Promoting and Supporting Breastfeeding

Research shows that breastfeeding offers many health benefits for infants and mothers. From birth, breastfeeding provides the baby with antibodies that protects against and reduces the risk of viruses and bacteria, such as upper respiratory infections, influenza, asthma, and eczema. For mothers, breastfeeding has health benefits like lowering the risk of ovarian cancer, breast cancer, osteoporosis, diabetes, and metabolic syndrome.

Minnesota 2016-2020 statewide needs assessment identified promoting and supporting breastfeeding a major priority need. Creating an environment where women are supported and cared for with evidence-based practices help ensure all mothers and infants get off to the best start. National Performance Measure (NPM) 4a and 4b address breastfeeding and are most linked to Minnesota’s priority need to promote and support breastfeeding.

Our objective for FY2020 for NPM 4a, was to have 93% 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 95.3% in 2017 (see Figure 1). This means our target for FY2020 was met.

Figure 1. Percent of Infants Ever Breastfed (NPM 4a)

The five-year Action Plan objectives related to NPM 4b focus on increasing the percent of infants who are exclusively breastfed through 6 months. Minnesota’s objective for FY2020 was 36.4%. Data from NIS, illustrated in Figure 2 below, indicate we exceeded our NPM 4b objective for FY2020 since the percent of infants who are exclusively breastfed through 6 months was 38.7%.  Minnesota’s programmatic efforts during FY2020 to promote and support breastfeeding with evidence-based practices are discussed below.

Figure 2. Percent of Infants Breastfed Exclusively through 6 months (NPM 4b)

Increasing the rates of breastfeeding initiation and exclusive breastfeeding through six months

Over FFYs 2016 through 2020, Minnesota has made significant strides in improving the environment for breastfeeding through partnerships and collaborations. The WIC program, which leads Minnesota’s breastfeeding efforts, has expanded its collaborations with community partners and has seen progress among all communities in breastfeeding. The Minnesota Breastfeeding Coalition (MBC) has grown from an all-volunteer organization to a 503(c) organization with an Executive Director, as their reach and scope has broadened and become more inclusive. For example:

• The Hmong Breastfeeding Coalition and the Indigenous Breastfeeding Coalition are two new cultural breastfeeding coalitions that were formed and are expanding.

• The Metro Regional Coalition was also formed.
• The creation of lactation spaces in workplaces and schools helped to reduce economic disparities in workplace support.

Due to a combination of factors breastfeeding rates faltered in 2020 while retaining much of the gains made over the previous 4 years (2015 to 2019). FFY 2020 saw many challenges such as the COVID-19 pandemic and the civil unrest due to the murder of George Floyd, both of which disproportionately impacted some communities. Additionally, the reassignment of most of our staff resulted in the postponement of several initiatives, but Minnesota is well positioned for recovery and is anticipating the resumption of many and varied activities moving into the next five years.

From 2016 to 2020, Minnesota breastfeeding initiation rates increased across all racial and ethnic groups except for non-Hmong Asian. Figure 3 illustrates the significant differences in the percentage of moms who initiated breastfeeding in 2020 by race. East African mothers had the highest rate (94.6%) and Hmong mothers the lowest rate (64.1%) of initiation. Over a 5-year period from 2016-2020, initiation improved in almost all groups: East African, White, and Hispanic mothers’ initiation rates increased around 1.5 to 2.6%; American Indian initiation rates improved by 8.1%. Those communities with the historically lowest rates, Hmong (8.8%), American Indian (2.6%) and African American (4.8%), achieved the most improvement over the five-year period.

Figure 3. Breastfeeding Initiation Rates over 5 years, by Race/Ethnicity and Cultural Identity

Changes in hospital and clinic policies and procedures in response to the virus created new barriers to initiating and sustaining breastfeeding. Reduced access to labor and lactation support in the hospital, early separation, early discharge (within 24 hours of birth), and fewer resources post-discharge negatively impacted breastfeeding rates. The economic disruptions of 2020 heavily impacted low wage workers in the health care and service industries, who are disproportionately women of color.

Prior to 2020, there had been significant increases in breastfeeding initiation in the Black/African American community. Much, but not all, of this increase was lost in 2020, as initiation rates declined by 7.7 percentage points from the first to the fourth quarter of 2020 (Figure 4). White breastfeeding rates were also impacted, especially in rural areas of the state, dropping 4 percentage points, while non-Hmong Asian rates declined by 4.4 percentage points.

In contrast, American Indian and Hmong initiation rates showed improvement across 2020. This may be partially attributable to work in these communities to promote breastfeeding, including the activities of the Hmong Breastfeeding Coalition (established in 2019) and the Indigenous Breastfeeding Coalition (established in 2017). There are similar efforts underway in African American communities, with Ramsey County Public Health SHIP funding for the Moving Equity into Data (MEDA) project.

Figure 4. Quarterly Breastfeeding Initiation Rates in 2020 among WIC Participants, by Race/Ethnicity and Selected Cultural Identities

Source: MN WIC information system

Some of the ethnic differences in initiation can be explained by demographic factors. WIC serves a population whose circumstances—low income, less education, unmarried, and younger—have historically been associated with lower breastfeeding rates. For WIC participants, 82.2% were ever breastfed (2019), while 94.1% of those not on WIC were ever breastfed. For those participating in WIC born in 2017, 36.3% breastfed for at least six months compared to the statewide rate of 79.1% (NIS). Minnesota’s strategies during FY2020 for increasing the percent of infants ever breastfed and infants breastfed exclusively through six months are discussed below.

Strategy A. Educating/Training Mothers, Providers, and Organizations

Minnesota overall has high rates of breastfeeding initiation, and our efforts to improve initiation rates are ongoing. During this reporting period, staff provided breastfeeding education and training to mothers, providers, and organizations.

Family Home Visiting

Minnesota’s family home visiting programs (FHV) promote breastfeeding to support the health of mother and baby, promote child growth and development, and support the parent-child relationship. One of Title V strategies is to promote and support breastfeeding through FHV training and referrals to WIC breastfeeding support, including peer support where available. Calendar year 2020 FHV data reports 11,992 families were served through evidence-based model and non-model family home visiting programs in Minnesota. This number is slightly decreased from calendar year 2019 most likely due to COVID-19. While all family home visiting programs continued to serve families via virtual visits starting in March of 2020, all were not able to maintain previous caseloads related to both family preference and staff capacity.

