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 Perinatal and Infant Health Section within DMIH oversees many programs including the Regional Perinatal Quality Collaboratives, Maternal Infant Health Program (MIHP), Infant Safe Sleep, Fetal Infant Mortality Review, Safe Delivery, 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, breastfeeding, and vision and hearing screening. Title V funds a variety of programs and initiatives related to perinatal and infant health, including projects related to sudden infant death syndrome, prenatal care outreach, fetal alcohol spectrum disorder, PRAMS, and infant and maternal mortality reduction. Title V also funds regional perinatal quality collaboratives across the state that are using quality improvement methods to test strategies for reducing infant mortality and improving infant health. Other federal funding is also 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, the Maternal Infant Strategy Group, the Michigan Association for Infant Mental Health, and universities.

Michigan’s approach for perinatal and infant health emphasizes implementing strategies that prevent infant mortality, which is a critical indicator of the degree to which a community takes care of its women and children. 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 (NVSS) in 2017. A similar trend has been documented nationwide. However, the risk doubles to 14.6 among non-Hispanic Black babies and is substantially greater (9.0) for babies born to mothers who are under 20 year of age. These data suggest that, while we are better prioritizing the needs of women and children in general, the needs of Black families and young families remain unmet. Another critical signal of wellbeing in the perinatal period and an important factor in the health of infants is postpartum depression. From 2012 through 2017, Michigan PRAMS reports the proportion of mothers reporting postpartum depression symptoms has remained constant at 13.5%. However, 18.2% of women with Medicaid prenatal care experienced depression symptoms postpartum compared to 9.0% for those without Medicaid, suggesting that women living with limited incomes face stressors around childbirth that women with greater resources are more protected from experiencing.

Risk-appropriate Perinatal Care (FY 2018 Annual Report)

Building on Michigan’s existing perinatal care system, FY 2018 resulted in ongoing Regional Perinatal Quality Collaborative quality improvement efforts in northern lower, west, southeast, southwest and the Upper Peninsula of Michigan and efforts to begin expansion into the Saginaw/Bay and Thumb areas of Michigan. Regional Perinatal Quality Collaborative efforts have served as the backbone of addressing risk-appropriate care for mothers, infants and perinatal substance use. In FY 2018, Title V federal funding was used to support four Regional Perinatal Quality Collaboratives.  Title V funding was also used to support other activities related to maternal health, including the Michigan Maternal Mortality Surveillance (MMMS) Program and the Pregnancy Risk Assessment Monitoring System (PRAMS). Focus remained on linking families to the evidence-based CenteringPregnancy and CenteringParenting prenatal and postnatal care models and evidence-based home visiting, which have been proven to improve birth outcomes.

The importance of comprehensive system linkages and quality improvement remain the driving force behind Michigan’s efforts to improve maternal, infant and family health. In FY 2018, partnerships and collaborations were solidified and strengthened with Healthy Start projects; WIC clinics; Maternal, Infant and Early Childhood Home Visiting (MIECHV) Programs; local health departments (LHDs) receiving Title V funding; and many other maternal and child health partners.

Objective A: By 2020, support the implementation and evaluation of Regional Perinatal Care Systems in five pilot communities or regions.

In FY 2018, Regional Perinatal Quality Collaborative projects encompassed seven of the ten Michigan-designated Prosperity Regions. Perinatal Quality Collaboratives are in southeast, west, northern Lower, southwest, the Saginaw/Bay area and the Upper Peninsula of Michigan. Each regional project is charged with utilizing quality improvement methodology aimed at improving maternal and infant health. All projects are required to review available birth outcome data (stratified by race, ethnicity, age and socioeconomic status) to identify inequities and gaps in care; both of which shape the focus of each region’s quality improvement project(s). Additionally, every region is to address the social determinants of health as the root cause of health inequity. Each regional collaborative is composed of diverse regional partners vested in improving maternal and child health outcomes. Birthing hospitals, LHDs, Medicaid Health Plans, Healthy Start projects, evidence-based home visiting programs, Great Start Collaborative representatives and Community Foundations are just a sample of the stakeholders and members of the Regional Perinatal Quality Collaborative projects. The most important stakeholders, however, are the families residing in each region. Family input on the regional efforts, as well as barriers and inequities experienced, has been garnered in the form of focus groups, attendance at regional meetings and regional “town hall” meetings.

