Perinatal/Infant Health Overview
Perinatal and infant health is a central focus of the Division of Maternal and Infant Health (DMIH), which supports programs designed to ensure infants are born healthy and ready to thrive. The Women and Maternal Health Section and Perinatal and Infant Health Section within DMIH oversee many programs including the Regional Perinatal Quality Collaboratives, Maternal Infant Health Program (MIHP), Infant Safe Sleep, Breastfeeding, Fetal Infant Mortality Review, Safe Delivery of Newborns, and the Early Hearing Detection and Intervention program. MIHP provides Medicaid-funded home visits to women while pregnant and infants in their first year of life, and other infant health services focused on needs such as infant mortality prevention, safe sleep, and vision and hearing screening. Title V funds a variety of programs and initiatives related to perinatal and infant health, including projects related to safe sleep, breastfeeding, prenatal care outreach, PRAMS, and infant and maternal mortality reduction. MCH program staff also support Regional Perinatal Quality Collaboratives (RPQCs) that use quality improvement methods to test strategies for improving maternal and infant health. Title V funding is also used as a gap-filling funding source for RPQCs. Other federal funding is used to identify and meet the needs of this population, such as WIC (USDA), Universal Newborn Hearing Screening and Intervention (HRSA), and PRAMS (CDC). Perinatal and infant health is promoted through a network of partnerships, including those with health care providers, labor and delivery hospitals, universities, the Mother Infant Health and Equity Collaborative, and the Michigan Association for Infant Mental Health.
At the local level, LHDs expended Title V funds in two NPMs and Local Performance Measures (LPMs) in FY 2021. Breastfeeding (NPM 4) activities among 18 LHDs included breastfeeding support through groups, home visits and/or telehealth visits, lactation consultants and phone consultations; virtual staff development; and participation in virtual community breastfeeding coalition meetings. One LHD reported that it was difficult to build public interest in breastfeeding media campaigns and the pandemic dominated the media. Ten LHDs addressed infant safe sleep (NPM 5) through education in a variety of creative, socially distanced ways and distributed pack-n-plays to families with an assessed need. COVID-19 safety precautions continued to cause disruptions in agencies’ ability to do in-person visits and in-person services at provider offices. LPM activities included FIMR team processes, car seat safety, and epidemiology surveillance work for birth outcomes/infant mortality reduction.
Michigan’s approach to perinatal and infant health emphasizes implementing strategies that prevent maternal and infant morbidity and mortality, which are critical indicators of the degree to which a community takes care of its women and children. Focus areas include safe sleep and breastfeeding. In Michigan, the infant mortality rate has decreased from 7.5 deaths per 1,000 births in 2009 to 6.8 per 1,000 births (MDHHS) in 2020. A similar trend has been documented nationwide. However, the risk more than doubles to 14.0 per 1,000 births among non-Hispanic Black babies and is substantially greater (10.9 per 1,000 births) for babies born to mothers who are under 20 years of age. These data suggest that while the needs of women and children are being better prioritized in general, the needs of Black families and young families remain unmet. Another critical signal of wellbeing in the perinatal period and a factor in the health of infants is postpartum depression. From 2012 through 2017, the proportion of mothers reporting postpartum depression symptoms remained constant at 13.5%, but the number jumped to 16.4% in 2018, then declined to 14.8% in 2019 (Michigan PRAMS).
Breastfeeding (FY 2021 Annual Report)
The American Academy of Pediatrics recommends all infants are exclusively breastfed for six months to support optimal growth and development. Breastfeeding has health benefits for infants and mothers, including significant benefits to the mental health of both mothers and babies. For infants, breastfeeding can reduce risk of asthma, obesity, SIDS, diabetes, ear infections and some respiratory diseases. For mothers, breastfeeding can reduce feelings of anxiety and postnatal depression, reduce post-partum hemorrhage, and may decrease the likelihood of developing breast, uterine and ovarian cancers. Human milk remains the optimal source of nutrition for the first months of life. Additionally, the Title V needs assessment revealed that breastfeeding is still a critical MCH issue for Michigan’s mothers and infants. Needs assessment themes showed that families want more breastfeeding support and education and that families are having difficulty accessing breastfeeding support professionals and providers that support breastfeeding. During the Title V needs assessment, stakeholders identified the priority need to “Create and enhance support systems that empower families, protect and strengthen family relationships, promote care for self and children, and connect families to their communities” as an important way to achieve breastfeeding initiation and duration. The COVID-19 pandemic has highlighted the need to ensure that emergency preparedness plans support access to human milk especially in Black, Indigenous, and People of Color (BIPOC) communities that have been disproportionately impacted by COVID-19. MDHHS will work to expand collaboration with BIPOC led organizations and communities that lead in addressing this health equity work, especially in relation to dismantling barriers to breastfeeding.
