Infant Mortality

The 2021-2025 priority need related to perinatal/infant health domain is reducing infant mortality and racial/ethnic disparities in infant and perinatal outcomes. Programmatic efforts in FY2021 aimed at addressing this priority are discussed below. We conclude the report with measurement of our progress/impact of reducing infant mortality in Minnesota.

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

To address disparities among infants born to African American/Black and American Indian mothers, staff engaged and worked to build authentic partnerships with programs and community partners working on infant mortality. The Needs Assessment and Strategy Team recommended shifting priorities for infant health, so there is continued development of strategies to address community needs. Some examples of strategies explored with partners and other community representatives are included in the report.

Activity 1: Provide Supports for Healthy Pregnancy and Parenting Outcomes through the Provision of Activities such as but Not Limited to Prenatal Care Services, Nutrition Education and Parenting Classes

African American Babies Coalition

In 2021, the Minnesota State Legislature allocated a total of $520,000 grant to the African American Babies Coalition (AABC) for state fiscal year 2022 and 2023 to:

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

AABC is a community group focused on improving birth outcomes in Black and Brown communities in Minneapolis and St. Paul. AABC hosted its second “Biannual Black and Brown Baby Summit, Shifting the Power Narrative in Black and Brown Birthing Networks” in September 2021. The summit provided an opportunity for health care providers, public health, legislative representatives, and others to learn about “shifting the power narrative.” The summit focused on father figures in the parenting process, transferring knowledge and traditional practices from elders to younger generations in our communities, and processing anxiety, trauma, grief, and loss as it relates to maternal and infant mortality/morbidity.

Positive Alternatives

MDH’s Positive Alternatives (PA) grant program, is a statewide initiative that supports, encourages, and assists women to carry their pregnancies to term by offering local resources to develop and maintain family stability and self-sufficiency.

PA grantees provide birthing and postpartum persons with information on, referral to, and assistance with securing necessary services to promote healthy pregnancies and care for their babies after birth or in making an adoption plan. Necessary services include but are not limited to medical care, nutrition services, housing assistance, adoption services, education, and employment assistance, including services that support the continuation and completion of high school, childcare assistance, parenting education and other related support services.

In October 2020 through September of 2021, PA provided car seat safety instruction and distribution of car seats to 412 families. In addition, 388 clients received housing assistance, 8,804 clients received parenting education such as prevention of abusive head trauma, and more than 8,800 material supports services such as diapers, maternity clothes, and infant equipment were provided by 27 grantee organizations throughout the state.

Activity 2: Partnerships with Community Organizations to Support System Change and Innovative Solutions

In 2017, St. Paul-Ramsey County Public Health used Title V funds to create and implement the Birth Equity Community Council (BECC), a community-led collaborative to improve birth outcomes and reduce infant mortality racial disparities. Since BECC’s inception, Title V staff have been and continue to be a partner, serving as a state public health advisor and participating on BECC subcommittees, as well as providing TA, strategic planning, and data analysis support. MDH benefits from this partnership by learning from the African American community about what matters to them in improving birth outcomes through drawing from their expertise, wisdom, strength, and resilience.  BECC finalized its vision and mission statements and began implementing activities around core strategy areas of training, celebrations, policy, and a key priority of supporting fathers, which created the Doula Dads project.

This innovative project empowers fathers to be supportive and vocal in the birth process by training men as certified perinatal educators (doula certification) to provide education on perinatal care topics. Ten men received certification, with several having established their own practice.

BECC convened a policy work group in FY2021 to address the low Medicaid reimbursement rates for doula care. The policy workgroup included community members, DHS (Medicaid agency), MDH, Everyday Miracles (https://www.everyday-miracles.org/), advocates, and representatives of health plans. The work group purpose was to influence policy change through legislation to increase payment for doula services. BECC partnered with the Minnesota Children’s Defense Fund to provide training to community members on how to navigate the legislative process.

Another innovative project BECC implemented was partnering with a local ethnic radio station to announce the births and birthdays of infants born to their community partners and participants in their Club Mom and Club Dad programs to help celebrate births and community support.

Activity 3: Promote Safe-Sleep Practices for All Infants

Reducing Sudden and Unexpected Infant Death (SUID) rates, the third leading cause of infant mortality, about 11% of state’s total 330 infant deaths each year is one area of focus.

By 2025, Minnesota aims to reduce the overall SUID rate by 15% and reduce the SUID rates between whites and African Americans and American Indians by 15%.