Southeast Michigan (inclusive of Wayne, Oakland and Macomb counties) is home to 24 of Michigan’s 81 birthing hospitals. Of these 24 birthing hospitals in southeast Michigan, ten are neonatal intensive care units (NICUs) and represent just under half of the NICUs in Michigan. In calendar year 2017, 45,691 (41%) of the births in Michigan occurred in southeast Michigan. Prior to designing their quality improvement project, the southeast Michigan team received data related to zip codes in the City of Detroit with the highest infant mortality rates. In an effort to address these areas of high infant mortality, the team designed its quality improvement project around increasing referrals and utilization of evidence-based home visiting from three prenatal care clinics and a NICU in the City of Detroit. These clinics, NICU and home visiting agencies serve the areas of the City identified as ‘hot spots’ for infant mortality.

West Michigan contains 13 rural and urban counties, nine LHDs, 12 birthing hospitals, two NICUs and a reported 19,377 births in calendar year 2017. This regional quality collaborative has divided into two workgroups: one to increase substance use screening in pregnant women and one to increase utilization of evidence-based home visiting services. Each workgroup is hoping to implement their interventions in both rural and urban settings. The populations of focus for these two workgroups were identified through stratification of data and noting that certain geographic areas of the region had poorer birth outcomes and more cases of infant morbidity.

Northern Lower Michigan is made up of 21 counties, nine birthing hospitals, and one NICU. In calendar year 2017, 4,693 live births were reported. This region is working to increase substance use screening in pregnant women through an electronic screening tool, ensure women with Perinatal Substance Use Disorder (PSUD) are linked to appropriate providers for treatment and increase referrals and utilization of home visiting programs. Northern Lower Michigan identified a need for PSUD screening, based on data related to smoking in pregnancy, Neonatal Abstinence Syndrome cases and after surveying prenatal clinics on their use of screening tools.

The Upper Peninsula is 16,377 square miles, has 15 counties, eight birthing hospitals, and one NICU. In calendar year 2017, 2,664 live births were reported. Recent Neonatal Abstinence Syndrome (NAS) data reflects the highest rates occurring in the Upper Peninsula. Given these results, along with the high number of women who smoke while pregnant, the team decided to focus their efforts on increasing substance use screening in pregnant women, increase care coordination of PSUD treatment and obstetric care, reduce stigma related to care of babies with Neonatal Abstinence Syndrome (NAS) and implement the Society for Public Health Education (SOPHE) Smoking Cessation and Reduction in Pregnancy Treatment (SCRIPT) program at several agencies throughout the region.

Southwest Michigan is comprised of seven counties, nine birthing hospitals, and one NICU. In calendar year 2017, 8,964 live births were reported. In 2016, it was reported that only 66% of pregnant women began prenatal care in the first trimester. This data was a key driver in the decision to work on increasing early entry into prenatal care in this region.

Outreach to the Saginaw/Bay and Thumb areas in Michigan began in FY2018 with stakeholders in each region meeting to discuss operationalizing a Regional Perinatal Quality Collaborative. The Saginaw/Bay area is made up of eight counties, five birthing hospitals and one NICU. In calendar year 2017, 5,884 live births were reported. In 2017, 16-34% of pregnant women in this region reported smoking while pregnant. These are some of the highest numbers in the state. The Thumb area is made up of seven counties, eight birthing hospitals and two NICUs. In calendar year 2017, 8,930 live births were reported. In 2016, this area of the state had the second highest NAS rates for Michigan at 1,454 per 100,000 live births. Launching Regional Perinatal Quality Collaboratives in both the Saginaw/Bay and Thumb areas in Michigan will prove beneficial toward the overall improvement of maternal and infant health.

Objective B: By 2020, increase Risk Appropriate Care for mothers and infants from baseline data indicators by 20%.