Many family home visiting programs in Minnesota are implemented through local public health agencies, and many local public health as well as MDH FHV were reassigned to COVID Response efforts. Most home visitors in FHV supported by MDH are public health nurses, many of whom have received ongoing breastfeeding education at a variety of levels from short workshops to multiple days training and certification.

Beginning in March 2019, 31 family home visiting programs from across the state participated in a 12-month Breast Feeding Learning Collaborative. The goal of this collaborative was to increase the intention, initiation, duration, and exclusivity of infants receiving breastmilk and programs were asked to collect additional data over this 12-month period. Ongoing education for home visitors was a strategy used to achieve this goal. Baseline data indicated that 72.3% of the home visitors had received ongoing breastfeeding education and by the end of the Learning Collaborative in February 2020, this number had risen to 95.1%. Many of Minnesota’s home visitors working in smaller or rural public health agencies serve in several capacities, including as WIC staff. In larger agencies, home visitors work closely with WIC staff and with breastfeeding peer educators, local breastfeeding coalitions and Baby Cafés in their communities.

Minnesota WIC

Minnesota WIC continues to offer its successful peer-counseling program. Peer counselors served about 9000 women (2019), representing around 35% of WIC infants served and 14% of infants born in Minnesota that year.

During this reporting period Minnesota WIC provided the following trainings:

• Building Bridges for Breastfeeding Duration, June 23-24,2020 and September 15 16, 2020. Over 450 attendees including staff from hospitals, clinics, community organizations, public health (WIC, FHV, et.), colleges and universities, and others.
• Certified Lactation Specialist Course, September 21-25, 2020, attended by 58 WIC staff and peer counselors.
• Minnesota supported partners who provided additional trainings: the Great Lakes Breastfeeding monthly webinar series and the MBC Fall Workshop. The MBC made a conscious effort to identify and highlight diverse speakers, and to increase awareness among mostly white event attendees of the experiences and expertise of people of color, fathers, and transgender people, with a goal of improving breastfeeding support in all communities.

Other collaborations to promote and support breastfeeding from Minnesota WIC during FY2020 included:

• Contracted with a Twin Cities radio station. Part of those grant funds are for hosting the Lactation Station at the Minnesota State Fair; since the fair was canceled in 2020, we used the marketing funds to promote the WIC program, breastfeeding and emphasize that WIC services are still open during the pandemic. A total of 506 radio ads ran between April and September of 2020.
• Coordinated the Metro Breastfeeding meetings, bringing together public health, providers, community groups and others, for sharing and networking.
• Hosted a Chocolate Milk Documentary virtual viewing and panel discussion during Black Breastfeeding Week.
• Supported leadership roles in Hmong and Indigenous Breastfeeding Coalitions.
• Developed posters supporting exclusive breastfeeding featuring diverse women, infants, and children from our local WIC programs. Breastfeeding promotion transit shelter posters were displayed from July 17-October11, 2020 at eight locations in Hennepin and Ramsey Counties. The posters reflected diverse families and were placed within diverse neighborhoods to help promote and build breastfeeding support.
• Worked with Coffective to offer coaching to five local WIC agencies (or groups of WIC agencies) on hospital relationship-building. Coffective has experienced coaches who have worked in WIC and hospitals and facilitated relationship-building in other communities. The coaches’ role was to assist WIC agencies to build relationships with hospital(s) in their communities, and possibly other community partners, as desired. The coaches helped navigate any existing barriers (such as coordination across multiple local WIC agencies or hospitals or challenges with current hospital relationships) or explore how to enhance existing relationships.  In addition, Coffective provided an on-line platform to connect 155 maternal and child health partners.
• Developed breastfeeding support flyer in collaboration with Hennepin and Ramsey County WIC Breastfeeding Coordinators and the MBC to be used at local metro county food shelves.  The flyer helped encourage breastfeeding and provided information on where to find breastfeeding support.  This was in response to the concern with the increase in donated formula to food shelves after the loss of several major grocery stores in Minneapolis and St. Paul due to protests over the killing of George Floyd.
• Brought breastfeeding data to various audiences in the state including Minnesota Perinatal Quality Collaborative and Northland Breastfeeding Coalition, and published breastfeeding data, tracking the impact of the pandemic in real time.

Minnesota Breastfeeding Coalition

Minnesota Breastfeeding Coalition (MBC) pivoted quickly in 2020 to change from in-person conferences to shorter, more frequent online events, including:

• Baby Behavior Workshop trained 64 Community Health Workers as part of a larger project with the Minnesota Community Health Worker Alliance (August 8, 2020).
• "Supporting Chest/Breastfeeding Families During COVID-19", September 3, 2020, workshop; 107 attendees including lactation advocates and professionals.
• Co-created three online learning webinars for CHWs for the 2020 Fall workshop, held October 25, 2019, as part of the Bigelow Foundation grant and in partnership with the Minnesota Community Health Worker Alliance, and MBC. These CHW webinars can be viewed at https://www.youtube.com/channel/UCikmw-ui5fL8QsXwPGpvC2w. Over 100 attendees heard keynote speaker, Dr. Tiffany Manuel, on making the case for breastfeeding equity and speaker William Moore on engaging fathers in the perinatal and postpartum process. Dr. Manuel is President and CEO of TheCaseMade, an organization dedicated to helping leaders nationally build stronger communities that are diverse, equitable and inclusive. Mr. Moore, C.P.E. is a health educator at St. Paul-Ramsey Public Health and the first male doula in Minnesota.