According to the Data from the Minnesota Sudden Death in the Young (SDY)/SUID Case Registry for 2016-2020 infants born to American Indian mothers experience highest disparities and are approximately three to fifteen times more likely to die suddenly and unexpectedly before age one than infants born to white and Asian mothers, respectively. The majority of SUID in the state are preventable. Of the 100 SUID that occurred between 2018 and 2019, 93% were related to unsafe sleep practices.

MDH disseminated safe sleep educational materials and resources to fathers and immigrants whose primary language is not English and others. Activities to help reduce SUID deaths included community partners, local public and tribal health, and PA grantees distributing educational maternal and resources to families including:

• 6,000 “Sleep Baby Safe and Snug” books statewide (in English and Spanish)
• 500 cards on the ABCs of safe sleep; The cards are available in Hmong, Somali, Karen, Spanish-languages
• 100 ethnic/racially focused safe sleep materials from the National Institute of Child Health and Human Development

PA grantees provided their clients with 1,667 portable cribs and 2,985 clients with safe sleep information. Cradle of Hope, a non-profit organization, and a PA grantee, distributed 1,626 cribs via a network of 188 partner sites throughout the state. Cradle of Hope partnered with Red Lake Band of Chippewa, Bois Forte 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 to distribute cribs. The race/ethnicity of the clients that received cribs were 35% white, 36% African American/Black, 15% multiracial, 8% American Indian, and 6% were Somali.

FHV encourages home visitors to provide safe sleep education to families receiving home visiting services. MIECHV funded grantees report on safe sleep practices for families receiving their services. Due to the COVID-19 necessity of virtual visits, data on this topic area was reduced to one third of the families’ receiving services, which reported more than half of the families used safe sleep practices.

Activity 4: Safe Sleep Workgroup and Cradleboard Usage in Licensed Childcare Settings

In FY 2020, CFH staff participated in a workgroup convened by the state legislature to examine current DHS statutes to ensure infant sleep safety in childcare settings and make recommendations for updating policy. In FY2021, MDH provided TA to DHS for statute revisions related to licensed childcare providers requesting a variance to use cradleboards for cultural reasons when a parent requests one (Cradleboard is a traditional baby-carrier used by many Indigenous populations). The suggested revised language calls for MDH and DHS to create a Cradleboard variance form in partnership with tribal social service agencies. The suggested language changes did not pass during the 2021 legislative session and is being considered for the 2022 session.

Activity 5: Promote Infant Sleep Safety by Providing Consistent and Inclusive Safe Sleep Messaging

MDH and stakeholders promoted consistent and inclusive safe sleep messaging from the American Academy of Pediatrics (AAP) safe sleep recommendations to support preventable sleep-related tragedies during infancy. With our stakeholders, FHV, DHS, local public health agencies, grantees, and community organizations we implemented activities to support placing infants to sleep on their back and in a safe sleeping environment and raise awareness of sleep related SUID and infant mortality.

During “Infant Safe Sleep Week” November 14-20, 2020, a few of the activities included:

• A Governor’s proclamation with the SUID
• Social media messaging to than 29,000 views and shared 1,100 times.
• “Frequently Asked Questions” (FAQ) to 17,500 childcare providers.
• Local radio stations promotion with community partners.
• FHV Tuesday Topics e-newsletter sent to more than 2,000 subscribers.

Activity 6: Provide Trainings on Infant Mortality, Bereavement, and Breastfeeding to Partners

MCH staff and grantee, Star Legacy Foundation, presented on the grief and loss support activities to a local public health professionals conference for home visiting, WIC and other MCH program staff. Star Legacy presented comprehensive overview of the types of grief and loss services provided, and the process used by the organization to connect grieving families to the resources and services they need.

Staff presented at several virtual summits, meetings, and conferences on MN’s infant mortality rates, the disparities experienced by the African American/Black and American Indian communities and identified factors contributing to these deaths. Some of the conferences were AWHONN, MNPQC, and AABC Summit.

To promote protective factors for infant health, FHV programs are encouraged to use grant funds for staff to become lactation counselors, which may support the initiation and duration of breastfeeding. In FY 2021, 68% of infants whose mothers participated prenatally in FHV programs received some amount of breast milk at six months of age as compared to only 35% in FY 2020.

