Perinatal and infant health is a central focus of the Minnesota Department of Health (MDH), which implements and supports programs to ensure all Minnesota infants are born healthy and thrive. In 2015, MDH developed and released Part One of the state’s infant mortality reduction plan. Part One of the plan, developed in partnership with stakeholders from around the state, including community members affected by these disparities, contained seven broad recommendations to reduce infant mortality overall and to address disparities in rates across communities in Minnesota. As in past years, MDH will continue our collaborative efforts with internal and external partners in addressing our priority needs to promote and support breastfeeding, to reduce infant mortality rates and racial and ethnic disparities in infant deaths.

Priority Need: Promote and support breastfeeding

Minnesota’s collaborative efforts to increase the percentage of infants who are breastfed are ongoing and extend across multiple programs MDH.  This includes the Women, Infants and Children Supplemental Nutrition (WIC) program, Family Home Visiting (FHV) program, Statewide Health Improvement Partnership (SHIP) program, Office of Health Equity (OHE), MDH Tribal Liaison and the Infant Mortality program.  External partners include a number of local and tribal public health agencies, and community partners such as the Minnesota Breastfeeding Coalition, the Minnesota Perinatal Organization and other nonprofits.

National Performance Measure 4A and 4B address breastfeeding and relate most to this priority need. Our programmatic efforts in FFY2018 that promoted and supported breastfeeding are outlined in the strategies and activities that follow.

NPM 4A: Percent of infants who ever breastfed

Minnesota’s annual objectives for FFY2018 was that 92% of infants be breastfed for any length of time. According to CDC National Immunization Survey (NIS) data, 89.2% of infants born in 2015 were ever breastfed. This means our breastfeeding target for initiation was not met.

Objective 1: By 2020, increase infants who are breastfed by 10%

However, when looking at our Minnesota’s birth certificate data, as illustrated in Figure 2 below, we find that breastfeeding initiation rates among four populations (East African 94.2%, white 92.3%, Asian Other and Hispanic 90.0%) were 90% or more in calendar year 2018.

NPM 4B: Percent of infants who breastfed exclusively through 6 months

Minnesota’s annual objectives for FFY2018 is 31% of infants be breastfed exclusively through six months. According to the 2016 CDC National Immunization Survey (NIS) data (latest data available), 37.2% of infants were breastfed through six months. This means that that we exceeded our target for infants breastfed exclusively through six months by more than 6%. Key strategies for increasing the percentage of infants ever breastfed and breastfed exclusively through six months are described in the four areas below.

Objective 2: By 2020, increase infants breastfed exclusively through six months by 10%

Five-year objectives related to promotion and support of breastfeeding include increasing the percentage of infant breastfeeding initiation, increasing the percentage of infant breastfed exclusively through six months, and reducing disparities in breastfeeding rates. Staff participated in and supported a number of training and educational opportunities as well as a broad range of activities to increase breastfeeding rates and to reduce breastfeeding disparities during this reporting period.

A. Building and sustaining partnerships through collaboration and advocacy

Minnesota promotes and supports breastfeeding through collaboration with internal MDH programs (Family Home Visiting, WIC, Statewide Health Improvement Programs, MCH, and the Infant Mortality Initiative) as well as external stakeholders, including local public health, Minnesota Breastfeeding Coalition, and the Minnesota Perinatal Organization.

Minnesota’s family home visiting programs (FHV) promote breastfeeding to support the health of mother and baby, promote child growth and development, and support the parent-child relationship. One of Title V strategies is to promote and support breastfeeding through FHV training and referrals to WIC breastfeeding support, including peer support where available. FHV provisional 2018 data reports more than 4,223 families received home visiting services during this reporting period. Most home visitors in FHV supported by MDH are public health nurses, many of whom have received ongoing breastfeeding education at a variety of levels from short workshops to multiple days training and certification. Many of Minnesota’s home visitors working in smaller or rural public health agencies serve in several capacities, including as WIC staff. In larger agencies, home visitors work closely with WIC staff and with breastfeeding peer educators, local breastfeeding coalitions and Baby Cafés in their communities.

Baby Cafés are community-based, free resources that support pregnant and breastfeeding mothers through education and support from International Board Certified Lactation Consultants, Certified Lactation Counselors, and other trained professionals.  Baby Cafés provide opportunities for women to share their experiences and knowledge with other mothers. Minnesota has 18 official Baby Café sites, most hosted by health systems, clinic, or hospitals. Many are staffed by a collaboration of professionals including hospital, clinic, local public health nurses who are family home visiting staff, WIC staff and/or State Health Improvement Plan (SHIP) staff. Mothers receive support on the benefits of breastfeeding to mother and baby, on initiation of breastfeeding, and on pumping and breastfeeding when returning to work or school. Baby Cafés work to assure equity by welcoming people with diverse cultural backgrounds and with fresh ideas. In addition to the 18 sites officially listed on the Baby Café USA site: http://www.babycafeusa.org/, local public health departments and their partners host  similar drop in parenting programs to bring professionals and new parents together in group settings to support parents in their new role.

The FHV Evaluation Unit gathers data from local FHV programs on the number of infants/children receiving breast milk. During calendar year 2018, 18% of infants of mothers participating prenatally in FHV programs received breast milk at six months of age.

