2019 Annual Report

SPM 2 - Percent of infants placed to sleep on their backs

Objectives:

• Increase the number of NM birthing facilities trained by the NMDOH in safe sleep education protocols from 3 to 15 by 2020.
• Transition at least five NM birthing facilities to report standardized statistics for Shaken Baby Education to the NMDOH in 2019.
• Leverage existing program partners to increase the number of home visitation and perinatal case management programs trained in Safe Sleep and Shaken Baby education from 5 to 15, statewide by 2020.

Strategies

• Create an incentive program to award hospitals with Safe Sleep certification.
• Develop and track a data collection protocol for Shaken Baby Syndrome Education at NMDOH; tie use of protocol to certification to incentivize hospitals.
• Participate in an evaluation of Shaken Baby and Safe Sleep Education delivered by NMDOH.
• Draft and present a statewide, multi-sector Safe Sleep Strategy Plan by 2020.

Safe Sleep/ Sudden Unexpected Infant Death - SUID Prevention

Background - Definitions and program activities informing FY19 report

Sudden Unexpected Infant Death (SUID) includes deaths of infants which are either unexplained after thorough case investigation (i.e. SIDS ICD-10 R95, Unknown ICD-10 R99) or explained by Accidental Suffocation or Strangulation in Bed (ICD-10, W-75). All cases are reviewed in field investigation and autopsy to assess sleep environment-related risks and prevention factors. New Mexico joined the Centers for Disease Control and Prevention (CDC) Sudden Unexpected Infant Death (SUID) Registry in 2009, and in 2011 the NMDOH Office of Injury Prevention and MCH Epidemiology began formally planning and implementing safe sleep prevention plans. Since 2011 SUID rates initially decreased slightly in 2012-2013 but resumed to about 1 death per 1,000 live births through 2017. Rates are about twice as high among male infants compared to female.  By ethnicity, rates are 2.3 per 1,000 for Black/African American infants, 1.0 per 1,000 among Native American infants and .8 per 1,000 among non-Hispanic white babies (NM-IBIS, 2009-2017).

To address disparate outcomes requiring complex interventions, and to provide education to health and home visiting providers, NMDOH offered webinar trainings for perinatal case management, midwifery, and WIC nutrition programs starting in 2012.  These trainings informed initial strategies to work with perinatal clinicians and hospital staff responsible for policy development and regulations at clinical or facility settings. We developed those trainings in collaboration with Dr. Michael Goodstein, a nationally recognized neonatologist and board member of Cribs for Kids, who we later contracted with to train New Mexico hospital staff in safe sleep hospital policy and procedure development (Oct. 2014). From FY17-FY19, Title V and Office of Injury Prevention work with UNM Prevention Research Center professionals to train hospital staff in AAP safe sleep recommendations and to assess current practices. All three programs also collaborated on legislation, statewide strategic planning, and environmental scans of program policies and practice across the state.

Safe Sleep Products

Home Visiting program staff in CYFD researched safe sleep products in 2017-2018 and determined that the most versatile product would be the Munchkin BRICA travel bassinet https://www.munchkin.com/fold-n-go-travel-bassinet.html. Travel bassinets or baby boxes, and co-sleepers/ in-bed sleepers, are portable and may be easier to manage than cribs for mobile or homeless families, and they can also be used for camping.  Alternatives are presented to families who do not have access to or cannot afford to purchase any of these products. Plastic tubs, clothing drawers, laundry baskets and other no-cost or low-cost sleep surfaces are promoted in situations where families need something fast or unexpectedly.  The Office of Injury Prevention has representation on the Consumer Product Safety Commission (CPSC) and circulates recall notices and articles biweekly to alert the public on recalls of defective sleeping products. Notices from CPSC, Safe Kids Worldwide, and Kids in Danger help alert public health programs and community-based organizations about defective products designed for infants, toddlers and children.

Many Mothers, a volunteer-staffed maternal support program serving families in Santa Fe and Rio Arriba Counties, provides prenatal and postpartum support to pregnant women, stay-at-home fathers, and families with babies, six months or younger. The program started offering Baby Boxes or Travel Bassinets to promote safe sleep with clients beginning in 2018. Many Mothers also partners with Tewa Women United YVK Doula Program in Española to provide baby boxes to families prenatally or at delivery. The doula program’s experience with Baby Box products has been positive among Latino and some Native American families, and doula staff also encourage clients to view short video trainings to obtain more information and resources on safe sleep. However, there are no evaluation plans among partnering organizations to assess the use of baby boxes or bassinets, and that is a gap in the program activities addressed in the statewide safe sleep strategic plan.

