PERINATAL/INFANT Priority Need 1: Ensure all infants are born healthy and thrive in their first year of life.
PERINATAL/INFANT Priority Need 2: Reduce infant mortality with a focus on eliminating disparities.
Surveillance:
The Maternal, Child, and Adolescent Health division of the California Department of Public Health (CDPH/MCAH) monitored select quantifiable characteristics to track the health of California’s infants as part of its routine health surveillance efforts. The indicators and measures listed in the table below are continuously and systematically collected, analyzed, and interpreted to guide program planning, implementation, and evaluation of interventions. CDPH/MCAH will continue to analyze at the state level and, when possible, county, race/ethnicity, and other sub-state levels to identify specific improvement opportunities.
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Select Perinatal/Infant Health Indicators and Measures |
Data Source |
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Breastfeeding initiation and duration |
Maternal and Infant Health Assessment Survey and Genetic Disease Screening Program, Newborn Screening Data |
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Infant mortality, including SUID/SIDS |
CA Birth Cohort File or CA Comprehensive Master Birth and Death Files |
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Grief and bereavement services |
SIDS Program Data |
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Infant Safe Sleep practices |
Maternal and Infant Health Assessment Survey |
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Preterm birth rate, including rate among infants born to non-Hispanic Black women |
CA Comprehensive Master Birth File |
As part of California’s Title V State Action Plan, focus areas were identified in each population domain. Each year, the 61 Local Health Jurisdictions (LHJs) in California develop annual Scopes of Work (SOW) that contain activities that align with the Title V Action Plan and these focus areas.
The following graph shows the number of LHJs and the related focus areas in the Perinatal/Infant Health Domain that had activities the LHJs planned to implement in their 2021-2022 SOWs.
- 42 LHJs (70%) worked on Perinatal/Infant Focus Area 1: Improve healthy infant development through breastfeeding and caregiver/infant bonding, in FY 2021-2022
- 51 LHJs (85%) worked on Perinatal/Infant Focus Area 2: Reduce infant mortality with a focus on reducing disparities, in FY 2021-2022
- 18 LHJs (30%) worked on Perinatal/Infant Focus Area 3: Reduce preterm births, in FY 2021-2022
The following graph shows the number of activities in each focus area in which the LHJs conducted efforts to address these areas in their 2021-2022 SOWs.
- 63 SOW activities supported Perinatal/Infant Focus Area 1: Improve healthy infant development through breastfeeding and caregiver/infant bonding were implemented by 42 LHJs (70%) in FY 2021-2022
- 124 SOW activities supported Perinatal/Infant Focus Area 2: Reduce infant mortality with a focus on reducing disparities were implemented by 51 LHJs (85%) in FY 2021-2022
- 34 SOW activities supported Perinatal/Infant Focus Area 3: Reduce preterm births were implemented by 18 LHJs (30%) in FY 2021-2022
Perinatal/Infant Focus Area 1: Improve healthy infant development through breastfeeding.
Perinatal/Infant Objective 1:
By 2025, increase the percentage of women who report exclusive in-hospital breastfeeding from 70.2% (2018 GDSP) to 72.5%.
Perinatal/Infant Objective 1: Strategy 1:
Lead surveillance of breastfeeding practices and assessment of initiation and duration trends.
Story Behind the Curve:
Breastfeeding is linked to a reduced risk from many illnesses in children and mothers. Exclusive breastfeeding for the first six months of life is linked to health benefits for infants. Although breastfeeding initiation rates are high in the United States, most women do not breastfeed exclusively for the first six months and most of the challenges to exclusive breastfeeding are environmental[1]. Strategies like peer support, education, longer maternity leaves, lactation accommodation, transportation services, and breastfeeding support in the hospital, workplace, and community have been shown to increase rates of exclusive breastfeeding. Improvements in hospital policies have resulted in increases in breastfeeding rates.[2] From 2010 to 2020, California exclusive in-hospital breastfeeding rates rose from 56.6% to 70%, and population differences were reduced significantly. Recent data show that progress has slowed, and smaller but important disparities persist.[3] While Baby-Friendly and similar policies improve maternity care, not all California women experience these policies and practices the same way.
Sixty percent of mothers do not breastfeed for as long as they initially intended. Exclusive breastfeeding is influenced by factors including, but not limited to, issues with lactation and latching, concerns about infant nutrition and weight, unsupportive work policies and lack of parental leave, cultural norms and lack of family support, and unsupportive hospital practices and policies.
