The domain of Perinatal/Infant Health sets the trajectory of the health of a child throughout the Life Course. NJDOH has identified the following State Priority Needs (SPN) of Reducing Black Infant Mortality and Improving Nutrition & Physical Activity and selected the related NPMs 4 (Breastfeeding) and 5 (Infant Safe Sleep) because of the Five-Year Needs Assessment process. NJ has implemented several evidence-based strategies related to NPM 4 & 5 which impacts several NOMs (4, 5, 6, 8, 9.1, 9.5).

Annual Report - NPM 4:

Percent of infants who are ever breastfed and Percent of infants breastfed exclusively through 6 months.

Promoting breastfeeding has been a long-standing priority for FHS. Breastfeeding is universally accepted as the optimal way to nourish and nurture infants, and it is recommended that infants be exclusively breastfed for the first six months. Breastfeeding is a cost-effective preventive intervention with far-reaching effects for mothers and babies and significant cost savings for families, health providers, employers, and the government. Breastfeeding provides biologically normal, appropriate nutrition and encourages normal infant development.  This form of nurturing is especially important considering the lack of breastfeeding increases the risk of disease and obesity. FHS has developed multiple partnerships to strengthen breastfeeding-related hospital regulations, promoting breastfeeding education, training, and community support.

In 2022, in collaboration with TVP, WIC, and SNAP-ed within the NJDOH released the Breastfeeding Strategic Plan (BSP). Presently, TVP staff sit on the committee that partakes in the implementation of the BSP. The Title V Director also secured funding from the FY24 Governor’s budget for dedicated staff to lead implementation of the BSP. A statewide coordinator was hired effective March 2024, and a project associate shortly after.

ESM 4.1 (Increase the Percentage of Births in Baby-Friendly Hospitals) was selected for its positive impact on NPM #4 and NJ's ongoing efforts to promote the Baby-Friendly Hospital Initiative and its ability to monitor breastfeeding rates from birth certificate data and the mPINC Survey.

According to the Centers for Disease Control and Prevention (CDC) 2021, National Immunization Survey Breastfeeding Rate Report Card, NJ rates for newborns ever breastfed in 2019 was 82.5% (NPM 4A). NJ breastfeeding rates in four categories of interest from 2018 to 2020 are depicted in the table below.

All breastfeeding rates in New Jersey increased annually among babies born in 2018-2020 in all five categories. The greatest improvement was seen in the rate of breastfeeding at six months – an increase of 5.7 percentage points.

Notes - Source – the CDC's National Immunization Survey. http://www.cdc.gov/breastfeeding/data/NIS_data/ ; DNPAO Data, Trends and Maps: Explore by Location | CDC

DOH has supported Baby-Friendly™ Hospital designation through training, technical assistance, and mini-grants. The Baby- Friendly Hospital Initiative (BFHI) is a global program launched by the World Health Organization and the United Nations Children's Fund to encourage and recognize hospitals and birthing centers that offer optimal care for infant feeding and mother/baby bonding. BFHI recognizes and awards birthing facilities that implement the Ten Steps to Successful Breastfeeding and follow the International Code of Marketing of Breast-milk Substitutes. Thirteen NJ hospitals have earned the "Baby-Friendly" designation.

NJ hospitals participate in the Maternity Practices in Infant Nutrition and Care (mPINC) Survey, a national survey of maternity care practices and policies conducted by the CDC every two years, beginning in 2007. In 2020, 40 of 49 (82%) eligible hospitals participated in the mPINC Survey, which examines best practices and policies in maternity care to improve breastfeeding outcomes.  Various domains of health, encouraging behaviors for breastfeeding are examined such as immediate postpartum care, rooming in, feeding and educational support, discharge support and institutional practices which help set a birthing parent up for success in breastfeeding.  Each state was given a score, from 1-100, based on the characteristics present in birthing hospitals.  and the total score was 82 (above the national score of 81).