The ESM for this NPM, which aligns to this objective, is the number of CenteringPregnancy sites in Michigan. Ongoing support of this evidence-based strategy measure is a key component to assuring risk-appropriate care for Michigan mothers and infants. CenteringPregnancy is an evidence-based prenatal model that has proven health outcomes including reductions in preterm and low birth weight infants. The CenterPregnancy model is patient-driven, resulting in a patient/clinician partnership that values the voices of women during pregnancy and interconception. In FY 2018, through the partnership of MDHHS and the Michigan Primary Care Association,14 CenteringPregnancy sites were supported. The Michigan Primary Care Association contracted with the Centering Health Institute to offer training and technical assistance for new and existing CenteringPregnancy sites. To date, one CenteringParenting site exists in Michigan.

In calendar year 2017, 88% of low birth weight (LBW) babies were born at hospitals offering neonatal intensive care units (NICU) or special care nurseries (SCN). In 2017, 9,577 babies were born with LBW and of those, 8,415 were born at a facility with a NICU or SCN. In the same year, 90% of very low birth weight (VLBW) babies were born at hospitals offering a NICU. There were 1,619 babies born with VLBW in 2017, and of those, 1,457 were born at a facility with a NICU.

NICUs of Michigan most closely correlate with Level III nurseries and SCNs of Michigan most closely correlate with Level II nurseries. Based on data received from MDHHS Vital Statistics, the majority of LBW and VLBW babies were born at hospitals that best medically meet their needs. However, more work needs to be done to understand why 12% of LBW babies are born at hospitals without NICUs and SCNs, why 10% of VLBW babies are born at hospitals without NICUs, and how we can ensure that all LBW and VLBW babies are born at hospitals that best meet their needs. Stratification of data may give insight into any inequities or barriers that exist for pregnant women who delivered LBW or VLBW babies at hospitals without NICUs or SCNs.

Objective C: By 2020, expand quality improvement efforts related to the prevention and response of Perinatal Substance Use.

The MDHHS-supported Michigan Collaborative Quality Initiative is a voluntary quality collaborative of approximately 25 Michigan birthing hospitals. In FY 2018, the Michigan Collaborative Quality Initiative held monthly webinars to share best practices and discuss collaborative efforts and collected data to monitor improvements regarding NAS, breast milk use for very low birth weight babies, and infection rates of infants cared for in Neonatal Intensive Care Units.

The Regional Perinatal Quality Collaborative of northern lower Michigan, as mentioned above, implemented quality improvement efforts aimed at increasing the number of prenatal substance use screenings and conducted brief interventions and referrals via the innovative use of handheld technology while patients waited at prenatal appointments. These efforts are slated to continue in FY 2019. West Michigan has been working to implement a paper version of an evidence-based screening tool and the Upper Peninsula and Thumb area will be piloting the innovative screening technology, referenced above, in FY2019. All Regional Perinatal Quality Collaborative projects have also been instrumental in ensuring that education and outreach efforts to address Perinatal Substance Use have occurred in the forms of SOPHE SCRIPT training and use of Finnegan scoring of infants to identify NAS.

Michigan also participated in the 2017 Policy Academy: Improving Outcomes for Pregnant and Postpartum Women with Opioid Use Disorders and their Infants, Families and Caregivers hosted by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the National Center on Substance Abuse and Child Welfare (NCSACW). The Policy Academy resulted in a unified cross-departmental approach to address and prevent perinatal substance use. The linking of efforts, both internally and externally to MDHHS, resulted in increased communication and more streamlined efforts to positively impact the lives of those affected by Perinatal Substance Use Disorder (PSUD). Furthermore, this partnership led the MDHHS Office of Recovery Oriented Systems of Care to provide funding for the Regional Perinatal Quality Collaborative in the Saginaw/Bay region, with the caveat that quality improvement efforts must focus on PSUD.

Breastfeeding (FY 2018 Annual Report)

Breastfeeding initiation continues to rise in Michigan. PRAMS data indicate that in 2004, 71% of Michigan mothers initiated breastfeeding. By 2017 that rate has increased to 87.6%. From 2004-2009 initiation was relatively stable, ranging between 69% and 73% with no clear trend. From 2009-2017 sustained growth in initiation occurred, from 73.2% to 87.6% of mothers, gaining an additional 1.8% of the total population of moms who initiated each year (a 14.5% gain across 8 years).

