Domain: Perinatal/Infant Health

Reporting for October 2021-September 2022

Objectives

• By 2025, Minnesota aims to increase the percentage of infants who have been breastfed ever by 5% and increase the percentage of infants breastfed exclusively through 6 months by 20%.
• By 2025, Minnesota aims to increase the percentage of infants placed to sleep on their backs by 5%; increase the percentage of infants placed to sleep on a separate sleep surface by 15%; and increase the percentage of infants placed to sleep without soft objects or bedding by 15%
• By 2025, Minnesota aims to reduce the overall SUID rate by 15% and reduce the SUID rates between whites and African Americans and American Indians by 15%.

National Performance Measure

(NPM 4) A) Percent of infants who are ever breastfed; B) Percent of infants breastfed exclusively through 6 months.

Our objective for FFY2021 for NPM 4a, was to have 93.5% of Minnesota infants ever breastfed. According to the most recent data available from National Immunization Survey (NIS), the percent of infants who were ever breastfed was 91.9% in 2019. This means our target for FFY2021 was not met but we did see an increase from 2018 (88.6% of NIS respondents reported breastfeeding their infants). For NPM 4b Minnesota’s objective for FFY2021 was 37.8%. Data from NIS, indicate we didn’t meet our NPM 4b objective for FY2021 since the percent of infants who are exclusively breastfed through 6 months was 36.5% for the most recent year of data (2019). We did see improvements from the previous reporting year.

(NPM 5) A) Percent of infants placed to sleep on their backs; B) Percent of infants placed to sleep on a separate approved sleep surface; C) Percent of infants placed to sleep without soft objects or loose bedding.

For FFY2021, our objective for NPM 5a was to have 88% of infants placed to sleep on their backs. This objective was met. Our objective for NPM 5b was to have 42.5% of infants placed to sleep on a separate approved sleep surface. This objective was not met. Our objective for NPM 5c was to have 56% of infants placed to sleep without soft objects or loose bedding. This objective was met.

Table 1. Minnesota National Performance Measure 5, 2018-2021

Year	Percent of infants placed to sleep on their backs	Percent of infants placed to sleep on a separate approved sleep surface	Percent of infants placed to sleep without soft objects or loose bedding
2021	90.3%	39.7%	69.4%
2020	86.4%	43.5%	63.8%
2019	86.0%	39.6%	59.2%
2018	86.7%	40.4%	53.5%

Data Source: Pregnancy Risk Assessment Monitoring System (MN PRAMS)

Evidence-Informed Strategy Measure

(ESM 4.1) Percent of births delivered at MDH Breastfeeding- Friendly Birth Centers.

Minnesota works toward policy and systems changes that foster optimal infant health outcomes in Minnesota. Supporting baby-friendly hospitals and birth centers[1], as well as environments, policies, and practices conducive to breastfeeding, are two avenues that Minnesota is fostering toward optimal infant health outcomes. MDH’s Minnesota Breastfeeding Friendly Birth Center (BFFBC) Recognition Program recognizes birth centers across the state that have taken steps toward implementing the Ten Steps to Successful Breastfeeding, and, in partnership with the Minnesota Breastfeeding Coalition, MDH convenes the monthly community of practice - 10 Steps Learning Collaborative for Birth Centers.

Figure 1. Percent of births delivered at MDH Breastfeeding-Friendly Maternity Centers

The percentage of infants born in breastfeeding-friendly recognized birth centers decreased (figure 1) as several large hospital systems chose not to redesignate. However, two hospitals were re-designated to continue their commitment from 2020-2025 and two other facilities have partially completed Breastfeeding-Friendly Birth Center recognition requirements.

(ESM 5.2) Proportion of mothers who were told by a healthcare provider to place their baby on their back to sleep.

Safe sleep modeling occurs when hospitals develop, implement, maintain, and enforce a safe sleep policy that aims to prevent sleep-related injuries and deaths. Additionally, staff in turn serve as role models for safe sleep by intentionally conveying messages and cues to parents that promote sleep safety for infants.

In 2021, 93.7% of mothers were told by a healthcare provider to place their baby on their back to sleep.

Community-Identified Priority Need: Infant Mortality

Infant mortality is a multifaceted societal problem that effects the health and well-being of individuals, family systems, and communities. Some factors that have been connected to and influence infant mortality occurrences include maternal health, family socioeconomic status, quality and access to medical care, and knowledge about and support to implement public health best practices such as breastfeeding and safe sleep. Each of these factors are linked to systemic issues including racism and its impacts, leading to the racial disparities in infant mortality seen in Minnesota. Additionally, the stress associated with racism and discrimination causes harmful impacts to the body – mentally and physically - that can increase the rate of infant mortality.

310 infants born in Minnesota in 2021 died before their first birthday.

While Minnesota’s infant mortality rate has declined 34.2% since 1990, from a high of 7.3 deaths per 1,000 live births to 4.8 in 2021, the state’s overall rate disguises substantial variation by race/ethnicity – the burden of infant mortality is not shared equally across population groups.

