NPM 3-Percent of very low birth weight (VLBW) infants born in a hospital with a Level III+ Neonatal Intensive Care Unit (NICU)
ESM 3.2 - To improve the system of perinatal regionalization statewide in order to increase the number of very low birthweight (VLBW) deliveries at an appropriate level of care facility.
Alabama continue d to focus on preterm births with the selection of a new ESM to address improving the system of perinatal referral and transfer for high risk mothers and infants. State Perinatal Program staff w ork ed to establish the comprehensive system of regionalized perinatal care in Alabam a . AHA and ADPH met on multiple occasions with State Health Planning and Development Agency ( SHPDA ), to revise the questions related to perinatal levels of care on the annual hospital survey. The revisions corresponded with the Alabama Perinatal Regionalization System Guidelines. The survey was provided to all delivering hospitals to self-declare their neonatal level of care as a baseline assessment. In September 2018, AHA , ADPH, and the Women and Children’s Directors from three delivering hospitals in the pilot counties met to discuss the implementation of perinatal regionalization. A recommendation was made to model perinatal regionalization after the Alabama Trauma Stroke system. Next steps include bringing a national expert to speak to healthcare providers about the implementation, utilization, processes, and policies required to develop an evidence-based system of perinatal care. Challenges include keeping members engaged with multiple initiatives occurring simultaneously.
NPM 5-Percent of infants placed to sleep on their backs
ESM 5.1 –To conduct the Direct on Scene Education (DOSE) Train-the-Trainer Program to first responders in order to reduce Alabama’s high rate of unsafe sleep-related deaths in infants less than one year of age
Activities related to the DOSE Train-the-Trainer Program remained stagnant in FY 2018.
Other Perinatal Health Initiatives
ADPH Cribs for Kids® Program Provider
In 2017, Alabama had 111 sleep related deaths. Th at number wa s a decrease of 19 sleep related deaths from 2016. ADPH continues to provide pack-n-plays and safety kits to families in Alabama who are in need of a safe sleep environment for their infant.
Alabama Safe Sleep Outreach Project
In 2017, the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) awarded 25 mini-grants to 16 new grantees and nine repeat grantees to conduct the Alabama Safe Sleep Outreach Project. There were 242 outreach activities conducted and 36,116 safe sleep educational materials distributed. Alabama had 291 nurses complete and pass the Safe Infant Sleep Continuing Education Curriculum. Of the 2,409 people who received safe sleep education provided by grantees, there was an 11 percent knowledge increase related to the safety of room sharing rather than bed sharing and a 17 percent knowledge increase that infants reduce the risk of s udden infant death syndrome ( SIDS ) when placed to sleep on their backs. In August 2018, the NICHD extended the Alabama Safe Sleep Outreach Project for an additional 3 years. Currently, a work plan is being established to determine strategies to be conducted over the next 3 years.
In September 2018, approximately 13,000 English and 1,300 Spanish books were shipped to the delivering hospitals in Alabama to educate new families about the importance of placing infants alone, on their back, and in a crib to reduce the risk for s udden unexpected infant death ( SUID ) . These books will be shipped on a quarterly basis to the delivering hospitals. One challenge encountered with this initiative has been one hospital declined to participate indicating that the book was against Baby Friendly guidelines because one picture in the book shows an infant with a pacifier in his mouth. The books in this county are now being distributed through the Medicaid Maternity Care Providers to parents.
Alabama Baby Box Initiative
The statewide initiative was launched in March 2016. The Department of Human Resources is the lead agency for Alabama. ADPH has collaborated with the project from initiation by identifying education topics and presenters for the educational videos. The Baby Box funders committed to 100,000 free boxes for Alabama participants in the original conversations; however, the funder now has committed to as many baby boxes as needed indefinitely to Alabama participants. From March 2018 through September 201 8 , Alabama residents ha d registered with Baby Box University. From January 2018 through September 201 8 , Baby Boxes were distributed in Alabama. As of September 2018, Alabama ha d distribution sites available in 67 counties where families may obtain a Baby Box.
The Alabama DHR remains the lead state agency for administering the Baby Box Program which is coordinated by a full-time Baby Box l iaison employee. As of September 2018, this agency ha d provided safe sleep education to obstetrician and gynecology offices, delivering hospitals, and collaborating agencies throughout the state .
Ongoing a ctivities in Alabama to improve birth outcomes and reduce morbidity and mortality:
Early Elective Deliveries - Ongoing education efforts to reduce the number of non-medically indicated early elective deliveries continue d statewide.