Another Minnesota strategy was to promote and support efforts of the WIC peer breastfeeding program and partnership with the Minnesota Breastfeeding Coalition (MBC). Minnesota WIC’s collaboration with the MBC is ongoing. Some accomplishments of note in FFY2018 include:

• WIC peer support program continues to demonstrate increase in breastfeeding initiation rates among all racial and ethnic populations. According to WIC data, during FFY2018, breastfeeding initiation rates continue to be higher for WIC participants in the peer support program. (See Figure 4 below)
• Title V provided continued support of WIC and the Minnesota Breastfeeding Coalition (MBC) in planning and supporting the annual MBC meeting and workshop and presenting educational webinars to maternity center staff. Staff participated in and provided support to the MBC’s 10th Annual Statewide Meeting and Workshop held November 2-3, 2017.

B. Educating/Training mothers, providers and organizations

Throughout this reporting period, staff provided technical assistance and training to support local public and tribal health home visiting programs. Examples include training on the NCAST feeding scales, which provides the home visitor with a tool to assess parent-child interactions and plan interventions to support the parent-child interactions and optimize over 200 feeding sessions a month for newborns, including breastfeeding. In FFY2018, 17 home visitors received training in the NCAST feeding scales and 18 attended training to maintain reliability. MDH FHV also provides home visitors other online training courses and videos that support breastfeeding, such as NCAST Beginning Rhythms and the Keys to Caregiving.

Another ongoing Minnesota strategy is to promote and support the efforts of the Minnesota Breastfeeding Coalition (MBC) and its activities to encourage Minnesota hospitals for achieving Baby-Friendly designation. This partnership continued its work throughout FFY2018. Formed in 2006, the MBC has grown to include 36 local breastfeeding locations, with coalitions in 57 of the 87 Minnesota counties. The MBC membership has representation from the state and local health departments, the Minnesota WIC, hospital lactation departments, La Leche League, and other organizations and individuals who support and promote breastfeeding.

WIC and Minnesota Breastfeeding Coalition (MBC) held their annual metro breastfeeding meeting with local coalitions in May. On June 13, 2018, the MDH Statewide Health Improvement Program (SHIP) and the MBC hosted a live webinar, “Baby-Friendly Hospital Initiative Update”, a presentation of upcoming changes to Baby-Friendly designation. The webinar was posted on the MBC’s YouTube channel for future viewing and online training. Also, during this reporting period, staff encouraged hospitals to achieve MDH Ten Steps to Successful Breastfeeding award through participation in the MDH Breastfeeding Friendly Recognition Program. The MDH Breastfeeding Friendly designation recognizes maternity centers statewide that have taken steps toward implementing the Ten Steps program and achieving Baby-Friendly designation. Local breastfeeding coalitions also encourage and support hospitals.

C. Collaborating to fund programs and initiatives to expand capacity of our community partners and local family health

Minnesota’s work to fund programs and initiatives to promote and support breastfeeding is ongoing. Continuing the work that began in 2017 that: 1) provided funding for African American and American Indian local WIC staff to attend U.S.B.C. annual conferences, and 2) provided resources, including financial and in-kind support, through collaboration with our tribal partner, the Indigenous Breastfeeding Coalition and the Twin Cities Breastfeeding Coalition were created during this reporting period.

One Minnesota strategy implemented this reporting period was to promote and support breastfeeding through funding. MCH and Family Home Visiting provides federal and state funding (including MIECHV, TANF and State Evidence-Based Home Visiting, Title V) to community health boards, tribal nations, and non-profit organizations. Programs can use a portion of the funding for breastfeeding training to home visitors and supervisors so they can provide education and support to mothers during prenatal and postpartum home visits.

Minnesota Department of Health (MDH) recognizes breastfeeding is a foundational way to ensure that babies receive optimal nutrition during their first years of life. Through collaborative efforts, Title V and MDH are working to make breastfeeding the norm. MDH’s Statewide Health Improvement Program (SHIP) breastfeeding initiative is a collaborative effort among WIC (who takes the lead in Minnesota breastfeeding), the Minnesota Breastfeeding Coalition (MBC), and SHIP grantees to recognize breastfeeding-friendly hospitals, child care professionals, employers (including medical clinics), and health departments throughout the state. Staff continued to support SHIP and MBC efforts to expand the number of maternity centers and organizations participating in MDH Breastfeeding Friendly Recognition (5-Star) and MDH Ten Steps to Successful Breastfeeding Award programs. Accomplishments around Minnesota’s strategy to promote and assist the MBC and SHIP with MDH Breastfeeding-Friendly initiative are of note. During FFY2018, four hospitals that achieved USA Baby-Friendly designation applied for MDH Ten Steps award, and 27 workplaces, 12 health departments, and five childcare centers received MDH Breastfeeding-Friendly 5-Star recognition. The total number of organizations participating in MDH Breastfeeding-Friendly Recognition program in FFY 2018 is 150, an increase from the 97 achieving this recognition in FFY 2017.