Additional MBC collaborative activities to promote and support breastfeeding during FY2020 including:

• Supported the Hmong Breastfeeding Coalition (HBC) – acting as fiscal agent for the new HBC, MBC provided technical assistance for grant writing and support for work developing media related to Pregnancy/Breastfeeding/COVID for the Hmong community. Through a grant awarded in FY2019, MBC and HBC partnered to develop educational videos about breastfeeding for different segments of the Hmong community. These videos were made available during this reporting period and can be viewed at: Hmong Breastfeeding Coalition on Vimeo. The HBC is recognized by national organizations focusing on equity in first food movements, and several members are developing as lactation leaders.

• Conducted conversations with food insecurity partners and food pantries to learn how MBC and MDH lactation advocates and professionals can better support families experiencing food insecurity.  As a result of these conversations, infographics (attached as Supporting Documents 3 and 4 in English and Spanish, respectively) were developed that food pantries an distribute to their clients, and a one-page guide to help the food pantry support clients who are breast/chestfeeding. Guidelines are posted on MBC’s website and can be accessed at: https://www.mnbreastfeedingcoalition.org/resources/working-with-food-pantries.
• Developed several guidance documents and resource materials for food pantries and submitted several funding proposals to increase the capacity of food pantries to support breastfeeding clients.
• Distributed over $12,000 in seed money mini grants to 11 local coalitions around the state to provide lactation related resources and books to their local libraries, to create Facebook Live events to promote breastfeeding coalitions incentivizing lactation spaces in schools for teachers and staff, and to work with local childcare providers to improve lactation-related policies and practices.
• Partnered with the MBC Interim Executive Director, as a member of the MNCHWA Education Committee, to oversee revision of the CHW certificate curriculum to infuse more up-to-date lactation content.

Title V staff worked with the MBC on several initiatives related to Breastfeeding Friendly Maternity Practices. MBC hosted its 7th Annual Perinatal Hospital Leadership Summit virtually on November 5-6, 2020, with the theme Human Milk’s Role in Reducing Infant Mortality. Sessions included topics on state and local initiatives to reduce infant mortality, how and why human milk reduces infant mortality, and promoting Baby-Friendly Hospital practices.

Reducing Disparities in Breastfeeding Rates

Strategy A. Expanding Capacity, Outreach, and Advocacy to Reduce Disparities

Several bills in the Minnesota Legislature were introduced in 2020 aiming to improve lactation support in the workplace. The proposals include making pumping breaks paid instead of unpaid, removing the qualifier that pumping must be ‘for her infant child’, making the statute language more gender-inclusive, removing the exemption for businesses for ‘undue hardship’ removing the exemption for employers with 20 or fewer employees, and removing the tenure requirement for eligibility for workplace accommodations. These changes will aid in reducing barriers especially for parents in unskilled and low-paying jobs.

Minnesota WIC

A strategy implemented through Minnesota’s WIC program during FY2020 to reduce breastfeeding disparities included a peer program, training, and partnerships with community organizations.

It is essential that Minnesota continue to work directly with populations experiencing the highest disparities in breastfeeding rates. An accomplishment of note is our ongoing collaboration with MDH WIC, the Hmong Health Care Professionals Coalition (HCCPC), MDH Statewide Health Improvement Initiative (SHIP), the Birth Equity Community Collaborative, and Minnesota Breastfeeding Coalition (MBC). A key strategy is to increase community member engagement by paying for participation, for those who not reimbursed by an employer. Our engagement with the Hmong community through the Hmong Breastfeeding Coalition coincides with an increase in breastfeeding initiation among Hmong mothers during FY2020.

Although American Indian, Hmong, and African American mothers experience wide disparities, Minnesota has made progress in reducing breastfeeding initiation disparities. As shown in Figure 5 below, the biggest gains were made among populations with the lowest breastfeeding rates. Over the 5-year period, the disparity between American Indian and white initiation rates decreased by 0.6 percentage points, a 4% improvement, the disparity for Hmong infants decreased 3.8 points, a 12% improvement, and the disparity for African American infants decreased 2.2 points, a 14.6% improvement.

Another Minnesota strategy implemented in FY2020 was publication of an analysis of breastfeeding exclusivity and its impact on duration of breastfeeding among WIC participants. While birth records still do not collect information on in-hospital formula supplementation of breastfed infants, Minnesota is collecting this data for WIC participants and continues to look at disparate impacts of hospital formula supplementation on breastfeeding in diverse communities.

Figure 5. Percentage Point Disparities in Breastfeeding Initiation with Change in Disparity from 2015 to 2020

Minnesota Breastfeeding Coalition

The MBC has made a concerted effort to increase the diversity of its membership and its Board of Directors, and to center equity in all its activities. For example, MBC rewrote and revised their recruitment and application process. In 2020, the board membership changed from all-White to a more diverse board of directors identifying as African American, American Indian, and Hispanic. Other successes of diversity, inclusion and access are:

• Active participation in MBC by members of the LGBTQ community
• Updated website for access to breastfeeding resources/publications in other languages
• Creation of the Equity and Access Subcommittee to assist MBC and local coalitions in addressing equity and access and reducing barriers to breastfeeding statewide by increasing the diversity of board and committee participants.
  • This group now acts as an advisory board for all MBC activities.

Family Home Visiting

In FFY2020, the Family Home Visiting (FHV) program continued their collaborative relationship with the Indigenous Breastfeeding Coalition of Minnesota to provide culturally sensitive breastfeeding input for the Breastfeeding Learning Collaborative, which was extended an additional 5 months, concluding in February 2020. Another Minnesota strategy that continued was to promote and support breastfeeding in the family home visiting program through training and referrals to WIC breastfeeding support, including peer support where available. The FHV Evaluation Unit regularly gathers data from local FHV programs on the number of infants/children receiving any amount of breast milk at 6 months of age. During FFY2020, 60% of infants of mothers participating prenatally in FHV programs received breast milk at six months of age. This is an increase from only 35% of infants receiving breastmilk at 6 months of age from FFY2019. This increase was most likely related to the 12-month Breast Feeding Learning Collaborative that in which 31 family home visiting programs participated, beginning in March 2019. These 31 programs collectively saw increases from March 2019 to February 2020 in both the exclusivity and the duration of breastfeeding among their families.