Figure 2. Infant Mortality Rates by Race/Ethnicity, 3-year rolling averages

Minnesota is tracking and disaggregating the infant mortality rate data by race/ethnicity (Figure 2). For infants born between 2019-2021, Minnesota’s infant mortality rate was 1.8 greater for infants born to African American/Black and American Indian mothers than infants born to non-Hispanic white mothers. Additionally, the infant mortality rates among African Americans/Blacks in Minnesota vary depending on the mother’s birth country. From 2019-2021 infants born to U.S.-born African Americans/Black mothers had an infant mortality rate that is almost two times (11.3 per 1,000) that of infants born to foreign-born black mothers (5.8 per 1,000).

Figure 3. Leading Causes of Infant Mortality, 2017-2021

Data Source: Linked Birth-Infant Death Minnesota Resident Period Cohort Data File

Minnesota aimed to accelerate declines in infant mortality by addressing prematurity, congenital anomalies, other perinatal conditions, and SUID/SIDS (including preventative practices such as breastfeeding and safe sleep). These four causes of infant mortality make up 85% of all infant deaths between 2019-2021 (figure 3). We can also see the racial disparities within these specific causal areas. For example, infants born to African American/Black and American Indian mothers—the populations with the highest SUID rate in Minnesota—are approximately six and fifteen times more likely, respectively, to die suddenly and unexpectedly before age one than infants born to white and Asian mothers.

Strategies and Activities

A.  Strategy A: Apply Culturally Specific, Community Based Best Practices

1.  State Level Activities

1.1  Provide Supports for Healthy Pregnancy and Parenting Outcomes

African American Babies Coalition (AABC)  

The AABC is a local community group through the Wilder Foundation focused on improving birth outcomes in Black and Brown communities. In 2021, the Minnesota State Legislature allocated a total of $520,000 grant to the AABC for state FY 2022 and 2023 to: 

• Provide community-driven training and education on community-informed best practices to support healthy development of babies during pregnancy and postpartum. 
• Build capacity, train, educate, and improve practices among individuals, from youth to elders, serving families with members who are Black, Indigenous, or people of color during pregnancy and postpartum. 

In September 2022, AABC hosted its third Annual Black and Brown Baby Summit & Network Gathering -  Are Our Babies of Color Safe at Birth? The summit provided an opportunity for health care providers, doulas, community advocates, consumers, public health, legislative representatives, and others to learn about how to keep babies safe during and after pregnancy. The summit focused on driving systems changes in the health and human services sectors with an explicit aim of reducing disparities in maternal and infant health outcomes in Minnesota’s Black and Brown populations.

Positive Alternatives (PA)

The PA grant program, is a statewide initiative that supports, encourages, and assists women to carry their pregnancies to term by offering local resources to develop and maintain family stability and self-sufficiency. PA grantees provide birthing and postpartum persons with information on, referral to, and assistance with securing necessary services to promote healthy pregnancies and care for their babies after birth or in making an adoption plan. Necessary services include but are not limited to medical care, nutrition services, housing assistance, adoption services, education, and employment assistance, including services that support the continuation and completion of high school, childcare assistance, parenting education and other related support services. 

In FFY 2022, PA provided:

• Car seat safety instruction and distribution of car seats to 640 families
• Housing assistance to 447 clients.
• Parenting education to 12,550 clients.
• More than 12,013 material supports services – such as diapers, maternity clothes, and infant equipment – to 27 PA grantees throughout the state. 

1.2  Promote Safe-Sleep Practices for All Infants

Sudden and Unexpected Infant Death (SUID) is the third leading cause of infant mortality in Minnesota - approximately 12% of the state’s 330 infant deaths each year. According to data from the Minnesota Sudden Death in the Young (SDY)/SUID Case Registry for 2014-2018, infants born to American Indian mothers experienced the highest rates and are approximately three and twelve times more likely to die suddenly and unexpectedly before age one than infants born to white and Asian mothers, respectively. The majority of SUID in the state are preventable. Of the 82 SUID cases that occurred between 2019 and 2020, 99% were related to unsafe sleep practices. 

In FFY 2022, Minnesota promoted consistent and inclusive safe sleep messaging statewide and collaborated with community stakeholders to expand community-based infant mortality prevention and culturally specific resources for populations at greatest risk of experiencing an infant death. MDH disseminated safe sleep educational materials and resources, including to fathers and immigrants whose primary language is not English. Community partners, local public and tribal health, and PA grantees distributed educational materials, equipment, and resources to families including: 

• 1,290 “Sleep Baby Safe and Snug” books statewide – available in English and Spanish
• 300 cards on the ABCs of safe sleep – available in English, Hmong, Somali, Karen, and Spanish
• PA grantees provided their clients with 1,957 portable cribs, as well as 2,276 clients with safe sleep information. Cradle of Hope, a non-profit organization, and a PA grantee, distributed 1,335 cribs via a network of 204 partner sites throughout the state. Cradle of Hope partnered with eight tribal communities to distribute portable cribs. Of the clients that received cribs, were 34% white, 32% African American/Black, 20% multiracial,7% American Indian, 7% were Somali, and 29% Hispanic.