According to the National Immunization Survey (NIS), in 2018 Michigan’s initiation rate was 84.4% (CI 79.3-88.5). This meets the annual objective set of 80.5%. Michigan’s breastfeeding exclusivity rate through six months was 29.8% and predicted to be 31.1%. Michigan’s goal is to reach 45.4% by 2025.
PRAMS data 2019 tells a more complicated story with an initiation rate of 87.3%, which is above Healthy People 2020 goals and NIS projections. PRAMS has shown that Michigan’s initiation rate has increased steadily from 2009 to 2019 gaining 14.1% across ten years from 73.2% to 87.3%. However, disparities in breastfeeding initiation persist among non-Hispanic white women and non-Hispanic black women. According to PRAMS, while from 2009-2014 initiation rates grew among black women at a comparable or even faster rate than white women, from 2014 to 2017, initiation rates among black women remained unchanged (77.3% to 77.2%) compared to increases among white mothers (86.3% to 90.1%). Alarmingly, we have seen our first multi-year period of decrease in a breastfeeding measure, with initiation rates among black women falling between 2017 (77.2%) and 2019 (72.0%). Initiation rates among black mothers are now about 18% lower than white mothers. This 18% gap in initiation has grown from what used to be a gap of 10% in 2014-2016 [86.3% NHW - 73.8% NHB]. Data from MDHHS Office of Vital Statistics also show slightly lower initiation rates among Hispanic and Native American women when compared to white women. MDHHS will continue to intentionally gather data as it relates to Native American breastfeeding rates.
Based on the above disparity data, the Title V state action plan continues to focus on reducing disparities in breastfeeding rates among women of color. The plan also focuses on increasing breastfeeding knowledge among maternal and infant health professionals, who work with pregnant or postpartum women, offering breastfeeding educational opportunities statewide through a webinar series, and the release of the revised State Breastfeeding Plan to provide a framework for improving breastfeeding rates statewide. The evidence continues to support that babies born in Baby-Friendly designated hospitals are more likely to be breastfed; therefore, increasing the percent of Baby-Friendly hospitals in Michigan remains the Evidence-based Strategy Measure (ESM) for this NPM.
MDHHS receives parent and community input on breastfeeding related issues through several means including the Statewide Breastfeeding Workgroup; discussions at the Town Hall meetings held in relation to the Mother Infant Health and Equity Improvement Plan; PRAMS, and participation in local breastfeeding coalition meetings when possible.
Objective A: Increase the percent of infants who are breastfed exclusively until 6 months to 41.1% by 2025.
The Michigan Breastfeeding Plan was released to the public in February 2021. The Plan sets a common agenda necessary for a collaborative approach to support breastfeeding in Michigan. It is guided by the vision of removing barriers, advancing equity, and promoting breastfeeding, as essential for infant nutrition, social emotional health and chronic disease prevention, by ensuring that all families have the opportunity to breastfeed for as long as they chose. The Plan was developed based on community feedback from a statewide survey with over 160 responses and over 40 public comment responses. MDHHS staff promoted the Michigan Breastfeeding Plan through presentations, listservs, and newsletters. In May 2021, a Breastfeeding Plan Advisory group was formed with local breastfeeding supporters, health departments, clinical staff, and community members.