MDH Statewide Health Improvement Program (SHIP)

The Office of Statewide Health Improvement Initiatives directed a portion of funds from the CDC’s 1807 grants to the MBC to address maternity center practices. Minnesota's 10-Step Learning Collaborative (10-SLC) has met monthly as a quality improvement community focused on improving maternity care practices. Additional meetings occurred between each participating hospital's Team Lead and the project director to assist with hospital-specific improvement in maternity practice. Individual hospitals’ workgroups have identified at least two of these steps, evaluated current practice, and formulated action plans. The goal has been to submit applications to the Minnesota Department of Health's Breastfeeding 5-Star Recognition Program. One hospital from the 10-SLC has implemented four steps and applied for two-star recognition and another hospital has implemented three steps and applied for one-star recognition. Two hospitals received mini grants to assist with maternity staff education. Networking and sharing of evidence-based resources has been part of the monthly meetings. Hospitals have maintained their focus and have continued with work plans, albeit on an adjusted timeline due to the pandemic.

Minnesota’s strategy to promote the MDH Breastfeeding Friendly Recognition programs for childcare centers, family childcare homes, workplaces, and local health departments has proven successful. During FY2020, 15 workplaces and three health departments were recognized as Breastfeeding Friendly. Two hospitals were recognized with the Ten STEPS Award totaling 13 Breastfeeding Friendly Maternity Care Centers. The total number of organizations participating in MDH Breastfeeding Friendly Recognition program rose from 172 in FY2019 to 187 in FY 2020.

Strategy B. Funding Programs and Initiatives through Collaboration and Partnerships

Minnesota WIC

Minnesota’s WIC, Title V and SHIP programs collaborated with the Minnesota Breastfeeding Coalition (MBC), providing financial and technical support on various projects, including a statewide teleconference of local and cultural coalitions in April 2020.

Students from the University of Minnesota’s School of Public Health have participated in efforts to expand breastfeeding awareness in Hmong and African American communities. From these activities, a Hmong Breastfeeding Coalition evolved. In this reporting period, Minnesota WIC partnered with U of M researchers on a qualitative research study that includes data on breastfeeding attitudes and behaviors among WIC participants at higher risk of obesity.

MBC-affiliated coalitions mentored workplaces and childcare organizations to achieve MDH Breastfeeding-Friendly recognition. Ramsey County SHIP and MBC provided mini grants to St. Paul’s Union Depot (a city office building), two schools, and four libraries to develop lactation spaces.

Minnesota Expectant and Parenting Student Program

The Minnesota Expectant and Parenting Student Program, funded by the United States Department of Health and Human Services’ Pregnancy Assistance Fund, promoted WIC’s services during this reporting period. For example, community health care workers and care coordinators referred expectant and parenting high school and college students to WIC during the prenatal and post-partum period of their pregnancies. Per the participant survey (n=727), referrals for breastfeeding skills and resources were the fourth most common personal health referral. These services were provided in three communities that have leading indicators of health disparities and inequities pertaining to educational achievement and economic security.

Family Home Visiting

One Minnesota strategy that continued to be implemented this reporting period was to promote and support breastfeeding through funding. MCH and Family Home Visiting (FHV) provides over $35 million/year of federal and state funding (including MIECHV, TANF and State Evidence-Based Home Visiting) to community health boards, tribal nations, and non-profit organizations. Programs can use a portion of the funding for breastfeeding training to home visitors and supervisors so they can provide education and support to mothers during prenatal and postpartum home visits. MDH FHV extended the Breast-Feeding Learning Collaborative through February of 2020. This extension resulted in increasing the percentage of home visitors with advanced lactation training from 89.5% to 95.1% for the 31 participating agencies.

MDH Statewide Health Improvement Program

The Office of Statewide Health Improvement Initiatives directed a portion of funds from the CDC’s 1807 grants to the MBC to address maternity center practices. The MBC continued a Ten-Step Learning Collaborative with five hospitals working on implementing Baby-Friendly Steps, with a goal of receiving at least one star for recognition of achieving two Steps in MDH Breastfeeding Friendly 5-Star Recognition program.

Minnesota’s strategy to advocate for increased Medicaid reimbursement for births that occur at Baby Friendly Hospitals has been an ongoing challenge. The path forward to effect regulatory change is not clear. Our challenges are identifying an organization capable of carrying it forward and identifying partners among the various organizations to implement the needed changes.

ESM 4.1: Number of Baby Friendly Hospitals

Promote and support efforts of state WIC program in partnership with Minnesota Breastfeeding Coalition to promote Minnesota Hospitals becoming Baby Friendly (10-steps).

Figure 6. Number of Baby Friendly Hospitals (ESM 4.1)

The number of Baby-Friendly hospitals in Minnesota declined from 15 to 14 during FY2020. Two large hospital systems in the state have chosen to not seek Baby-Friendly re-designation citing budget constraints.

Reducing Infant Mortality Rate and Racial and Ethnic Disparities in Infant Deaths

The 2015 five-year needs assessment identified reducing the state’s overall infant mortality rate and the racial and ethnic disparities in infant death rates as priority. NPM 5a, b and c address the importance of safe-sleep practices to reduce infant mortality and are related to this priority need. Minnesota’s infant mortality reduction initiative have considerable work currently underway in this area.

Recent data from MDH linked birth/infant death file show that the state’s infant mortality rate declined from 5.0 infant deaths per 1,000 live births in 2000-2004 to 4.8 in 2014-2018 (see Figure 7 below). Except for Hispanics, rates also declined for all other racial and ethnic groups in the state overall between 2013-2017 and 2014-2018. Even so, disparities in rates by race/ethnicity are evident and troubling. Of note are the infant mortality rates for African American/Black and American Indians— the groups that have historically had the highest infant mortality rates in the state. Data from 2014-2018 show the rates of infant mortality were 2.3 and 2.5 times that of non-Hispanic Whites, respectively.

Figure 7. Infant Mortality Rates by Race/Ethnicity of Mother, 5-year Rolling Averages,

2000-2018

The 5-year objectives outlined in our State Action Plan table aimed to decrease the infant mortality rate by reducing Minnesota’s sudden unexpected infant death (SUID) and preterm birth rates and to reduce disparities. To achieve these goals, key strategies were developed to reduce sleep related SUID and promote the use of progesterone to reduce repeat preterm births.