Existing breastfeeding-related programs:

Presently, the WIC program provides breastfeeding promotion and support services for WIC participants through grants to all 16 local WIC agencies. International Board-Certified Lactation Consultants (IBCLC) and breastfeeding peer counselors provide direct education counseling and support services, literature, and breastfeeding aids, which include breast pumps, breast shells, and other breastfeeding aids. WIC staff conducts the Loving Support© through the Peer Counseling Breastfeeding Program. Moreover, WIC breastfeeding staff conducts professional outreach in their communities and education to healthcare providers who serve WIC participants. Close collaboration between Maternal and Child Health Services (MCHS), WIC Services, and the Office of Community Health and Wellness is ongoing. All three programs, in addition to the Office of Minority and Multicultural Health, have an interest in breastfeeding protection, promotion, and support and have similar constituencies.  This is best evidenced by the rollout of activities included in the State’s Breastfeeding Strategic Plan, led by the State’s Breastfeeding Coordinator and her support team.

Through the HWHF initiative, TVP implements community-level programs that promote breastfeeding and potentially address persistent racial and ethnic disparities. For instance, one of the target outcomes of HWHF is, increasing exclusive breastfeeding. Additionally, to address the racial/ethnic disparity in breastfeeding rates, implementing breastfeeding support and education to non-traditional audiences as a mechanism to increase support for NH-Black and Hispanic women is one of the interventions/strategies of HWHF. Moreover, CHWs, postpartum doulas, and their supervisors receive breastfeeding education through multiple trainings, educational sessions, and professional development opportunities to become CLCs and IBLCs. Considering that breastfeeding is a “family affair”, fathers’ and other family members’ involvement in the process is a puzzle piece that is supported by the HWHF initiative through its focus on non-traditional audiences.

Annual Report NPM #5 (infant safe sleep)

NJ TVP utilizes block grant funding to fund the Sudden Infant Death Syndrome Center of New Jersey (SCNJ). SCNJ provides bereavement support to families whose infants died suddenly and unexpectedly, often of unknown causes, analyzes etiologies and risks and contributes findings to the American Academy of Pediatrics policy statement and guidelines for risk reduction, and develops and provides public health education to reduce the risk of Sudden Unexpected Infant Death (SUID), which is inclusive of Sudden Infant Death Syndrome, Ill-defined and Unknown Causes, and Accidental Suffocation and Strangulation in Bed.  With respect to risk reduction education, the SCNJ develops and provides educational programs, tools, and methodologies that assist the public, health care, social service, childcare, and public health institutions, programs and providers, faith- based communities, home visiting programs, doulas, community organizations, and other systems that interface with parents and other caregivers. The SCNJ also identifies disparities in the adverse social and health determinants that increase the risk of SUID and contribute to disparities in rates and collaborates with the public health systems that address these factors. In working with all programs with the shared goal of reducing infant mortality, the SCNJ has developed the access and trust needed to raise knowledge of safe infant sleep and other risk-reducing behaviors. In association with the work of the SCNJ, New Jersey’s SUID rate dropped from 0.61 per 1000 live births in the pandemic year 2020 to 0.52 in 2021 (CDC WONDER). New Jersey’s 2021 SUID rate was nearly half the national rate of 0.99 and ranked second lowest in the US for all reported states (CDC WONDER).  The Black NH rate, along with one other state with an equivalent rate, was the second lowest of all reported states in that group, and the White NH rate was the lowest of all reported states in its group. However, although the SUID rates for New Jersey's population groups compared favorably to national data and relative to other states, racial disparity continues to be evident across states and in summary national data. Nationally, from 2020 to 2021 the disparity in rates rose, but for New Jersey, the disparity was reduced from 2020 to 2021. The SCNJ works to identify and address contributory factors.  It collaborates with all programs working to address infant mortality and the adverse social and health determinants that contribute to it. TVP plays a key role in monitoring the activities and ensuring they respond to New Jerseyans’ needs.

Promoting infant safe sleep was selected as NPM #5 during the Five-Year Needs Assessment process for its importance in reducing often preventable infant deaths and its potential impact on improving NPMs 1, 2, 3, 4, 5, and 6. Sleep-related infant deaths are one of the leading causes of infant death.  They have declined since the onset of risk reduction strategies.  However, even on its own, the component of SUID identified as SIDS remains the third leading cause of infant mortality behind a) short gestation and low birthweight and b) birth defects.