Objective 3: By 2020, reduce disparities in breastfeeding rates by 10%

A. Expanding capacity, outreach and advocacy to reduce disparities

To be able to reduce disparities in our breastfeeding rates, it is essential that Minnesota continue to work directly with populations experiencing the highest disparities in breastfeeding rates. The WIC program continued ongoing collaboration with the Minnesota Breastfeeding Coalition (MBC) to support breastfeeding among tribal and other populations experiencing breastfeeding disparities. Figure five (5) below shows breastfeeding rates by race and cultural identify among WIC participants, with Hmong women having the lowest rates. During FFY2018, Minnesota began exploring ways to support and promote breastfeeding through outreach and collaboration among the Minnesota Hmong population.

One accomplishment of note during this reporting is Minnesota WIC’s efforts to engage the Hmong community in supporting and promoting breastfeeding. In May of 2018, MDH staff served as a preceptor for a Hmong student to complete her Master’s in Public Health field experience. The student began assessing needs for breastfeeding promotion and support in the Hmong community by building connections, which included convening listening sessions and attending community organization meetings, such as the Hmong Health Care Professionals Coalition’s (HHCPC) monthly meetings. The student developed data and narrative information on perinatal outcomes, including breastfeeding, among Minnesota Hmong mothers which has been published online and in Fact Sheet form. Staff acquired grant funding from the University of Minnesota’s Community Health Initiative so that the student could continue this very important work into the Fall semester.

This ongoing work is now a collaboration among MDH WIC, HHCPC, MDH SHIP, Ramsey County SHIP, the States of Solutions Initiative (funded by the Robert Wood Johnson Foundation), and the MBC. This collaborative effort has gathered qualitative data on attitudes, strengths and challenges around breastfeeding in the Hmong community, supports planning of Hmong-led community projects to support breastfeeding in the Hmong community and continues to apply for funding.

Another accomplishment of note is Minnesota’s continued partnership with the Somali community. Through discussions with local public health, Somali WIC staff and other community partners, including Somali moms, MDH learned that when educating Somali moms in breastfeeding it is helpful to show visually that exclusively breastfed infants are healthy and formula supplementation is not necessary. Because of these discussions, staff took photos of infants and children who were exclusively breastfed as a first step in developing posters to support our efforts to reduce disparities in exclusive breastfeeding rates among Somali women.

Another Minnesota strategy was to promote and support breastfeeding in the family home visiting program through training and referrals to WIC breastfeeding support, including peer support where available. In FFY2018, the Family Home Visiting (FHV) program collaborated with the Indigenous Women’s Breastfeeding Coalition to provide culturally sensitive breastfeeding training and support.

Other Minnesota efforts to reduce disparities implemented during FFY2018 are listed below:

• Staff participated on the Minnesota Breastfeeding Coalition Equity and Access subcommittee.
• Staff developed breastfeeding reports by cultural identify to augment race and ethnicity reports. These reports are available on website at: https://www.health.state.mn.us/people/wic/localagency/reports/bf/info/index.html
• Grow and Glow, a Certified Lactation Specialist Course, and Building Bridges for Breastfeeding Duration training were all offered in FFY2018.

B. Promoting and supporting breastfeeding through collaboration and advocacy

Minnesota’s strategy to partner with and support the Minnesota Breastfeeding Coalition workgroup looking at ways to reduce formula samples to decrease hospital and clinic supplementation promotion practice is ongoing. According to CDC’s mPINC, breastfeeding exclusivity in hospitals scores in Minnesota improved in all regions of the state. WIC data shows that although breastfeeding initiation is similar statewide, wide disparities in exclusivity exist by regions. In regions of Minnesota where hospitals are providing a higher level of evidence-based maternity care than in other regions (Northeast), the exclusivity rates are much higher. Collaborative work between the coalition, hospitals and public health in the Northeast Region included work on reducing formula supplementation (increasing exclusivity in the hospital). Baby-Friendly hospital re-certifications include clinic support for breastfeeding. This Baby-Friendly work will help in achieving reductions of sample formula. The effectiveness of the ongoing work in the Northeast is shown when comparing supplemental formula use between regions in Minnesota (see Figure 6 below).

The Minnesota Breastfeeding Coalition (MBC) held a webinar on donor human milk. These webinars are available on the MBC YouTube channel. Additionally, one accomplishment worthy of note regarding our collaboration with MBC’s efforts to have a donor human milk bank in Minnesota during this reporting period is the spring 2018 opening of the first donor human milk depot in a public health agency. The Isanti County Public Health breast milk depot opened in February 2018 and provides a convenient drop off for women to donate their extra breast milk for processing at the Mother’s Milk Bank of the Western Great Lakes. The breast milk donated through the milk depot is used to help very low birth weight babies in neonatal intensive care units (NICUs) and other medically fragile infants.

ESM 4.1: Increase the Number of Baby-Friendly Hospitals

According to the Baby-Friendly USA website list of baby-friendly facilities, the number of hospitals in Minnesota that have Baby-Friendly designation for FFY2018 is 15, which means we exceeded our target of 12 hospitals attaining National Baby-Friendly Designation.  Hospitals/birthing centers that receive this designation promote and support breastfeeding by providing moms with information and supporting skills to successfully initiate and continue breastfeeding their babies.