1.3  Promote Culturally Specific Policy for Cradleboard Usage in Licensed Childcare Settings

MDH staff participate in a workgroup convened by the state legislature to examine current Department of Human Services (DHS) statutes to ensure infant sleep safety in childcare settings and make recommendations for updating policy. In FY2021 and 2022, MDH staff provided technical assistance to DHS for statute revisions related to licensed childcare providers requesting a variance to use cradleboards for cultural reasons when a parent requests one – a cradleboard is a traditional baby-carrier used by many Indigenous populations. The suggested revised language calls for MDH and DHS to create a cradleboard variance form in partnership with tribal social service agencies. The suggested language changes did not pass during the 2021 legislative session.

1.4  Expand Community-Based Infant Mortality Prevention Education

Community-Based Infant Mortality Initiatives

One goal during FY 2022 was to collaborate with existing community-based infant mortality initiatives and programs serving families of color and American Indian Communities – including the Birth Equity Community Council (BECC), St. Paul-Ramsey County FHV, AABC, and PA grantees – to:

• Develop strategies to reduce infant mortality.
• Increase awareness of infant mortality and the multi-factorial causes.
• Deliver infant health promotion education to families. 

Infant Mortality Prevention Education Initiatives

Minnesota provided educational information to families and health providers on Shaken Baby Syndrome/Abusive Head Trauma (SBS/AHT). On June 30th, 2022, MDH, in partnership with the National Center on Shaken Baby Syndrome, hosted a free webinar, Shaken Baby Syndrome Prevention Programming in Minnesota, for professionals serving families with newborns in Minnesota. Approximately 300 individuals, including social workers and doulas, participated in the webinar. The webinar covered data on the incidence of shaken baby syndrome/abusive head trauma in Minnesota; addressed evidence-based shaken baby syndrome prevention strategies; presented evidence that infant crying is normal; and featured partners of the National Center on Shaken Baby Syndrome in Minnesota who have successfully implemented the Period of Purple Crying program and their experiences in doing so. Then, MDH and the National Center on Shaken Baby Syndrome launched a joint social media campaign from July 10 -16, 2022 to further raise awareness about SBS/AHT.

Additional activities in FFY 2022 included the following:

• MDH approved video material for hospitals to use to educate birthing people and their families on AHT and have written material – called “Baby Cry” cards - for hospitals and other health providers to distribute to parents and caregivers. In 2021, MDH distributed approximately 200 “Baby Cry” cards to local public health home visitors and PA Grantees for parent and caregiver education on safe infant care.
• MDH participated in a Region V Infant Mortality Session from CityMatCH to support MCH staff working with community partners to create an action plan for reducing infant mortality in our Black/African American and Indigenous families. Leaders from community organizations, state Medicaid program staff, and LPH participated in this session. 

1.5  Reduce Disparities in Modifiable Risk Factors for Birth Defects

Health Communities for Healthy Futures (HCHF)

The HCHF grant aims to reduce disparities in modifiable risk factors of birth defects by an innovative, community-driven approach, and is grounded in the perspective that communities know what they need to address disparities. Community-led approaches of addressing these risk factors are necessary to create positive, sustainable change. Two grantees were selected to implement interventions for women of childbearing age to address diabetes, obesity, smoking, hypertension, substance misuse, intrauterine infections, chemical exposures, or maternal stress. The focus populations for this work are groups experiencing health disparities in one or more of the risk factors listed above, including but not limited to People of Color, American Indian, people with disabilities, LGBTQ, rural residents, limited English proficiency, immigrant/refugee, and low-income.

The IMPLICIT Model

The IMPLICIT grant (Interventions to Minimize Preterm and Low Birth-Weight Infants Using Continuous Quality-Improvement Techniques) facilitates the implementation of the IMPLICIT Interconception Care Model in primary care and family practice clinical settings, which involves parental screening at well child checks to identify risk factors for birth defects for future pregnancies. The grantee selected to implement the program recruited two Minnesota clinics for cohort one, which ran from January 2021 through March 2022. A third clinic was recruited for cohort two, running from October 2021 through September 2023. The clinics of cohort one supported the implementation for cohort two.

Universal Congenital Cytomegalovirus (cCMV) Newborn Screening

In 2021, the Minnesota legislature passed a law known as the Vivian Act – named for Vivian Henrikson who was identified with congenital cytomegalovirus (cCMV) shortly after birth. The Vivian Act directs the Commissioner of Health to:

• Make information about cCMV, including preventative measures, available to health care providers, women who may become pregnant, expectant parents, and parents of infants.
• Establish an outreach program to educate women who many become pregnant, expectant parents, and parents of infants about cCMV.
• Raise awareness for cCMV among health care providers.
• Require the Advisory Committee on Heritable and Congenital Disorders to review cCMV for possible inclusion on Minnesota's newborn screening panel.

In 2022, the Advisory Committee recommended adding cCMV to the newborn screening panel, and the Commissioner of Health approved the recommendation. In 2023 Minnesota became the first state in the nation to screen every newborn for cCMV.