MDHHS worked to improve the knowledge of breastfeeding support among staff working in maternal and infant health programs including home visitors. In August 2021, staff presented on Breastfeeding for the 2021 Michigan Home Visiting Conference, Individual Model Day Sessions. Topics included the Michigan Breastfeeding Plan and how home visitors could support the plan; a presentation from the Michigan Women Infant and Children (WIC) Division on breastfeeding support; a presentation on community-based breastfeeding activities and advocacy from the Michigan Breastfeeding Network and updates to breastfeeding related plans of care.
A key activity to train home visitors and other maternal and infant health staff are the Great Lakes Breastfeeding Webinar Series, a project of the Michigan Breastfeeding Network, which provides breastfeeding specific information every month at no cost to participants. Participation in the webinars varies but many webinars have over 1,000 attendees nationally and over 140 attendees from Michigan. Statistics show that of people participating from Michigan roughly 10-11% are home visitors and 8-10% are maternity care nurses.
MDHHS continues to work with Michigan Birthing hospitals to encourage, support and acknowledge hospitals achieving Baby-Friendly status. This is Michigan’s ESM for this NPM. MDHHS staff promote the implementation of breastfeeding friendly maternity care practices through trainings and encouraging hospitals to review and complete the CDC Maternity Practices in Infant Nutrition and Care (mPINC) survey. The Great Lakes Breastfeeding Webinar series is promoted with hospital staff and an estimated 5-10% of participants identify maternity care nurse as their primary job function. Unfortunately, the number of Baby-Friendly Hospitals in Michigan has declined from 18.8% to 16%. Responding to the COVID-19 pandemic has placed incredible strain on Michigan’s hospitals for the past two years and has inhibited their ability to meet and/or maintain the Baby Friendly USA standards.
According to PRAMS data, breastfeeding initiation among Michigan’s non-Hispanic Black women was 72.0% in 2019, the lowest percent for this group since 2013. Non-Hispanic white women breastfeeding initiation rates were relatively consistent since 2017 with a 2019 rate of 90.2%. When asked about 10 different possible barriers to initiating breastfeeding, more non-Hispanic Black women report that they had multiple reasons for not initiating breastfeeding (51.3% vs. 39.2%) compared to non-Hispanic white mothers. This reflects persistent challenges in reducing the disparity in breastfeeding. While PRAMS data often illustrate individual reasons for not breastfeeding, systems level reasons—including historical and present-day racism—must be examined. Still, about half of non-Hispanic Black mothers, who did not initiate, stated that there was just one barrier to initiate breastfeeding. As we investigate systems-level barriers and other complex problems, we will seek to support those whose single stated barriers may be more readily addressed.
To reduce the gap in disparities, Michigan’s first strategy was to provide and promote training opportunities to improve the number, availability, and racial and cultural diversity of trained breastfeeding professionals. MDHHS partners with and provides support to the Great Lakes Breastfeeding webinar series, a project of the Michigan Breastfeeding Network, which offers breastfeeding-specific information every month at no cost to participants. The webinar provides contact hours for nurses, social workers, lactation consultants and dietitians. This free, easy-to-access education allows all providers the ability to receive advanced training, which diversifies and strengthens Michigan’s lactation workforce. Topics have a strong focus on health equity and supporting community-driven work in Black Indigenous People of Color (BIPOC) communities. The webinars continue to be popular with WIC, hospitals, health departments and home visitors. As many as 40 states attend the webinars monthly and are viewed by the following job functions: peer counselors, maternity care nurses, home visitors, other breastfeeding services, nutrition, childbirth support, social work, and coalition leadership. In FY 2020, MDHHS worked with the Michigan Breastfeeding Network to obtain funding from maternal and child health partners in Region V to support the webinars and to move toward regional collaboration.
To recognize Black Breastfeeding Week and Indigenous Breastfeeding Week, MDHHS hosted a virtual panel discussion in FY 2021 with statewide BIPOC-led community breastfeeding groups to raise awareness about the commemorations, disparities in breastfeeding rates, and how systemic racism affects those disparities. The panel discussed the importance of community and diversity in breastfeeding leadership, and shared actionable steps registrants could take to better support parents and babies. The event was moderated by Priority Health. Over 95 individuals registered for the event, and it was widely promoted on MDHHS social media and among breastfeeding partners and listservs.