FIMR – In 2018, State Perinatal Program staff abstracted and reviewed a total of 152 fetal and infant deaths.
In September 2018, ADPH repealed and replaced the Fetal, Infant, and Maternal Mortality Review Administrative Rule which was approved by the State Committee of Public Health.
Collaborating Partners and Initiatives for the MCH Population
ABC – ADPH continue d to collaborate with the ABC on initiatives to promote and increase breastfeeding statewide. Several ADPH staff serve d as board members on the ABC.
Babypalooza – Babypalooza is an annual statewide event that educates and informs new or expecting parents about community resources and is held in the five largest cities in Alabama. The event is free to the public and focuses on maternity wellness, child safety, and early learning. The state perinatal coordinators exhibit ed a booth at each of the events and provide d educational literature on an array of perinatal topics that aim to improve birth outcomes, reduce morbidity and mortality , and support healthy moms, infants, and families.
Exhibits – Annually, SPP staff travel to conferences, summits, health-fairs, and other exhibiting opportunities such as the Alabama Chapter-American Academy of Pediatrics, Alabama Chapter-March of Dimes Perinatal Conference, Alabama Section-American Congress of Obstetricians and Gynecologists, Medical Association State of Alabama, the Association of Women’s Health, and Obstetric and Neonatal Nurses Conference to provide outreach education and collaboration on perinatal issues that are pertinent to strategies being addressed in Alabama.
Alabama Perinatal Quality Collaborative – In March 2018, the annual Ann McDowell Lecture series was held in Birmingham. A consortium of maternal and child health professionals came together to discuss forward movement on transitioning the Alabama Perinatal Excellence Collaborative into ALPQC. The ALPQC leadership developed a steering committee and established the vision and mission for the collaborative. The first quality improvement project selected was the Alabama Birth Data Accuracy Project aimed at increasing the accuracy of data collected on the birth certificate. Currently 26 of the 46 delivering hospitals across the state are participating in the voluntary project. The variables being assessed are birthweight, obstetric estimate of gestational age, ventilation longer than 6 hours, neonatal intensive care unit admissions, steroids for fetal lung maturation, method of deliver y , diabetes, hypertension, maternal transfusion, previous preterm birth (s) , and main source of payment.
Pregnancy Risk Assessment Monitoring System
The Alabama PRAMS Project seeks to help improve the health of mothers and babies in Alabama. To do this task, the PRAMS questionnaire asks mothers questions about their behaviors and experiences around the time of their pregnancy. Approximately 1,450 Alabama mothers a year are randomly selected from the state birth certificate registry to receive the questionnaire, via mail, for completion. Mothers in Alabama now have the option to answer the PRAMS survey via a web application, which the Alabama PRAMS Project will seek to implement in the future. With improved rewards and increased brand recognition, Alabama PRAMS response rates have recently exceeded the CDC response rate threshold. Maternal behavior and pregnancy outcomes have been strongly associated, thus the impetus for seeking to improve efforts to understand contributing factors to infant mortality and low birth weight. The information provided includes topics ranging from obstetrical history and prenatal care to maternal stress factors and pregnancy intentions.
Since Healthy People 2020 goals and objectives include numerous maternal and child health indicators, Alabama PRAMS data will be used to measure the status of the maternal and child health related indicators, as applicable. Alabama PRAMS data will also be used by the state's Title V MCH program to monitor progress related to the NPMs selected for programmatic focus during the current funding cycle.
The Alabama PRAMS Project will participate in the supplemental opioid research. The main goal of the o pioid s upplement is to use the existing methodology to a ss ess maternal behaviors and experiences related to opioid use among women before, during, and after pregnancy.
The Alabama Zika Program resides within FHS in the Perinatal Health Division. It consists of the Zika Pregnancy Registry and the Alabama Birth Defects Surveillance Program (AZBDSP) . AZBDSP was established in 2016 for the purpose of rapid, active surveillance for infants with microcephaly or other adverse outcomes linked to Zika virus with support from CDC grant funding. As of April 6, 2018, 366 pregnant women have been reported to the US Zika Pregnancy Registry and 20 eligible infants have been reported to the US Zika Infant Registry. In 2018, active surveillance, intervention, and referral activities continued, and the AZBDSP managed 166 pregnant referrals and 13 newborn referrals. There have been no infants identified in Alabama with congenital Zika syndrome since surveillance began. A Zika Birth Defects Surveillance Nurse Coordinator resigned which left the position vacant from April to December of 2018. Effective March 31, 2018, the CDC stopped collecting information on pregnant women exposed to Zika. Funding for this project is set to terminate on July 31, 2019.