1.6  Provide Culturally Specific Support for Breastfeeding

The Minnesota Women Infant and Children program (MN WIC) serves populations whose circumstances—low income, less education, less access to resources, and younger—are impacted by inequities attributable to social determinants of health. Systemic racism found in these systems and their policies, along with historical trauma around breastfeeding, create barriers to breastfeeding for these populations. For MN WIC participants in 2021, 80.6% were ever breastfed while 93.4% of those not on WIC were ever breastfed. For those participating in MN WIC born in 2018, 36.9% breastfed for at least six months compared to the statewide rate of 66.2% (NIS). 

WIC families have been impacted by many factors, including the following:

• Many WIC parents report having to return to work shortly after birth to workplaces that don’t support breastfeeding.
• Mental health concerns and stress exacerbated by pandemic circumstances are impacting initiation and duration of breastfeeding.
• Lack of support presents another challenge – especially in FFY2022 when, due to COVID-19, in-person and community support groups were halted, there was limited contact with family and friends, and earlier hospital discharges.
• There has been a decrease in prenatal education participation with many MN WIC agencies reporting pregnant women entering the program later in pregnancy, not attending prenatal classes, and not regularly visiting health care providers during pregnancy. 

The MN WIC Peer Breastfeeding Support Program (PBSP) supports families to meet their breastfeeding goals by pairing families with peer counselors, parents with personal experience breastfeeding their own children. Peer counselors are recruited from the communities they serve and often speak the same language, have similar life circumstances and experiences as their clients. MN WIC peer counselors improve health by increasing breastfeeding initiation, exclusivity, and duration. With increased federal funding, the PBSP was able to expand the number of peer programs from 14 to 18 for the grant period of January 2022 – December 2026. The expansion will make peer support available to 15% more WIC families across the state, in addition to serving a higher percentage of families at local agencies with existing peer programs.

MN WIC provides culturally specific support for breastfeeding through statewide partnerships, including developing breastfeeding materials and expanding outreach to targeted cultural groups, including Hmong, Karen, American Indian and Somali communities. Additionally, during this reporting period, MN WIC conducted the following activities:

• Collaborated with tribal nations and cultural communities, which involved sharing and developing a better understanding of the meaning behind the breastfeeding data, determining data to share, and discussing community-driven strategies to reduce disparities. 
• Sponsored monthly breastfeeding webinars hosted by the Michigan Breastfeeding Network, which were/are available to WIC staff and partners to learn more about timely breastfeeding topics and earn a variety of continuing education credits.
• Worked with Coffective on the Strengthening Maternal and Child Health (MCH) Partners Collaboration Initiative that recognizes improved collaboration helps to reduce disparities in birth and breastfeeding outcomes. The initiative partnered with WIC local agencies and local public health to provide stipends to use towards projects that strengthen local networks and improve community partnership coordination, with an emphasis on building relationship with local hospitals and clinics. 
• Held lunch and learns with local hospitals to promote WIC nutrition and breastfeeding services, which strengthened connections between hospital and WIC.
• Used funds to provide advanced lactation trainings, purchase breastfeeding support supplies and breastfeeding promotion materials, within local WIC agencies.
• Worked to increase the availability of breastfeeding friendly childcare providers in Houston County.
• Offered lactation continuing education courses to WIC staff and community partners such as the Indigenous breastfeeding coalition members and family home visiting staff.

2.  Local Public Health and Community Spotlights

2.1  Lead Systems Change through Innovative Solutions and Partnership

In 2017, St. Paul-Ramsey County Public Health used Title V funds to create and implement the Birth Equity Community Council (BECC), a community-led collaborative to improve birth outcomes and reduce infant mortality racial disparities. BECC’s activities are around the core strategy areas of training, celebrations, and policy. Since BECC’s inception, Title V staff have been and continue to be a partner, serving as a state public health advisor and participating on BECC subcommittees, as well as providing technical assistance, strategic planning, and data analysis support. From this partnership, MDH learns firsthand from the African American community about what matters to them in improving birth outcomes – drawing from their expertise, wisdom, strength, and resilience. Highlights of BECC’s work during FFY 2022 include the following:

• Convened ongoing meetings of the BECC policy workgroup to address the problem of low Medicaid reimbursement rates for doula care in Minnesota. The policy workgroup comprised community members, DHS (MN’s Medicaid agency), MDH, Everyday Miracles, advocates, and representatives of health plans. The workgroup drafted a proposal to be introduced during the 2023 legislative session to increase Doula Reimbursement for Medicaid subscribers up to $1400 for birthing services and covers six additional visits up to $100 for a total package of $2000. This is the largest amount of reimbursement proposed by any state to date.
• Convened an end-of-year conference in December 2021, which focused on equity in action. The conference included discussions and conversations around BECC's three themes-- Training, Policy, and Celebrations. It also brought together different systems working to address inequities that adversely affect maternal and infant health outcomes in Ramsey and Hennepin counties’ African American populations, including housing, education, and employment. Participants also learned about other local perinatal health initiatives and had an opportunity to network with one another.
• Offered a training on implicit bias and anti-racism attended by providers, public health professionals, doulas, social workers, and community advocates.
• Held bi-monthly meetings that allowed BECC members/stakeholder to learn about local issues affecting MCH populations or culturally appropriate services available to families. For example, Star Legacy presented on the grief and loss support services and resources available to families through the MDH grant – Grant to Support Grieving Parents and Caregivers Experiencing the Death of an Infant or a Stillbirth in Minnesota; and a St. Paul-Ramsey County Public Health staff presented information on environmental justice and birth equity by focusing on the intersection of environmental hazards and racism on birth outcomes.
• Collaborated with several community partners, including Mothers First and AABC to host its first annual community baby shower in August 2022. The baby shower offered expectant and new families an opportunity to learn about a variety of resources available, such as free books, college savings account, and how to obtain gently used clothing for mothers and babies. In addition, goodie bags, diapers, and maternity and postpartum supplies were available to families/anyone who needed them.
• Started a newsletter in August 2022, which provides a recap of the most recent BECC meeting, spotlights a community partner, and includes information on upcoming trainings, conferences, local and national MCH news, policy changes, and links to resources and services.