During FFY2015-2020, MDH implemented many of the strategies outlined in the action plan aimed at reducing the incidence of sleep related SUID in Minnesota. Noteworthy accomplishments include:

• Making safe sleep resources available to the public by partnering with the NICHD’s Safe to Sleep campaign, developing, and releasing safe sleep materials in multiple languages, and launching an annual safe sleep book campaign.
• Proclaiming Infant Safe Week in Minnesota every year with social media messages, press release, bridge illumination, and other activities designed to increase awareness about infant sleep safety.
• Expanding community partnerships and involving community safe sleep champions in discussions about the importance of infant safe sleep on a local ethnic radio station on several occasions.
• Initiating systems changes through recognizing birthing hospitals receiving safe sleep certification through the National Safe Sleep Hospital Certification Program.

Despite these efforts our state’s overall sleep related SUID rate has remained about the same since 2015 and did not decline by 10 percent or more during the five-year period as planned. In 2015 the rate was 7.0 infant deaths per 1,000 live births, while it was 6.7 in 2018. Additionally, we also did not meet our goal of increasing the proportion of mothers who reported putting their babies to sleep on their back by 10 percent or more during the period. Possible explanations for not realizing our stated goals include persistent disparities in social determinants of health such as a critical shortage of affordable housing across the state, which directly relate to infant sleep practices. Additional discussion pertaining to some of Minnesota’s challenges and emerging issues compromising our efforts to achieve SUID and infant mortality declines overall are discussed in a subsequent section. Ongoing strategies and related activities implemented and completed during FFY 2020 are discussed below.

Strategy A: Promoting Safe-Sleep Best Practices

One of Minnesota’s specific aims was to accelerate the reduction of infant mortality by reducing the state’s overall SUID rate by 10 percent or more by 2020. We focused on SUID for several reasons. SUID is the third leading cause of infant mortality in Minnesota, contributing about 11% of state’s total 350 to 380 infant deaths each year. Secondly, data from Minnesota Sudden Death in the Young (SDY)/SUID Case Registry for 2014-2018 demonstrate health disparities such as infants born to American Indian mothers—the population with the highest SUID rate in Minnesota—are approximately eight to eleven times more likely to die suddenly and unexpectedly before age one than infants born to White and Asian mothers, respectively. Third, the overwhelming majority of SUID in Minnesota occur because infants are placed to sleep in hazardous sleep spaces or in unsafe positions putting them at increased risk of dying during sleep. Thus, the vast majority of SUID in the state are preventable. To illustrate, of the 141 SUID that occurred between 2016 and 2018, 119 (84.3%) were sleep related. Further, in 2019, MDH, conducted an in-depth analysis of the SUID that occurred between 2016 and 2017 and found that of the 90 deaths, 74 (82%) occurred in unsafe sleep environments. Among other findings:

• 85% were not in a crib, bassinette, or a side sleeper
• 81% had an unsafe bedding or toys. Unsafe objects in the sleep environment included pillow, comforter, thin blanket/flat sheet, cushion, U-shaped pillow, sleep positioner, bumper pads, or toy(s)
• 61% of the babies shared a sleep surface, such as a bed, sofa or recliner, with another person
• 59% were in an unsafe sleep position, such as being placed on their side or belly rather than on their back.

Educating the Public and Training Professionals about Best Practices to Prevent Sleep-Related Tragedies/Reduce Infant Mortality through Partnerships

An annual strategy to reduce the state’s overall SUID rate is a collaboration among MDH Title V and FHV, DHS, LPH agencies and other external stakeholders to raise awareness of SUID and infant mortality. This collaboration declares one week in the fall “Infant Safe Sleep Week” in Minnesota. During this reporting period, major activities included:

• Release of the Governor’s proclamation highlighting SUID in the state, how to prevent them, and encouraging all stakeholders across multiple sectors (e.g., childcare, and medical providers, parents, and babysitters) to implement best practices to prevent these tragedies. The proclamation was posted on the Governor’s website and publicized via the Governor and Assistant Governor’s Twitter, Facebook, and Instagram accounts. Together, these posts had more than 25,000 views and were shared approximately 900 times.
• The FHV section announced the 2020 Safe Sleep Week awareness campaigns in their Tuesday Topics e-newsletter, which is distributed weekly to approximately 2,100 subscribers. In addition, messages were shared through Tuesday Topics e-newsletter about educational opportunities and product safety announcements related to safe sleep.
• Other external partners such as DHS, and LPH agencies (e.g., Hennepin and Ramsey Counties), made announcements about Safe Sleep Week using social media and other electronic platforms. DHS, for example, announced Safe Sleep Week and the proclamation via GovDelivery to approximately 17,500 childcare providers and other stakeholders.
• Title V staff collaborated with Minnesota Department of Transportation (MnDOT) and Hennepin County to illuminate the I-35W and the Lowry Avenue bridges in Minneapolis in pink, blue, and white from sundown on November 10 to shortly after sunrise on November 11.

Additionally, Title V staff seized opportunities to present infant safe sleep information at conferences and to provide technical assistance to professionals during this reporting period. For example, in 2020, Title V staff, at the invitation of the Minnesota Breastfeeding Coalition, presented An Update on Minnesota Department of Health’s Infant Safe Sleep Initiative, at the Coalition’s Perinatal Hospital Leadership Summit. The presentation included information on:

• The scope of the sleep related SUID problem in Minnesota
• Risks and protective factors related to sleep-related tragedies
• The intersection of health equity and SUID prevention
• Examples of current MDH led efforts to reduce sleep-related tragedies through the lens of the socioecological framework

The socioecological framework explains how different levels of influences operating at multiple levels—interpersonal, institutional/organizational, community, and the structural/policy/and systems levels—shape individual’s decisions, choices, opportunities, and behaviors in influencing health outcomes.