From 2009-2017, the gains seen at the state level have been evenly distributed between non-Hispanic white and non-Hispanic black mothers. From 2009-2014 initiation grew from 64.9% of black mothers to 77.3% (+12.4%), almost identical to the change from 74.5% to 86.3% seen among white mothers (+11.8%). However, from 2014 to 2017, initiation among black mothers has remained unchanged (77.3% to 77.2%) compared to increases among white mothers (86.3% to 90.1%). We celebrate the overall increase of initiation for all mothers but continue to seek ways to better support breastfeeding among non-Hispanic black mothers. Starting in 2016, PRAMS asks mothers why they did not initiate breastfeeding. Among mothers who choose not to initiate the top reasons included not wanting to breastfeed, not liking breastfeeding and having other children to care for. Mothers completing the survey could choose multiple reasons. Non-Hispanic black mothers reported more reasons for not initiating than non-Hispanic white mothers.

Families and consumers have significant input into local breastfeeding activities through breastfeeding coalitions and peer support groups. At the state level, families and consumers were invited to participate in the breastfeeding regional summits and their input was utilized in the writing of Michigan’s first breastfeeding state plan.

In 2018, Michigan’s Title V program went through a facilitated logic model process which resulted in changes to FY 2019 state action plans and associated objectives.  Therefore, the FY 2018 Breastfeeding annual report (based on previous action plans) may contain different objectives and strategies than the new FY 2020 application narrative.

Objective A: By 2018, develop a system for state breastfeeding plan implementation, along with a method to measure progress.

The first State of Michigan Breastfeeding Plan was published in October 2017. Creation of the plan utilized a collaborative approach and included input from key stakeholders including employers, health care professionals, health care systems, public health professionals, community organizations and community members including mothers and families. In FY 2018, MDHHS promoted the plan widely including a press release, distribution among partners and listservs and posting on the MDHHS website. The plan’s executive summary was presented at over 20 statewide presentations and a radio interview promoting the plan was aired on “Morning Edition”, “All Things Considered” and “Current State.”

MDHHS then moved into implementation. A statewide work group was formed to collaborate, implement strategies, and determine a method to measure progress on the plan. The group meets quarterly and includes internal and external state-level partners. Nineteen members of the group completed a Collaboration Multiplier to assess their role in each of the strategies outlined in the plan. The Plan is discussed at all workgroup meetings and the group agreed to update the Collaboration Multiplier routinely to gather information from external partners on accomplishments and progress toward meeting the Plan’s goals and objectives.

Objective B: By 2020, increase Baby-Friendly hospitals to 20% across Michigan.

Increasing the number of Baby-Friendly designated birthing hospitals is the ESM for this NPM. In FY 2018, the number of Baby-Friendly designated birthing hospitals increased from 12 to 14 of the 83 Michigan birthing hospitals or 17% across Michigan. Additional birthing hospitals are currently on the path to Baby-Friendly designation.

The first strategy to achieve this objective was to use Michigan’s mPINC scores to target educational and outreach efforts by Prosperity Region. A statewide assessment of hospital maternity care practices was completed in close collaboration with our maternal child health epidemiologist team. The team used Michigan’s mPINC scores to focus our education and outreach towards Prosperity Regions that had the greatest opportunity for improvement. Michigan’s mPINC scores revealed that the state needed to focus on staff training and discharge planning. As a result, the MDHHS Breastfeeding Coordinator provided presentations to hospitals and coalitions on a variety of topics including safe sleep, breastfeeding and marijuana use, and community support. To address discharge training, the coordinator worked to connect hospital staff with the community and trained pediatric practices on supporting breastfeeding in their practices.