CDPH/MCAH collects infant-feeding data for all maternity hospitals in the state. In 2020, 93.5% of California mothers began breastfeeding, but 30% of those mothers also fed their infants formula during their hospital stay.[4] Healthy People 2020 objectives indicated that in-hospital supplementation should be limited to approximately 14% of breastfed infants.[5] Though rates of exclusive breastfeeding in California have not declined, this outcome demonstrates a widening racial/ethnic gap rather than a stabilization across all populations. Despite significant increases in exclusive breastfeeding among all racial groups since 2010, disparities in breastfeeding rates persist in California. For example, nationally, Black women still are less likely to initiate breastfeeding. Hispanic women are less likely to exclusively breastfeed than other groups despite having generally higher rates of initiation. While the Baby-Friendly Hospital Initiative and similar policies improve breastfeeding initiation, not all California women experience these policies and practices the same way. To achieve breastfeeding equity in California, it is important to build on the foundation created by widespread adoption of supportive polices. Resources, quality improvement processes, and community partnerships are needed to ensure equitable structures and approaches are in place to meet the needs of California’s diverse families.
CDPH/MCAH will lead breastfeeding data collection and surveillance in collaboration with WIC and UCSF on Social Disparities in Health utilizing the Maternal and Infant Health Assessment (MIHA) survey.
Narrative:
Development of the MIHA 2022 survey occurred from September 2021 through March 2022 and involved collaboration between subject matter experts, leadership from CDPH/MCAH and UCSF Center for Health Equity (CHE), and input from other CDPH programs, the CDC, and key MCAH/MIHA stakeholders. As in previous years, the survey included questions about breastfeeding intention, whether a mother has ever breastfed, breastfeeding duration, and supplementation. Additional questions included WIC participation, reasons for not enrolling in WIC prenatally and benefits participants liked, including support for breastfeeding and help getting a breast pump. CDPH/MCAH and UCSF CHE collaborated closely with WIC breastfeeding program staff to develop a series of questions related to hospital practices that support breastfeeding. This and the other topics of workplace breastfeeding support and postpartum leave were added to the MIHA 2022 survey. CDPH/MCAH supported UCSF CHE in MIHA data collection for the MIHA 2021 and 2022 surveys and had regular meetings to discuss data collection.
Activity:
CDPH/MCAH will lead the dissemination of breastfeeding data findings to increase breastfeeding initiation.
Narrative:
CDPH/MCAH created indicator-specific data dashboards designed to serve the data needs of our partners and stakeholders. State-, county-, and/or regional-level indicator data are shown by various stratifications or subgroups and by year. Each dashboard also includes a link to download the data. The dashboards are organized by the five Title V health domains. The Breastfeeding Dashboard was in progress during this reporting period.
Local MCAH Program Examples:
- El Dorado County breastfeeding rates are higher than the state objective. The Breastfeeding Coalition is led by MCAH Public Health Nursing and includes participation by MCAH, WIC, our local birthing hospitals, doulas, and mothers. The Breastfeeding Coalition meets quarterly to monitor these rates and support breastfeeding from delivery and beyond.
- Riverside County monitored and tracked breastfeeding initiation and duration rates and disseminated data to community and local partners to support expansion to all home visiting programs in the local MCAH.
- Through partnership with local Hazel Hawkins Memorial Hospital (HHMH) and the Baby-Friendly Task Force, San Benito County MCAH accesses data regarding breastfeeding initiation rates and exclusive breastfeeding rates in-hospital for those residents that delivered at HHMH. This data is disseminated through the local Healthy Mothers Healthy Babies.
- Trinity County collaborated with and disseminated information through the Perinatal Coalition which is the primary method for engaging providers and partners who serve pregnant and postpartum women and their infants. COVID-19 limited some of the work around this objective.
Perinatal/Infant Objective 1: Strategy 2:
Lead technical assistance and training to support breastfeeding initiation, including the implementation of the Model Hospital Policy or Baby-Friendly in all California birthing hospitals by 2025.
Activity:
CDPH/MCAH will lead the completion and dissemination of the Model Hospital Policy.
Narrative:
The focus of this reporting period was to complete and finalize the fourth edition of Providing Breastfeeding Support: Model Hospital Policy Recommendations. The recommendations give guidance to birthing hospitals who wish to revise policies to align with the Baby-Friendly Hospital Initiative, or an alternate evidenced-based process by 2025. The CDPH/MCAH Nutrition and Physical Activity (NUPA) Coordinator worked with RPPC contractor Perinatal Advisory Council/Leadership, Advocacy, and Consultation (PAC/LAC) and WIC Regional Breastfeeding Liaisons to finalize the recommendations. They were released in March 2022. CDPH/WIC partnered with 84 WIC Local Agencies, including the 29 Regional Breastfeeding Liaison (RBL) Programs to distribute the recommendations within their communities.
Activity:
CDPH/MCAH will lead technical assistance and breastfeeding quality improvement initiatives with RPPC birthing hospitals to support local MCAH work efforts.
Narrative:
The RPPC Directors continued educating hospitals in their regions about breastfeeding legislation and provided support to stay compliant and/or meet state mandates. The RPPC Director also provided technical assistance to the hospitals by linking them with local MCAH programs or local RBLs when appropriate. Northeast Valley Health Corporation WIC collaborated with the PAC/LAC to provide updated information to hospitals on the implementation of the Model Hospital Policy Recommendations. CDPH/MCAH provided training to all Local MCAH Directors in the spring.