Activity 7: Expand Community-Based Infant Mortality Prevention Education

During Infant Mortality Awareness Month, Governor Walz proclaimed the week of October 17-23, 2021, as Infant Mortality Awareness Week. The proclamation stated that infant mortality is a multi-factorial, complex societal problem that requires a response from across many sectors and disciplines to address conditions that negatively affect birth outcomes. Factors include maternal health and wellbeing, housing and job insecurity, environmental toxins, lack of social support and community connections, and a lack of access to health care. Systemic racism and discrimination against Black/African American, American Indian, and other people of color directly contributes to inequities in infant mortality. Infant Mortality Awareness Week provided an opportunity for individuals, organizations, government entities, healthcare systems, community partners, and coalitions to promote awareness and education about infant mortality. Educational messages related to infant mortality were posted on MDH social media platforms throughout the week.

Minnesota also provided educational information to families and health providers on Shaken Baby Syndrome/Abusive Head Trauma (AHT). MDH approves video material for hospitals to use to educate birthing people and their families on AHT and have written material – called “Baby Cry” cards - for hospitals and other health providers to distribute to parents and caregivers. In 2021, MDH distributed approximately 400 “Baby Cry” cards to local public health home visitors and PA Grantees for parent and caregiver education on safe infant care.

The Region V Infant Mortality TA Session supported our MCH staff working with our community partners to plan a course of action and move forward with reducing infant mortality in our Black/African American and Indigenous families, the populations impacted the most. Our team included leaders from community organizations serving these families, the state Medicaid program, local public health, and others.

To improve community outreach, one goal during FY 2021 was to collaborate with existing community-based infant mortality initiatives and programs serving families of color and American Indian Communities to develop strategies to reduce infant mortality. During the reporting period, MDH collaborated with multiple existing initiatives that focus on improving infant health outcomes such as BECC, St. Paul-Ramsey County Parents as Teachers (PAT) initiative, FHV, and PA grantees to increase awareness of infant mortality and the multi-factorial causes and to deliver infant health promotion education to families.

The bandwidth to further plan and implement infant mortality reduction activities in 2021 was limited due MCH staff reassignments to work on the state’s COVID-19 response.

Activity 8: Reduce Disparities in Modifiable Risk Factors for Birth Defects

The Healthy Communities for Healthy Futures grant, a collaboration between the MCH and CYSHN Sections, aims to reduce disparities in modifiable risk factors of birth defects by a community-driven innovative approach. The grant is grounded in the perspective that communities know what they need to address disparities. Grant applicants deliver projects addressing health disparities in leading risk factors for the most common birth conditions in Minnesota. Community-led approaches of addressing these risk factors are necessary to create positive, sustainable change in these disparities. Two grantees were selected to implement interventions for women of childbearing age to address diabetes, obesity, smoking, hypertension, substance misuse, intrauterine infections, chemical exposures, or maternal stress. The focus populations for this work are groups experiencing health disparities in one or more of the risk factors listed above, including but not limited to People of Color, American Indian, people with disabilities, LGBTQ, rural residents, limited English proficiency, immigrant/refugee, and low-income communities. More information about the work of these grantees will be included in future reports.

Activity 9: Grief and Loss Support Grant

In 2019, MDH awarded a grant to the Minnesota Center for Stillbirth and Infant Death (MNCSID), run by the Star Legacy Foundation, to connect families who have experienced an infant death or a stillbirth to grief and loss support resources. This grant is a collaboration of Title V and the birth defects prevention program. For 2021, MNCSID reported 577 referrals, 46% were infant deaths and 49% were fetal deaths. As part of their communications with families, MNCSID sent out 552 condolence letters, held 597 initial consultations with clients, and sent out 2,063 packets of grief and loss resources in response to requests for this information of which 93% were to providers and 7% to families.

Activity 10: Culturally Specific Support for Breastfeeding

Minnesota’s breastfeeding activities are led by the state WIC program. Minnesota WIC (MN WIC) provides culturally specific support for breastfeeding through its partnerships and collaboration throughout the state to develop breastfeeding materials and expand outreach to targeted cultural groups, including Hmong, Karen, American Indian and Somali communities. During this reporting period, MN WIC’s collaboration with the tribal nations and cultural communities involved sharing and developing a better understanding of the meaning behind the data, determining data to share, and discussing community-driven strategies to reduce disparities.  Described below are activities led by Minnesota’s breastfeeding partners and MN WIC in FY2021.

