Ongoing Needs Assessment Activities

The Bureau of Assessment and Evaluation (BAE) leads the collection, analysis, and interpretation of public health maternal child health data at the Arizona Department of Health Services. BAE’s mission is to serve as a resource to all stakeholders so that programs and partners make data-driven decisions that provide equitable opportunities for achieving optimal health for all children, women, and families in Arizona. BAE provides technical assistance and expertise in data analytics, data management, epidemiology, program evaluation, public health assessment, and surveillance.

In addition, ongoing assessment activities help identify emerging and continuing needs for Arizona’s MCH populations:

• Maternal Mortality Review (MMR): The MMR is a subcommittee to the Child Fatality that started in June 2012 to review all identified maternal deaths in the State of Arizona. ADHS staff work hand in hand with members of the MMRC to complete maternal mortality reviews, develop recommendations to prevent maternal mortality and severe maternal morbidity, disseminate findings to the public, and implement quality improvement initiatives for clinical and non-clinical providers. Currently, the committee has completed reviews on maternal deaths from 2017-2019 and is reviewing 2020 deaths. Multiple topical reports and infographics have resulted from these activities to provide stakeholders with updated information on maternal mortality in Arizona.

• Child Fatality Review (CFR): The Arizona Child Fatality Review (CFR) Program’s goal is to reduce child deaths in Arizona by conducting a comprehensive review of all child deaths to determine what steps could have been taken, if any, to prevent each child’s death. In 2021, 863 children died in Arizona, an increase from 838 deaths in 2020. The leading causes of death were prematurity, congenital anomalies, motor vehicle crashes, poisonings, and firearm injuries. Prematurity was the most common cause of death for neonates (infants less than 28 days old) while suffocation was the common cause of death among infants 28 days to less than 1 year of age. The program’s latest report can be found here.
• Behavioral Risk Factor Surveillance System (BRFSS): The Arizona Behavioral Risk Factor Surveillance System (BRFSS) telephone survey has been in existence since 1984 and is partially funded by the Centers for Disease Control and Prevention (CDC). This surveillance collects data from Arizona adults aged 18 and over living at home. The Title V Program has supported the BRFSS in its implementations of the Adverse Childhood Experiences questionnaire, the family planning module, and the social determinants of health module.
• Pregnancy Risk Assessment Monitoring System (PRAMS): PRAMS is a collaborative research project between ADHS and the CDC. PRAMS surveys women who have recently given birth and provides cross-sectional approach data, across Arizona’s diverse maternal population, on factors such as low birth weight, preterm birth, ante/postpartum obesity, mental health, COVID-19, breastfeeding, and social determinants of health. AZ PRAMS aims to obtain data of high scientific quality on maternal behaviors before, during, and shortly after pregnancy that can be used to monitor health status as well as allow ADHS to more effectively tailor preconception, pregnancy, and postpartum services and programs to Arizona’s diverse population. More information on PRAMS can be found in the Women’s Health domain.

• Youth Risk Behaviour Survey (YRBS): YRBS is a voluntary, anonymous survey of high-school students across the nation. Every 2 years, The CDC (via Westat) selects a sample of roughly 40 Arizona high schools to participate. Each school is allowed to refuse participation, and another school will be selected in its place. Students are invited to complete the survey, which does not collect any identifiable information, and discuss behaviors related to alcohol, drug, and tobacco use, violence, sexual behaviors related to STIs and unintended pregnancies, and dietary and physical activity behaviors.

