Priority: Reduce Infant Mortality

Performance Measure: A) Percent of infants placed to sleep on their backs B) Percent of infants placed to sleep on a separate approved sleep surface C) Percent of infants placed to sleep without soft objects or loose bedding.

In 2020, 90.0% of Maine infants were most often placed to sleep on their backs only. Maine’s percentage is the second highest among states that participate in the Pregnancy Risk Assessment Monitoring System (PRAMS) survey. The U.S. rate in 2020 was 89.9%. The percentage of Maine mothers who report placing their infant to sleep on their back has increased since 2007 when 77% placed their infant to sleep on their back. About 38% of Maine infants are placed to sleep on a separate, approved safe sleep surface (U.S. = 36.9%) and 67% are placed to sleep without soft bedding (3rd highest; U.S.= 52.5%). Maine’s 2019 rates represent significant increases compared to previous years. Between 2007 and 2019, Maine averaged 12 infant deaths each year due to sudden infant death syndrome/sudden unexpected infant deaths (SIDS/SUIDS). In 2020, there were six deaths, the fewest Maine has had in over 10 years. During calendar year 2021, there were nine SIDS/SUIDS deaths.

Strategy: Expand the distribution of the Cribs for Kids Program in Maine with fidelity

Maine’s birthing hospitals are safe sleep certified and required to provide a safe place to sleep for infants born at their facilities. All 24 birthing hospitals in Maine achieved Safe Sleep certificates. Maine is the second state nationally to achieve this milestone. Eight hospitals achieved “Gold” status, 10 achieved “Silver” and six achieved “Bronze.” To be designated a Certified Safe Sleep Hospital, the hospital must develop and maintain a safe sleep policy; provide safe sleep training to staff serving infants and children under the age of one; and provide infant safe sleep education to the parents of infants prior to hospital discharge. We are pleased to share that we've been accepted to @AMCHP_Innovate's MCH Innovations Database as a model example of Evidence-Informed Policy Implementation https://amchp.org/database_entry/maine-safe-sleep-kit-program/.

The Maine CDC is partnering with hospitals to provide reimbursement for safe sleep kits that hospitals distribute. The kits include a cribette, fitted sheet and sleep sack. During FY21 the Maine CDC disseminated safe sleep materials and baby board books to families. Magnets with safe sleep messaging were included in the PRAMS Survey sent to new mothers.

The Maine CDC purchased safe sleep board books and distributed them to birthing hospitals as well as community groups working with pregnant women. The books were also supplied to WIC, Public Health Nursing and Maine Families Home Visiting staff to hand out when visiting families.

Strategy: Expand social media awareness campaigns promoting safe sleep

Maine’s safe sleep efforts are focused on ensuring parents have safe places for infants to sleep, as well as ensuring proper care for drug-affected infants, which can be at high risk for unsafe sleep deaths. The Maine DHHS promoted a statewide Safe Sleep Campaign ABCD (ALONE in their crib, on their BACK, clean clear CRIB, DRUG-FREE home. The Maine CDC promotes the safe sleep website, www.safesleepforme.org that houses the campaign and associated resources. The Maine CDC began adding translated materials to the website. Attention to cultural differences was taken into consideration in developing the materials. For example, the ABCs of safe sleep does not translate well to other languages so the messaging was changed to the 123s (a copy is included in Section V. Supporting Documents). Campaign materials are also distributed by the Maine Prevention Store (www.mainepreventionstore.org) enabling access to free materials for those who need them. Maine’s Title V program wishes to thank the Kentucky Title V program for allowing us to use their campaign materials.

Maine CDC surveyed WIC participants to determine the degree of behavior change that resulted from seeing the campaign. 961 responses were received during the month of the survey. About 80% of infant caregivers enrolled in WIC reported that they saw safe sleep messages or received safe sleep materials associated with the campaign. Approximately 30% reported they changed how or where they place their infant to sleep after seeing or hearing the safe sleep messages; 49% reported the materials led them to know more about how to keep their infant safe and 50% reported that they spoke with others about safe sleep after seeing/hearing safe sleep messages. Another survey of WIC participants was conducted in Spring 2022. Results will be available by Fall 2022.