Minnesota’s multiple ongoing strategies to promote and support hospitals becoming Baby Friendly continued in FFY2018. Title V partners at the local level, along with WIC and other programs, provided technical assistance and offered resources for transitioning from hospital to ongoing sources of support, step 10 of the Baby-Friendly Hospital Initiative (BFHI). The Minnesota Breastfeeding Coalition offered resources and information to help hospitals learn from each other and progress toward Baby-Friendly designation. These efforts resulted in three hospitals achieving Baby-Friendly Designation in this reporting period: North Memorial (12/17), Mercy Hospital, Moose Lake (2/18) and Maple Grove Hospital (3/18).

Minnesota’s strategy to support and advocate for increased Medicaid reimbursement for births that occur at Baby-Friendly hospitals was not completed this reporting period. Although we began discussions with Minnesota Department of Human Services (DHS) in 2017, we were unable to continue working on this strategy due to a shift in priorities that had a significant impact on staff resources.

Priority Need: Reduce infant mortality rate and racial and ethnic disparities in infant death rates

The 5-year needs assessment identified reducing the state’s overall infant mortality rate and the racial and ethnic disparities in infant death rates as priority. NPM 5a, b and c address the importance of safe sleep and are related to the identified priority need to reduce the infant mortality rate and decrease disparities in infant deaths.

NPM 5: Percent of infants placed to sleep on their backs

Objective 1: By 2020, reduce the state’s overall SUID rate by 10% or more

Objective 2: By 2020, reduce disparity in SUID rates between whites and African American and American Indians by 10% or more

Objective 3: By 2020, increase percentage of mothers who reported that their infants sleep on their backs by 10% or more (and by race/ethnicity)

Recent data from MDH Linked Birth/Infant Death File show that the state’s overall infant mortality rate has remained unchanged at 5.1 infant deaths per 1,000 live births between 2000-2004 and 2012-2016. Despite Minnesota’s favorable infant mortality rate, the state’s overall infant mortality rate masks substantial variation in rates by race/ethnicity. Infant death rates are rising for Asian/Pacific Islanders, Hispanics and American Indians; rates actually declined in the black/African American population during 2012-2016. The infant mortality rates have remained relatively stable for the non-Hispanic white population, the group with the lowest infant mortality rate in Minnesota. Disparities in rates by race/ethnicity are evident and troubling. Between 2012 and 2016, the infant mortality rate for black/African Americans was 2.3 times the white rate and American Indians was 2.5 times the white rate.

One of Minnesota’s specific aims is to accelerate infant mortality declines by reducing the state’s overall SUID rate by 10% or more by 2020. We focus on SUID for several reasons. First, SUID is a leading cause of infant mortality in Minnesota, contributing about 50 to 60 deaths (on average) to the state’s total 350 to 380 infant deaths each year. Secondly, data from Minnesota SUID Case Registry for 2010-2016 show that infants born to American Indian mothers—the population with the highest SUID rate in Minnesota—are approximately five to 12 times more likely to die suddenly and unexpectedly before age one than infants born to white and Asian mothers, respectively. Third, the overwhelming majority of SUID in Minnesota occur because infants are placed to sleep in hazardous sleep spaces or in unsafe positions that put them at increased risk of dying during sleep. Thus, virtually all SUID in the state are preventable. To illustrate, in 2015, MDH conducted an analysis of SUID and found that 53 out of 54 (98%) deaths occurred because infants slept in environments with many modifiable risk factors present. Among the findings:

• 93% had loose objects in the sleep space, including pillows or blankets, or were not placed to sleep on a firm surface such as a mattress or crib.
• 49% of the infants shared a sleep surface such as a bed, sofa or recliner with another person.
• 27% were placed to sleep in an unsafe sleep position such as on their side or on their stomachs.

The 5-year needs assessment identified the need to reduce the infant mortality rate and racial and ethnic disparities in infant death rates as priority areas. The 5-year objectives outlined in our State Action Plan table aim to support a decrease in the infant mortality rate by reducing Minnesota’s SUID and preterm birth rates. To achieve these goals, key strategies were developed to support our current work to reduce sleep-related SUID and launch our latest efforts around promoting the use of progesterone to reduce repeat preterm births.

Objective 1: By 2020, reduce the state’s overall SUID rate by 10% or more

A. Expanding and maintaining existing partnerships

Strategy:  Educating the public and training professionals about best practices to prevent sleep-related tragedies/reduce infant mortality

Annually, since 2014, one of Minnesota’s strategies to reduce the state’s overall SUID rate is a collaboration among MDH, the Department of Human Services, local public health agencies and other external stakeholders to raise awareness of SUID and infant mortality. This collaboration declares one week in the fall “Infant Safe Sleep Week” (November 2017) in Minnesota. During this reporting period, major activities included:

• Release of a Proclamation: During each safe sleep week, MDH drafted a proclamation that is signed by the Governor. The 2017 and 2018 proclamations highlighted the scope of the problem associated with sleep-related sudden unexpected infant deaths (SUID) in the state, how to prevent them, and called on all stakeholders across multiple sectors (e.g., childcare and medical providers, parents, and babysitters) to implement best practices to prevent these tragedies. MDH released the proclamation to the public using multiple venues, which included the state’s infant mortality reduction website and a few social media platforms such as Facebook and Twitter.
• Press Release and Media Event: In planning safe sleep week media activities, Minnesota and its partners select a topic to increase public awareness across the state about sleep-related tragedies. Past press releases have always included data on sudden unexpected infant deaths (SUID) by race/ethnicity or the state’s overall infant death rates from the SUID Subcommittee of the Child Death Review Panel as well as highlight prevention strategies and include messaging on the ABCs of safe sleep.