The second strategy was to use a collaborative approach to move hospitals toward Baby-Friendly status. In FY 2017, eight birthing hospitals were awarded mini-grants from MDHHS to assist in Baby-Friendly Hospital Initiative implementation. All the awarded hospitals chose to work on staff training and formed a collaborative called the Quality Improvement Jumpstart or QI Jumpstart. The goal of QI Jumpstart was to propel hospitals toward the implementation of hospital-based maternity care practices with the creation of QI culture and the provision of training and tools. Two of the funded hospitals did not have the capacity to complete the grant objectives, and therefore, withdrew. An additional three hospitals were added to the original group of six for total of nine. From January 2017 to September 2017, staff from these nine Michigan birthing hospitals participated in monthly collaborative webinars to allow for group learning; monthly office hours to provide technical assistance, accessed customized materials from Coffective designed to assist with QI work and all-staff activities; and received training on strategies for effective and efficient data collection and reporting. The results achieved were outstanding as four hospitals moved on to the Baby-Friendly pathway (D1 designation), two hospitals moved from D1 to D2 designation, and one hospital plans to apply soon. Although the mini-grants were not available in FY 2018, the hospitals continued the collaborative approach in FY 2018 and met through the QI Jumpstart Collaborative using the format described above. The MDHHS Breastfeeding Coordinator offered technical support and participated in the monthly webinars and calls. The Coordinator also collaborated with the hospitals by presenting and exhibiting at the Mother Baby Summit.

Objective C: By 2020, determine all available resources to accurately measure breastfeeding initiation, duration, and exclusivity rates and measure racial and ethnic differences.

The MDHHS Breastfeeding Coordinator formed a workgroup (described above in strategy one) with data partners in the Maternal and Infant Health Division and the Maternal Child Health Epidemiology Section to obtain input on a baseline for breastfeeding data collection in Michigan. The workgroup determined that many of Michigan’s breastfeeding stakeholders were unaware of data parameters or how to access data. Research was completed on accurate data sources including MI PRAMS, Vital Records, mPINC, WIC Hospital Practice Survey 2016, WIC ad hoc rate and duration report, WIC Pediatric Nutrition Surveillance Survey (PedNSS), Metabolic screening, Center for Disease Control (CDC) National Immunization Survey and Morbidity and Mortality Weekly Report (MMWR). The second strategy to create and disseminate a breastfeeding data source document was completed and has been shared extensively across Michigan at local breastfeeding coalition meetings, to local maternal and child health providers and to QI Jumpstart Collaborative hospital participants. It was also posted on the Michigan Breastfeeding Network website. The third strategy to create an annual data sheet highlighting Michigan’s breastfeeding statistics was put on hold as partners were routinely using the one-page infographic published in the Breastfeeding State Plan. MDHHS may revisit this strategy in the future or continue to update the infographic with current data.

Objective D: Reduce the gap between non-Hispanic white and non-Hispanic black women in breastfeeding initiation from 9% in 2014 to 8% in 2020, and in 3-month duration from 20.5% in 2014 to 19.5% in 2020.

As stated earlier, breastfeeding initiation rates have increased among all women.  However, the gap between non-Hispanic white and non-Hispanic black women in breastfeeding initiation increased from 9% in 2014 to 12.9% in 2017 (PRAMS). The gap between non-Hispanic white and non-Hispanic black women in breastfeeding duration at 3 months increased from 20.5% in 2014 to 24.5% in 2017. PRAMS data indicate that mothers who receive breastfeeding information from multiple sources are more likely to initiate breastfeeding. MDHHS will continue to encourage consistent breastfeeding supportive messaging across the state with a focus on communities of color.

In FY 2018, the MDHHS Breastfeeding Coordinator reviewed data analyzed by the MDHHS PRAMS epidemiologist for possible contributors to breastfeeding disparity as described in strategy one. Disparities in access to breastfeeding support and care were identified. The Great Lakes Breastfeeding Webinar series is one tool used in strategy two to improve the diversity of breastfeeding professionals in Michigan and to improve access to support across communities. The webinar series offers monthly continuing education at no cost to participants and without transportation barriers. The series is widely promoted throughout the state including in communities of color. Webinar topics use a health equity approach and speakers of color are prioritized. A Certified Lactation Consultant Training was also held in the City of Flint to increase the diversity of breastfeeding professionals in that area. The third strategy to support the development of peer support groups that are culturally representative of their communities was not accomplished, as MDHHS did not obtain a grant opportunity to support this activity.

Objective E: By 2020, increase the percentage of mothers who discussed feeding only breastmilk to their babies with their health care worker from almost 44% in 2013 to 48% as measured by PRAMS.