Newborn Screening Branch
The Alabama Newborn Screening Follow-up Program (NSP) is housed in the Perinatal Health Division of FHS. Newborn screening blood analysis is performed by the Bureau of Clinical Laboratories (BCL). Abnormal results are sent by the BCL to NSP follow-up staff for reporting to the physician of record .
The newborn screening consists of the bloodspot screening, newborn hearing screening, and the pulse oximetry screening to detect critical congenital heart defects. The Alabama NSP panel includes 31 conditions of the 35 nationally r ecommended u niform s creening p anel. In October 2018, testing for s evere c ombined i mmunodeficiency was implemented.
The NSP provided follow up to definitive diagnoses for infants who screened positive for 1) metabolic, 2) endocrine, 3) hearing loss, 4) hemoglobinopathy disorders, 5) cystic fibrosis, 6) critical congenital heart defects, and 7) severe combined immunodeficiency. For CY 2018, the following numbers of infants were identified as having these specified conditions:
NSP mandates the initial newborn bloodspot screen be collected at 24-48 hours of age and recommends a second newborn bloodspot screen at 2-6 weeks of age in order to detect delayed thyroid stimulating hormone elevated levels. The majority of pediatric providers collect a second newborn screen between 2-6 weeks of age. In addition, the NSP notifies providers if an infant had an initial unsatisfactory newborn screen. The program tracks infants who did not receive an initial satisfactory screen and sends notification to the provider and family regarding the need for a satisfactory screen.
The NSP renewed seven contracts with medical consultants in the state that provide comprehensive follow up services, confirmatory testing, medical treatment, and education. The specialty centers provided confirmatory testing and treatment to patients identified by the NSP. Genetic counseling, follow-up care, and nutritional counseling were also included. NSP referred infants with positive results, when there was no physician of record listed and when appointments for repeat screens to determine a definitive diagnosis had been missed. Care coordination is provided by county health department staff. In addition, the N S P supported a grant with the UAB Sparks Clinic to provide metabolic food and formula to infants and children identified with a metabolic condition.
Children diagnosed with sickle cell disease received consultation with a board-certified pediatric hematologist at one of three regional pediatric hematology clinics in N orth, C entral, or S outh Alabama. The NSP referred parents of all infants diagnosed with sickle cell disease or trait for education and counseling to one of six community-based sickle cell organizations that collectively serve all Alabama counties. In addition, the NSP referred infants diagnosed with presumptive positive cystic fibrosis newborn screening results to the sole accredited Cystic Fibrosis Care Center in Birmingham, Alabama for diagnostic testing, genetic counseling, and clinical management as needed.
The NSP used a language line to facilitate communication with Hispanic\Latino families about follow-up care. Newborn screening brochures were available in English and Spanish and provided to all 48 Alabama birthing hospitals. In 2018, the number of birthing facilities in the state was reduced from 48 to 46 with two delivery unit closings.
Information for parents and healthcare providers was provided on the NSP web page, which contains a variety of information , including newborn screening brochures and fact sheets on various genetic disorders provided by the American College of Medical Genetics.
In 2018, the Alabama NSP Advisory Committee met on February 22 , to discuss newborn screening program updates and technical issues. The NSP Advisory Committee continues to meet twice a year. In addition, the Alabama NSP hosted a statewide Newborn Hearing Screening Workshop in April 2018 in which approximately 75 audiology professionals attended.
NSP renewed a grant to the UAB-affiliated Civitan-Sparks Clinics to supply medical food and formula to address the needs of families with inherited inborn errors of metabolism.
NSP worked with the software vendor, Neometrics , to improve the ability to receive and analyze hearing screening results and to perform queries for research purposes.
NSP has developed educational materials and will continue to focus educational outreach to obstetricians and prospective parents during the prenatal period about the benefits of newborn screening.
In 2018, the NSP developed two training videos as part of a four video training module. The first video is an overview of the newborn screening program and the second video is a specimen collection training video. The program plans to add the National Center for Hearing Assessment and Management web-based hearing training video to the module as well as develop a training video for pulse oximetry screening to detect critical congenital heart defects.
Many activities contributed to the Universal Newborn Hearing Screening (UNHS) Program's continued success in FY 2018. Key activities follow. Unless stated otherwise, the activities were conducted by UNHS program staff.
