health partners to promote the Count the Kicks program.

The Genetics and Healthy Childhood (GHC) Home Visiting Program will provide information and resources to all contracted home visitors on pre-conception and prenatal care including materials from DHSS and the MOD to educate clients on the signs of pre-term labor. GHC Home Visiting Program Managers will review the receipt and use of resources provided during monthly subrecipient monitoring calls. Annual performance measure data will be collected on the percentage of infants who are born preterm to mothers who enrolled in the program prenatally, before 37 weeks gestation. 

The Newborn Screening Program will continue to work towards increasing awareness of newborn screening with the goal of ensuring all newborns have access to newborn screening shortly after birth thereby reducing the risk of mortality/morbidity related to undiagnosed and untreated metabolic, genetic, and endocrine disorders. The Program will continue to work with the Missouri Midwives Association and the Amish and Mennonite communities to provide education and technical assistance when needed. The Newborn Screening Program implemented full population pilot screening for Hunter syndrome in November 2018 and for Spinal Muscular Atrophy in January 2019.

Missouri was among the first states in the country to screen for both of these disorders. Spinal Muscular Atrophy is the number one genetic cause of death for infants; adding this disorder to the newborn screening list has the potential to make a significant impact on infant mortality. It is anticipated that screening and reporting for both of these disorders will be fully implemented in FY 2020.

SPM #1 Breastfeeding – Improve health outcomes for Missouri mothers and infants by increasing breastfeeding initiation and duration rates.

Hospitals

The State Breastfeeding Coordinator will continue to collaborate with the Missouri Breastfeeding Coalition on statewide initiatives, including the Missouri “Show-Me 5” Hospital Initiative and the Missouri Breastfeeding Friendly Worksite and Child Care programs. In collaboration with Department of Health and Senior Services (DHSS) and other supporting partners, such as the Missouri Chapters of the American Academy of Pediatrics (AAP), American College of Obstetricians and Gynecologists (ACOG) and the March of Dimes, the Missouri Breastfeeding Coalition will host a fifth MotherBaby Summit to encourage hospitals to implement Missouri “Show-Me 5” and Baby Friendly Hospital practices. The Missouri Breastfeeding Coalition Board identified lactation training for nursing staff as a major need in Missouri, and an important barrier to Baby Friendly Hospital designation. Statewide training for all health care providers in Missouri will continue with the ultimate goal to increase the number of International Board Certified Lactation Consultants (IBCLCs) in the state. The training “Fundamentals of Breastfeeding: an 18 hour course” will be offered twice at no cost to WIC local agency staff, hospital nurses working with new mothers and infants, and community partners working with breastfeeding mothers.

Local Public Health Agencies (LPHA)

The Bureau of Community Health and Wellness (CHW), through Preventive Health and Health Services Block Grant funds, will assist LPHAs in building their capacity to achieve policy and environmental changes that increase access to healthy foods (including breastfeeding support). The primary objective of services provided by contractors is to increase the capacity of community coalitions within their service area to make measurable improvements in chronic disease related health outcomes.

The Missouri WIC program will provide additional funding through the Breastfeeding Friendly WIC Clinic program to local WIC agencies that provide breastfeeding support beyond what is federally required through the WIC program, which includes providing afterhours support, classes, support groups, breast pumps and working with other community partners to increase breastfeeding awareness. The state will also provide education to local WIC agencies and health department professionals on breastfeeding and work to increase the number of IBCLCs in these facilities, as well as increasing the number of trained peer counselors that can provide mother-to-mother support and encourage partnerships with health care providers and other community organizations. Many of the local agency staff who work in WIC also partner with or work directly on MCH initiatives, and serve many of the same participants. 

The Maternal Child Health Services Program will support LPHA efforts to promote breastfeeding initiation at birth and continuation of exclusive breastfeeding through the first six months of life, and continuation of breastfeeding as long thereafter as mother and child desire, including:

• provision of breastfeeding peer counseling;
• breastfeeding support groups;
• individual, community, and provider education;
• breast pump loan programs; and
• promotion of breastfeeding friendly worksites and child cares.

Breastfeeding Friendly Sites

CHW will partner with the Missouri Chamber of Commerce, the Missouri Chapter of Society of Human Resource Managers, and the Missouri Council for Activity and Nutrition’s Worksites workgroup, to educate employers on the Affordable Care Act (ACA) provision for employers to provide workplace accommodations that enable breastfeeding employees to express breast milk. CHW will continue to recognize employers achieving criteria for the Missouri Breastfeeding Friendly Worksite program. Many local breastfeeding coalitions and LPHA WIC peer counselors will continue doing outreach to businesses about the importance of worksite lactation support.

CHW will provide lactation room mini-grants, to employers to increase interest in the Missouri Breastfeeding Friendly Worksite Program and to assist employers with providing an adequate space for employees to express breast milk. As a result of past efforts, schools, daycares, banks, and other worksites improved their culture to better support lactation in the workplace. Privacy screens, window shades, comfortable chairs, benches, end tables, mini fridges, and other equipment were added to ensure private, comfortable, breastfeeding-friendly areas. Moreover, worksites implemented written policies to ensure these spaces would be sustained and that breastfeeding mothers would be supported moving forward.