• Neonatal Abstinence Syndrome (NAS): BAE performs data analysis and produces a monthly report based on available NAS data and the latest case definition provided by the Council of State and Territorial Epidemiologists (CSTE). BAE is part of an internal agency workgroup to implement the CSTE NAS Standardized Case Definition more broadly and build our capacity to address the suspected cases and the non-opioid cases.
• Home Visiting Data: BAE supports the Home Visiting Efforts-to-Outcome (ETO) Data System. ADHS holds the enterprise account for the ETO which includes all demographic and programmatic data across four (4) home visiting programs (Healthy Families, Nurse Family Partnership, Health Start, and High-Risk Perinatal) funded across three (3) state agencies (Arizona Department of Health Services, Arizona Department of Child Safety and First Things First which is Arizona’s Early Education and Health Board).
• As part of our ongoing needs assessment process Title V collaborated with the Navajo Nation’s Diné College and the University of Arizona’s Mel and Enid Zuckerman College of Public Health to engage in public input through the ‘Maternal Health Needs Assessment’ project. This project aimed to provide in-depth information to the Title V Program on maternal health priorities in Arizona. The assessment revealed racial and residential disparities that impact maternal health outcomes in Arizona. The assessment was completed in 2020, and the report was published in July 2021. Since then, a supplementary study was conducted to explore the findings and better understand the maternity care experiences of women residing in rural areas and African American women. In September 2022, a slide deck was published describing the supplementary analysis and results. In this supplementary analysis, a total of 39 participants provided input from 8 of Arizona’s counties.
• Healthy Smiles Healthy Bodies Oral Health Study: The Office of Oral Health led and BAE supported the implementation of an oral health study to assess the current oral health status of Arizona’s elementary school children, through a statewide stratified oral health survey of kindergarten and third-grade children in Arizona’s public schools. Data collection resumed during the 2022-2023 school year to complete all schools that were part of the original sample.
• Adverse Childhood Experiences (ACEs) Surveillance: BAE established an agency-wide work group with prevention and preparedness epidemiologists on creating dashboards to report the prevalence of ACEs using the National Survey of Children's Health data, the Youth Risk Behavior Survey data, the Behavioral Risk Factor Surveillance System data, and the syndromic surveillance data which includes risk factors and protective factors. BAE is working with ASU’s Morrison Institute to conduct policy analysis to analyze other states’ existing policies and public initiatives to prevent or mitigate the impact of ACEs; the final report on this policy analysis is expected to be complete by December 2023. Lastly, ADHS has launched the ‘Surviving to Thriving’ initiative with a team of ADHS staff and committees to help ADHS transition to a trauma-informed agency. BAE recently published a website for ACE surveillance.
• In 2022-2023, BAE partnered with the Bureau of Chronic Disease and Health Promotion to conduct an organizational health equity capacity assessment of sexual violence prevention and education program agencies in Arizona. This assessment interviewed 15 staff from 6 organizations to assess staff knowledge, organizational policies, leadership actions, work plan activities, data collection, use and needs, training and TA, state of partnerships, and focus within the socioecological model for health equity within their work. The assessment found that while knowledge of health equity is high, the practice of health equity strategies is average and strategic alignment is minimal.

Changes in the health status and needs of the state’s MCH population

The following sections focus on changes to the health status of MCH populations in Arizona and presents data from two recent morbidity and mortality reports. Morbidity and mortality data provides critical health status information, highlights noticeable disparities, and provides direction for public health programming.

Maternal Health

Maternal Mortality

The MMRC identified 203 maternal deaths between January 1, 2016, and December 31, 2018, of which they determined that 23% (n=46) were Pregnancy-Related deaths, with the remaining being either Pregnancy-Associated but not Related (68%, n=138) or Unable to Determine Relatedness to Pregnancy (9%, n=19). The 2016-2018 Pregnancy-Associated Mortality Ratio was 80.6 and the Pregnancy-Related Mortality Ratio was 18.3 deaths per 100,000 live births in Arizona for women ages 15-49. American Indian or Alaska Native women had the highest Pregnancy-Associated Mortality Ratio (PAMR) at 140.4 deaths per 100,000 live births (based on fewer than 20 cases; interpret with caution). The PAMR was 105.0 for White, non-Hispanic women, 116.5 for Black or African American (based on fewer than 20 cases; interpret with caution), and 41.5 for Hispanic or Latina women.

For Pregnancy-Related deaths, the MMRC assigned an underlying cause of death or the disease or injury that initiated the chain of events leading to death or the circumstances of the accident or violence which produced the fatal injury. The two most common underlying cause categories among Pregnancy-Related deaths were Cardiovascular, Coronary, or Cerebrovascular Conditions (25.8%) and Conditions of Pregnancy (22.6%), which include Amniotic Fluid Embolism, Preeclampsia, and Eclampsia.

