Perinatal/Infant Health Overview
Perinatal and infant health is a central focus of the Division of Maternal and Infant Health (DMIH), which supports programs designed to ensure infants are born healthy and ready to thrive. The Women and Maternal Health Section and Perinatal and Infant Health Section within DMIH oversee many programs including the Michigan Perinatal Quality Collaborative, Maternal Infant Health Program (MIHP), Infant Safe Sleep, Breastfeeding, Fetal Infant Mortality Review (FIMR), Safe Delivery of Newborns, and the Early Hearing Detection and Intervention program. Title V funding supports a variety of programs and initiatives related to perinatal and infant health, including infant safe sleep, breastfeeding, PRAMS, and infant mortality reduction. Title V funding is also used as a gap-filling funding source for Regional Perinatal Quality Collaboratives (RPQCs). DMIH provides funding, staff support, and infrastructure for the RPQC network that uses quality improvement methods to implement strategies to improve maternal and infant health. Other federal funding is used to identify and meet the needs of this population, such as WIC (USDA), Universal Newborn Hearing Screening and Intervention (HRSA), and PRAMS (CDC). Perinatal and infant health is promoted through a network of partnerships, including those with health care providers, labor and delivery hospitals, universities, the Mother Infant Health and Equity Collaborative, and the Michigan Association for Infant Mental Health.
Title V funding also supports the Local Maternal Child Health (LMCH) program which provides funding to all 45 Local Health Departments (LHDs). In FY 2023, Title V funds via the LMCH program were expended on NPM 4 (breastfeeding), NPM 5 (infant safe sleep), and Local Performance Measures (LPMs) in the perinatal/infant health domain. Nineteen LHDs implemented breastfeeding (NPM 4) activities including breastfeeding support in a variety of settings for pregnant people and women to provide infants with human milk. Other activities included staff development and lactation training; participation in virtual community breastfeeding coalition meetings; promoting breastfeeding friendly businesses; social media posts; and community outreach events. Twelve LHDs addressed infant safe sleep (NPM 5) through education in a variety of ways such as prenatal/postnatal classes, home visits, social media posts, and community events. Infant safe sleep, breastfeeding, and tobacco dependance treatment education was provided to childcare, faith-based entities, emergency management, and nursing students. Sleep sacks, pack-n-plays, and books were distributed to families with an assessed need.
Four agencies selected an LPM based on local priorities. Activities included FIMR team processes, gap-filling administration of infant immunizations, and Healthy Families America program support for infants. For half of the fiscal year, COVID-19 safety precautions continued to cause disruptions in agencies’ ability to conduct in-person visits and in-person services at provider offices. A significant number of agencies reported unprecedented staff turnover which impacted institutional knowledge and the ability to provide services.
Michigan’s approach to perinatal and infant health through Title V emphasizes implementation of strategies that prevent maternal and infant morbidity and mortality, which are critical indicators of the degree to which a community takes care of its women and children. Focus areas for Title V are infant safe sleep and breastfeeding.
Breastfeeding (FY2023 Annual Report)
The American Academy of Pediatrics (AAP) recommends all infants are exclusively breastfed for six months to support optimal growth and development. Additionally, in 2022 the AAP published updated guidance supporting continued breastfeeding for two years or beyond, as long as mutually desired by mother and child. Breastfeeding has health benefits for infants and mothers, including mental health benefits for both mothers and babies. For infants, breastfeeding can reduce risk of asthma, obesity, sudden infant death syndrome (SIDS), diabetes, ear infections, childhood leukemia, and some respiratory diseases. For mothers, breastfeeding can reduce feelings of anxiety and postnatal depression, reduce post-partum hemorrhage, lower the risk of type 2 diabetes, and may decrease the likelihood of developing breast, uterine, and ovarian cancers. Human milk remains the optimal source of nutrition for the first months of life.