The Alabama UNHS Program is administered through ADPH and was established in late 2001 with voluntary hearing screening. In 2008, a mandate for universal hearing screening was established to ensure that every infant received appropriate methods of hearing screening and that results were reported.
An initial newborn hearing screening is mandated at birth in order to detect congenital hearing loss. Currently, there are 48 birthing hospitals that provide hearing screening to infants using either otoacoustic emissions or automated auditory brainstem response (AABR) testing. In 2018, all birthing hospitals were using the preferred AABR method for testing with seventeen hospitals contracting with private agencies to perform newborn hearing screenings.
The UNHS Program continues to maintain the electronic reporting process for the collection of hearing screening results to obtain accurate and timely hearing results from hospitals. All but two of the 46 Alabama birthing hospitals currently report newborn hearing results electronically directly from the hearing equipment. In 2018, approximately 64 infants were identified with congenital hearing loss, and all infants identified with hearing loss were referred to early intervention services.
In addition, the second newborn hearing learning community was established in Birmingham, Alabama in 2018. The learning community consists of a pediatrician, a parent of a child with hearing loss, and a social worker with the objective to engage in a shared learning process to increase knowledge regarding the Joint Committee on Infant Hearing 1-3-6 guidelines: hearing screening before 1 month of age, diagnostic evaluation before 3 months of age, and early intervention before 6 months of age.
The Alabama Early Hearing Detection and Intervention (EHDI) Program participated in the quarterly Interagency Coordinating Council meetings on behalf of the State Health Officer as required by the MCH Block grant.
Alabama receives additional grant funding from HRSA and CDC, which is used for salaries and to assist with family engagement activities and improvement in the capture of hearing data via the EHDI-Information System.
Hearing screening equipment continued to be maintained and available for use as loaner equipment to hospitals when the facility's equipment was being repaired. The goal of the loaner equipment was to reduce the number of infants leaving the hospital without a hearing screening. Twelve hospitals were identified as needing updated equipment to meet compliance with the program screening and reporting requirements. Newborn hearing equipment was provided to assist these facilities with improve d reporting and training and provided for the utilization of the equipment and proper reporting protocols.
The Alabama UNHS program has also assisted CRS in getting updated hearing equipment to perform the rescreen or outpatient newborn hearing screening in rural areas throughout the state.
The UNHS program continued its contract with Auburn University. This contract provided two doctoral-level audiology student assistants who work 10 hours a week under the direction of the UNHS c oordinator. The student assistants provided data entry and follow-up assistance.
The UNHS program continued to have an EHDI nurse supervisor who works 1.0 FTE for the program and is the project manager of the HRSA and CDC grant activities. The EHDI nurse supervisor coordinated all aspects of the project and assisted the 0.75 FTE UNHS surveillance nurse coordinator in providing follow up for infants who failed the initial hearing screening, infants for whom data were missing on the initial screening, and infants identified with risk factors associated with late onset hearing loss. In addition, the program continued to have a 0.15 FTE research analyst to assist with data analysis and a 0.50 FTE programmer analyst associate to assist with the device case management system ( dCMS ) application and technical issues regarding the electronic reporting system.
The UNHS program s eeks to improve reporting and data capture in Alabama. The program's most important objective is to maintain the electronic reporting process in order to obtain accurate tracking and surveillance of hearing data to ensure timely follow-up and intervention. There continues to be technical issues with the dCMS and with uploading hearing results electronically as well as delays with testing in NICU s . As a result, these issues lead to untimely reporting of results and delay initiation of follow-up activities. The program plans to continue to monitor the frequency of electronic uploads from each hospital.
The program continued to seek primary care physicians and outpatient audiology clinics to perform follow-up hearing screening in rural areas lacking needed services.
Monthly statistical reports are being modified to include an encrypted listing of the individual infants without screening results. This encrypted listing allows an opportunity for the birthing facility to provide the screening results or the infant's admission status to the UNHS program.
In addition, the UNHS program completed and submitted all parts of the 2016 CDC survey, which captures hearing data to include screening, diagnostic, and intervention data.
Finally, the program continued to work on the QI initiative to match birth records to newborn screening records to ensure all infants born in the state receive a hearing screen. According to the 2015 hearing data, 94 percent of infants born in Alabama received a newborn hearing screening with approximately 92 percent of infants screened passing before 1 month of age.
The Alabama National Electronic Disease Surveillance System was utilized as the surveillance database for documenting Zika related birth defects data. Pregnant and infant pages were created and added into the database based on the CDC consultation forms. Aggregate data was extracted and submitted to the CDC USZPR to ascertain Zika-related health outcomes.