Partner Activities

Minnesota Breastfeeding Coalition

The Minnesota Breastfeeding Coalition (MBC) in partnership with MDH, the Minnesota Milk Bank for Babies (MMBB) and several food pantries developed a project to increase equitable access to pasteurized donor human milk (PDHM) to fully support chest/breastfeeding families. The project is funded by the Association of State and Territorial Officials and includes gathering qualitative and quantitative data in collaboration with three food pantry sites (NorthPoint Health and Wellness, Pillsbury United Communities, Falls Hunger Coalition), and co-creating recommendations for policies, systems or environmental updates that will provide optimal support for food pantry clients who want to breastfeed their infants. In FY2021, surveys were completed with food pantry visitors and frontline staff to ensure community voice was central to the development of the project. MMBB developed PDHM distribution guidelines and provided orientation of the process to food pantry partners.

In addition to regional coalitions, the MBC is working with cultural coalitions such as the Hmong Breastfeeding Coalition (established in 2019) and the Indigenous Breastfeeding Coalition (established in 2017).

The Hmong Breastfeeding Coalition

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

Ramsey County Public Health

There are similar efforts underway in African American communities, with Ramsey County Public Health’s State Health Improvement Plan (SHIP) funding for the Moving Equity into Data (MEDA) project. The MEDA project conducted community listening sessions with members of the U.S. born African American community to co-create breastfeeding friendly messages. From the themes that emerged, messaging and art were created by the community members. Ramsey county will be part of the MEDA cohort two, working on expanding the project to U.S. born African American young men and males.

Several initiatives began during FY2021 to diversify the community of lactation professionals in Minnesota. Ramsey County WIC was awarded funding from the Bigelow Foundation to partner with Regions Hospital and MBC to support five BIPOC WIC peer counselors toward careers as certified lactation professionals. Hennepin County WIC was awarded a National WIC Association Advancing Health Equity to Achieve Diversity and Inclusion (AHEAD) grant to support seven BIPOC peers in partnership with Hennepin County Medical Center. For both grant projects, the peers are completing health science courses, lactation education and mentorship through the hospital and WIC to meet the requirements to sit for the IBLCE exam.  The peers are also participating in a workgroup to develop a sustainable program to increase the number of BIPOC certified lactation professionals with culturally relevant training. MBC also provided five scholarships for BIPOC individuals working independently on the path towards advanced lactation professional certification.

Minnesota WIC Program Activities

Minnesota WIC program supported breastfeeding in American Indian, Black, and other communities of color through grants supported by federal WIC operational adjustment funds. WIC supported four local agencies with grants up to $5,000 to support breastfeeding related projects. Projects included:

• Aitkin County provided breastfeeding support baskets for prenatal peer home visits.
• Beltrami County designed and posted a billboard promoting equity in lactation within the American Indian community.
• Cook County commissioned 2 original public art pieces representing cultural practices that support breastfeeding in the Indigenous community that will be displayed in their local WIC clinics.
• Hennepin County supported numerous initiatives supporting breastfeeding in Black, American Indian, Hmong, Latino and low-income families. Their grant was used to provide support to the Chocolate Milk Club, Hmong Breastfeeding Coalition, Nitamising Gimashkikinaan-Indigenous Perinatal and Lactation Support Circle, and the Hennepin Peer Program during National Breastfeeding Month.
• Additional funding was provided to support the food pantry pilot providing ‘bridge packs’ of PDHM to families by training two peers to work with PDHM recipients and supply milk cooler bags to package the milk.

Minnesota WIC co-sponsored an Indigenous Breastfeeding Counselor training hosted by Nitamising Gimashkikinaan. This was a 45-hour, week-long training for Indigenous identifying people who wanted in depth breastfeeding training. This training trained 40 participants.

MN WIC sponsored monthly breastfeeding webinars hosted by the Michigan Breastfeeding Network. These webinars are available to WIC staff and partners to learn more about timely breastfeeding topics and earn a variety of continuing education credits.

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

Figure 1. Breastfeeding Initiation Rates 2019 to 2021 comparing WIC participants to non-participants, by Race/Ethnicity and Selected Cultural Identities

Source: MN WIC information system

From 2012 to 2019, there had been significant increases in breastfeeding initiation in the Black/African American community, from 70.0% to 79.8%. By 2021, initiation in this community declined to 76.2%. (Figure 1) Rates dropped for Black/African American non-WIC participants and WIC participants by 4.9 and 4.6 percentage points, respectively. Among American Indians, rates increased by 4.2 percentage points among non-WIC participants while declining slightly among WIC participants. The opposite was seen in the Hmong community, where initiation decreased 6.9 percentage points among non-WIC participants and only 1.7 percentage points among WIC recipients.