2.2  Promote and Support Breastfeeding through Community Engagement

MN WIC supported seven local agencies with grants up to $5,000 to support breastfeeding related projects. Projects included: 

• Anoka County partnered with the Anoka County Breastfeeding Coalition to host an event promoting the WIC peer breastfeeding support program, public health programs and the local breastfeeding coalition. A photographer took portraits of families attending to be used in promotional materials.
• Beltrami County commissioned a sculpture promoting and normalizing breastfeeding in the American Indian community. The artwork depicted a native woman breastfeeding her baby. The sculpture integrates themes such as the medicine wheel, black and white eagle feathers, and locally made hand-beaded earrings as a finishing touch. The sculpture will be permanently housed in the Sanford Health pediatric clinic lobby.
• Nicollet, Faribault, and Martin counties collaborated to create and post 4 billboards promoting breastfeeding and depict real diverse families breastfeeding, along with the tagline “Breastfeeding: Good for baby, Good for you!”.
• Isanti County WIC hosted a community baby shower/resource fair to promote breastfeeding resources and support services in their local community and spread the word about the new Baby Café. The event was a great success with 119 people attending and 12 organizations sharing resources at tables during the event.
• Ramsey County WIC created 20 lactation kits for individuals in Ramsey County corrections facilities. The kits were distributed to the adult detention center and 6 of the 20 to the juvenile detention center.
• St. Joseph’s WIC program created a rock and rest tent for the Hubbard County Fair. The goal was to promote WIC lactation support and encourage longer breastfeeding/chest feeding duration especially in the non-white population.
• White Earth Tribal WIC partnered with the White Earth farmer’s market to set up a table to promote WIC breastfeeding support during the month of August. Each Thursday in August WIC tabled at the market. The table included breastfeeding facts and promotion information, how to sign up for WIC, breastfeeding education cards, and additional WIC breastfeeding promotional materials. Over 60 families visited the table over the 4 weeks of the market.

2.3  Co-Create Communication Strategies Around Breastfeeding with Community

Ramsey County Public Health’s Moving Equity into Data (MEDA) project conducted community listening sessions with members of the U.S. born African American community to co-create breastfeeding friendly messages. From the themes that emerged from the community listening sessions, messaging and art were created by the community members for distribution into communities. The artwork created can be found at https://www.strongblackbabies.org/. Ramsey County will continue to be part of the MEDA cohort two, working on expanding the project to U.S. born African American young men and males. 

2.4  Increase Equitable Access to Pasteurized Donor Human Milk

The Minnesota Breastfeeding Coalition (MBC) in partnership with MDH, the Minnesota Milk Bank for Babies (MMBB) and several food pantries expanded a program to increase equitable access to pasteurized donor human milk (PDHM) to support chest/breastfeeding families who cannot afford to pay out-of-pocket for donor milk, which is currently not covered by insurance. Northpoint Health and Wellness began distributing PDHM in January of 2022. Division of Indian Works completed planning to become another distribution site, and acquired the supplies (freezer, bags, and marketing materials) needed to become a site. Olmsted County Public Health FHV program worked on a pilot for a bridge bag program in partnership with WIC and applied for SHIP funding to purchase a freezer, bags, and marketing materials. Those on WIC/MA would receive PDHM at no cost.

2.5  Provide Professional Development Support to Emerging and Established Lactation Professionals

Efforts to diversify the community of lactation professionals in Minnesota continued in 2022. The MBC kicked off the Next Gen project, a continuation of a partnership between Ramsey County WIC, Regions Hospital, Hennepin County WIC, and Hennepin County Medical Center to support candidates who are completing health science courses, lactation education and mentorship through the hospital and WIC to meet the requirements to sit for the IBLCE exam.  The Next Gen project is providing resources and support to the learning cohort, including in FFY 2022 over $10,000 in stipends to cover tuition, exam prep and fees, and costs of acquiring mentorship hours.