Due to evidence of the heightened risk of SUID when infants are placed to sleep on side or stomach sleep positions, health experts and the American Academy of Pediatrics (AAP) have long recommended the back sleep position. The back sleep position has been called one of the seven leading research findings in pediatrics in the last 40 years (Goodstein & Ostfeld, Pediatrics, 2017). Although, by definition, SIDS and ill-defined and unknown causes refer to deaths whose etiology has not been identified, the conditions that elevate risk are known. In 2011, 2016, and in 2022, the AAP updated its recommendations to help reduce the risk of SIDS and other sleep-related deaths by incorporating new research findings. The AAP recommendations for a safe sleep environment include placing infants to sleep on their backs and having the infant share a parent's room but in his/her own sleep space (e.g., crib, bassinet, portable crib, or play yard) that meets current Consumer Product Safety Commission standards. The AAP also recommends that the sleep space contain a firm flat mattress of the type intended for the sleep product and that the sleeping space be free of soft and loose bedding such as bumpers, pillows, and blankets.

Additional recommendations include breastfeeding or the provision of human milk, avoiding overheating, and avoiding tobacco exposure. These expanded, evidence-based recommendations for the first twelve months of life underlie the National Institute of Child Health and Development (NICHD) Safe to Sleep Campaign and that of the SIDS Center of New Jersey. Adverse social and health determinants, including poverty and preterm birth, also increase vulnerability to SUID and are thus incorporated into strategies to reduce risk. Disparities in these adverse social and health determinants contribute to disparities in SUID rates.  Research by faculty of the SCNJ contributed to the AAP guidelines both with respect to safe sleep practices as well as adverse social and health determinants.

The selection of ESM 5.1 (Promote Infant Safe Sleep Environments) monitors and focuses on the safe sleep environment (Healthy Sleep), including back to sleep, no co-sleeping, and no soft bedding. There has been an upward trend in the use of back-to-sleep placement.

Notes - Source – NJ PRAMS. https://www-doh.state.nj.us/doh-shad/indicator/view/SafeSleep.Trend.html

In 2004, 60.6% of infants were placed to sleep on their backs. By 2017 the percentage of infants placed on their backs increased to 75%, surpassing the Healthy New Jersey 2020 NJ target of 74.1%. For 2018-20, the target fell within the 95% confidence interval of each year's achieved percentage. In 2022, the percentage rose to 76.2%. In 2004, 43.7% of Black NH and 69.8% of White NH infants were placed supine. For 2017-2020, the percentage of Black NH, and White NH infants placed on their backs surpassed the individual target goals of 53.7% for Black NH and 83.7% for White NH established by Healthy New Jersey 2020. In 2021, 57.4% of Black NH and 87.2% of White NH were placed supine to sleep. In 2022, compliance rose: 58.1% of Black NH and 84.8% of White NH were placed supine.

The SCNJ’s extensive train the trainer presentations and educational tools for the public, health care, social service, public health, and childcare providers, home visitors, community and faith-based organizations and others cover all aspects of risk reduction, including how to identify and resolve barriers to compliance and how to discuss information respectfully. Although there was improvement in each racial group and despite New Jersey having among the lowest SUID rates in the U.S., including for each racial group, there are enduring racial disparities in the reported use of back-to-sleep. Safe sleep education is essential, however, factors apart from informing a parent also play a role in choosing supine sleep, as a long history of research has demonstrated. In 2019, 92% of Black NH and 96% of White NH adults completing the PRAMS survey reported that a provider recommended the back to sleep position (Huber R et al., Midwifery, 2024). The most recurring provider contact for the first year of life is the pediatrician. In its provider education, the SCNJ advises that safe sleep be part of the discussion at every visit or at every opportunity.

The SCNJ also works with communities directly including through live webinars that are scheduled through community organizations such as childcare centers and faith-based communities. Potential challenges to safe sleep messaging are addressed in these forums, as well. For a provider to increase not only knowledge but also compliance, recipients respond best to providers with whom they perceive a relationship of trust. Absent that, education may not change behavior.  The intimacy of a home visit, whether by doulas, community workers or nurses, helps facilitate such relationships. Therefore, the SCNJ also provides safe sleep education to such groups as Healthy Women, Healthy Families and the Universal Nurse Home Visiting Program (Family Connects), doulas and midwives.