The Title V needs assessment revealed that breastfeeding is still a critical maternal and child health (MCH) issue for Michigan’s mothers and infants. Needs assessment themes showed that families want more breastfeeding support and education and that families are having difficulty accessing breastfeeding support professionals and providers that support breastfeeding. During the Title V needs assessment, stakeholders identified the priority need to “Create and enhance support systems that empower families, protect and strengthen family relationships, promote care for self and children, and connect families to their communities” as an important way to achieve breastfeeding initiation and duration. The COVID-19 pandemic highlighted the need for emergency preparedness plans to support access to human milk especially in Black, Indigenous, and People of Color (BIPOC) communities that were disproportionately impacted by COVID-19. MDHHS will continue to expand collaboration with BIPOC-led organizations and communities that lead in addressing this health equity work, especially in relation to dismantling barriers to breastfeeding.
According to the National Immunization Survey (NIS), in 2020 Michigan’s initiation rate was 82.8% (CI 76.4-87.7). This meets the annual objective set of 82.7%. Michigan’s breastfeeding exclusivity rate through six months was 23.9%, and Michigan’s goal is to reach 41.1% by 2025.
Data from the Michigan Pregnancy Risk Assessment Monitoring System (MI PRAMS) can supplement what is learned from the NIS and help inform Michigan’s strategies to reach breastfeeding-related goals for Title V. Since MI PRAMS does not collect data through 6 months postpartum or ask about feeding exclusivity, the survey does not measure breastfeeding in a way that allows for direct comparison against Healthy People 2030 goals. Still, MI PRAMS provides timely information at the state level for initiation and duration through about three months postpartum, in addition to information about barriers to initiation and duration. Michigan cannot achieve its goals of increasing the percent of infants who are breastfed exclusively until 6 months without first having supported mothers through initiation and the 3-month duration that is measured by MI PRAMS. Title V funding is used to support PRAMS in Michigan.
PRAMS data through the 2021 birth year continue to tell a story of relatively static rates of initiation (88.4%), as well as 1-month (76.3%), 2-month (67.0%), and 3-month (56.9%) breastfeeding duration. PRAMS has shown that Michigan’s initiation rate had increased steadily from 2009 to 2014, rising from 73.2% to 84.3%. However, from 2014 through 2021, there has been a leveling out in breastfeeding initiation, with no significant increase nor decrease across these years. It is possible that 2021 initiation numbers (88.4%) reflect the start of an increase in initiation at the state level, but this cannot be determined reliably from a single year of data.
Across a time period where breastfeeding statistics have remained relatively static in Michigan (2016-2021), about nine in ten non-Hispanic white mothers initiated breastfeeding (88.5%; 95% CI: 87.3% - 89.6%). Initiation was comparable for Hispanic mothers (87.8%; 95% CI: 83.6% - 91.1%) and those in the non-Hispanic "Other" category (87.3%; 95% CI: 80.4% - 92.0%), yet relatively lower for non-Hispanic Black mothers (75.1%; 95% CI: 73.7% - 76.6%). Mothers from the non-Hispanic Asian and Pacific Islander subgroup had the highest proportion who initiated breastfeeding (95.6%; 95% CI: 90.8% - 97.9%). By incorporating birth certificate information on maternal ancestry categories and also looking at paternal race / ethnicity / ancestry, we are able to describe two other groups. Initiation among mothers of Infants with Native American / American Indian / Alaskan Native ancestry was quite high, at 93.7% (95% CI: 88.5% - 96.6%). The final group is one that can likely only be found at sufficient numbers in Michigan, which is mothers of infants with Middle Eastern / North African ancestry. Among these mothers, initiation was also very high at 92.7% (95% CI: 88.5% - 95.4%).
The Title V state action plan continues to focus on reducing disparities in breastfeeding rates among women of color. In alignment with the plan, MDHHS has continued to prioritize using culturally responsive, evidence-based images and messages within public health campaigns to support the normalization of breastfeeding. The plan also focuses on increasing breastfeeding knowledge among maternal and infant health professionals who work with pregnant or postpartum people by offering breastfeeding educational opportunities statewide through a webinar series and online breastfeeding training course. The evidence continues to support that babies born in Baby-Friendly designated hospitals are more likely to be breastfed; therefore, increasing the percent of Baby-Friendly hospitals in Michigan remains the Evidence-based Strategy Measure (ESM) for this NPM.