Maine Children's Trust (MCT), a Cribs For Kids (C4K) affiliate, partners with the Maine Families Home Visiting Program and Child Abuse and Neglect (CAN) Prevention Councils to distribute cribettes (pack 'n plays) to identified families in need of a safe place for their infant to sleep. Both programs train their staff on the American Academy of Pediatrics' latest recommendations and guidelines. MCT requires that all families receiving a cribette receive safe sleep education and that staff complete a survey with families to gather data requested by both C4K and funders. MCT conducts a follow-up phone survey with families 30 - 60 days later to assess if families that received safe sleep education at the time of the crib distribution are maintaining a safe sleep environment for their infant. MCT and their partners distributed 34 cribettes in calendar year 2021. The decrease of over 160 cribs from 2020 can, in part, be attributed to birthing hospitals being reimbursed directly through the Maine CDC. Another cause for the decline may be due to decreased enrollment in Maine Families Home Visiting.

Strategy: Partner with WIC, Maine Families Home Visiting, public Health Nursing or other programs to provide safe sleep education and counseling

The Maine DHHS recognizes the importance of educating everyone on how to safely place an infant to sleep. There are ongoing efforts to streamline training for Maine DHHS staff who interact with pregnant and postpartum women. Maine DHHS created a training for all new Maine DHHS staff in this role to ensure consistent messaging across Maine DHHS programs.

Public Health Nursing continued to provide a safe sleep environment assessment and parent education within direct service visits, inclusive of high-risk families. The program became a Crib’s for Kids distributor in FY20 and distributed 30 cribettes during this timeframe. Public Health Nursing continues to grow a body of knowledge within the team to offer evidence-based assessment, care and education to pregnant women and newborns. This education includes in-service education from subject matter experts as well as an electronic medical record change to capture results of a safe sleep checklist. New staff receive training on the importance of discussing safe sleep with pregnant and postpartum women.

Maine Families home visitors provide safe sleep education to all enrolled families. Additionally, a Maternal, Infant, and Early Childhood Home Visiting Program performance measure requires family visitors to ask families at three different time periods if they ALWAYS put their baby on his/her back to sleep without bed sharing or use of soft bedding. Data from FY21 revealed that 75.5% of caregivers reported that this was ALWAYS their practice. This is a substantial increase from FY20 when 64.9% of caregivers reported always practicing safe sleep. Family visitors check in frequently about sleep and sleep practices and help to mitigate any circumstances that might lead to bed sharing such as lack of heat or lack of a safe sleep environment. Maine Families home visitors deliver cribettes, provided through MCT and Cribs for Kids, along with safe sleep education, to families identified as not having a safe place for their infant to sleep. Many of these families are immigrants/refugees located in the more populous Portland area.

Strategy: Utilize the recommendations from MFIMR to guide policy/protocols/training needed for MCH Providers

The Maternal, Fetal and Infant Mortality Review (MFIMR) Panel continued to meet virtually throughout the pandemic. The Panel is comprised of experts across the state, including the Title V Director, MCH Epidemiologists, Public Health Nursing, WIC, State Police, a retired OBGYN, a pediatrician and other clinical and public health representatives. The Panel reviewed and made recommendations on maternal, fetal and infant death cases. The number of unsafe sleep related deaths declined in Maine since the launch of the safe sleep campaign in early FY20 and has remained stable. At each meeting the MFIMR panel is provided a data summary of infant mortality to date including the number of SIDS/SUID deaths.

Priority: Increase Breastfeeding Initiation and Duration

Performance Measure: A) Percent of infants who are ever breastfed and B) Percent of infants breastfed exclusively through 6 months

Among infants born in 2018 in Maine, 82.3% were ever breastfed (U.S. = 83.9%) and 30% were breastfed exclusively for at least six months (U.S.=26%). Maine ranked 34th highest on breastfeeding initiation and duration, dropping from 18th highest in 2017. Among Maine infants born in 2019, 86.6% were ever breastfed and 28.7% were exclusively breastfed for at least six months, returning to 18th highest for both measures. Although Maine’s breastfeeding and exclusive breastfeeding rates have increased overall since 2007, data from the most recent National Immunization Surveys show a decline in breastfeeding duration and exclusive breastfeeding in recent years. Birth certificate data also show declining breastfeeding rates at hospital discharge for 2019 and 2020. Recent analyses of breastfeeding using PRAMS data from 2016-2019 indicate that breastfeeding is lowest among women less than 24 years of age, those with less than a high school education, and those with incomes <$20,000. Among women who never breastfed, their reasons for not breastfeeding included that they didn’t want to (40%); they had other children to take care of (24%) and they didn’t like it (23%). Among those who stopped breastfeeding at the time they took the survey, most reported it was because they thought they were not producing enough milk (56%). Others stopped because they felt that breast milk alone did not satisfy their infant (38%) or their infant had difficulty latching (32%). Other factors related to decreased likelihood of continuing breastfeeding for at least 8 weeks were domestic violence, food insecurity, and stressful life events.