Adverse social and health determinants may also play a role in compliance disparity.  These determinants include poverty, smoke exposure, preterm birth, the absence of breastfeeding or human milk, preconception health challenges, including in dental care, inadequate or absent prenatal care, diminished access to pre-conceptional healthcare, implicit bias, and systemic racism. For example, preterm birth increases the risk of SUID, rising to a four-fold greater risk for those born between 24 and 27 weeks of gestation (Ostfeld et al., Pediatrics, 2017). Median household income is inversely correlated with SUID rates (Ostfeld & Hegyi, SPR-PAS, 2019). In 2020, 36% of Black NH vs 11% of White NH children in NJ received public assistance (Annie E. Casey Foundation, Kids Count). in 2021, New Jersey’s Gini index of income inequality was at its highest (NJSHAD). Poverty poses challenges to safe infant sleep in multiple ways including a greater use of non-parental care (Holochwost SJ, Dev. Rev., 2020).

Intergenerational education is important to NJ’s SIDS-reduction strategy. To broaden access to safe sleep beyond traditional caregivers, the SCNJ created a high school student ambassador for safe sleep curriculum for high school students in higher-risk communities, and it was effective in increasing their knowledge of back to sleep and their ability to educate adults in their communities. With schools now out of COVID-related restrictions, the SCNJ will seek to extend this initiative. Finally, despite the proven risk of prone sleep, interpretation of risk can be idiosyncratic. A well-intentioned grandparent may not support their adult children in the use of supine sleep. "I put all of my babies to sleep on their tummies, and they were just fine," is an often-repeated comment that underscores the challenge in public health education. When one does not comply with evidence-based recommendations, be they dietary or exercise advice, seatbelt wearing, or back to sleep, the refusal does not automatically elicit the worst-case outcome. Working through these challenges has resulted in increased compliance over time and a low SUID rate in NJ for all groups relative to their national and state counterparts.

 To promote infant safe sleep (NPM #5), NJDOH has supported the evidence-based strategies of the American Academy of Pediatrics, the NICHD’s Safe to Sleep Campaign, the activities of the SIDS Center of New Jersey (SCNJ), www.facebook.com/sidscenternj/, and www.rwjms.rutgers.edu/sids, and the work of the Sudden Unexpected Infant Death Case Review Workgroup which includes representation from the SCNJ. To improve the surveillance of infant safe sleep practices, TVP conducts the PRAMS survey, which includes questions on infant safe sleep, and participates in the SUID-CR Workgroup.

The SCNJ is a program funded by the TVP program to Robert Wood Johnson Medical School (RWJMS), a part of Rutgers, The State University of New Jersey, New Brunswick, and is based both at RWJMS and the Joseph M. Sanzari Children’s Hospital at Hackensack University Medical Center, Hackensack. SCNJ was established in 1988 through the SIDS Assistance Act. The SCNJ’s missions are to: 1) provide public health education to reduce the risk of sudden infant death, 2) offer emotional support to bereaved families, and 3) participate in efforts to learn about possible causes of and risk factors associated with sudden unexpected infant deaths, best practices for providing safe sleep education and other risk-reducing messages and identifying systemic challenges and barriers. Research by the SCNJ faculty has contributed to the identification of risk factors and risk-reducing strategies. The SCNJ provides consultation to other States in the service of risk reduction.

The SCNJ develops novel safe sleep interventions and tools to educate providers and the public including parents, grandparents, physicians, nurses, the childcare community, hospitals, clinics, first responders, schools, social service agencies, home visiting programs, doulas, and faith-based communities. It provides safe sleep education for the Division of Child Protection and Permanency, Managed Care, Federally Qualified Health Centers, the Universal Nurse Home Visiting Program, Healthy Women Healthy Families, childcare programs, first responders, programs managed by the Maternal and Child Health Consortia, and other groups.