MBC also hosted the following learning and development opportunities:

• The Perinatal Hospital Leadership Summit on February 25, 2022. The Summit’s theme was Using an Equity Lens in Moving from Practice to Policy. The virtual summit engaged 50 registrants from birth center leadership, public health, and community groups to share evidence-based perinatal care and infant feeding practices.
• In recognition of August 2022 National Breast/Chestfeeding month, MBC hosted the Reclaiming and Celebrating Cultural Human Milk Feeding Traditions webinar series, which celebrated voices and traditions from the LGBTQIA+, Indigenous, Asian American/Pacific Islander, and Black communities in Minnesota.
• The Power of Prenatal Education webinar on September 30, 2022, which provided the opportunity to share the results of the 2022 Infant Feeding Practices Survey (IFPS), which examined birthing facilities maternity care and infant feeding practices, including the use of pasteurized donor human milk.

2.6  Conduct a Breastfeeding Assessment and Storytelling Collection with Hmong Women and Families

With additional funding from Reducing Disparities in Breastfeeding through Continuity of Care Identifying Care Gaps grant, from the National Association of County and City Health Officials (NACCHO), the Hmong Breastfeeding Coalition conducted an environmental scan of Minneapolis and Saint Paul on breastfeeding promotion and support for child-bearing age Hmong women and families. The project included a breastfeeding assessment and storytelling collection initiative since oral history is deeply rooted in the Hmong culture. These two methods portrayed how the lifestyle of a Hmong woman’s role resembles what is found in a Confucius model of the family, where an individual’s success is celebrated and viewed as the whole family’s success. Likewise, individual interests and needs are never put above the interests and needs of the family’s general welfare. This may be contributing to low breastfeeding rates in the Hmong community but can also be leveraged for information sharing, resources, and encouragement to be more supportive. 

B.  Strategy B: Improve Data Collection and Evaluation

1.  State Level Activities

1.1  Improve Data-Sharing Between MDH and Partners

During FFY 2022, Minnesota accomplished the following to improve data-sharing between MDH, local public health, and partners: 

• Shared weekly data files with partner, the Star Legacy Foundation, which were often revised and monitored with feedback from Star Legacy Foundation to ensure accuracy. 
• Explored whether to continue sharing SUID/SDY registry data with birthing hospitals.
• Shared demographic and other relevant data for infants identified through MDH’s Birth Defects Information System and Newborn Screening Programs with LPH to connect families with needed information and services.

1.2  Establish a Fetal and Infant Mortality Review (FIMR)

In 2001, statute authorizing the Commissioner of Health to conduct a FIMR was repealed. Without the legislation in place, MDH lacks statutory authority to establish a FIMR process and committee. Since 2014, there have been legislative proposals to reinstate the FIMR without success. In 2022 MDH did not propose a FIMR. Instead, MDH put forth a proposal to support Healthy Beginnings, Healthy Families, which included the creation of the Minnesota Partnership to Prevent Infant Mortality (MPPIM). The proposed MPPIM is a statewide multisectoral effort that seeks to leverage existing partnerships and award competitive grants to community-based organizations, tribes, and local public health to improve infant health outcomes in the state’s Black/African American, American Indian, and communities of color in Minnesota. Unfortunately, the budget bill containing proposals for health initiatives did not pass in 2022.

C.  Strategy C: Facilitate Policy and Systems Changes to Reduce Infant Mortality

1.  State Level Activities

1.1  Promote Infant Sleep Safety by Providing Consistent and Inclusive Safe Sleep Messaging

MDH and partners promoted consistent and inclusive safe sleep messaging from the AAP safe sleep recommendations to support preventable sleep-related tragedies during infancy. Staff also alerted partners and stakeholders of the newly updated AAP safe sleep recommendations when they were released in June 2022 via several electronic publications/platforms such as MDH’s FHV Tuesday Topics e-newsletter, MN Perinatal Quality Collaborative e-newsletter, and GovDelivery – a MDH e-mailing list for the public. The FHV Tuesday Topics e-newsletter alone is sent to more than 2,000 subscribers.

Additionally, FHV, DHS, LPH, various grantees, and community organizations implemented activities to support placing infants to sleep on their back and in a safe sleeping environment and raise awareness of sleep related SUID and infant mortality. 

During Infant Mortality Awareness Month 2022, Governor Walz proclaimed the week of September 11-17, as Infant Mortality Awareness Week. The proclamation stated that infant mortality is a multi-factorial, complex societal problem that requires a response from across many sectors and disciplines to address conditions that negatively affect birth outcomes. Factors include maternal health and wellbeing, housing and job insecurity, environmental toxins, lack of social support and community connections, and a lack of access to health care. Systemic racism and discrimination against Black/African American, American Indian, and other people of color directly contributes to inequities in infant mortality.

Infant Mortality Awareness Week provided an opportunity for individuals, organizations, government entities, healthcare systems, community partners, and coalitions to promote awareness and education about infant mortality. Educational messages related to infant mortality – posted on MDH social media platforms – yielded more than 129,000 views. One post summarizing some basic facts about infant mortality in Minnesota generated approximately 106,820 views alone. Additionally, MDH:

• Collaborated with Beltrami County Public Health to create a social media post that highlighted the importance of breastmilk as the first medicine/first traditional food for American Indian infants. The post also emphasized the importance of breastmilk in lowering the risk of infant mortality.
• Called attention to the Emerging Narrative Frames for African American Infant Mortality Project in a social media post. These frames draw on the strength, resilience, and wisdom of U.S.-born Black families to help shape, improve, and expand community and policy conversations around infant mortality in the state’s U.S.-born Black community.
• Partnered with local radio stations serving diverse communities for promotion of messaging.