In FY 2021, MDHHS prioritized creating and posting breastfeeding promotional messages on the department’s social media accounts. Breastfeeding related content posts were created monthly and submitted to MDHHS Communications for distribution. The MDHHS Facebook page has over 144,000 followers and over 34,000 Twitter followers. As part of August Breastfeeding awareness month commemorations, MDHHS created and posted quotes from local breastfeeding supporters, advocates, and families about the importance of breastfeeding. Eight posts were featured throughout the month on MDHHS social media pages and shared with partners. A MDHHS media campaign was developed and issued in late FY 2021 and early FY 2022 focusing on breastfeeding and infant safe sleep messaging. Input on the campaign was received from young adults in partnership with the Michigan Organization on Adolescent Sexual Health. This campaign was directly supported by Title V funds. Additional details on the campaign can be found in the Safe Sleep (NPM 5) annual report.
Rather than facilitating community efforts in one community to impact low breastfeeding rates among women of color, a more complete approach was used by funding 10 BIPOC-led breastfeeding organizations as described above. The mini-grants were awarded to support the provision of breastfeeding support primarily to families of color. Organizations were based throughout the state in Detroit, Grand Rapids, Saginaw, Benton Harbor, Battle Creek, Pontiac, the Upper Peninsula, and Flint. Virtual options have expanded the ability to provide support services statewide. In addition to providing direct breastfeeding support to families, organizations were able to provide breastfeeding education and trainings, build community connections, establish and/or maintain breastfeeding support groups, purchase supplies, purchase safe sleep spaces, and strengthen referral resources for families. Organizations also worked together and with the Michigan Breastfeeding Network on sustainability skills such as organizational budgeting, fund development, web pages and reports. MDHHS continues to work with the Genesee County Health Department, located in the City of Flint, to increase breastfeeding rates in that community. Activities have been impacted by COVID-19 and competing demands, but progress has resumed.
Safe Sleep (FY 2021 Annual Report)
Michigan’s safe sleep strategies and activities promote three key messages to parents and caregivers: infants should sleep 1) alone, 2) on the back, and 3) in a crib, bassinet or pack and play. These behaviors are critical to the prevention of sleep-related infant death. Of the leading causes of infant death, sleep-related causes are considered the most preventable. In FY 2021, Title V federal funding was used for activities that support Michigan’s safe sleep work, including PRAMS, infant mortality communication, Fetal Infant Mortality Reviews, breastfeeding support, and funding to local health departments to support community-based safe sleep prevention efforts.
When comparing birth year 2018 to birth year 2019, there were improvements in the weighted percentage of mothers placing infant to sleep on back, placing infant to sleep in separate approved sleep surface, and placing infant to sleep with no soft objects or loose bedding. However, none of the measures reached a statistically significant improvement. In 2018, 82.5% of Michigan mothers placed their infants to sleep on their back, compared to 84.9% in 2019. The proportion of infants sleeping with no soft objects (i.e., pillows, bumpers, blankets, toys) has increased from 59.8% in 2018 to 63.1 in 2019. For the fourth year in a row, Michigan mothers continued to lead all other states for this measure. In 2018, 38.9% of infants were placed to sleep on a separate approved sleep surface, which has increased to 40.6 percent in 2019. Starting in 2016, this measure is based on the combination of five different sleep risk factors: always or often 1) sleeps alone in own bed; 2) in a crib, bassinet or pack and play; 3) does not sleep on a twin or larger mattress; 4) does not sleep on couches, sofas, armchairs; and 5) does not sleep in a car set or swing. Asking whether infants sleep in a car seat or swing, a new question since 2016, has had an especially large impact on this measure.
While four distinct objectives for infant safe sleep were identified, the strategies to address them are combined, since the safe sleep behaviors are so closely related. All strategies and activities will promote the key messages to parents, caregivers, and providers that infants should sleeps alone and without objects on the back, in a crib, bassinet or pack and play and will continue to address ways to increase those behaviors by all families, while also addressing the disparity for non-Hispanic Black families.