The pandemic has disproportionately impacted WIC families, and these impacts can be seen in the breastfeeding initiation rates of WIC vs. non-WIC parents. WIC families, and their breastfeeding rates, have been impacted by many factors. Many WIC parents report having to return to work shortly after birth to workplaces that don’t support breastfeeding. Mental health concerns and stress exacerbated by pandemic circumstances are impacting initiation and duration of breastfeeding. Lack of support is another reason many share with in-person and community support groups shut down, limited contact with family and friends and earlier hospital discharges mean that many families don’t have anyone to turn to when breastfeeding is challenging. Lastly, decreased prenatal education could be reducing successful breastfeeding. Many WIC agencies report pregnant women entering the program later in pregnancy, not attending prenatal classes and not seeing health care providers as often during pregnancy.

The WIC Peer Breastfeeding Support Program (PBSP) supports families to meet their breastfeeding goals by pairing families with peer counselors, parents with personal experience feeding their own children. Peer counselors are recruited from the communities they serve and often speak the same language, have similar life circumstances and experiences as their clients. Minnesota WIC peer counselors improve health by increasing breastfeeding initiation, exclusivity, and duration. With increased federal funding, the PBSP was able to expand the number of peer programs from 14 to 18, making services available to more WIC families.  The new programs were awarded funding in June 2021 for the grant period January 2022 – December 2026.

Activity 11: Addressing Prematurity

Preterm Birth Prevention Collaborative via the Minnesota Perinatal Quality Collaborative (MNPQC)

In October 2020, MNPQC’s Preterm Birth Prevention Collaborative (PBPC) concluded, and resources are being developed to share lessons learned. The goal of PBPC was to reduce preterm birth and improve pregnancy outcomes for women and their families. Four health systems implemented strategies to prevent preterm birth through a learning collaborative launched December 2019. Implementation of quality improvement activities across these health systems included 18 hospitals with at least 18,000 deliveries annually.

The MNPQC PBPC faculty re-evaluated the project design based on release of Makena/FDA statement on failure to confirm the benefit of 17p to newborns or reduce the risk of preterm birth. A comprehensive approach as a “Preterm Birth Prevention” change package was designed to offer a menu of strategies for teams to use with their health systems. These strategies included:

1. Screening and identification of previous preterm birth
2. 17P use, tracking and clinic management
3. Cervical length and
4. Commercial tobacco cessation.

An important success was the continual access to key content experts (smoking cessation; antiracism; data sources) during a virtual platform to support the PBPC. The PBPC had virtual calls for learning sessions, data coordination and other quality improvement action step support. Due to COVID-19, PBPC faculty re-evaluated timeline determined realistic next steps to support teams within their health systems.

The PBPC chair and members shared strategies to address preterm birth, which may be applied on a statewide level. COVID-19 response dramatically impacted the health system teams’ ability to sustain commitment. PBPC chair provided recommendations on how to implement strategies during a pandemic. These strategies were:

1. taking a thorough history at the new OB visit
2. using the electronic medical record problem list
3. updating the patient list that identify women with prior spontaneous preterm birth
4. providing education for providers to reinforce multi-faceted nature of condition.

Major lessons learned include the following:

• It was premature to assume all steps in the PBPC algorithm were reliably in place.
• There is not one single solution, i.e., one big change to the medical record would not ensure patient centered, reliable, safe, comprehensive care.
• Many changes to improve a woman’s prenatal health can be implemented despite a pandemic.
• It is hard to motivate change without “pull” from partners like regulators, payors, Joint Commission on Accreditation of Healthcare Organizations, professional organization priorities and consensus.
• Lastly, excellent prenatal care is complex, and complex system change has a lag in outcome data, thus making it hard to ascertain in 11 months if improvement occurred and was sustained.

Strategy B. Improve Data Collection and Evaluation

Minnesota will improve data collection and evaluation as a strategy to reduce infant mortality. This will ensure availability of data for planning, programing, and informing policy decisions aimed at improving maternal and infant health outcomes in communities around the state. Data for evaluation will help with determining our progress in achieving our desired maternal and infant health outcomes.