 

• During the November 2017 Infant Safe Sleep Week campaign, the press release called on parents and hospitals to implement best practices to prevent sleep-related deaths from occurring. The press release also included PRAMS data and highlighted the proportion of mothers (9%) who reported their provider did not talk to them about how to lay their babies down to sleep. These survey results suggest providers need to do more work to educate families about the importance of safe sleep practices for infants.

• In 2018, the press release specifically addressed advertising and called on advertisers to use safe sleep images in advertisements that depict infants in a safe sleeping environment and position. The idea to focus on advertisers was informed by meetings hosted by our community partners in which parents expressed their disappointment with the number advertisements they had seen in magazines that depicted infants in hazardous sleeping spaces. To engage the public during safe sleep week, MDH posted images of what a safe sleep environment and sleeping position looked like, and invited parents/caregivers to post images depicting their infant in a safe sleeping environment on MDH social media platforms.
• Several newspaper outlets and one major viewed television station in the Greater Twin-Cities Metro area covered MDH’s press release in fall of 2018. A community-based radio station interviewed staff to learn more about the importance of safe sleep week, the scope of the infant mortality/SUID problem in Minnesota, and why evidence-based sleep practices work to keep infants safe while they sleep.

• The Family Home Visiting section announced both Safe Sleep Week awareness campaigns in their Tuesday Topics e-newsletter, which is distributed weekly to approximately 2100 subscribers. In addition, messages are shared through Tuesday Topics e-newsletter about educational opportunities and product safety announcements related to safe sleep.

In addition to increasing the public’s awareness about evidence-based practices to prevent sleep-related strategies during infancy, MDH also seized opportunities to present information on safe sleep at conferences and/or conduct safe sleep trainings at professional gatherings during this reporting period. For example, staff convened a Teen Pregnancy Prevention Symposium 2018 to share data, information, and resources with professionals from organizations that received teen pregnancy prevention grant funds from MDH. Staff presented on trends, causes, and strategies to prevent infant mortality in Minnesota’s teen population. The presentation highlighted SUID as a major cause of infant mortality among infants born to adolescents in Minnesota. In addition to the keynote presentation, one of the breakout sessions was devoted to exploring SUID further. During this session, staff presented trend data, highlighted risk and protective factors, discussed the American Academy of Pediatrics (AAP) safe sleep guidelines, discussed opportunities for intervention, and guided participants to safe sleep resources, tools, and evidence-based practices that adolescent parents and other caregivers can implement to prevent sleep-related tragedies from happening to infants

B. Providing ongoing technical assistance and outreach to internal and external partners

One of our strategies was to disseminate safe sleep messages to the public using a variety of social media platforms, including Twitter and Facebook. During the reporting period, MDH distributed links to published articles, shared information about upcoming webinars, trainings, conferences, and statistics via e-mail, and used social media to repost or retweet information from professional or scientific organizations as soon as they became available. In 2018, the MDH Communications office decided to focus on quality rather than the quantity of the messages posted to promote public health observances such as infant mortality week. As a result, slightly more than 55,000 individuals viewed safe sleep message on Facebook during safe sleep week. Although this represented an 18% decrease in the number of views over the previous year, 13,750 individuals viewed the posts daily over four days in 2018 compared to 8,406 daily views (on average) over six days in 2018. Were we given an additional two days  to post messages, and had the number of viewers held constant during those days, it is possible that we could have surpassed our goal to increase the number of messages viewed by 1.5% from 67,000 in 2017 to more than 68,000 in 2018.

MDH Family Home Visiting Nurse Consultants facilitate regional meetings of MCH Coordinators from local public health departments (mostly quarterly) and share safe sleep messages, resource materials, and product safety notices. Staff also share information about MDH grantee programs/organizations that provide resources. For example, Cradle of Hope, an organization where families in need of a safe place for their infant to sleep can receive a portable crib. Meeting participants also share their experiences with families accessing these resources.

Objective 2: By 2020, reduce disparity in SUID rates between whites and African American/black and American Indians by 10% or more

A. Collaborating with internal and external partners to increase the public’s awareness about infant sleep safety

Data from MDH’s SUID Case Registry show that infants born to African American/black and American Indian mothers are two to five times more likely to die suddenly and unexpectedly during sleep than infants born to white mothers. Additionally, babies born to African American/black and American Indian mothers have a four to twelve-fold greater risk of dying during sleep than infants born to Asian/Pacific Islander women. To reverse these trends, MDH collaborated with community-based radio stations and safe sleep community champions to deliver information to the public about the importance of safe sleep.

Every year since 2014, MDH has invited safe sleep champions from the community to participate in a discussion about the importance of safe sleep practices on a local radio station.