Objective A: Increase the percent of infants put to sleep on their backs to 92.6% by 2025.
Objective B: Increase the percent of infants put to sleep on a separate approved sleep surface to 58.1% by 2025.
Objective C: Increase the percent of infants placed to sleep without soft objects or loose bedding to 83.0% by 2025.
Objective D: Increase the percent of non-Hispanic Black infants put to sleep on their backs, put to sleep on a separate approved sleep surface, and put to sleep without soft objects or loose bedding.
In FY 2021, activities occurred within six strategies:
- Support safe sleep activities of local health departments and the Inter-Tribal Council of Michigan.
- Support providers to implement safe sleep policies/protocols/programming to ensure families receive infant safe sleep education and access to resources.
- Explore legislative/regulatory change to increase the number of babies that are safely sleeping.
- Develop and share tools with providers, families, and workers regarding having client/patient centered conversations regarding safe sleep.
- Promote protective factors (i.e., smoking cessation, breastfeeding, immunizations) and evidence-based programs (i.e., home visiting) to enhance the overall health and well-being of moms and babies.
- Engage hospitals in areas with a high rate of sleep-related infant deaths and disparities to explore needed policies and resources to ensure families of NICU infants are practicing safe sleep behaviors after discharge.
In FY 2021, the COVID-19 pandemic continues to have a significant impact on grantees; throughout the year, staff were pulled away to assist with pandemic-related activities. When necessary, activities were done virtually and distribution of pack and plays and other items was done with no or distanced contact. Several LHDs planned to implement the Society for Public Health Education (SOPHE) SCRIPT® (Smoking Cessation and Reduction in Pregnancy Treatment) Program but were unable to due to the pandemic. Despite challenges, grantees were able to provide infant safe sleep education to nearly 12,000 individuals (parents, caregivers, professionals, and community members) through virtual and some in-person classes and community events. LHDs continued to be creative in ways to reach families, hosting virtual house parties and gender reveal parties, as well as virtual bingo. Some LHDs were able to use COVID-19 vaccination events as an avenue to share safe sleep resources with attendees.
Social Determinants of Health (SDOH) are drivers in the disparity of sleep-related infant deaths. Grantees are required to have a local advisory council that includes partners that can address SDOH. This includes partners that can meet resource needs of families, as well as partners that work further upstream to address systemic policies and practices that drive disparities.
A new strategy was to support providers in implementing and updating existing safe sleep policies or protocols to ensure families receive infant safe sleep education and access to resources. A new evidence-based or -informed strategy measure (ESM) was established to increase the number of agencies that have a safe sleep policy/protocol. Eight programs (i.e., substance use treatment, domestic violence services, services for homeless families and home visiting programs) volunteered to participate in this project. Individual meetings and assessments were done to assess staff knowledge on infant safe sleep. Customized trainings were done with six of the programs.
With the input and feedback of the participating programs, a recommendations document was developed for agencies implementing or updating a safe sleep protocol/policy. The final recommendations document was provided to the participating programs to use as a guide for developing a policy. Due to a variety of constraints including staff turnover, the pandemic, and etcetera, most of the programs were unable to implement a policy. However, the project did raise awareness of safe sleep and community resources to program staff. One participating program, the Kent County Health Department, developed a policy that will be piloted next fiscal year with seven of their health department programs (i.e., Maternal Infant Health Program, Nurse-Family Partnership, Strong Beginnings, Children’s Special Health Care Services, Lead, Refugee Services, and WIC). After the pilot, the policy may be expanded to include all health department programs.
As part of the third strategy, the MDHHS Infant Safe Sleep (ISS) program met with MDHHS Legislative Affairs to discuss how to increase awareness among the legislature about maternal child health and infant safe sleep. Work on this item was put on hold due to the pandemic. At the end FY 2021, plans were made for a presentation to the Senate Families, Seniors, and Veterans Committee and a Lunch and Learn for Legislative staff in October 2021. This strategy also included identifying possible legislative or regulatory changes that would increase the number of babies safely sleeping. A scan of regulations was completed, and a proposed policy/regulation change document was developed. This document was shared with the Maternal Infant Health (MIH) Policy and Legislation Action Committee and the committee will determine next steps in FY 2022.