Strategy: Ensure breastfeeding promotion and access to breastfeeding information and support

FY21 activities were limited due to COVID-19. Public Health Nursing continued home visits as needed. The Maine CDC continued to promote breastfeeding through educational materials. Public Health Nursing offered Certified Lactation Counselor (CLC) training to all clinical staff to ensure they would be available to breastfeeding mothers as needed.

Strategy: Ensure families have access to inpatient breastfeeding support after birth

During FY21 the Perinatal Outreach Breastfeeding consultant and Nurse Educator provided 16 technical assistance events, reaching over 112 individuals including four physicians, 63 nurses and 45 other categorical staff. These events included presentations, webinars, meetings, newsletter dissemination and quality assurance outreach on breastfeeding.

Overall, the most significant success in the area of breastfeeding rates was the addition of Donor Milk sites in Maine. The interest in and development of multiple sites across the state in a short time frame was reflective of the efforts of multiple community partners, including the education and resources provided by the perinatal outreach education initiative. Maine currently has six (6) sites for milk sharing and are affiliated with Mothers' Milk Bank Northeast.

Strategy: Increase community breastfeeding support across the state of Maine

The Maine State Breastfeeding Coalition remained a key partner throughout the year. Quarterly meetings brought together a broad network of people supporting families who value human milk and breastfeeding. The MSBC worked to enhance the culture of breastfeeding around the state through professional networking, advocacy, and education. The group hosted several virtual events to promote breastfeed during World Breastfeeding Week including topics on milk supply, donor milk and cultural beliefs on breastfeeding.

The Maine Families Home visiting (MFHV) program, funded by a Maternal Infant and Early Childhood Home Visiting (MIECHV) grant, offered newly employed home visitors the opportunity to become CLC trained after their first year of employment. All MFHV sites have CLC trained staff available to support breastfeeding mothers, with several sites offering breastfeeding support groups.

The Women, Infants and Children (WIC) program has breastfeeding peer counselors in all 16 Maine counties. The peer counselors implemented a phone text support system allowing for increased hours of access and support from peer counselors. The WIC program conducted outreach to all 24 Maine birthing hospitals to share information about the program that included assisting moms with breastfeeding. WIC provided loaner breast pumps to breastfeeding mothers and silicone passive pumps and reusable and disposable breast pads for all breastfeeding mothers. Feedback from participants reported the collection, on average, of 4-8 ounces of breastmilk per feeding. Maine currently has approximately 1,500 breastfeeding participants in the program.

PHN continued to offer CLC training for clinical staff enabling staff to provide support to families of a newborn on feeding practices. Public Health Nursing clinical staff also have discussions with families about the importance of breastfeeding.

Maine continued to reevaluate parent, provider and community needs to address breastfeeding rates. Consistent with strategies used across the perinatal outreach and education, breastfeeding support and resources were expanded and stored in an easily accessible online platform that can be accessed at: https://www.mainehealth.org/Barbara-Bush-Childrens-Hospital/Services/Perinatal-Outreach. Of particular interest are resources for breastfeeding education in multiple languages.

Strategy: Increase breastfeeding support and education for families affected by substance use

Each of Maine’s birthing hospitals has been trained in Eat Sleep Console decreasing the stigma for birthing people who have a substance use disorder as well as their families. Eat Sleep Console provides for the birthing person to create a bond with their newborn and breastfeed, as appropriate. It also enables hospital staff to have a dialogue with families in a non-judgmental way and allow for families to participate in the newborn’s care. Data has shown that newborns whose families participate in Eat Sleep Console are less likely to need pharmacological interventions and spend less time as an inpatient.