Collaboration will continue with the Missouri Breastfeeding Coalition and local breastfeeding coalitions to promote the Breastfeeding Friendly Child Care Program. Similar to the “Breastfeeding Friendly Worksite Award,” the “Breastfeeding Friendly Child Care” award recognizes child care facilities who meet advanced criteria on the topic of breastfeeding support. The Child Care Health Consultation Program (CCHC) provided 7 hours of continuing education training and 1.5 hours of specialized consultation to child care providers that promote child care facilities as breastfeeding friendly both for parents of children enrolled who are breastfeeding and as a breastfeeding friendly workplace for employees who are breastfeeding. LPHAs utilize the CCHC program as a partner in promoting the award, as well as an important source of training. An online training is available for this program due to high provider demand. Both of these award programs are low cost, efficient, and provide realistic means to sustain support for breastfeeding families. Partnering with Child Care Aware, the “Breastfeeding Friendly Child Care” award, and corresponding online training will be promoted, as well as recognizing those who meet the criteria and earn the award distinction. Plans to further promote the award to parents as well as providers is being considered. DHSS and Missouri Council for Activity & Nutrition (MOCAN) will ensure that these two awards are highlighted during all worksite wellness outreach efforts. The MOCAN worksites workgroup encourages businesses to start and implement a wellness program for their staff. The WorkWell Missouri Toolkit was developed to assist employers with reducing risk factors for chronic diseases, poor nutrition (including breastfeeding support), inactivity, stress, and tobacco use. The Toolkit is designed to help organizations assess and improve workplace wellness policies and practices. MOCAN members promote this toolkit as well as partner with organizations assisting businesses in the state to improve health. 

Health Equity

The State Breastfeeding Coordinator will continue to partner with the University of Missouri on breastfeeding research to determine interventions that would decrease disparities in breastfeeding of women of different races, ethnicities, and low socioeconomic status. With leveraged funding from CDC 1807 grant, the state will provide a lactation consultant preparation course yearly for the next 5 years in areas of the state that currently have low breastfeeding rates and disparities in the care available to women of color. Every effort will be made to encourage women of color to become peer counselors or IBCLCs in regions where disparities in care exist.

Resources for Parents

The Bureau of Genetics and Healthy Childhood (GHC), Newborn Health Program participates in statewide educational activities that increase awareness and promote recommended maternal child health practices, including breastfeeding. The Newborn Health Program also provides, free of charge, Missouri’s prenatal and newborn health booklet, Pregnancy and Beyond, as well as other educational literature that raises awareness and educates Missourians on the importance of breastfeeding and directs the public to resources to assist with breastfeeding. In addition to print materials, the Newborn Health Program maintains websites that provide electronic access to similar breastfeeding information/resources. The program will track the distribution of these materials and obtain feedback from its partners on how the materials are used and ways to improve these materials.

The GHC Home Visiting Program’s contracted home visitors will provide education, resources, and support to enrolled prenatal participants to promote breastfeeding initiation and sustained duration. Annual performance measure data will be collected on the percent of infants who were breastfed any amount at 6 months of age among mothers who enrolled in home visiting prenatally. The Home Visiting Program will assess home visitors’ breastfeeding technical assistance needs through monthly subrecipient monitoring and provide resources and training opportunities through ongoing communication including: email; postings on the Missouri Home Visiting Gateway Website (http://health.mo.gov/hvcqigateway/) under resources and weekly updates; during the annual Home Visiting Summit conference, and through the continuous quality improvement home visiting newsletter, Quality Outlook (http://health.mo.gov/homevisiting/cqinewsletters.php). Collaboration with the State Breastfeeding Coordinator and the Home Visiting Program will continue to assure up to date information, training opportunities, and support for all contracted home visitors. 

SPM #2 Safe Sleep – Percent of infants placed to sleep on their backs.

Child Care Providers

The Section for Child Care Regulation (SCCR) is responsible for licensing and regulating child care programs. Through ongoing regulatory inspections, SCCR will verify compliance with licensing rules regarding infant safe sleep. SCCR will educate child care providers about infant safe sleep practices through technical assistance and training. Child care providers that work in programs licensed to care for infants are required to complete department approved training regarding the current American Academy of Pediatrics (AAP) guidelines for infant safe sleep. SCCR is the sole authority for clock hour training approval in Missouri and will continue to review and approve trainings that meet the AAP guidelines. During child care inspections, SCCR staff will review training records to ensure all required staff have successfully completed department-approved training on safe sleep for infants within the required timeframes. Child care providers are required to share their approved safe sleep plan that meets the AAP guidelines with families upon enrollment. By providing new families with the policy that meets the current AAP guidelines, child care providers are able to further advance the educational outreach to families with infant children. The Child Care Enrollment form, which is completed by the parent(s), contains the following acknowledgement, “I have been informed and have received a copy of the facility’s safe sleep policy when enrolling a child less than one (1) year of age.” The parent then initials next to the statement to acknowledge receipt of the information. Section 210.223.4, RSMo requires all employees of licensed child care facilities who care for infants under one year of age, and any volunteer who may be assisting at the facility, to successfully complete department-approved training on the most recent safe sleep recommendations of the AAP prior to initial licensure, within their first 30 days of employment and every three years thereafter. SCCR will review and approve safe sleep training, and ensure training is available via a variety of delivery systems, to increase licensed child care providers’ knowledge of safe sleep practices for infants. As a visual reminder, SCCR developed a Safe Sleep poster specifically addressing infants in group care and ways to maintain a safe sleeping environment that will be distributed to child care providers in the state.