Another strategy implemented by MDH to reduce the infant mortality rate and address disparities was to disseminate safe sleep educational materials and resources to audiences not commonly targeted. These populations included, but were not limited to, grandparents, fathers, and immigrants whose primary language is not English. During this reporting period:

• MCH Infant Mortality Reduction Initiative disseminated safe sleep flyers, brochures, quick informational cards, and safe sleep books. Throughout the five-week campaign that began on November 14, 2017, and ended on December 22, 2017, staff distributed approximately 3,200 safe sleep books to interested local public health agencies and community partners across the state.
• Staff collaborated with our home visiting partners during our 2018 safe sleep book campaign to promote the books in rural Minnesota. Consequently, 40% of the books are distributed to partnering agencies serving families in Greater Minnesota, including local public health agencies, Tribes, and Head Start agencies.
• Since 2015, staff have collaborated with MDH’s Communication Office to distribute quick cards covering the ABCs of safe sleep at the Minnesota State Fair, the largest social event and gathering in our state. Each day at the State Fair in FFY2017, staff distributed safe sleep quick cards from August 28-September 1, 2018. Through our partnership, MDH Communication Office has translated the cards into multiple languages widely spoken in Minnesota, such as Hmong, Somali, and Spanish, for subsequent distribution throughout the year. Staff distributes more than 2,000 quick cards across the state annually.
• As a partner of the National Institute of Child Health and Human Development’s (NICHD) national Safe to Sleep Campaign, during the reporting period staff distributed approximately 3,000 safe sleep flyers and brochures targeting racial and ethnic populations and other populations, such as grandparents. Materials were distributed at health fairs and conferences, but were mostly sent to organizations serving families across that state that requested them, including hospitals and clinics.
• Staff developed and translated Tummy Time flyers into multiple languages, which were requested by local public health and other agencies. About 1,200 flyers were shared with our community partners between October 1, 2017 and September 30, 2018.

Activities to implement our strategy to provide technical assistance and expertise to our internal and external partners working to reduce infant mortality relate to the ongoing work of Minnesota. Staff served on a number of working groups and committees, including the SUID subcommittee, the Child Fatality Review Panel, Minneapolis Healthy Start Community Action Network (CAN), African American Community Voices and Solution (CVAS), and the Birth Equity Community Council (BECC). Our partnerships with and roles on these groups ranged from participating in reviews of SUID cases with the SUID subcommittee, providing technical advice to the CVAS group, and serving as a state advisor on the BECC.

The Birth Equity Community Council (BECC) is a partnership between the St. Paul-Ramsey County Public Health Department and CityMatch. BECC has two meeting structures: the Ramsey County PH & CityMatch Planning Team (comprised primarily of health care providers and professionals) and the BECC Council (comprised of families and health care professionals). BECC engages the local community in bi-monthly dialogues aimed at prioritizing health topics using the Perinatal Periods of Risk methodology (PPOR). BECC members also develop action plans to implement strategies prioritized using the PPOR for implementation to reduce infant mortality in Ramsey County’s African American/black population. Through the prioritization process, BECC members identified addressing SUID through safe sleep education and supporting fathers as key priority areas to focus on moving forward.

In FFY2018, BECC developed and implemented an innovative initiative called Doula Dads. Doula Dads trains fathers/men as certified perinatal health educators to provide support to their partners during pregnancy and the birthing process. The Doula Dads training also includes a component on safe sleep. In addition, the BECC is currently developing PSAs focusing on safe sleep education that target multiple populations, including African American/black fathers and grandparents. Staff is a member of the planning committee and serves on the safe sleep committee, where she currently provides technical assistance on the messages being developed for these videos.

Objective 3: By 2020, increase the percentage of mothers who reported that their infants sleep on their backs by 10% or more

According to Minnesota PRAMS, in 2016, about 85% of mothers surveyed reported that they placed their infants on their back to sleep (Figure 8 above). Ideally, close to 100% of parents should be placing their infants to sleep on their backs. During this reporting period, MDH implemented a couple of critical strategies to ensure that the state meets its goal of having 87.5% or more of parents placing their babies to sleep in the supine position by 2020. This means our target was not met. Minnesota’s collaborative efforts are discussed in the strategies and activities described below.

Minnesota recognizes that placing infants on their backs to sleep or nap is critical in preventing suffocation and choking during sleep. One of our strategies is to support external organizations in distributing and providing safe-sleep education to families. Title V staff presented on infant mortality, including the ABC’s of safe-sleep at the Positive Alternatives (PA) semi-annual grantee meeting held in FFY2018 and provided safe-sleep materials to the grantees for distribution to their clients. The PA grants program is a statewide initiative of MDH that funds qualified organizations working to promote healthy pregnancy outcomes by assisting pregnant and parenting women to develop and maintain family stability and self-sufficiency. Cradle of Hope, a non-profit organization funded by the PA grant, distributes cribs via a network of 150 partner sites throughout the state. Thirty-three of the PA grantees collaborate with Cradle of Hope to receive portable cribs. All families who receive cribs also get safe sleep information and education from staff working at the partner sites. Stressing the importance of putting babies on their backs to sleep is an important component of this education. Between October 1, 2017 and September 30, 2018, Cradle of Hope distributed 1,682 cribs. Among those who received cribs:

75% were between 20 and 34 years of age

50% were in their third trimester

39% were postpartum

35% of clients were white

33% were African American/black

6% were multi-racial

4% were Somali

B. Leveraging national initiatives and engaging stakeholders in plans to improve infant sleep safety

MDH developed and released Part One of the state’s infant mortality reduction plan in 2015. Part One was developed in partnership with stakeholders from around the state, including members of communities with the greatest disparities and included seven broad recommendations to reduce infant mortality. To date, MDH drafted a nearly completed safe sleep action plan with strategies across multiple sectors to reduce the incidence of sleep-related SUID and reduce disparities in rates across communities in Minnesota. The state’s Maternal and Child Health Advisory Task Force approved these strategies, along with an action plan with a proposal to reinstate Fetal and Infant Mortality Reviews (FIMR) in the future. Progress towards finalizing plans for each of the recommendations has stalled due to unforeseen circumstances such as staffing changes and the closing of the Minnesota Sudden Infant Death (SID) Center, which redirected much or the center’s SUID prevention and other related work back to MDH. Despite these challenges, staff have begun implementing some the strategies identified in the safe sleep action plan, and, Title V leadership continued to explore legislative opportunities to reinstate the FIMR in the American Indian and African American/black population.

ESM 5.1: Number of Minnesota hospitals with national Safe Sleep Hospital Certification

Strategy: Recruiting and encouraging birthing hospitals to receive safe sleep certification

In December 2016, MDH by hosted a webinar in partnership with the National Safe Sleep Hospital Certification Program to introduce the certification program to providers across Minnesota, and to present information on why it is important for providers to model best practices in hospital settings based on AAP safe sleep recommendations.

In 2017, St. Luke’s Hospital, located in Duluth, Minnesota, became the first ever hospital in the state to receive safe sleep certification. The hospital received certification at the silver level, and it is the first hospital in Greater Minnesota to have received this title. MDH recognized St Luke’s Hospital by hosting a media event that spotlighted the hospital’s safe sleep initiative. Since then, MDH has worked to encourage further other birthing hospitals to obtain certification. At a minimum, hospitals that receive certification are required to provide safe sleep education to parents/caregivers before they are discharged from the hospital, develop and maintain a hospital safe sleep policy based on AAP safe sleep guidelines, and train staff about the importance of modeling safe sleep practices for parents to see during their hospital stay.

MDH’s stated goal during the last reporting period was to increase the total number of birthing hospitals in Minnesota that are safe sleep certified from one in 2017 to three by the end of 2019. Thus far, we are on target to meet that goal. We now have two hospitals in the state that have received safe sleep designation and know that other hospitals are working towards that designation.

Some of Minnesota’s challenges and emerging issues related to infant mortality are as follows:

• Key challenges in our work include staff changes and the lack of funding to get some activities implemented. This includes, for example, not being able to plan and provide training for all home visitors that covers infant safe sleep messaging and best practices, as well as the delivery of compassionate care/services to grieving families. This effort did not materialize because of staff changes.

 

• Infant mortality rates by race/ethnicity are not trending in the right direction for most groups in our state. This is despite a wide range of programs, services, and interventions currently in place to benefit families. This is particularly true for non-white populations in our state, and a likely explanation for this is the impact of social determinants and trauma on our disparate populations. For example, there is a critical shortage of affordable housing across Minnesota, and rental costs have soared dramatically during the past decade. Despite a healthy state economy, not all populations are benefiting equally. The median household income for African American/blacks and American Indians is significantly lower than that of whites and Asian/Pacific Islanders. According to data from the Minnesota Demographic Center, in 2017, the median household income for African Americans/blacks and American Indians in Minnesota were $38,100 and $36,900, respectively, compared to $71, 900 among whites (Minnesota Demographic Center). These data suggest that the African American/black and American Indian populations do not have the financial resources needed to purchase services and resources beneficial to health, including those that promote improved infant health outcomes. As long as the African American/black and American Indian populations continue to have unequal access to resources and opportunities that benefit health, their infant mortality rates may continue to rise and the infant mortality gaps between these populations and whites will continue to widen.

 

• For more than a decade, MDH has collaborated with Healthy Start to implement strategies to improve poor birth outcomes and reduce infant mortality in the Twin-Cities metro area. MDH staff, including the Infant Mortality Specialist is a member of the Community Action Network (CAN).

Priority Need: Reduce infant mortality rate and racial and ethnic disparities in infant death rates

SPM 1: Percent of pregnant women enrolled in Minnesota Health Care Programs that receive 17-alpha-hydroxyprogesteronecaproate (17P)

Minnesota recognizes that preterm births increase the risk of health-related complications and infant mortality, and coupled with the disparities in preterm birth among American Indian and African American women are of concern. Minnesota Department of Health (MDH) was aware that the use of 17P in some women with previous preterm births could increase the length of pregnancy and reduce the rate of preterm births. The MCH 5-year needs assessment identified reduction in infant mortality and racial and ethnic disparities in infant deaths as a priority need. Minnesota created SPM 1 as a proxy to address this priority. MDH implemented the 17P quality improvement project to reduce the disparity in preterm births for African American and American Indian mothers.