MDHHS receives and shares parent and community input on breastfeeding-related issues through several means, including through a series of townhall meetings held in 2023 across Michigan, as well as collaboration with the Michigan Breastfeeding Network. MDHHS recruits and encourages local breastfeeding clinicians and advocates to speak at maternal child health conferences. In addition, MDHHS team members attend state and local breastfeeding conferences in order to support breastfeeding networks.
Objective A: Increase the percent of infants who are breastfed exclusively until 6 months to 41.1% by 2025.
Since its public release in February 2021, the Michigan Breastfeeding Plan has continued to set a common agenda necessary for a collaborative approach to support breastfeeding in Michigan. One of the key initiatives outlined in the Michigan Breastfeeding Plan was the creation of a breastfeeding training course for maternal child health professionals in Michigan. The free online course, “Breastfeeding for Professionals Working with Families” was released in June 2023, and 88 participants have completed the course through the end of FY 2023. Content in the training course covers breastfeeding disparities in Michigan, the root causes of breastfeeding inequities and how to address them, information to support consistent messaging about breastfeeding, and community-based, culturally responsive breastfeeding resources to support families and professionals. In accordance with the vision of the Michigan Breastfeeding Plan, MDHHS has promoted the training course widely and will continue to work toward improving the knowledge of breastfeeding support among staff working in maternal and infant health programs.
A key activity to train maternal and infant health staff is the Great Lakes Breastfeeding Webinar Series, a project of the Michigan Breastfeeding Network. These webinars have continued to be offered every month at no cost to participants and are available on demand for up to one year after their initial release dates. Participation in the webinars varies, but most webinars have over 1,700 attendees nationally. During FY 2023, nearly 500 participants from Michigan viewed the webinars, with a combined total of over 4,700 unique webinar participants during FY 2023. Statistics show that among webinar participants from Michigan, about 18% work for WIC and nearly 20% work for a state or local health department.
MDHHS continues to work with Michigan Birthing hospitals to encourage, support, and acknowledge hospitals achieving Baby-Friendly status. This is Michigan’s ESM for this NPM. MDHHS staff promote the implementation of breastfeeding-friendly maternity care practices through trainings and in FY 2023, MDHHS hosted an informational webinar about the Baby-Friendly accreditation. MDHHS continues to remain engaged with partners that support Baby-Friendly efforts across the state. The Great Lakes Breastfeeding Webinar series is promoted with hospital staff, and it is estimated that over 15% of participants identify maternity care nurse as their primary job function. Unfortunately, one birthing unit in Michigan closed in February 2023, and a second birthing unit closed in June 2023, bringing the total number of birthing hospitals from 79 to 77. One birthing hospital in Michigan achieved initial Baby-Friendly designation in FY 2023, however one of the birthing units that closed was also a Baby-Friendly facility. Therefore, at the close of FY 2023 the total number of Baby-Friendly Hospitals in Michigan has remained at 13, with the percent of Baby-Friendly designated birthing hospitals also staying about the same at 16.9%. A variety of challenges related to the COVID-19 pandemic have continued to place incredible strain on Michigan’s hospitals in recent years, which has impacted their ability to meet and/or maintain the Baby Friendly USA standards.
To reduce ongoing breastfeeding disparity gaps, MDHHS continues to partner and support the Great Lakes Breastfeeding webinar series, a project of the Michigan Breastfeeding Network, which offers breastfeeding-specific information every month at no cost to participants. Michigan Breastfeeding Network continues to offer expanded options for continuing education through the webinars for a variety of professionals, including nurses, social workers, lactation consultants, community health workers, certified health education specialists, physicians, and dietitians. In FY 2023, the Michigan Breastfeeding Network began hosting the webinars through a new online learning platform, which now provides instant access to continuing education certificates after completion of the post-webinar evaluation. This free, easy-to-access education allows all providers the ability to receive advanced training, which diversifies and strengthens Michigan’s lactation workforce. Topics have a strong focus on health equity and supporting community-driven work in BIPOC communities. The webinars have been viewed by participants in 23 countries; in the U.S., there have been participants from all 50 states and the District of Columbia. Webinar participants report a variety of job functions including peer counselors, maternity care nurses, home visitors, other breastfeeding services, nutrition, childbirth support, and nurse practitioners.