Maternal Mental Health and Substance Use-Related Deaths

In Arizona, approximately 30-40 women die within 365 days of pregnancy each year from a mental health- or substance use-related cause. The MMRC determined that almost half (48.8%) of all Pregnancy-Associated deaths and 30.4% of Pregnancy-Related deaths were related to mental health conditions or substance use disorders. The majority (59.6%) of Pregnancy-Associated deaths related to mental health conditions or substance use disorders occurred between 43 and 365 days postpartum. The majority of deaths were among White, Non-Hispanic women (61.6%), followed by Hispanic (20.2%), American Indian/Alaska Native (11.1%) women, and Black/African American (5.1%). The biggest disparity when comparing the proportion of deaths to live births was among American Indian/Alaska Native women. Almost half (49.5%) of all deaths were among women aged 20-29 years old and 42.4% of deaths were among women 30-39 years old. The MMRC determined that 98% of deaths were preventable. During 2016-2018 substance use death (n=84), the MMRC determined that 1.9% had used at least one type of Opiate (e.g., Heroine, Fentanyl, Methadone), 54.8% had used at least one type of Sympathomimetic (e.g., Methamphetamine, Cocaine), 32.1% had used a type of GABA Agonist (e.g., Barbiturates, Alprazolam), 27.4% had used Alcohol, and 27.4% had used Marijuana.

COVID-19 Maternal Experiences

Data from PRAMS demonstrated a high proportion of women adopting behavioral strategies to prevent COVID-19 infection in 2020. Survey results indicated that the most implemented behaviors were washing hands for 20 seconds with soap and water, covering coughs and sneezing with a tissue or elbow, masking, keeping a 6-foot distance from others in public, using alcohol-based hand sanitizer, and avoiding gatherings involving more than 10 people, all of which were reported by more than 95% participating mothers. Although still extremely high, the least adopted preventive measure by women was the avoidance of visitors inside their own homes, with 92.1% of women interviewed always or sometimes conducting this behavior.

PRAMS also indicated that healthcare-seeking behaviors among pregnant women were impacted due to COVID-19. Between 2020-2021 Mothers reported canceling or delaying their prenatal care appointment. While the majority of mothers preferred in-person prenatal care visits with 81.1% in 2020, and 86.9% in 2021, the logistics posed by COVID-19 proved challenging. Some mothers were afraid of being exposed to COVID-19 (10.2% and 6.0% in 2020 and 2021, respectively), had to self-isolate due to possible COVID-19 infection (9.2% and 12.7% in 2020 and 2021, respectively), or because the provider's office was closed or had reduced hours due to the pandemic (14.0% and 6.0% in 2020 and 2021, respectively).

In 2021, PRAMS asked mothers about their pregnancy and delivery experiences during the COVID-19 pandemic. While 67.8% of pregnant mothers had discussed the COVID-19 vaccine with their doctors, 76.1% chose not to get the vaccine while pregnant. The predominant concern, at 60.4%, was possible side effects resulting from the vaccine. In the 6 months after their child was born, the majority of mothers who had not received the COVID-19 vaccine while pregnant continued to choose not to receive the vaccine (72.0%), and 28.0% chose to receive the vaccination postpartum.

Infant and Child Health

Infant Mortality

Overall, Arizona’s infant mortality rate has been fluctuating since 2012. Arizona’s infant mortality rate has increased to 12.2% from 4.9 deaths per 1,000 live births in 2020 to 5.5 deaths per 1,000 live births in 2021. The Arizona infant mortality rate has consistently been lower than the U.S. rate. Black and American Indian infants have consistently had the highest rates of infant mortality from 2012-2021. In 2021, the infant mortality rates of Black and American Indians were 14.0 and 5.4 deaths per 1,000 live births, respectively. In comparison, the infant mortality rates for Hispanic and White infants were 5.9 and 4.0 deaths per 1,000 live births, respectively. All infant mortality rates, except for American Indian and White infants increased with the highest rate increase for Black infants of 10.3% from 2020 to 2021.

Congenital Syphilis

In Arizona, there is an outbreak of syphilis among women and babies, a bacterial infection that is usually spread by sexual contact. Medical providers are seeing the largest increase in syphilis cases in women and newborns. Since 2015, the yearly average of syphilis cases in women has increased. The number of babies born with syphilis doubled each year. In the year 2021, of the 116 babies born with syphilis, 10 babies died.

Developmental Screenings

Developmental screenings for infants and toddlers in well-child visits with a health care provider are an integral part of promoting healthy growth and development of children. During these visits, doctors monitor and screen for delays or problems in the child’s development. A delay in the detection of developmental disorders is a missed opportunity to provide services and interventions that reduce the costs and burdens associated with developmental disorders. The percentage of children ages 9-35 months whose parents completed a standardized developmental screening tool in the past 12 months (2-year estimate) decreased from 28.2% to 18.9% from the years 2018 to 2021 in Arizona. This is lower than the national average of 34.8% in 2021.