Multi-year PRAMS data from 2012-2014 revealed that 45.3% of all Michigan mothers discussed feeding only breast milk with their provider. Disparities continue to exist with 48.3% of non-Hispanic white mothers discussed feeding only breast milk to their infant with their provider compared to 38.5% of non-Hispanic black mothers. This question was removed from the Phase 8 PRAMS survey, so this objective will not be included in future state action plans. However, activities continued to support progress toward this objective in 2017 and 2018.

The Michigan Women, Infants and Children (WIC) Supplemental Food Program completed a survey of 922 hospital staff in February 2017. This survey provided a baseline understanding of current hospital practices, perceptions about mothers’ willingness and preparedness to receive evidence-based care, staff perceptions about relationships with community organizations (including referrals), and interest in broader collective impact and quality improvement efforts. In FY 2018, the MDHHS Breastfeeding Coordinator used the survey results to inform education and outreach efforts including presentation and materials content and focused coalition building in Muskegon and Saginaw.

The second strategy was to facilitate collaboration between home visiting, WIC and hospitals to ensure consistent messaging using evidence-based maternity care materials. Education and tools for providers who work with pregnant women and families were provided through multiple venues, including the home visiting conference, the Great Lakes Breastfeeding Webinars, presentations for child care providers, and coalitions. WIC has been working diligently on increasing collaboration between home visiting, WIC and hospitals through the WIC hospital survey and implementation strategies and four Building Bridges for Breastfeeding Duration trainings offered in 2018. The purpose was to bring together the hospital and community to build a bridge of support for the mother-baby dyad after discharge. In addition, this strategy is being accomplished using Coffective evidence-based, prenatal educational materials among maternal and child health programs.

Safe Sleep Environments (FY 2018 Annual Report)

In Michigan’s original five-year plan, the priority area to “Foster safer homes, schools and environments with a focus on prevention” was linked to promotion of infant safe sleep environments through the following two-part SPM:

1. The percent of infants put to sleep alone in their crib, bassinet or pack and play.
2. The percent of infants put to sleep without objects in their crib, bassinet or pack and play.

HRSA added two PRAMS measures to the original NPM, that previously only measured the percent of infants placed to sleep on their backs. Given this change, Michigan converted its original SPM to the new NPM for FY 2019. Michigan did not choose “infants being placed to sleep on the back” as a performance measure because it exceeded the Healthy People 2020 goal of 75.9%.

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 FY2018, Title V federal funding was used for activities that support Michigan’s safe sleep work, including the Pregnancy Risk Assessment Monitory Survey (PRAMS), infant mortality communication, Fetal Infant Mortality Reviews, and funding to local health departments.

Data from the Michigan Pregnancy Risk Assessment Monitoring Survey (PRAMS) for 2016 show that the percentage of parents and caregivers practicing these behaviors has decreased compared to 2015. However, it is important to note that all PRAMS states began asking different safe sleep questions in 2016, so it is difficult to compare these questions over time. The proportion of Michigan mothers meeting Michigan’s SPMs is lower than in prior years, except for back sleeping, but the measurement now provides a more comprehensive picture of infant sleep practices.

In 2016, 83.2% of Michigan infants were usually sleeping on their back. In addition, 34% of infants were placed to sleep on a separate approved sleep surface. In prior years, this measure was based on only two sleep risk factors—does the infant sleep in his or her own crib and does the infant sleep with other people. 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—has had an especially large impact on this measure. Also in 2016, many more mothers reported that their infants had at least one soft item in the sleep space. This increase may be due to changes in the wording of the question regarding blankets (any blanket versus only plush or thick blankets). The proportion of infants sleeping with no soft objects (pillows, bumpers, blankets, toys) is 51.8%. Although the number is lower than the number reported in the past, in 2016, Michigan had the highest proportion of mothers reporting that their infants do not sleep with soft objects (compared to 28 other PRAMS states reporting this data).

In FY 2018, MDHHS continued its work to identify the touchpoints where a family could and should receive infant safe sleep information. For example, we built upon connections with existing partners, such as WIC, home visiting programs, and the Regional Perinatal Quality Collaboratives and explored ways to enhance partnerships with others such as MDHHS Tobacco Prevention and Immunizations. Challenges exist in ensuring that families are receiving consistent infant safe sleep messages at all potential touchpoints. For example, families sometime receive inconsistent messages from health care providers and family members, who may have been taught and used outdated infant sleep techniques.