In August 2023, the State of Michigan issued a proclamation recognizing August 2023 as Breastfeeding Month in Michigan. This proclamation recognized that breastfeeding is a racial equity and public health imperative.
MDHHS continues to identify new and innovative methods, including via social media, to promote breastfeeding within the communities most affected by breastfeeding-related disparities. After a successful social media campaign in FY 2022, MDHHS began developing plans for campaigns focused on promoting breastfeeding and infant safe sleep among young parents in Michigan in FY 2023 and FY 2024, supported by Title V funding.
For the FY 2023 media campaign, materials were developed by first having the Michigan Organization on Adolescent Sexual Health (MOASH) complete education sessions and focus groups on safe sleep and breastfeeding with a diverse group of youth ages 13-21. Themes that emerged in the focus groups were used to develop media (social media posts and audio streaming app ads) that ran in the last quarter of FY 2023. The campaign targeted zip codes with the greatest poverty in select areas of the state and people of color under the age of 21. Through audio streaming, over 740,000 impressions were delivered; through Facebook/Instagram, almost 1.5 million impressions were delivered; mobile display ads resulted in over 5 million impressions, and paid search resulted in over 27,000 impressions.
As a continuation and expansion of this work, the FY 2024 media campaign will focus on reaching young (13-21 years) Black, Indigenous, and People of Color in zip codes with the highest poverty levels and relatively higher rates of sleep-related deaths and lower rates of breastfeeding initiation. The FY 2024 campaign will be discussed in next year’s annual report.
The MDHHS Communications team has continued to prioritize creating and posting breastfeeding promotional messages on the department’s social media accounts. MDHHS has over 150,000 Facebook followers, over 34,000 Twitter followers, and over 14,000 followers on Instagram. As part of breastfeeding awareness commemorations during August, MDHHS created and shared nine posts promoting breastfeeding across all MDHHS social media pages. Social media posts were created to recognize specific groups and celebrations throughout the month of August, including Indigenous Milk Medicine providers, Asian American, Native Hawaiian and Pacific Islander Breastfeeding Week, and Black Breastfeeding Week.
MDHHS continues to work with the Genesee County Health Department to increase breastfeeding rates within Genesee County and the City of Flint. Of Genesee County WIC clients enrolled prenatally, 72% initiated breastfeeding in FY 2023, which was a 2% increase from the previous fiscal year. Genesee County has continued to expand efforts to promote breastfeeding, including through the Supporting Mothers In Lactation Efforts (SMILE) Club, which is a program that encourages moms to breastfeed by offering support and breastfeeding-related rewards for breastfeeding efforts. Throughout FY 2023, about 160 breastfeeding mothers remained engaged in the SMILE Club. In addition, during FY 2023 a series of videos promoting breastfeeding in Genesee County were created, which featured both WIC clients and clinic staff members. While local health department activities have been impacted by the COVID-19 pandemic in recent years, breastfeeding promotion progress has resumed.
Safe Sleep (FY 2023 Annual Report)
Michigan’s safe sleep strategies and activities promote three key messages to parents and caregivers: infants should sleep 1) alone, 2) on the back, and 3) in a crib, bassinet or pack and play. These behaviors are critical to the prevention of sleep-related infant death. Of the leading causes of infant death, sleep-related causes are considered the most preventable. In FY 2023, Title V federal funding was used for activities that support Michigan’s safe sleep work, including PRAMS, infant mortality communication, Fetal Infant Mortality Reviews, breastfeeding support, and funding to local health departments to support community-based safe sleep prevention efforts.
There was a slight increase in the proportion of Michigan mothers placing their infants to sleep exclusively on their backs in 2021 (86.5%) versus 2020 (85.4%). Looking back to 2016 (81.9%), there has been a clear and sustained improvement in back sleeping in Michigan since that time. About 2/3 of Michigan mothers in 2021 report that their infants were usually placed to sleep in a space without soft or loose bedding or objects (64.1%). This is relatively close to what was seen in 2019 (63.1%) and 2020 (66.7%). While this measure did not increase in 2021, it shows that the general improvement Michigan has seen since 2016 (51.8%) has been sustained. Across the last three years, the measure of a separate approved sleep surface has been somewhat resistant to change, remaining just above 40% (40.6% in 2019, 41.5% in 2020, 41.3% in 2021). This remains an improvement from what was seen starting in 2016 (34.0%), when this measure began being based on the combination of five different sleep risk factors, including whether infants sleep in a car seat or swing. Michigan has seen a notable and sustained improvement in the proportion of mothers who are not sleeping their infants in car seats or swings (from 47.4% in 2016 to 56.9% in 2021), but smaller year-by-year changes in other components seem to be offsetting changes in the composite measure.