Breastfeeding

It is recommended that all infants be breastfed exclusively for 6 months, if possible. According to the National Immunization Survey collected in 2018, 76.9% of Arizona infants were ever breastfed, with 24.6% breastfed exclusively for 6 months. This is lower than the national average for that year, with 83.9% of infants breastfed, and 25.8% breastfed exclusively for 6 months.

Prematurity

Prematurity was the leading cause of death for infants 0-27 days while suffocation was the leading cause of death among infants 28 days to less than 1 year of age in 2021. Arizona’s prematurity mortality rate increased to 5.2% from 25.2 per 1,000 live premature births in 2020 to 26.5 per 1,000 live premature births in 2021. Black and Hispanic infants made up 19% and 4% of prematurity deaths, respectively, but only comprised 6% and 40% of premature births. While there are numerous risk factors that can contribute to prematurity deaths (preterm labor, no prenatal care, hypertension), the most commonly identified risk factors were poverty (50%) and premature rupture of membranes (PROM) (40%).

Sudden Unexpected Infant Deaths

Sudden Unexpected Infant Death (SUID) is the death of an infant less than 1 year of age where the cause of death was not apparent prior to a death investigation. In 2021, there were 65 SUIDs (Suffocation n=53; Undetermined n=12). While there are numerous risk factors that can contribute to SUIDs, the most commonly identified risk factors were unsafe sleep environment (95%), objects in the sleep environment (86%), poverty (82%), and unsafe sleep location (not in crib/bassinet) (69%). 11% of SUIDs occurred in neonates (infants less than 28 days) and 89% of SUIDs occurred in post-neonates (infants >28 days but <1 year of age) in 2021. The Arizona Child Fatality Review program determined that 99% of SUIDS were preventable. Black/African American infants were disproportionately affected. Black/African American infants made up 15% of SUIDs but only makeup 6% of the total population. Overall, Arizona’s SUID rate increased 23.1% from 0.65 deaths per 1,000 live births in 2020 to 0.80 deaths per 1,000 live births in 2021. Additionally, Arizona’s unsafe sleep environment mortality rate and suffocation mortality rate have increased since 2012.

Child Mortality

In 2021, the Child Fatality Review reported that a total of 863 child deaths took place. Arizona’s child mortality rate increased to 4.7% from 51.0 deaths per 100,000 children in 2020 to 53.4 deaths per 100,000 children in 2021. Black and American Indian children made up 15% and 8% of child deaths, respectively, but only make up 6% and 5% of the total child population in 2021. The mortality rate of children ages 1 to 17 remained relatively the same from 28.1 deaths per 100,000 children in 2020 to 28.3 deaths per 100,000 children in 2021. Children ages 15-17 experienced the highest increase in mortality rate of 20.6% from 53.5 deaths per 100,000 children in 2020 to 64.5 deaths per 100,000 children in 2021. The mortality rate for all racial groups increased from 2020 to 2021 except Hispanic and White children 1-17 years. In 2021, the child mortality rate for American Indian and Black children was 66.2 and 62.2 deaths per 100,000 children and had a 15% and 17% increase respectively among children 1-17 years.

The CFRP identified 31 direct COVID-19 deaths in 2021 and 27 indirect COVID-19 deaths in 2021. 61% of the direct COVID-19 deaths and 56% of the indirect COVID-19 deaths occurred in children 0-11 years. Of the COVID-19 direct deaths, the manner of death for 100% of the deaths was natural. American Indian children made up the largest percentage of indirect COVID-19 deaths (30%) but only 5% of the total child population.

 In 2021, CFRP teams determined that 410 child deaths were probably preventable. The data shows that 12% of natural deaths (n=61), 100% of accidental injury deaths (n=238), 100% of suicides (n=44), 100% of homicides (n=47), and 87% of undetermined deaths (n=20) were preventable. Black and American Indian children made up 17% and 11% of preventable child deaths, respectively, but only comprised 6% and 5% of the total child population.

Adolescent Health

Adolescent Mortality

The adolescent mortality rate in 2021 was 19.4 and 64.5.5 deaths per 100,000 for children between the ages of 10 to 14 and 15 to 17, respectively. Children ages 15-17 had the highest increase, 20.6% from 53.5 deaths per 100,000 children in 2020 to 64.5 deaths per 100,000 in 2021.