Some communities continue to decline distribution of the boxes, since they may seem uncomfortable for sleep or culturally inappropriate, as with the Navajo Nation service area or Navajo Area Indian Health Service (IHS) families.  Prenatally, and at delivery, families receive safe sleep and breastfeeding education/promotion in the Navajo IHS service area, but they are not offered a specific sleeping product. Families are encouraged to place their infants on firm mattresses in a supine position, and this is aligned with cradle boarding and cultural practices. Breastfeeding is strongly encouraged by health promotion and lactation staff in IHS hospitals, which were also the first facilities in New Mexico to achieve Baby-Friendly Hospital Initiative (BFHI) breastfeeding designation.  

Objective- Increase the number of NM birthing facilities trained by the NMDOH in safe sleep education protocols from 3 to 15 by 2020.

NMDOH Office of Injury Prevention (OIP) and MCH Epidemiology collaborated to expand a scope of work for hospital safe sleep education and continue the work through a contract with the UNM Prevention Research Center. Theresa Cruz, PhD, is the Project Director who initiated trainings with University of New Mexico delivery and nursing staff in 2017. The contract was expanded to include two train two southern facilities by the end of 2019; Memorial Medical Center and Mountainview Hospital staff in Las Cruces, NM were trained during period, and another contract to continue birthing hospital trainings will be executed for FY21. These two facilities provide maternity and obstetric services to approximately 2,500 families residing in NM US-Mexico border counties, annually.

To address the need for coordinated efforts to increase safe sleep education, Title V staff completed a statewide, multi-sector Safe Sleep Strategic Plan. Evaluator Nicholas Sharp drafted the plan, which was developed with input from the NMDOH Tribal Liaison, the Child Fatality Review SUID Registry staff, Title V program and UNM partners.  The NM Children’s Cabinet was re-established in 2019 and was consulted for support in the implementation of the statewide plan. 

The new Early Childhood department will officially begin operations in July 2020 as the “umbrella” for virtually all child development and childcare operations statewide.  It is anticipated that the creation of the new department will significantly increase the number of trainers and trainings available to educate parents, grandparents, home visitors and health professionals about all aspects of safe sleep and safe pregnancies, as well as general home and vehicle safety protocols for all children under the age of 6 years.

Objective- Transition at least five (5) NM birthing facilities to report standardized statistics for Shaken Baby Education to the NMDOH in 2019

The legislation for Shaken Baby Syndrome (SBS) was enacted during the report year, and it mandated that every birthing facility in New Mexico educate families about SBS prevention before discharge.  The law was based on strong evidence from a nationally researched model, locally replicated at the University of New Mexico.  The 2018 SBS education law requires DOH-approved education for staff and families delivering at every birthing facility, but the rules providing guidance and appropriate curriculum have not yet been approved or published in administrative code.  Therefore, no data have been collected from hospitals on their SBS prevention education statistics.

While Family Health Bureau (FHB)/Title V staff are eager to advance the education and support evaluation of hospital compliance, we were not allowed to collect data from facilities and we were not included in the effort to promulgate rules for traumatic brain injury. Evaluation design will be contingent upon the specific rules and requirements written and delivered to birthing hospitals. It is not clear whether Title V MCH staff or the Office of Injury Prevention staff will be required to perform an evaluation, but it is our goal to provide impact evaluation on the education provided to families at delivery.

FHB/Title V staff analyzed a 2019 bill introduced on safe sleep education which closely resembles the current SBS education law; however, the safe sleep bill did not pass in 2019 or 2020.  Assuming the bill is submitted again for the 2021 legislative session, we will recommend that the Governor and the NM Children’s Cabinet be consulted on the proposed legislation and that it be tied to the SBS prevention education already conducted at the same birthing facilities (both hospitals and birthing centers).

Objective: Leverage existing program partners to increase the number of home visitation and perinatal case management programs trained in Safe Sleep and Shaken Baby education from 5 to 15, statewide by 2020.

NMDOH OIP Health Educator, John McPhee developed a Train-the-Trainer education model for safe sleep and general home safety for families interacting with Child Protective Services (CPS), starting in 2017.  CPS used web-based trainings to continue safe sleep education for all staff throughout 2018 and 2019, with approximately 1200 additional staff trained in safe sleep, shaken baby prevention and safe home trainings via e-learning modules. NMDOH MCH Health Educator, Sabrina Curry, supports early childhood screening and safe sleep education efforts through home visiting, Early Head Start, and case management staff trainings.   Ms. Curry and Mr. McPhee (OIP) have joined efforts to provide safe sleep and shaken baby syndrome trainings to CPS and perinatal case management staff throughout the state. 