The SCNJ also works with programs to review their safe sleep curricula and websites and to create bespoke tools such as safe sleep checklists. Most recently these activities have involved the Family Connects program.  In addition to live lectures, including medical grand rounds, and lectures in Spanish as well as English, examples of the SCNJ tools and resources the SCNJ created to promote provider and parent knowledge include SIDS Info, its free mobile phone app in English and Spanish with voiceover to eliminate any concerns about literacy, education postcards in multiple languages, recorded seminars for nurses with continuing education credits, and other virtual resources such as public service announcements, and live and on-demand webinars in English and Spanish. In the current grant cycle, the SCNJ is distributing 100,000 English and 20,000 Spanish postcards with double-sided safe sleep messaging to hospitals, clinics, Family Connects, and other programs. The SCNJ has created a baby onesie with “back to sleep” messaging and provides supplies to home visiting programs, hospitals, health clinics, community organizations, and other public health programs. From July 2023 to January 2024, 18,104 onesies in English and Spanish were distributed among these systems. Nurses report that the onesies make the safe sleep discussion easier to conduct.  Parents focus on the item and ask more questions.  It also serves to facilitate recollection of the discussion.  for iOS and Android devices to enhance the education of parents and providers about safe infant sleep and enable parents and others to have direct access to this information. This novel and interactive tool https://www.facebook.com/SIDSCenterNJ/

Annual Report – SPM #1 (The percentage of Black non-Hispanic preterm births in NJ)

The selection of SPM #1 (The percentage of Black non-Hispanic preterm births in NJ) during the Five-Year Needs Assessment process recognizes the persisting racial/ethnic disparities in healthy birth outcomes in NJ Infants born prematurely. Premature infants are at the highest risk for infant mortality and morbidity. The percentage of Black preterm births was selected to potentially address the underlying causes of Black infant mortality and the racial disparity between preterm birth rates.

The selection of ESM 5.2 (Promote referrals to evidence-based interventions aiming at reducing Black infant mortality) was selected for both SPM # 1 and 7.

Table SPM1 Percentage of Black, NH preterm births in NJ from 2012-2021.

Notes - Source - Birth Certificate data from the SHAD system https://www-doh.state.nj.us/doh-shad/

Improving maternal and infant health and reducing Black, NH infant mortality is a priority within the NJDOH/FHS. Key maternal and child health indicators (including low birth weight, preterm births, and infant and maternal mortality) have not improved significantly over the last decade in New Jersey, and significant racial and ethnic disparities persist.

In 2023, preterm birth affected about 1 of every 11 infants born in the US. New Jersey's overall very preterm birth rate (< 32 weeks) decreased from its peak of 1.8% in 2006 to 1.3% in 2021 and, among singletons, the rate declined from 1.4% in 2000 to 1.1% in 2021.NJ's preterm birth rate (< 37 weeks) was 9.3%. However, racial, and ethnic disparities persist. During 2020-2022 (average) in New Jersey, preterm birth rates were highest for black infants (12.8%), followed by American Indian/Alaska Natives (10.1%), Asian/Pacific Islanders (8.6%) and Whites (8.5%). Black infants (12.8%) were about 2 times as likely as White infants (8.5%) to be born preterm during 2020-2022 (average). In the United States, prematurity/low birthweight is the second leading cause of all infant deaths (during the first year of life) and the leading cause of infant death among black infants. To address these disparities and reduce the preterm birth rates, the TV Reproductive and Perinatal Health Services Team implement the Preterm Birth Prevention Program (PBPP). In collaboration with TVP staff, during SFY24, the PBPP accomplished the following:

• Designed and launched a doula-focused survey to identify potential information barriers and opportunities for partnership.
• Created new markers in the Perinatal Risk Assessment (PRA) to identify patients at risk for preterm delivery and began working on a self-service tool based on data pre-populated sections of the PRA.
• Distributed 539 To-Go Kits with health monitoring tools (e.g., blood pressure cuffs, odometers), self-care resources, and health information referral pamphlets to patients with specific chronic conditions who have been identified as being at risk for preterm delivery.
• Distributed over 3,330 flyers about clinical services to prevent preterm birth to providers, administrative staff, and birthing people across the State.
• Engaged with more than 12,000 unique accounts via social media platforms LinkedIn and Instagram.
• Hosted 21 community events that engaged 851 community members and attended 58 professional meetings and events providing information that focused on health risks for preterm delivery and resource allocation in NJ Communities.
• Designed and planned new educational workshops and whole-health events for birthing people with complex care needs (e.g., cardiovascular diseases, diabetes, hypertension, and chronic behavioral health needs) at risk for preterm delivery.