While two distinct objectives for infant safe sleep have been identified, the strategies to address them are combined since the safe sleep behaviors are so closely related.

Objective A: By 2020, increase the percent of infants put to sleep alone in their crib, bassinet or pack and play by 4%.

Objective B: By 2020, increase the percent of infants put to sleep without objects in their crib, bassinet or pack and play by 4%.

In FY 2018, activities occurred within six strategies:

1. Increase the capacity of communities to implement infant safe sleep education, awareness and outreach activities to promote infants being placed to sleep alone in their cribs, bassinets or pack and plays with no objects.
2. Facilitate new collaborations with non-traditional partners so the safe sleep message spreads in communities that may not have been reached previously.
3. Develop and implement more effective core messages that are best-practice driven, reflect the needs and choices of families, align safe sleep implementation within a real-life context and provide messaging that is appropriate and relevant to diverse population groups.
4. Provide education and tools for providers who work with pregnant and parenting families (in programs such as home visiting, WIC, child care, prenatal care, etc.) to have effective conversations about infant safe sleep.
5. Produce a safe sleep report.
6. Reduce the racial disparity related to unsafe sleep practices.

All strategies were designed to meet these objectives. In the FY 2018 application, the sixth strategy, to reduce racial disparities, was tied to activities in the other five strategies and was not singled out. However, in FY 2019, additional efforts are being implemented to specifically address racial disparities and health equity. Specifically, providing training and support to local health departments (LHDs) on health equity; dedicating at least one infant safe sleep webinar annually to the topic of health equity; and sending at least one message on the topic of health equity via the Infant Safe Sleep for Professionals list per quarter. Finally, additional strategies and partnerships to integrate infant safe sleep program activities within the Mother Infant Health and Equity Improvement Plan (MIHEIP) and the MIHEIP Ambassador Program are being explored.

To continue and further expand a program initiated in 2013, funding in the form of mini-grants was provided to 15 local health departments (LHDs) and the Inter-Tribal Council of Michigan in FY 2018. The LHDs and Inter-Tribal Council of Michigan represent Michigan communities with the highest numbers of Sudden Unexpected Infant Deaths (SUIDs). Grant funding is provided in the amount of $22,500 for all grantees, except for Wayne County ($45,000) and the City of Detroit ($90,000) due to the higher number of SUIDs in these communities. The mini-grants allow communities to develop local programming which is culturally relevant and informed by the community. For example, activities range from providing safe sleep education sessions at home or in a community setting; purchasing billboards; providing group classes; conducting community awareness events; translating safe sleep materials; and promoting protective behaviors such as breastfeeding and smoking cessation. A portion of the grant funds can be used to purchase pack and plays or sleep sacks. In FY 2018, grantees provided infant safe sleep education to nearly 5,800 individuals (parents, caregivers, professionals and community members) through classes and workshops. Over 12,000 people were provided infant safe sleep information at community events such as health fairs. Analysis of pre/post test scores of people who attended classes and workshops revealed that infant safe sleep knowledge and intention to practice safe sleep behaviors increased after attendance.

The faith-based collaboration that was initiated in FY 2016 in Detroit expanded in FY 2017 through collaboration between the Detroit Health Department, the MDHHS Infant Safe Sleep Program and the MDHHS Office of Community and Faith Engagement. The plan for FY 2018 was to add at least four faith-based organizations in each of four high-risk SUIDs counties. However, due to staffing limitations at both the Office of Community and Faith Engagement and local health departments, Oakland County Health Division and Wayne County Health Department (serving out-Wayne County) began faith-based work in FY 2018. In addition, the work of the Detroit Health Department was expanded. At the end of FY 2018, at least 20 faith-based organizations were involved in these efforts which included hosting infant safe sleep educational sessions, distributing safe sleep messages in church bulletins, holding prayer times for infants and posting infant safe sleep educational material in nurseries and public spaces. Additional, non-traditional partners will be explored in FY 2019 through the work of the Mother Infant Health and Equity Improvement Plan (MIHEIP) Ambassador Program.