1.2  Draft and Publish a Perinatal Health Strategic Plan for Minnesota

In 2015, MDH developed and released part one of the state’s infant mortality reduction plan.  Developed in partnership with stakeholders from around the state, it contained seven broad recommendations to reduce infant mortality overall and to address disparities in rates across communities in Minnesota. This plan expired in 2020. 

Part One of the plan focused exclusively on infant mortality. During FFY 2022, staff began drafting the second part, the Perinatal Strategic Health Plan, focusing on improving both maternal and infant health outcomes. The draft plan articulated a vision for the state, and outlined values, guiding principles, goals and accompanying evidence- and practice-based strategies based on the input or recommendations generated by stakeholders in past strategic planning meetings. In August 2022, MDH was awarded a State Maternal Health Innovation and Data Capacity Program Grant, which requires creating and implementing a strategic plan that includes activities outlined in the state’s most recent Title V strategic plan. 

1.3  Increase the Number of Safe Sleep Certified Hospitals

In FFY 2022, staff conducted a survey of all 84 birthing hospitals in Minnesota to determine whether they had a hospital safe sleep policy in place, provided safe sleep training for their staff, or provided safe sleep education to mom/parents before they are discharged from the hospital. MDH used the information gathered from the survey to further encourage hospitals to become safe sleep certified. Survey results were also used to plan and invite all hospitals that responded to the survey to attend an informational webinar with Crib for Kids ® National Safe Sleep Hospital Certification Program on June 2, 2022. Six health care providers representing three hospital systems participated in the session. The session covered data on the incidence of sleep related SUID in Minnesota, provided an overview of the certification program, and offered participants an opportunity to ask questions. Since then, MDH has provided technical assistance to one of the hospital systems, which has expressed serious interest in becoming certified.   

1.4  Increase the Number of MDH Breastfeeding-Friendly Recognized Birth Centers

Maternity hospital practices and policies can undermine maternal and infant health by creating barriers to supporting a parent’s decision to breast/chestfeed. When birthing facilities implement the World Health Organization’s Ten Steps to Successful Breastfeeding, they have the tools to give parents the information, confidence, and skills necessary to successfully initiate, and continue, to breast/chestfeed their babies. Parents who get the support they need in the hospital are much more likely to continue breast/chestfeed once they return home. With funding from Statewide Health Improvement Partnership (SHIP), staff from the MBC facilitated a 10-Step Learning Collaborative (10-SLC) to work on implementation of the WHO’s Ten Steps. The 10-SLC brought together staff from hospitals across the state to work on a minimum of two steps, utilizing the MDH Breastfeeding-Friendly Birth Center 5-Star Recognition Program guidance and tools. Four hospitals were regularly engaged with the collaborative’s monthly meetings. During FFY2022, Northfield Hospital earned their first star and CentraCare Birth Center achieved three-star recognition. 

MBC and MDH, including two Title V interns, conducted an infant feeding practices survey and in-depth interviews with lactation care providers in the Summer 2022. The surveys collected information on maternity care and infant feeding practices, including utilization of donor milk, and written policies around infant feeding. Interviews explored perceptions, practices, and concerns around donor milk.

1.5  Address Prematurity

Babies born before 37 weeks represent just under 10% of all births in Minnesota, but prematurity remains one of the top causes of infant mortality, representing 25% of all infant deaths. Persistent racial and ethnic inequities contribute to the overall rates of premature birth. In 2019, American Indian (14.7%) and Black (11.1%) women had higher rates of premature births than white women (8.8%). The effects of prematurity can be long lasting for the child, including difficulty breathing, developmental and learning delays, as well as the family who may experience feelings of guilt, anger and increased financial and emotional stress while caring for babies born prematurely.

To address this important issue, Minnesota began implementing the IMPLICIT model to incorporate interconception care for the mother into well child visits to improve future birth outcomes. In addition, the Minnesota Perinatal Quality Collaborative (MNPQC) conducted two quality improvement efforts on hypertension and substance use disorder in pregnant and postpartum people both of which contribute to improving outcomes for babies born before 37 weeks. These activities are described in the 2022 Women/Maternal Health Report and 2024 Women/Maternal Health Plan. 

1.6  Participate in AMCHP’s Healthy Beginnings Cohort

In June 2021, MDH applied for and was selected as one of eight health departments in the U.S. to participate in the AMCHP Healthy Beginnings Cohort. The cohort was convened to help states develop action plans to dismantle racism in existing policies, data, and funding structures that have historically perpetuated and fostered inequities in perinatal health outcomes in BIPOC populations in Minnesota. MDH partnered with Minnesota Indian Women’s Resource Center (MIWRC) – a community organization serving urban American Indian women, children, and families since 1984 – to co-develop the action plan during FFY 2022. *See Local Public Health and Community Spotlight below for more details.