A continued strategy was to develop and share tools with providers and family support workers on how to have client/patient centered conversations regarding safe sleep. This strategy included continuing to promote the Helping Families Practice Infant Safe Sleep (Safe Sleep 201) training and incorporating into other educational venues the core tenets of this training—how to have more effective conversations with families by starting where the family is at, educating on the safe sleep guidelines and helping the family evaluate their current risk and explore strategies for risk reduction. A continued ESM is to increase the number of Maternal Infant Health Program (MIHP) agencies that have staff trained to use motivational interviewing with safe sleep. In FY 2021, all 78 MIHP agencies have staff trained to use the concepts of motivational interviewing with safe sleep by requiring the Safe Sleep 201 training for all staff.
To reach professionals, who work with pregnant and parenting families, the MDHHS ISS Program continued to build upon connections with existing partners, such as the Women, Infants and Children (WIC) Program, home visiting programs (Maternal, Infant, and Early Childhood Home Visiting and the MIHP), child welfare, the Regional Perinatal Quality Collaboratives, MDHHS Tobacco, and MDHHS Emergency Medical Services and Trauma (EMS). These continued collaborations led to training on the safe sleep basics, how to support families, and access to resources for a variety of professionals. In FY 2021, over 1,000 individuals attended a virtual safe sleep training and nearly half of those individuals received training on how to support families. In addition, over 7,900 individuals completed one of the three online infant safe sleep trainings, just over 230 hospital nurses and other staff took the online training Infant Safe Sleep: The Basics and Beyond, and over 250 participants attended one of three safe sleep webinars. Providers were also supported with access to free educational materials; over 250,000 educational items were distributed by MDHHS in FY 2021. By the end of FY 2021, over 3,200 professionals were subscribed to the infant safe sleep email listserv.
As an additional tool to integrate safe sleep education into prenatal visits, the High Touch, High Tech (HT2) e-screening tool, which delivers a brief motivational intervention and helps connect families to additional supports, was expanded to include screening for safe sleep knowledge and behaviors. The safe sleep education modules have been developed and will be rolled out in FY 2022.
Another strategy is to promote protective factors (i.e., smoking cessation, breastfeeding, immunizations) and evidence-based programs (i.e., home visiting) to enhance the overall health and well-being of moms and babies. As noted above, outreach to and coordination with other MDHHS programs continued. In conjunction with MDHHS Tobacco Section, the MDHHS ISS Program continued to host a quarterly call to support local health departments implementing SOPHE SCRIPT as well as other smoking cessation activities.
MDHHS ISS Program continued to explore other ways to engage families directly in the work, including support of the MIH Infant Safe Sleep Action team which included two parent members.
The final strategy is to engage hospitals in areas with a high rate of sleep-related infant and death and disparities to explore needed policies and resources to ensure families of NICU infants are practicing safe sleep behaviors after discharge. Two hospitals volunteered to participate: St. Joseph Mercy Oakland in Pontiac and Beaumont Hospital in Troy. With the input and feedback of the participating hospitals, sample infant safe sleep protocols for hospitals to use as a guide in creating or updating safe sleep policies for the Mother Baby Units, Neonatal Intensive Care Units (NICU) and Special Care Nurseries, and Other Units (pediatrics, emergency, and etcetera ) and sample crib audit forms were developed. The participating hospitals completed crib audits and found minor issues. Through regular meetings with the participating hospitals, as well as quarterly meetings with other birthing hospitals interested in safe sleep, the MDHHS ISS Program continued to explore how hospitals can educate and support families. Efforts to support birthing hospitals were impacted by the pandemic with staff having limited time to devote to safe sleep.
A new ESM was utilized to track the number of hospitals that have implemented or revised/updated a safe sleep policy/protocol. St. Joseph Mercy Oakland in Pontiac plans to update their policy next fiscal year and Beaumont Hospital in Troy did not make any revisions to their policy.
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