The third strategy was to develop and implement more effective core messages that are best-practice driven, reflect the needs and choices of families, align safe sleep implementation within a real-life context and provide messaging that is appropriate and relevant to diverse population groups. This strategy was informed from the results of focus groups, conducted in FY 2018, to identify preferences for safe sleep message type and delivery. Focus group results, innovative infant safe sleep research and programming were shared with the MDHHS media team. Several meetings were held, and preliminary recommendations were reviewed in January 2018. It was determined that additional community input, including input from communities that experience health inequities, was needed before moving forward with the development of new safe sleep messages and educational products. In FY 2019, the Infant Safe Sleep team is contracting with two community-based agencies to obtain the needed additional community input and to develop prototype materials. After initial development of messages and methodologies, market testing will be done so that refinements can be made prior to large scale dissemination.

The fourth strategy, to provide education and tools for providers who work with pregnant and parenting families to have effective conversations about infant safe sleep, is part of ongoing programmatic efforts. Program staff provide in-person training at conferences and professional trainings. In addition, three safe sleep trainings are available online, to ensure maximum reach. Providing technical assistance to the infant safe sleep grantees is another critical component of this work, as the grantees provide education for local groups such as hospitals, home visiting collaboratives, child care centers, and community agency staff.

In FY 2018, nearly 300 individuals attended an in-person safe sleep training and over 9,700 individuals completed one of the three online infant safe sleep trainings online. Providers are also supported with access to free educational materials to use in their work with families; 323,268 educational items were distributed by MDHHS in FY 2018. During FY 2017, an infant safe sleep email listserv for professionals was established and has grown to nearly 1,700 members. A quarterly webinar series on infant safe sleep was established in FY 2017, continued in FY 2018, and will continue through FY 2019.

Another focus for FY 2018 was to provide training and tools for providers to have more effective conversations with parents/caregivers about infant safe sleep. A “Safe Sleep 201” training for home visitors and child welfare workers that was piloted in FY 2017 was rolled out at the end of FY 2018. Both an in-person and online version of this training are currently available. This training is based on the principals of motivational interviewing and teaches professionals how to have more effective conversations with families around safe sleep, start where the family is at to address the challenges families face in following the guidelines, and reduce the risks in the sleep environment while educating families that following the AAP recommendations is the safest way for baby to sleep. The training also encourages professionals to include family members and other caregivers in the conversation to address the issue of when family members provide outdated advice. In addition, an Infant Safe Sleep Resource Book and Picture Ring were developed and finalized in FY 2018. These resources will be provided to anyone taking the “Safe Sleep 201” training, though this may be expanded to all home visitors and other professionals in FY 2019.

The fifth strategy was the production of an annual safe sleep report. Work on the Infant Safe Sleep Report was largely done in FY 2017; however, the final report was released in January 2018. The report “Infant Safe Sleep in Michigan: A Comprehensive Look at Sleep-Related Deaths” compiled data, research and information regarding local and statewide safe sleep initiatives into one comprehensive document. Racial disparities were also highlighted throughout the report. In FY 2019, the MIHEIP will be finalized. A standalone report on infant safe sleep will not be completed annually, as the sleep-related infant death data and safe sleep efforts will be rolled into any reports developed as part of the MIHEIP.

The final strategy focuses on the need to reduce the racial disparity that exists in sleep-related infant deaths in Michigan. As noted in the narrative above, each strategy integrates the need to address racial disparity. Approaches will vary according to activity but may involve allocating more resources to areas that experience greater racial disparity and gaining a better understanding of messages that may be more effective with different racial or ethnic groups.

Family input is another important component of program activities. One parent regularly attends quarterly meetings of the Michigan Infant Safe Sleep State Advisory Committee and is an active promoter of infant safe sleep in her community. Several other parents are on the distribution list for the meetings and/or are in contact with MDHHS Infant Safe Sleep Program staff about their interest in becoming involved. In FY 2019, family/parent involvement will be expanded. For example, the Infant Safe Sleep Program plans to utilize the MIHEIP Ambassador Program to gain more family input and extend the program’s reach.