The Child Care Health Consultation (CCHC) Program will continue to assist licensed child care providers in meeting the safe sleep training requirement set forth in Missouri Revised Statute 210.223.4. Consultants will provide department-approved safe sleep training, and provide individual consultations related to safe sleep as needed/requested by child care facilities.

Safe Sleep Resources

The Bureau of Community Health and Wellness (CHW) serves as the state lead for Safe Kids Worldwide to implement and facilitate accomplishment of common goals and objectives concerning childhood injury prevention. CHW also provides funding for nine Safe Kids (SK) coalitions. In FY19, the number of coalitions increased to 10. A new coalition was created in Hannibal, Safe Kids NEMO serving Marion, Ralls, Lewis, Shelby, and Monroe counties. Safe Kids St. Louis also added another county to their coalition, this increased the total number of counties served to 59. All 10 coalitions provide unintentional injury prevention services to children aged 0-19 years. The SK coalitions are led by a variety of agencies including local public health agencies (LPHAs), non-profit entities, and local hospital systems, and they address priorities including crib safety and safe sleep based on community needs. The SK coalitions provide cribs with safe sleep education, conduct media campaigns with prevention messages, and work with policy makers to address gaps in policies that could prevent injuries. The SK coalitions work closely with law enforcement officers, fire fighters, paramedics, medical professionals, educators, parents, businesses, public policy makers, and most importantly parents, children, and adolescents.

All Genetics and Healthy Childhood Home Visiting Program contracted home visitors will actively promote and provide resources on the ABCs (Alone, on their Back, in a Crib) of Safe Sleep. Home visitors will also promote safe sleep in obtaining portable cribs for families who do not have and cannot afford a crib for their infant through the Department of Health and Senior Services (DHSS) Safe Cribs for Missouri program or other local resources. Annual performance measure data on safe sleep will be collected on the percentage of infants enrolled in home visiting who are always placed to sleep on their backs, without bed-sharing, or soft bedding. This data will be collected at age zero, with follow-up continuing through the designated time points of 2, 3, 6, 9, and 12 months. The Home Visiting Program will continue to update and provide all contracted home visitors information on how to obtain portable cribs and create safe sleep environments as recommended by the AAP. This information can be shared with enrolled families through a variety of ongoing communication including: email; postings on the Missouri Home Visiting Gateway Website (http://health.mo.gov/hvcqigateway/) under resources and weekly updates; monthly subrecipient monitoring calls with contracted agencies; during the annual home visiting summit conference; and through the continuous quality improvement home visiting newsletter, Quality Outlook (http://health.mo.gov/homevisiting/cqinewsletters.php).

The Safe Cribs for Missouri Program provides safe sleep educational resources to participating agencies. In addition to the National Institute of Child Health and Human Development SIDS risk reduction online education program currently in use, the Safe Cribs for Missouri Program will expand access to other resources for safe sleep educators. All education programs and resources will comply with the evidence-based AAP safe sleep recommendations. 

The Safe Cribs for Missouri Program will continue to collaborate with the MCH Services Program on the Birth Certificate Project. The program will also collaborate with Children’s Trust Fund, the Department of Social Services Children’s Division and Child Fatality Review Program, Infant Loss Resources, Inc. (formerly SIDS Resources, Inc.), children’s hospitals and other partners to develop a safe sleep outreach campaign. The campaign will utilize multiple methods including social media.

Based on results from a survey of Missouri birthing hospitals, the Safe Cribs for Missouri Program will work with Infant Loss Resources, Inc. to provide safe sleep education and technical assistance to hospitals. Resources will include the safe sleep video, “This Side Up” t-shirt, and other educational materials available from DHSS at no charge. In addition, information about the National Safe Sleep Hospital Certification Program will be provided. Hospitals that have achieved National Safe Sleep Hospital Certification will be recognized by DHSS. 

The Safe Cribs for Missouri program will collaborate with the Department of Social Services Children’s Division (CD), Children’s Trust Fund (CTF) and the National Institute for Children’s Health Quality to develop a statewide strategic plan to reduce sleep related infant deaths. The strategic plan will be implemented through the State Safe Sleep Coalition.

The Safe Cribs for Missouri program will collaborate with CD and CTF to develop online safe sleep training for CD staff who work directly with families.     

The TEL-LINK Program will refer callers to safe crib providers to promote infant health. The program will continue to provide outreach to the underserved population through social media. 

The Maternal Child Health Services Program will contract with five LPHAs that selected the priority health issue to promote safe sleep practices among newborns to reduce sleep-related infant deaths.