Plans are to establish a birth defects registry program in Alabama with CDC funds. Several meetings, in 2018, were held with the Office of General Counsel and ADPH Administration to discuss establishing a birth defects rule. Ongoing efforts continue in the establishment of an administrative birth defects rule to provide authority and access to required data. Plans are to gather stakeholders to discuss plans to move forward with the birth defects registry to promote buy-in.
Infant Mortality Awareness Activities
ADPH held its first Infant Mortality Awareness Summit on Friday September 14, 2018 at Auburn University Montgomery (AUM) in Montgomery, Alabama. The summit was sponsored by ADPH, Birmingham Heathy Start Plu s (BHSP) , AUM Office of Diversity and Inclusion, and The Gift of Life Foundation, Inc. The theme of the summit was the State of Infant Mortality in Alabama. The goal and objectives of the summit were as follows:
Dr. Arthur R. James, MD, FACOG served as our keynote speaker and spoke on the subject of equity in birth outcomes. Dr. Tanya T. Funchess, DHA, MPH, MSM, an Assistant Professor in the College of Nursing and Health Professions at University of Southern Mississippi also spoke on health equity during the afternoon plenary. In addition to the plenary sessions, the summit included a panel discussion where parents were able to share experiences of fetal and infant loss and there were four breakout sessions offered to summit attendees. Breakout sessions focused on fatherhood, safe sleep, home visiting programs, and preconception and inter - conception care. All attendees received a gift bag and c ontinuing education units were offered for registered nurses and social workers. Recordings of the summit can be found at www.alabamapublichealth.gov
In conjunction with the summit, there were a few media events preceding the summit. ADPH, GOL, and BHSP directors were interviewed by various local news stations. The partnering agencies created a pinwheel display in the park outside of the ADPH central office. The pinwheels , which totaled the number of infant and fetal deaths in Alabama i n 2016, were on display for 3 weeks in September. There was also a proclamation signing where Governor Ivey declared September as Infant Mortality Awareness Month and October as SID/SUIDI Awareness M onth.
State of Alabama Infant Mortality Reduction Plan
In November 2017, the State Health Officer requested funding to reduce infant mortality because of the 2016 infant mortality rate of 9.4 infants deaths per 1,000 live births. The Alabama Legislature appropriated $1 million annually for 5 years beginning in October 2018.
Alabama Infant Mortality Reduction Plan is an effort in which multiple state agencies collaborate to improve birth outcomes. The agencies include Medicaid, Mental Health, Early Childhood Education, Human Resources, Minority Affairs and ADPH. The Children’s Cabinet adopted the agency expert recommendations to implement a pilot program to reduce infant mortality rates by at least 20 percent in three counties, Macon, Montgomery and Russell, within the next five years. Strategies that will be implemented or expanded to impact perinatal/infant health are home visiting, safe sleep, breastfeeding, perinatal regionalization, and the utilization of 17 Alpha-Hydroxyprogesterone ( 17P ) .
This initiative has supported the leveraging of state dollars which allow Medicaid to draw down federal dollars. Medicaid matching funds will provide approximately $1.5 million to operate home visiting programs in the three target counties and expand home visiting into other counties in the state. The home visiting activities are led by DECE . Staff have e nrolled participants in the first teacher home visitation programs using the Nurse Family Partnership (NFP) and the Parents as Teachers (PAT) models. To date, a total of ten families were enrolled in NFP: three families in Macon, one in Russell, and six in Montgomery. PAT enrolled one family in Russell. Recruitment and e nrollment will continue.
The safe sleep activities are led by DHR. Safe sleep post cards were mailed to 7,349 residences in Macon County and 28,036 residences in Russell County. Safe sleep information was mailed to six licensed daycares in Macon County. Safe sleep billboards were placed in four locations in Montgomery County and one location in Macon. Safe Sleep bus wraps were placed on two Montgomery Public Transit buses and fliers were placed in 35 Montgomery transit buses.
Perinatal regionalization strategies are being led by ADPH. A national expert for perinatal regionalization was secured to assist with education and implementation of the Alabama Perinatal Regionalization System Guidelines. The meetings are scheduled for May 14, 2019 , in Montgomery County.
The 17P activities are being led by ADPH. The March of Dimes “Pregnancy after Premature Birth: Treatment with 17P” brochures have been provided to WW, PAT, and SPP for distribution to eligible women.