The majority of preventable deaths occurred in children ages 15-17 years (35%) and male children in this age group made up a large proportion of male preventable deaths (43%). In adolescents 10 to 14 years of age, motor vehicle crashes were the leading cause of death (19%) and firearm injury was the leading cause of death for adolescents ages 15 to 17 years (23%).

In 2021, there were a total of 44 suicides death reported. This was a 9% decrease in the suicide rate from 2020 to 2021. Of the suicides, 64% were male and 36% were females. CFR reported that the majority of suicides 66% (n=49) occurred in children ages 15 to 17. Among suicides, strangulation (45%) was the leading cause of death for children ages 10-17 years followed by firearm injury deaths (39%).

American Indian/Alaskan Native, Black/African American, and White children were disproportionately affected. American Indian/Alaskan Native, Hispanic and White children made up 23%, 18%, and 48% of suicides but only make up 5%, 45%, and 40% of the total population, respectively. The leading causes of suicide deaths among children ages 10 to 17 were strangulation (45%), firearm injury deaths (39%), poisoning, and other injuries such as motor vehicle crashes and falls. While there are numerous risk factors that can contribute to the 2021 suicide rate, the most commonly identified risk factors were recent suicide warning (68%), relationship problems (61%), recent crisis (45%), prior suicide attempt (41%), CPS history with family (36%) and child mental health disorder (32%).

Adverse Childhood Experiences (ACEs)

According to the parent-reported 2021 National Survey of Children’s Health, the number of Arizona adolescents (12-17 years) with two or more ACEs is significantly higher than in the U.S. as a whole. In Arizona, of children ages 12 to 17, 28% have experienced two or more ACEs, compared to the national average of 25%. The most common types of ACEs in Arizona were parental divorce/separation (32%) and household mental issues (17%). The youth-reported 2021 Arizona Youth Risk Behavior Survey shows that of adolescents enrolled in 9-12 grades shows that 65% of adolescents have at least one ACE and 22% have four or more ACEs. Emotional abuse was the most frequently endorsed (59%) by adolescents, followed by household mental issues (43%) and household alcohol/drug abuse (37%).

Children and Youth with Special Health Care Needs (CYSHCN)

CYSHCN are children who have a chronic medical, behavioral, or developmental condition that has lasted or is expected to last 12 months or longer and need prescription medications and/or specialized therapies. Approximately 1 out of 5 children in Arizona is CYSHCN. Using data for 2020 and 2021 from the National Survey of Children’s Health, we determined the prevalence and predictors of flourishing among Arizona children and adolescents ages 6–17. A three-survey question included indicators of flourishing: children’s interest and curiosity in learning new things, persistence in completing tasks, and capacity to regulate emotions. This evaluation of the child is reported by their parent or guardian. The rate of CYSHCN that meet all three flourishing items was 34.4% compared to 66.7% for their non-CYSHCN counterparts. The families of CYSHCN reported a more even dispersal of meeting ‘2 flourishing items’ or ‘0-1 flourishing items’ (32.2% and 33.4%, respectively) when compared to families of non-CYSHCN counterparts (19.4% and 13.9%, respectively).

Components of a well-functioning health care system include family partnerships, medical home, early screening, early access to services, and preparation for adult transition, between 0-17 years of age. In 2020-2021, 9.8% of Arizona CYSHCN received care in a well-functioning system, compared to 13.7% of their national CYSHCN counterparts. For perspective, 16.2% of the state and 18.2% of national non-CYSHCN children (0-17 years) received care in a well-functioning system. The vast majority of children and youth with special health care needs (CYSHCN) in Arizona (90.2%) did not receive care in a well-functioning health care system.

Cross-Cutting

Oral Health

The percentage of women who had dental work during their pregnancy was 36.9% in 2021, which is a slight improvement from the reported 32.4% in 2020. Dental health, particularly while pregnant, is very important. Perinatal oral health education for medical, dental, and other healthcare professionals, as well as the increase in the number of inter-agency partnerships that have been implemented to coordinate dental services for pregnant women and children, will hopefully improve these numbers in the coming years. Since 2015, the state of Arizona has seen a decrease in the percentage of children, ages 1 through 17, who had a preventive dental visit, with 75.0% reported in 2020-2021. The percentage of children ages 0 through 17, who are continuously and adequately insured in 2020-2021 was 89.4% in Arizona compared to 91.4% in the U.S. Likewise, in 2020-2021, the largest proportion of Arizona children receiving one or more preventative dental care visit in the past 12 months were those between 6 to 11 years of age, with 83.8% of parents reporting a visit. Parents of older (12-17 years) and younger (1-5 years) children reported fewer annual preventative dental visits, with 78.2% and 59.0%, respectively.