Activity 1: Improve Data-Sharing

Minnesota has strict data privacy laws, which sometimes impede sharing infant health and mortality data among divisions within a state agency, with other state agencies and with the public. Of particular concern is not being able to share infant mortality data when there are fewer than twenty infant deaths in a population even when such data is needed for policy and programmatic purposes. To address this concern, in FY2021:

• CFH’s Health Equity Measurement Committee explored the possibility of removing barriers associated with sharing data with our partners when there are fewer than 20 infant deaths occur in a population. The group drafted a document titled Small Number Guidance to outline the standards and guidelines when using, analyzing, and reporting data related to small numbers. The guidance is designed to help balance the need to meet reporting requirements, adhere to legal requirements, and to protect individual’s personally identifiable information under federal and state law, while at the same time providing as much data back to communities as possible.

• Staff worked to gain access to data on births and deaths that occur in neighboring states for Minnesota residents. Meetings with internal teams resulted in an agreement to share data across the agency while at the same time working within the confines of Inter-Jurisdictional Exchange (IJE) agreement for the State and Territorial Exchange Vital Events.
• Weekly data shared with the Star Legacy Foundation were often revised and monitored to ensure accuracy.
• Plans to continue SUID and SDYC registry data sharing with birthing hospitals was put on hold due to staff being reassigned to the state’s COVID19 mitigation.

Activity 2: Establish a Fetal and Infant Mortality Review (FIMR)

In 2001, statute authorizing the Commissioner of Health to conduct FIMR was repealed. Without the legislation in place, MDH lacks statutory authority to establish a FIMR process and committee. Since 2014, there have been legislative proposals to reinstate the FIMR without success. The proposal advanced in 2021 as part of Governor’s budget, but the proposal was not adopted because of data privacy concerns.

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

MDH made efforts to encourage policy and systems changes aimed at fostering optimal infant health outcomes in Minnesota. This includes increasing the number of safe sleep certified hospitals, Baby-Friendly Hospitals, and breastfeeding friendly maternity centers around the state to ensure that providers are promoting best practices.

Legislation passed in 2021 increasing Medicaid Coverage for birthing people to 12 months, promote access to health services to support parent education, as well as screening and treatment for postpartum depression for birthing people. Also, includes coverage of family planning services which may promote birth spacing and interconception care.

Activity 1: Increase the Number of Safe Sleep Certified Hospitals

Staff conducted a survey of all 84 birthing hospitals in Minnesota to determine whether they had a hospital safe sleep policy in place, provided safe sleep training for their staff, or provided safe sleep education to mom/parents before they are discharged from the hospital. Although fewer than 20 hospitals responded to the survey possibly due to the pandemic. Using survey information to further encourage hospitals interested in becoming safe sleep certified and offering other TA and consultation.

Barriers to completing this work were due to staff reassignment for state’s COVID-19 response.

Evidence-Based Strategy Measure (ESM)

Safe sleep modeling occurs when hospitals develop, implement, maintain, and enforce a safe sleep policy that aims to prevent sleep-related injuries and deaths, and staff model safe sleep by intentionally conveying messages and cues to parents that promote sleep safety for infants. Because parents/caregivers tend to imitate the behaviors and practices they observe in the hospital later at home, it is important for birthing hospitals in Minnesota to seek certification through the national program.

Our ESM for FY2021 is measuring the proportion of births occurring at safe sleep certified hospitals. The goal to increase the number to four birthing hospitals being safe sleep certified was not met due to COVID19 pandemic.

Figure 2. Percent of Births Delivered at MN Birthing Hospitals with National Safe Sleep Hospital Certification (ESM 5.1)

Activity 2: Increase the Number of MDH Breastfeeding-Friendly Recognized Birth Centers

Most births in Minnesota occur in hospital settings. Maternity hospital practices and policies can undermine maternal and infant health by creating barriers to supporting a mother's decision to breastfeed. When hospitals become Baby-Friendly, they have the tools to give mothers the information, confidence, and skills necessary to successfully initiate and continue to breastfeed their babies. Women who get the support they need in the hospital are much more likely to continue once they return home.