In FFY 2020, staff participated in an informal workgroup convened by the state legislature to examine current Minnesota Statutes enacted to ensure infant sleep safety in childcare settings, and provided technical assistance to a work group tasked with examining:

• Minnesota Statute § 245A.1435 aimed at reducing sudden unexpected infant deaths in licensed childcare programs, to determine if it needs revisions and updating.
• How childcare providers can better determine safe infant sleepwear and know what sleepwear are not recommended or are unsafe for infants to sleep in.
• Ways to improve communications with providers about the safety of infant sleepwear.

Revisions to the statute were submitted to the State Legislature for review and consideration during the 2020 legislative session. However, the suggested language changes did not pass and are being considered for the 2021 legislative session. In addition to providing technical assistance and input into the legislative language changes, the safe sleepwear group tasked MDH with developing and posting a set of “Frequently Asked Questions” (FAQ) and responses on the state’s infant mortality website. The FAQ, which addresses several questions that cover topics such as the safest sleep position, swaddling, and where to find children’s products such as sleepwear that have been recalled by the Consumer Product Safety Commission (CPSC), has been posted on MDH’s Infant Mortality website and the DHS Licensing Family Child Care and Child Care Centers webpages for viewing and downloading. It is worth noting that during Safe Sleep Week, MDH and DHS distributed the FAQ widely. DHS, for example, announced the FAQ to approximately 17,500 childcare providers and other stakeholders in their network of licensed childcare providers. MDH distributed it to more than 200 of its stakeholders for them to share with their partners and contacts.

Another strategy was to disseminate safe sleep messages to the public using a variety of social media platforms, including Twitter and Facebook. During the reporting period, MDH distributed links to published articles, shared information about upcoming webinars, trainings, conferences, and statistics via e-mail, and used social media to repost or retweet information from professional or scientific organizations as soon as they became available.

During Safe Sleep Week, MDH targets high-risk people of childbearing age (15-49) with a special posting on Twitter and Facebook that covers what a safe sleep environment should look like. In 2020, approximately 41,000 people in the targeted population viewed the posts. Among those who viewed the posts, approximately 1,000 shared it with another person.

Family Home Visiting

The Family Home Visiting section announced Safe Sleep Week during October 2019 in their Tuesday Topics e-newsletter, which is distributed weekly to over 2,000 subscribers. In addition, messages are shared through Tuesday Topics e-newsletter about educational opportunities and product safety announcements related to safe sleep.

MDH Family Home Visiting Nurse Consultants’ ability to regularly facilitate regional meetings of MCH Coordinators from local public health departments was limited after March 2020 because of agency wide reassignment to the COVID-19 Response. Examples of safe sleep messages and information about resources were shared at the fall/winter 2019 regional meetings. Home visitors who participated in these meetings were also provided opportunity to share their experience with sharing materials related to safe sleep with the families they serve.

Strategy B. Reducing Disparities in SUID Rates between Whites and African Americans/Blacks and American Indians

Collaborating with Internal and External Partners to Increase the Public’s Awareness about Infant Sleep Safety

Data from MDH’s SUID Case Registry show that infants born to African American/Black and American Indian mothers are three to eight times more likely to die suddenly and unexpectedly during sleep than infants born to white mothers. Additionally, babies born to African American/Black and American Indian mothers have a four to twelve-fold greater risk of dying during sleep than infants born to Asian/Pacific Islander women. To reverse these trends, MDH has collaborated with community champions to deliver information to the public about the importance of safe sleep or has used a variety of media platforms (e.g., social media and community radio stations) to increase public awareness about infant safe sleep practices).

Activities during FY2020 around Minnesota’s strategy to reduce the infant mortality rate and address disparities was to disseminate safe sleep educational materials and resources to audiences not commonly targeted (include but not limited grandparents, fathers, and immigrants whose primary language is not English) are:

• MCH Infant Mortality Reduction Initiative disseminated safe sleep flyers, brochures, quick informational cards, and safe sleep books. Staff distributed 6,300 safe sleep books across the state, of which about 60% were disseminated to LPH, Tribes, and other partner organizations serving families and communities in Greater Minnesota.
• Staff distributed approximately 1,000 quick cards developed by MDH to address the ABCs of safe sleep. The cards are available in multiple languages widely spoken in Minnesota, including Hmong, Somali, Karen, and Spanish. The English and the Spanish cards are requested the most, followed by Somali, Hmong, and Karen.
• MDH partnered with the National Institute of Child Health and Human Development’s (NICHD) National Safe to Sleep Campaign to obtain safe sleep resources such as flyers and brochures for widespread distribution. As a result, staff distributed approximately 500 safe sleep flyers and brochures targeting racial and ethnic populations and other special populations such as grandparents. In most years, MDH distributes materials at health fairs and conferences. Due to the pandemic, however, all-in person conferences were cancelled for much of fiscal year 2020. Consequently, the number of safe sleep fliers and brochures that MDH normally distributes each year declined considerably. For example, the number of quick cards distributed in FY 2020 declined by 50% over the 2019 fiscal year.
• In 2020, Title V staff and staff from St.-Paul Ramsey County Public Health’s Birth Equity Community Council (BECC) and Parents as Teachers (PAT) initiatives were invited to discuss the importance of infant sleep safety and strategies known to reduce the incidence of sleep-related tragedies on a local radio station that targets the Black/African American population in Minnesota. The show covered data, best practices, available resources (e.g., cribs and materials), as well as efforts currently being implemented by MDH, BECC and PAT to prevent sleep related SUID and infant mortality more generally, and PAT’s efforts to promote family and child well-being through home visiting.

Providing Ongoing Technical Assistance and Outreach to Internal and External Partners

Staff served on several work groups and committees, including the SUID subcommittee, the Child Fatality Review Panel, African American Community Voices and Solution (CVAS), and the Birth Equity Community Council (BECC). Our partnerships with and roles on these groups ranged from participating in reviews of SUID cases with the Sudden Death in the Young (SDY)/SUID subcommittee, Child Mortality Review Panel, and providing technical advice to the CVAS group and serving as a state advisor on the BECC.