The objectives for SFY24 are in accordance with Healthy People 2030 objective, and are as follows:

• Between 10/2023 and 09/2024, PBPP staff will create or leverage three to five provider-focused resources (such as toolkits, surveys, and provider-focused presentations) to support their efforts in providing timely information about preterm birth prevention and available treatment options (e.g., vaginal progesterone cream, cerclage, and education).
• Between 10/2023 and 09/2024, PBPP will host at least four consumer-facing events and at least four Clinical Leadership meetings to develop additional resources and services for future preterm birth prevention service implementation.
• Between 10/2023 and 09/2024, PBPP staff, using the Perinatal Risk Assessment (PRA) data, will identify at least 300 individuals who are eligible for preterm birth prevention services in Cumberland, Mercer, Atlantic, Gloucester, Hudson, and Essex counties, which are 6 of the 12 counties with the highest rates of preterm birth in the state.
• Between 10/2023 and 09/2024, PBPP will create at least two statewide clinical service best practice standards and pilot these resources in collaboration with home visiting programs, FQHCs, doulas, and providers in the focus areas.

Annual Report – SPM #7 (The rate of Black Infant Mortality in NJ per 1,000 Live Births)

     Notes - Source - Birth Certificate data from the SHAD system https://www-doh.state.nj.us/doh-shad/

In 2021, the Black, NH infant mortality rate in NJ was 7.8 compared to 2.2 per 1,000 Live Births for White, NH infants. The Hispanic infant mortality rate was 3.7 per 1,000 Live Births. Disparities exist between NJ counties and municipalities in terms of Black Infant Mortality rates and other health outcomes. Counties such as Atlantic, Camden, and Cumberland have high Black Infant Mortality rates (Figure 17).  To tackle these disparities, TVP continues to implement HWHF in the communities.

Figure 17. Infant Mortality by NJ Counties, 2011-2021

Data Source: New Jersey State Health Assessment Data

There are many potential causes of these disparities, but recent research has highlighted the effects of social determinants of health such as economic disadvantages (i.e., underemployment, or unemployment), limited education (e.g., low educational attainment), environmental barriers (e.g., housing instability, structural racism), and social/behavioral factors (e.g., nutrition and exercise) as major contributors to health outcomes. Addressing these social determinants of health requires a comprehensive, system-level transformation that begins at the community level.

To better align the ESM with our current initiatives, ESM 5.4 (Number of individuals trained to become community- based doula) was selected. Through the New Jersey Doula Learning Collaborative, the professional home for community doulas in NJ, TVP seeks to reduce maternal and infant mortality and eliminate racial disparities in health outcomes. The NJ Doula Learning Collaborative provides training, workforce development, supervision support, mentoring, technical assistance, direct billing, and sustainability planning to community doulas and doula organizations throughout the State of NJ. The NJ Doula Learning Collaborative focuses on developing and supporting the doula workforce that delivers doula care to NJ’s Medicaid and CHIP members as enrolled NJ FamilyCare providers. They recruited, trained, and certified 32 Perinatal Community Health Workers (aka community doulas) since its inception in 2022 to further support birthing individuals and potentially decrease the infant mortality rate. These community doulas help birthing individuals navigate the healthcare system, access needed services, and improving adverse birth outcomes. The trained doulas provide equitable and culturally responsive care to pregnant people during pregnancy, birth, and postpartum, potentially lowering maternal and infant health complications rates. Multiple studies have shown that doula care can improve maternal and infant health outcomes; reduce preterm births and low birthweight infants; lower rates of cesarean sections; and increase rates of breastfeeding by amplifying pregnant people’s voices and listening to their needs.