While four distinct objectives for infant safe sleep were identified, the strategies to address them are combined, since the safe sleep behaviors are so closely related. All strategies and activities will promote the key messages to parents, caregivers, and providers that infants should sleep alone and without objects on the back, in a crib, bassinet or pack and play and will continue to address ways to increase those behaviors by all families, while also addressing the disparity for non-Hispanic Black families.
Objective A: Increase the percent of infants put to sleep on their backs from 84.9% in 2019 to 92.3% by 2025.
Objective B: Increase the percent of infants put to sleep on a separate approved sleep surface from 40.6% in 2019 to 53.5% by 2025.
Objective C: Increase the percent of infants placed to sleep without soft objects or loose bedding to from 63.1% in 2019 to 80.9% by 2025.
Objective D: Increase the percent of non-Hispanic Black infants put to sleep on their backs, put to sleep on a separate approved sleep surface, and put to sleep without soft objects or loose bedding.
In FY 2023, activities occurred within five strategies:
- Support safe sleep activities of local health departments and the Inter-Tribal Council of Michigan.
- Support providers to implement safe sleep policies/protocols/programming so that families receive infant safe sleep education and access to resources.
- Develop and share tools with providers, families, and workers regarding having client/patient centered conversations regarding safe sleep.
- Promote protective factors (i.e., smoking cessation, breastfeeding, immunizations) and evidence-based programs (i.e., home visiting, community-based doula support) to enhance the overall health and well-being of moms and babies.
- Engage hospitals in areas with a high rate of sleep-related infant deaths and disparities to explore needed policies and resources to support families of NICU infants in practicing safe sleep behaviors after discharge.
Changes that were made due to the COVID-19 pandemic have continued. Grantees have moved to a hybrid approach to be flexible on whether events are in-person or virtual. Several LHDs planned to implement the Society for Public Health Education (SOPHE) SCRIPT® (Smoking Cessation and Reduction in Pregnancy Treatment) Program but still were unable to due to only seeing families virtually. Despite challenges, grantees were able to provide infant safe sleep education to over 15,000 individuals (parents, caregivers, professionals, and community members) through virtual and in-person classes and community events.
Social Determinants of Health (SDOH) are drivers in the disparity of sleep-related infant deaths. In addition to community members, the local/regional advisory teams are required to include partners that can address SDOH. This includes partners that can meet resource needs of families, as well as partners that work further upstream to address systemic policies and practices that drive disparities.
A second strategy was to support providers in implementing and updating existing safe sleep policies or protocols so that families receive infant safe sleep education and access to resources. An evidence-based or -informed strategy measure (ESM) was established to increase the number of agencies that received technical assistance on updating or implementing a policy. Two agencies and four health departments requested the recommendations for how agencies serving families can support infant safe sleep (that were developed in FY 2021). MDHHS Housing and Homeless Services program shared the recommendations with all their housing providers. In addition, all Maternal, Infant, and Early Childhood Home Visiting (MIECV) Programs were required to implement a safe sleep policy by the end of FY 2023.
A continued strategy was to develop and share tools with providers and family support workers on how to have client/patient centered conversations regarding safe sleep. This strategy included continuing to promote the Helping Families Practice Infant Safe Sleep (Safe Sleep 201) training and incorporating the core tenets of this training into other educational venues: how to have more effective conversations with families by starting where the family is at, educating on safe sleep guidelines and helping the family evaluate their current risk and explore strategies for risk reduction. A related ESM is to require all new MIHP staff to complete the online Helping Families Practice Infant Safe Sleep training. In FY 2023, all 69 MIHP agencies have staff trained to use the concepts of motivational interviewing with safe sleep by requiring the Safe Sleep 201 training for all staff.