The BECC is an initiative between the St. Paul-Ramsey County Public Health Department, the residents of Ramsey County, and other stakeholders. BECC’s primary goals are to improve birth outcomes and reduce disparities in infant mortality. BECC has two meeting structures: the Planning Team (comprised primarily of health care providers and professionals) and the BECC Council (comprised of families, new and expecting parents, including fathers, and health care professionals). BECC engages the local community in monthly dialogues aimed at prioritizing health topics using the Perinatal Periods of Risk methodology. In FY 2020, BECC members finalized strategies to reduce infant mortality in Ramsey County’s African American/Black population. Through the prioritization process, BECC members identified addressing sleep related SUID through safe sleep education as one of several priority areas to focus on through community-wide education.

During FFY 2020 BECC developed and released a safe sleep educational video that features African American fathers, mothers, and community leaders who discussed the importance of infant sleep safety and promoted evidence-based strategies for keeping babies safe while they sleep or nap. The Title V Infant Health and Mortality Reduction Specialist is a member of the planning committee and provides technical assistance to the group on all priority strategy areas, as well the message developed for the PSA.

Increasing the Rate of Mothers Reporting Infants Sleep on their Backs

According to Minnesota PRAMS data, 86% of mothers surveyed in 2019 reported placing infants on their back to sleep (Figure 8). Ideally, close to 100% of parents should be placing their infants to sleep on their backs. During this reporting period, MDH implemented a couple of critical strategies to ensure that the state meets its goal of having 87.5% or more of parents placing their babies to sleep in the supine position by 2020. Despite these efforts our target was not met. Minnesota’s collaborative efforts are discussed in the strategies and activities described below.

Figure 8. Percent of Infants Placed to Sleep on Back (NPM 5a)

Strategy C. Providing Safe-Sleep Education and Materials

Another safe sleep partner are the grantees of the Positive Alternatives Grant. The Positive Alternatives Grant Program supports, encourages, and assists women to carry their pregnancies to term by offering local resources and supports, assistance to develop and maintain family stability and self-sufficiency, such as rental assistance. One activity the 34 grantees provide statewide to participants, is portable cribs (pak-n-plays) as well as safe sleep education.  For the grant period 2016 - 2020, the grantees provided 30,664 women with safe sleep education; and 11,597 cribs to women who did not have one.

During FY2020, collectively, all 34 Positive Alternatives grantees held safe sleep educational sessions with 2,985 clients and distributed 1,667 cribs in combination with safe sleep education to clients. The Positive Alternatives Grant Manager has provided significant support and technical assistance during the past five years, which assisted the grantees to continue this work while the grant manager was reassigned to COVID-19 mitigation.

One of the strategies implemented was to support external organizations in distributing and providing safe-sleep education to families. Cradle of Hope, a non-profit organization, and a PA grantee, distributes cribs via a network of 188 partner sites throughout the state. It is worth noting that during the reporting period, Cradle of Hope partnered with seven Tribal communities in Minnesota to distribute cribs: Red Lake (Band of Chippewa), Bois Forte (Nett Lake, Band of Chippewa), White Earth (Nation), Leech Lake (Band of Ojibwe), Mille Lacs (Band of Ojibwe), Upper Sioux (Community), and the Lower Sioux (Indian community).

All families who receive cribs also get safe sleep information and education from staff working at the partner sites. Between October 1, 2019, and September 30, 2020, Cradle of Hope distributed 1,745 cribs. Among those who received cribs:

• 70% were between 20 and 34 years of age
• 54% were in their third trimester
• 43% were postpartum
• 31% of clients were white
• 39% were African American/black
• 15% were multi-racial
• 10% were American Indian
• 5% were Somali

ESM 5.1: Number of Minnesota Hospitals with National Safe Sleep Hospital Certification

Another Minnesota strategy to reduce the infant mortality rate is to recruit and encourage birthing hospitals to receive safe sleep certification.

Our goal was to have four safe sleep certified hospitals in the state by the end of 2020. Currently, we have two hospitals in the state that have received safe sleep designation: St. Luke’s Hospital, located in Greater Minnesota is certified at the silver level, while Hennepin Healthcare in Minneapolis is certified at the gold level. Unfortunately, we did not meet our state goal because two of the health systems which had pledged to initiate the process of receiving safe sleep designation at the start of 2020, had to put their plans on hold due to the COVID-19 pandemic. Our Title V Infant Health and Mortality Reduction Specialist was also reassigned to assist with COVID-19 mitigation activities.  In the fall of 2020, MDH, with the help of a student intern from the University of Minnesota’s School of Public Health’s Maternal and Child Health Program, developed a short survey to collect information from birthing hospitals on their policies, practices, and procedures around promoting infant sleep safety in health care settings. MDH will implement the survey in spring 2021.

Figure 9. Number of Hospitals with National Safe Sleep Certification (ESM 5.1)

 

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

Although MDH implemented the strategies outlined and discussed above during the past five years, staff changes, lack of funding to implement some activities, and need for legislation were major challenges during the period. For example, with resource limitations, we were unable to complete and release Part Two of the state’s infant mortality reduction plan and without legislation we were unable to implement a Fetal and Infant Mortality Review (FIMR). In addition, due to staff being reassigned COVID-19-response, we were unsuccessful in providing a webinar/training to public health nurses/home visitors covering infant safe sleep practices and the delivery of in-person compassionate services to bereaved families grieving the loss of an infant.

Racial and ethnic disparities in infant mortality persist, especially for African American/Black and American Indian families, despite a wide range of programs, services, and interventions to support families. The impact of unaddressed social and economic determinants of health and trauma inflicted on our disparate populations are likely explanations.

Strategy D. Reducing Prematurity

Increasing Number of Pregnant Women Receiving Progesterone

Prematurity is the second leading cause of infant death accounting for 25.1% of infant deaths from infants born between 2014-2018 in Minnesota. In addition, American Indians (13.4%) and African Americans/Black (9.3%) have higher rates of giving birth prematurely than non-Hispanic Whites (8.5%). Minnesota recognizes preterm births increase the risk of health-related complications and infant mortality and coupled with the disparities in preterm birth among American Indian and African American women are of concern. Minnesota created SPM1, percent of women enrolled in Minnesota Health Care Programs (MHCP) that receive 17-Alpha-Hydroxyprogesterone Caproate (17P) as a proxy to measure the reduction in infant mortality rates and reduce the rate of racial and ethnic infant deaths.