Objective:  By 2020, increase the percentage of pregnant women on Medicaid with a previous preterm birth who receive progesterone by 20%.

Minnesota’s FFY2018 objective for pregnant women with a preterm birth and enrolled in Medicaid receiving 17P was 2 %. According to Minnesota Health Care Programs (MHCP) data, in calendar year 2017 only 1.2 % of pregnant women enrolled in Medicaid received 17P. This means our target was not met.

In Minnesota, prematurity is the second leading cause of infant death, 20.5% of infant deaths from 2012-2016. In addition, American Indians (13.9%) and African American (8.9%) women have higher rates of giving birth prematurely than white women (8.6%). During FFY2018 Minnesota continued to address preterm births by tracking the use of 17P by pregnant women enrolled in Medicaid and through participation on the Minnesota Perinatal Quality Collaborative.

The 17P initiative began as a coalition in 2016; partners were MDH, Minnesota Perinatal Organization, Minnesota Prematurity Coalition, and the March of Dimes, which provided a $10,000 grant, and with technical support from the National Institute for Child Health Quality Infant Mortality (CoIIN). The goal of the 17P QI initiative was to prevent preterm births by identifying and tracking mothers who have had a previous spontaneous preterm birth and her risk for preterm birth in current pregnancy. The work groups implemented a quality improvement aimed at identifying mothers who have had a previous preterm birth and her risk for preterm birth in current pregnancy. If the mother fits the criteria, they are a candidate for 17P, (medication to be administered intramuscularly or vaginally) the clinics administered this medication for the quality improvement project of cohort one. The leadership work group developed and provided webinars on risk assessment for healthcare providers and staff for patients who have had a preterm birth and if patient meets criteria for 17P. The 17P Infant Mortality CoIIN ended in May 2017. The work group planned to implement a second cohort building on the lessons learned from the first cohort. Before implementing the second cohort, the work group wanted to address the systems barriers that had been identified.

The Minnesota Perinatal Quality Collaborative (MNPQC) Leadership Committee, established in January 2018 with funding from the Centers for Disease Control and Prevention, is a collaborative of multiple organizations with a shared mission to improve maternal and infant health outcomes with a particular focus on decreasing racial and ethnic disparities. The MNPQC Leadership Committee is comprised of health providers from across the state, representing a variety of professional organizations, specialties, health systems, and populations. Shortly after the Minnesota Perinatal Quality Collaborative Leadership Committee formed, MDH and the 17P work group integrated the 17P quality improvement project into the Minnesota Perinatal Quality Collaborative.

During FFY2018, Minnesota’s strategies in this area focused on building and supporting existing work completed by the 17P CoIIN and developing activities to reduce systems barriers to accessing 17P to launch the second cohort.

A. Partner with professional organizations to provide continuing education on preterm birth and the use of progesterone to their members

Building on work completed by the 2016-2017 17P CoIIN, the 17P work group met monthly to develop driver diagrams for the systems barriers, as well as topic teams to develop activities to reduce them. Topic teams included the development of provider and patient education resources. The MNPQC Leadership Committee receives updates on from the work group and provides leadership for the project. The MNPQC leads quality improvement initiatives statewide to improve perinatal health by supporting best practices to address health disparities and improve health outcomes.

B. Work with payers (public and private) to ensure coverage of and eligibility screening for progesterone

The MNPQC Leadership Committee developed a prior authorization spreadsheet, identifying and evaluating coverage and payer requirements for 17P in different states. Leadership was able to map prior authorization for approval on 17P for payer (public and private) in the state. Representatives from the Leadership Committee met with Minnesota Department of Human Services to discuss prior authorization processes of payers.

Upon the formation of the MNPQC Leadership Committee in January 2018, MCHP designated a representative from their organization to provide leadership in MNPQC quality improvement projects. In August 2018, staff met with the Minnesota Council of Health Plans’ (MCHP) Medical Policy Committee to present on the progesterone (17P) project and discuss benefit coverage policy. Medical Policy Committee members were interested in taking the information back to their respective organizations for further discussions.

C. Increase patient, family, and community understanding of and demand for progesterone.

Educational interventions for patients, families, and communities were adapted for Minnesota by mirroring similar geographical states Perinatal Quality Collaborative tools and material from the March of Dimes. In FY 2018, patient and provider work groups/topic teams met to evaluate and provide recommendations from cohort 1 and current community practices. To enhance understanding of 17P, a literature review was completed based on best practices for administration of 17P (either vaginal progesterone or intramuscular progesterone). A frequently asked questions list was drafted based on these workgroups recommendations covering special circumstances like vaginal progesterone and late starts on 17P.

D. Lead quality improvement project aimed at addressing barriers to implementation of appropriate progesterone treatment in women with a previous preterm birth

During FFY 2018, the 17P work group reviewed findings of the 2017 cohort, process improvement discussions, provider feedback, and next steps in practice for 17P use to decrease preterm births. The work group developed clinical guidelines and protocols to use for the second cohort of 17P quality improvement project, which was discussed with the MNPQC Leadership Committee. The second cohort of the quality improvement project will focus on implementation of preterm birth risk assessments in hospital/clinic systems and administering 17P to women who meet criteria.