To reach professionals who work with pregnant and parenting families, the MDHHS ISS Program continued to build upon connections with existing partners, such as the Women, Infants and Children (WIC) Program, home visiting programs (MIECV and MIHP), child welfare, the Regional Perinatal Quality Collaboratives, MDHHS Tobacco, and MDHHS Bureau of Emergency Preparedness, EMS and Systems of Care. These continued collaborations led to training on the safe sleep basics, how to support families, and access to resources for a variety of professionals. In FY 2023, over 500 individuals attended a virtual or in-person safe sleep training and over half of those individuals received training on how to support families. In addition, over 13,500 individuals completed one of the three online infant safe sleep trainings; almost 300 hospital nurses and other staff took the online training Infant Safe Sleep: The Basics and Beyond; and over 200 participants attended one of four safe sleep webinars. Providers were also supported with access to free educational materials; over 240,000 educational items were distributed by MDHHS in FY 2023. By the end of FY 2023, over 8,900 professionals were subscribed to the infant safe sleep email listserv, a 55% increase over FY 2022.
In FY 2022, the MDHHS ISS Program established a partnership with MDHHS Bureau of Emergency Preparedness, EMS, and Systems of Care to implement an Infant Safe Sleep Certification Program for EMS Agencies and Fire Departments. As of the end of FY 2023, 13 EMS agencies and fire departments were certified, resulting in over 650 providers trained on safe sleep.
As an additional tool to integrate safe sleep education into prenatal visits, the High Touch, High Tech (HT2) e-screening tool, which delivers a brief motivational intervention and helps connect families to additional supports, was expanded to include screening for safe sleep knowledge and behaviors. The safe sleep education modules were rolled out in May 2022. To date, over 1,400 patients participated in the prenatal safe sleep intervention.
Another strategy is to promote protective factors (i.e., smoking cessation, breastfeeding, immunizations) and evidence-based programs (i.e., home visiting) to enhance the overall health and well-being of moms and babies. As noted above, outreach to and coordination with other MDHHS programs continued.
MDHHS ISS Program continued to explore other ways to engage families directly in the work, including support of the MIH Infant Safe Sleep Action team which included two parent members. In FY 2023, the parent members were active at meetings and helped plan Infant Safe Sleep Awareness month activities for October 2023. In addition, the ISS Program worked with three families, who wanted to share their stories of losing an infant due to unsafe sleep. This work resulted in the families creating a digital story and a supplemental guide on using those stories: Family Stories of Sleep-Related Loss - A Facilitation Guide for Using their Digital Stories. In addition, through MOASH, youth ages 13-21 years provided feedback on the infant safe sleep brochure and website. They were asked if the materials encouraged them to follow safe sleep, about the level of information provided regarding the risk of unsafe sleep practices, if the materials were inclusive, and for any recommendations for changes to the materials.
The final strategy is to engage hospitals in areas with a high rate of sleep-related infant death and disparities to explore needed policies and resources to support families of NICU infants in practicing safe sleep behaviors after discharge. In FY 2021, with the help of nurses from two hospitals, the MDHHS Infant Safe Sleep Program developed sample infant safe sleep protocols and crib audit forms for hospitals to use as a guide in creating or updating safe sleep policies. These resources are available online for any hospital that wants to utilize them to develop or update a policy.
An ESM was utilized to track the number of hospitals that received technical assistance and support on updating or implementing a policy. Technical assistance was provided to one hospital regarding the use of hats after birth per the updated AAP recommendations, and to another on their development of a Lotus Birth policy. One hospital implemented an updated safe sleep policy in January 2023, and another updated their safe sleep policy after taking the online training and receiving technical assistance.
The Infant Safe Sleep program worked with two hospitals to devise a way to track staff participation in the online training for hospital nurses and staff, Infant Safe Sleep: The Basics and Beyond. In FY 2023, both hospitals mandated this training for staff.
Finally, the program continues to host quarterly meetings for hospitals. The informal meetings are intended to be an avenue for hospitals to learn what other hospitals are doing to support safe sleep, learn about MDHHS activities, problem solve, and share resources.
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