Future Assessments

BAE will continue to collaborate with the Title V Program and the Bureau of Nutrition and Physical Activity and the Bureau of Chronic Disease and Health Promotion to identify leverage points for collaboration and to better understand the intersectionality of Arizona’s MCH populations The Title V Steering Committee was established and its first meeting took place on April 7, 2023. The goal of the 2025 assessment will be to identify the priority health needs and issues of Arizona’s maternal and child health populations through collaborative, inclusive, and systematic data collection and analytic processes. The principles of the 2025 needs assessment are the following:

1. Listen to those not traditionally involved in statewide assessments
2. Centering the margins
3. Partner with community members and individuals with lived experiences
4. Honor and respect the work others have done to assess the needs of Arizonans
5. Assess the root causes of health inequities
6. Use a life course development approach to understand health issues
7. Take account of the impact on social determinants of health

When the committee was asked to identify the most important issues affecting the health of MCH populations in the communities and settings they work in the majority of committee members stated the following:

• Postpartum care for new mothers
• Access to clinical breastfeeding support for the Medicaid population
• Maternal mental health
• Access to care for medical, mental, and substance abuse, especially in rural communities
• Black Maternal and Infant Mortality and Morbidity - largely preventable, is made worse by the racial and ethnic disparities that have persisted over time and increase as women age

When asked which communities should the Title V needs assessment should work towards including and hearing from for this cycle, the following groups were predominantly identified:

• Border and migrant communities
• Unsheltered or homeless populations
• Undocumented individuals
• Rural communities
• LGBTQ+ people

The remainder of 2023 will be dedicated to planning and designing the needs assessment while 2024 will commence the data collection activities, 2025 will include the priority setting with steering committee members, and 2026 will be devoted to statewide dissemination of the needs assessment findings and priorities. The image below shows the several methodologies that will be used for the 2025 Title V Needs Assessment.

Lastly, BAE and BWCH have developed a Fetal Infant Mortality Action Plan to address the increasing fetal-infant mortality rate in the state. Goal 5 of the plan is to improve surveillance of fetal-infant morbidity and mortality. The proposed actions of this goal include: 1) establish a fetal infant mortality review program in Arizona; 2) enhance NAS data collection and surveillance; 3) secure a sustainable solution to funding the child fatality review program; and 4) strengthen the AZ PRAMS project. Additional assessment activities that are outlined in this plan include:

• Assess the feasibility of becoming a Healthy Babies are Worth the Wait community program.
• Conduct focus groups for mothers and providers to test prematurity prevention campaign content.
• Evaluation of the Title V family planning program in Arizona.
• Investigate non-medically indicated elective inductions of labor.
• Conduct an assessment of unintended pregnancies using the PRAMS data.
• Evaluate the feasibility of adapting a model of the perinatal nurse navigator program in Arizona.
• Conduct an assessment of home births to identify options to include midwives in home births.
• Conduct an environmental scan of homegrown initiatives to promote fatherhood.
• Conduct a utility assessment for KidsCare.
• Assess gaps in improving access and utility of midwifery care services in the state.
• Collect and evaluate primary care office program participation by demographic characteristics.
• Identify areas with the highest SUID/Unsafe sleep deaths to establish a distribution plan.
• Conduct a literature review on COVID-19 vaccine hesitancy among pregnant women.

In addition, BAE will be supporting efforts to implement the CDC Levels of Care Assessment Tool (CDC LOCATe) to create standardized assessments of levels of maternal and neonatal care in Arizona. LOCATe produces standardized assessments that allow participating states to see levels of care by the facility and the distribution of staff and services throughout the state. States can combine CDC LOCATe data with public health surveillance data, including vital records and hospital discharge data. These data allow for more detailed analyses that support understanding of:

• Maternal and infant health outcomes by level of care.
• The relationship between the volume of services provided by a facility and maternal and infant health outcomes.