The Safe Sleep presentation produced by NMDOH circulated electronically throughout the state to home visitor and other caregiving programs during 2019. The slide deck for Department of Health Safe Sleep presentations was updated and approved in March 2020 and is still used in the statewide Home Visiting Collaborative and regional networks of home visiting programs, hospitals and birthing centers.  It has already been introduced to the New Mexico Early Childhood Education and Care Department, along with two other presentations specific to prenatal and postpartum guidance on health and safety for both the newborn and parents.

Title V/ OIP staff presented on Safe Sleep for over one hundred WIC providers in March 2020 at the New Mexico Breastfeeding Conference, however the event was virtual due to the COVID-19 pandemic. In addition, 38 providers from the Indian Health Service did receive Safe Sleep training at the Tribal PRAMS conference held at Isleta Pueblo in February 2020.

The panel for the NM Sudden Unexpected Infant Deaths (SUIDS) Registry is managed by the NM Office of the Medical Investigator. The panel is active and included ongoing representation from OIP and Title V throughout 2019-2020. Dr. Lori Proe, Office of the Medical Investigator (OMI) pathologist, led the death review panel with participation from lead field investigator, Rebecca Tarin. The team was rounded out by NMDOH staff to develop recommendations for the annual child fatality review.  Nicholas Sharp, the Title V MCH Epidemiologist/Evaluator, participated in the SUID panel and contributed to the recommendations for policy or program applications. She and John McPhee provide guidance to the development of program practice and prevention messaging in the Family Health Bureau.

The SUID panel drafted their 2019 prevention recommendations based on death review findings. Title V staff and OIP staff worked together to align Title V strategies and objectives with the findings applied to the recommendations. They were incorporated into the Safe Sleep Strategic Plan, updated in 2020. Primary areas of updated recommendations are described here:

1. Ongoing and expanded safe sleep education for parents, grandparents, home visitors and health professionals
   1. Legislation should require birth hospitals to provide one-on-one instruction on safe sleep to all birth, foster, and adoptive parents prior to a newborn’s discharge from the hospital.
   2. Birth hospitals, Ob-Gyn providers and pediatricians should be linked with state, county, or community resources that can provide free “baby boxes” bassinets, cribs, or other safe sleep surfaces when needed prior to the newborn going home.
   3. The newly created Early Childhood Education and Care Department (ECECD), again commencing official operations in July 2020, will be tasked with providing trainings for home visiting and daycare staff statewide regarding all aspects of health and safety for newborns and toddlers, with Safe Sleep guidelines being the priority.
2. Increased statewide participation in home visiting programs.
   1. Ob-Gyn providers, birth hospitals, and pediatricians should be the first points of contact for referrals to home visiting services.
   2. ECECD will be tasked with keeping providers up to date on the local home visiting services available in their respective counties for their referral to local parents.
3. Improved/expanded ability and opportunity for mandated reporters and community providers to initiate a face-to-face response from CYFD Protective Services when there are concerns about unsafe sleep or related risk factors.
   1. Under a differential response track, circumstances leading to assessment and follow-up from the agency could include:
      1. Caregivers whose infants are discharged from a birthing hospital with a “Plan of Safe Care” as required by the Child Abuse Prevention and Treatment Act as amended by the Comprehensive Addiction and Recovery Act of 2016 who do not follow through on appointments, services, or treatment as described in their Plan.
4. Revision of procedures and practices around safe sleep for foster care and respite care providers, per CYFD Protective Services Division.
   1. All CYFD field staff; licensed placement agency staff; prospective foster parents, adoptive parents, and respite care providers licensed through CYFD or a CYFD-regulated private agency should participate in annual safe sleep training based on American Academy of Pediatrics recommendations.
5. Strategies to improve investigation of SUID deaths and remove barriers to thorough data collection are implemented.
   1. All Field Deputy Medical Investigators should be routinely trained in SUID death investigations, including tribal police partners.
   2. Translation services should be available for parents/caregivers whose first language is not English, to complete thorough interviews and doll reenactments with law enforcement and Field Deputy Medical Investigators.

These strategies and recommendations will inform FY21 plans to continue the efforts to keep infants safe in sleep environments.