Minnesota’s FY2020 objective for pregnant women with a preterm birth and enrolled in Medicaid receiving 17P was 2%. According to Minnesota Health Care Programs (MHCP) data, in calendar year 2019 (the most recent data available) only 1.3% (see Figure 11 below) of pregnant women enrolled in Medicaid received 17P. This means our target was not met. There were numerous barriers including the 2019 FDA’s Bone, Reproductive, and Urologic Drugs Advisory Committee discussion and review of the results from the PROLONG study and Makena (17P). Because of this review process, MDH stopped promoting 17-P as a specific strategy, and instead broaden the prematurity prevention approach to include other factors such as tobacco use.

Figure 11. Percent of pregnant women enrolled in Minnesota Health Care Programs that receive 17-alpha-hydroxyprogesterone caproate (17-P) (SPM 1)

Leading Quality Improvement Initiatives to Prevent Preterm Birth

The Minnesota Preterm Birth Prevention Collaborative (PBPC) is a statewide, voluntary network designed to influence actions at a systems level through the implementation of evidence-based interventions to reduce preterm birth. Its goal is to reduce premature birth and improve pregnancy outcomes for women and their families.

On October 29, 2019, the FDA’s Bone, Reproductive, and Urologic Drugs Advisory Committee met to discuss Makena (17P) and review the results from the PROLONG study. Currently, Makena's approval remains in place and the drug remains on the market. Both ACOG and SMFM recommendations regarding use of 17P for preterm birth prevention remain unchanged and both societies advocate to offer 17P to women with a history of singleton spontaneous preterm birth. Based on this information, the PBPC continued the collaborative aims to reduce Preterm Birth in Minnesota by addressing its multifactorial etiologies, beyond 17P alone. The PBPC faculty revised the QI change package to reflect interventions on 17P, cervical length, and commercial tobacco cessation. The chair provided expertise to advise advances and clinical guidance, which is shared with the members of the learning collaborative. The design change reflected a comprehensive approach to prevention of preterm birth and incorporated the importance of addressing commercial tobacco cessation during every prenatal visit (5As evidence-based intervention).

By fall 2019, the PBPC recruited four teams from health systems (CentraCare, HealthPartners/Park Nicollet, M Health/Fairview, and Hennepin Health) statewide committed to participate in this year-long initiative on implementing preterm birth prevention strategies. Implementation of quality improvement activities across these health systems included up to 18 hospitals with at least 18,000 deliveries annually. Within this project period, the MNPQC facilitated multiple collaborative activities via online web calls and an in-person learning session held in December 2019 with 18 team members.

Best practices implemented within each of the team’s health system were highlighted as true collaborative opportunities to design shared strategies to address preterm birth prevention on a statewide effort. One shared strategy focused on designing an add-on package within the electronic medical record software specific to the interventions listed within the Preterm Birth Prevention Change Package. The monthly action period calls with the health systems teams focused on key topic areas to address from the change package, such as highlighting education on cervical length and 17P screening and counseling. Each call then had a status report along with an all-team discussion on how to achieve progress across each health system.

Due to the COVID-19 response, the second learning session scheduled for April 2020, was postponed along with two scheduled action period calls. The faculty team and PBPC members re-evaluated the timeline and determined next steps to support teams within the health systems. Therefore, in December, the second learning session was virtual and provided opportunity to continue with the initial momentum of the collaborative. This virtual meeting allowed the MNPQC to plan/structure other MNPQC initiatives using virtual collaborative engagement.

PBPC faculty team summarized the lessons learned below with a full report coming 2021:

• It’s premature to assume all steps in the PBPC algorithm were reliably in place.
• One big change to the medical record would ensure patient centered, reliable, safe, and comprehensive care.
• Many changes can be implemented to improve a woman’s prenatal health despite a pandemic.
• It is hard to motivate change without “pull” from partners like regulators, payors, JCAHO, professional organization priorities and consensus.
• Excellent prenatal care is a complex system, thus making it hard to ascertain in 11 months if improvement occurred and was sustained.

Establishing Partnerships to Provide Continuing Education and Training to Providers

In addition to prematurity, the MNPQC launched a hypertension quality improvement initiative, a condition that also results in premature birth. Hypertension Quality Improvement faculty from the MNPQC led a successful learning session in September 2020 with 251 registrations from health systems across Minnesota. The learning session was launched as a recruitment effort to engage interested health systems to participate in a Project ECHO model with a biweekly call to support the implementation of strategies shared at learning session one. MNPQC hypertension faculty key expertise shared at this learning session included: 1) history of hypertension in pregnancy and treatment; 2) racial disparities; 3) Case studies and current data; 4) MNPQC Hypertension in Pregnancy Therapy Care Process Model; Patient Education Resources; 5) Blue Band Project. Results of this work will be available in future years.

The MNPQC Hypertension in Pregnancy Therapy Care Process Model led by two MNPQC members was shared as an available resource to MNPQC learning session participants. Leadership from the MNPQC (Chairs and co-Chairs) attended a virtual rigorous training, offered by the Institute of Health Improvement (IHI), to share collaborative strategies for a model of improvement. These strategies align with the core mission of the MNPQC and long-term goals to achieve improved health outcomes for mothers and infants across Minnesota.

The Minnesota Perinatal Organization’s (MPO), co-lead organization for the MNPQC, Annual Fall conference was cancelled due to COVID-19. How the MPO Annual Conference can be used to build collaborative partnerships will be explored in 2021.

In July 2020, MNPQC and MDH staff attended the National Network of Perinatal Quality Collaboratives/Alliance for Innovation on Maternal Health (NNPQC/AIM) virtual conference. The virtual conference was held over two days with multiple breakout sessions focusing on addressing infant and maternal health topics, such as improving data sharing/collaboration, treatment of substance use disorders, neonatal opiate withdrawal syndrome, and addressing racial inequities in the healthcare delivery system. This conference provided opportunities to connect and collaborate with other quality collaboratives and share lessons learned and outcomes.