Based on these conversations, a draft plan was written by MDH and MIWRC and submitted to AMCHP in January 2023. However, next steps include continued engagement with our MIWRC partner to ensure that the draft plan ideas are incorporated into future MCH strategic plans, including the draft Perinatal Health Plan due to HRSA in September 2023.

2.  Local Public Health and Community Spotlight

2.1  Co-Develop Action Plans to Dismantle Racism in Policies, Data, and Funding Structures

In June 2021, MDH applied for and was selected as one of eight health departments in the U.S. to participate in the AMCHP Healthy Beginnings Cohort. The cohort was convened to help states develop action plans to dismantle racism in existing policies, data, and funding structures that have historically perpetuated and fostered inequities in perinatal health outcomes in BIPOC populations in Minnesota. MDH partnered with Minnesota Indian Women’s Resource Center (MIWRC) – a community organization serving urban American Indian women, children, and families since 1984 – to co-develop the action plan during FFY 2022. Guided by two broad objectives developed by AMCHP for states to address in their action plans, MIWRC led MDH in conversations during the 18-month long cohort that aimed explicitly to identify:

• Structural racism as a root cause within systems, policies, and practices that have historically perpetuated inequities in MCH outcomes in Minnesota’s American Indian population.
• Actions such as sustainable investments (and other systemic changes) that MDH/MCH (i.e., Title V programs) and other non-MDH entities can take to improve perinatal health outcomes in tribal communities. 

During these conversations, MIWRC identified five racist practices in policies, systems, and data across the two objectives to focus on, with proposed solutions for each. Regarding racism as a root cause of poor perinatal health outcomes in the American Indian population, our MIWRC partner mentioned that the adverse effects of systemic racism on American Indian health, including maternal and infant health outcomes, are either not measured at all or are poorly evaluated in Minnesota. A proposed anti-racist solution by our MIWRC partner is the use of an anti-racist lens by interested parties to better assess and understand structural and systemic issues that impede positive maternal and infant health outcomes in the American Indian population. This solution is important because there is a paucity of anti-racism work occurring in Minnesota, and much of it is not happening at satisfactory levels.  Consequently, MIWRC conveyed the importance of conducting community participatory research as an important approach to intentionally collect data alongside American Indian communities, beginning with the planning stage and ending with the data dissemination. Also, it is equally important to our partner that non-Tribal entities establish partnerships with American Indian communities to conduct a Racial Equity Impact Assessment to measure the adverse effects of racism on the health of American Indians.

As for identifying sustainable actions or investments that MDH programs and systems can implement to improve perinatal health outcomes in the Minnesota’s American Indian population, MDH and MIWRC discussed the fact that, historically, tribes in Minnesota do not receive Title V funding, and that tribal communities may not even be aware that the funding exists, how it is distributed, and who receives it. Anti-racist solutions suggested by MIWRC to address these problems include making separate MCH perinatal funding streams for tribes and increasing transparency around federal funding given to MDH to improve perinatal health outcomes in communities across the state.

Based on these conversations, a draft plan was written by MDH and MIWRC and submitted to AMCHP in January 2023. However, next steps include continued engagement with our MIWRC partner to ensure that the draft plan ideas are incorporated into future MCH strategic plans, including the draft Perinatal Health Plan due to HRSA in September 2023.

D.  Additional Related Activities

1.  State Level Activities

1.1  Provide Trainings on Safe Sleep, Infant Mortality, Bereavement, and Breastfeeding to Partners

MDH grantee, Star Legacy Foundation, reached out to or met with many organizations and community-based groups that serve Minnesota families to provide a comprehensive overview of the types of grief and loss services provided, as well as the process used by the organization to connect grieving families to the resources and services they need. This included reaching out to local public health agencies, clinics, immigrant organizations, nursing agencies, parent groups, hospitals, and community driven initiatives or organizations such as Ramsey County’s BECC and Wilder Foundation’s AABC. 

MDH staff presented at several grantee gatherings, stakeholder meetings, and conferences on Minnesota’s infant mortality rates, the disparities experienced by the African American/Black and American Indian communities and identified factors contributing to these deaths. Some of the venues were MNPQC, and the PA grantee meetings. 

Additionally, to promote protective factors for infant health, FHV programs are encouraged to use grant funds for staff to complete training to become lactation counselors, which may support the initiation and duration of breastfeeding. In FFY 2022, 66% (153 out of 233) of infants whose mothers participated prenatally in MIECHV funded FHV programs received some amount of breast milk at six months of age

1.2  Provide Resources through the Grief and Loss Support Grant

In 2019, MDH awarded a grant to the Minnesota Center for Stillbirth and Infant Death (MNCSID), run by the Star Legacy Foundation, to connect families who have experienced an infant death or a stillbirth to grief and loss support resources. This grant is a collaboration of Title V and Minnesota’s birth defects prevention program. For FFY 2022, MNCSID reported 609 referrals - 44% were infant deaths and 56% were fetal deaths. As part of their communications with families, MNCSID sent out 586 condolence letters, completed 311 initial consultations with clients, and sent out 575 packets of grief and loss resources in response to requests for this information, of which 85% were to providers and 16% to families.

[1] Baby-Friendly USA - About (babyfriendlyusa.org)