Evidence-Based Strategy Measure

Our work on policy and systems changes are aimed at fostering optimal infant health outcomes. Work to support Baby-Friendly hospitals and breastfeeding, includes convening the 10 Steps Learning Collaborative, a quality improvement community led in partnership by the MBC and MDH. Four hospitals meet monthly to share resources and progress toward implementing the 10 Steps to Successful Breastfeeding. Progress has been slowed due to COVID-19; however, two hospitals in the collaborative have achieved 1-star and 2-star recognition. Each star is awarded for implementing 2 of the 10 Steps up to 5-stars. The MBC’s 7th Annual Perinatal Hospital Leadership Summit provided lactation education to nearly 100 hospital providers and their partners. The Summit focused on reducing racial disparities in infant mortality, the importance of human milk feeding, and improving birth center care practices.

Minnesota’s second ESM for the perinatal/infant health domain is measuring the proportion of births that occur at MDH Breastfeeding-Friendly Recognized Birth Centers (BFRBCs).

Figure 3. Percentage of Infants Born in Breastfeeding-Friendly Recognized Birth Centers (ESM 4.1)

As illustrated in Figure 3 above, the percentage of infants born in Breastfeeding-Friendly recognized birth centers decreased as several large hospital systems chose not to redesignate. However, two hospitals were re-designated to continue their commitment from 2020-2025 and two other facilities have partially completed Breastfeeding-Friendly Birth Center recognition requirements.

Activity 3: Participation in AMCHP’s Healthy Beginnings Cohort

In June 2021, MDH applied for and was selected as one of eight health departments in the U.S. to participate in the AMCHP Healthy Beginnings Cohort. The cohort was convened to help states develop action plans to dismantle racism in existing policies, data, and funding structures that have historically perpetuated and fostered inequities in perinatal health outcomes in BIPOC populations in Minnesota. MDH was paired with Minnesota Indian Women’s Resource Center to co-develop the action plan during 2021 and 2022.

Measuring Progress in Infant Mortality

The work outlined in this priority area are focused on reducing infant mortality. Minnesota is tracking National Performance Measure (NPM) 5 A) Percent of infants placed to sleep on their backs B) Percent of infants placed to sleep on a separate approved sleep surface C) Percent of infants placed to sleep without soft objects or loose bedding for the current five-year cycle FY2021.

According to MN PRAMS data, 86.4% of mothers surveyed in 2020 reported placing infants on their back to sleep. Figure 4 shows a slight but modest progress towards increasing the proportion of infants placed to sleep on their backs.

Figure 4. Percent of Infants Placed to Sleep on Back (NPM 5A)

By 2025, Minnesota aims to reduce the overall SUID rate by 15% and reduce the SUID rates between whites and African Americans and American Indians by 15%.

Research shows 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. Because breastfeeding exclusively is most protective against SIDS, Minnesota is also tracking NPM 4A) Percent of infants who are ever breastfed and B) Percent of infants breastfed exclusively through 6 months. If possible, mothers should exclusively breastfeed or feed with expressed human milk for 6 months, in alignment with recommendations of the AAP. The protective effect of breastfeeding increases with exclusivity. However, any breastfeeding has been shown to be more protective against SIDS than no breastfeeding.

Our objective for FY2021 for NPM 4A, was to have 93.5% of infants ever breastfed. According to the most recent data available from National Immunization Survey (NIS), the percent of infants who were ever breastfed was 88.6% in 2018 (see Figure 5). This means our target for FY2021 was not met.

Figure 5. Percent of Infants Ever Breastfed (NPM 4a)

For NPM 4B Minnesota’s objective for FY2021 was 37.8%. Data from NIS indicate we didn’t meet our NPM 4B objective for FY2021 since the percent of infants who are exclusively breastfed through 6 months was 29.4%. Minnesota’s programmatic efforts during FY2021 to promote and support breastfeeding with evidence-based practices are discussed above showing how we have and continue to promote this work and hope the dip found in the NIS data is temporary.

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

Minnesota is also closely tracking the infant mortality rate by race/ethnicity. Recent data from MDH linked birth/infant death file show that the state’s infant mortality rate declined from 5.1 infant deaths per 1,000 live births in 2012-2016 to 4.7 in 2016-2020 (Figure 7). Except for Hispanics, rates also declined for all other racial and ethnic groups in the state overall between 2015-2019 and 2016-2020. 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 2016-2020 show that their infant mortality rates were 2.1 and 2.7 times that of non-Hispanic Whites, respectively.

Figure 7. Minnesota Infant Mortality Rate by Race/Ethnicity, 5-Year averages, 2012-2020