The following activities were paused during this report period and will be reassessed:
- CDPH/MCAH will identify best practices to support public health and health care workers in their efforts to educate families on the importance of the “Ten Steps to Baby Friendly places of care.
- CDPH/MCAH will partner with CMQCC to monitor progress of birthing hospitals and their adoption of the " Ten Steps to Successful Breastfeeding", or an alternate process that includes evidence-based policies and practices and targeted outcomes, or the Model Hospital Policy Recommendations.
- CDPH/MCAH partnered with MCAH programs to provide resources on evidence-based breastfeeding guidance.
Local MCAH Program Examples:
Many Local MCAH programs undertook efforts to promote breastfeeding education to pregnant individuals in their local communities, partnered to disseminate information to the community regarding evidence-based breastfeeding initiation guidance, and partnered with local county and community WIC programs to provide technical assistance on best lactation education practices, emphasizing health equity and moving away from a one size fits all approach.
- One adolescent mother of a baby with special needs was able to initiate breastfeeding because Lassen County MCAH gave direct instruction and encouragement in the hospital. This was especially important because there was a formula shortage at the time.
- Sonoma County MCAH staff joined the Sonoma County Breastfeeding Coalition Advisory Group and collaborated to create a Sonoma County Breastfeeding Stories Facebook event for World Breastfeeding Awareness Month in August 2021. Breastfeeding stories were solicited from staff, community members, and clients, and posted to the MCAH Facebook page. Stories were accompanied by links to resources for breastfeeding information and support.
- Sacramento County provided training to providers to increase knowledge of best practices to promote and support breastfeeding, including topics on breastfeeding and bonding with a newborn (hospital to home), utilizing WIC services, lactation accommodation and employment laws for working and student moms, common challenges to successful breastfeeding and solutions, and resources for refugee and immigrant breastfeeding mothers.
- Some AFLP agencies provided breastfeeding support through direct education while others referred youth to WIC and other lactation support. One agency provided virtual breastfeeding consultations during the pandemic. AFLP participants first enrolling in the program were assessed for breastfeeding support needs.
Perinatal/Infant Objective 1: Strategy 3:
Partner to develop and disseminate information and resources about policies and best practices to promote breastfeeding duration, including lactation accommodation within all MCAH programs.
Activity:
CDPH/MCAH will partner to increase the number of clinics adopting the 9 Steps To Breastfeeding Friendly: Guidelines for Community Health Centers and Outpatient Care Settings, guidelines developed in collaboration with input from community health centers, MCAH and CDIC, the California WIC Association (CWA), and the California Breastfeeding Coalition (CBC).
Narrative:
CDPH/MCAH partnered with various stakeholders to disseminate information and resources about policies and best practices to promote breastfeeding duration, including lactation accommodation within all MCAH programs. CWA promoted 9 Steps to Breastfeeding Friendly: Guidelines for Community Health Centers and Outpatient Care Settings with 250 hits on the CWA website.
The CWA May 2022 conference hosted 1580 attendees. Presentations addressed breastfeeding care and best practices, equity, diversity and inclusion, breastfeeding nutrients, ethical issues, health plan reforms to include lactation care, and national policy guidelines.
The bi-weekly newsletter, the CWA Flash, included a range of stories/articles on breastfeeding, including research updates on a wide range of areas, policy updates, and reports addressing equity, diversity and inclusion. The CWA Flash was sent to approximately 4,000 subscribers and shared on Facebook.
Activity:
CDPH/MCAH will partner with local MCAH Directors, LHJ Breastfeeding Coordinators, and WIC Regional Breastfeeding Liaison (RBLs) to develop and disseminate information to communities and businesses on lactation accommodation laws.
Narrative:
Lactation Support for Low-Wage Workers was released in 2021.
Activity:
CDPH/MCAH will partner with CWA and CBC on the Low Wage Lactation Accommodation Workgroup and the dissemination of the Low Wage Worker Lactation Accommodation Brief developed with the Childhood Obesity COIIN.
Narrative:
Several WIC local agencies whose parent agencies are affiliated with the Federally Qualified Health Centers have successfully implemented or are working towards implementing policies and best practices to promote breastfeeding duration.
Activity:
CDPH/MCAH will partner with the Childhood Obesity COIIN to promote the California Infant Feeding Guide, including development of social media promoting healthy infant feeding and addressing infant feeding cues, including an infographic.
Narrative:
CDPH/MCAH partnered with WIC to develop an infographic which was incorporated into WIC messaging.
Local MCAH Program Examples:
Several Local MCAH programs partnered to develop and disseminate information and resources about policies and best practices to promote extending breastfeeding duration, including lactation accommodation within their Local MCAH programs.
- All El Dorado County MCAH Public Health Nurses were trained in lactation education. PHN prenatal and postpartum home visits included breastfeeding support, education, and linkages to WIC and the El Dorado Breastfeeding Coalition. MCAH and local birthing hospitals discussed best practices to provide mothers with consistent education.
- Plumas County engaged in collaborative activities with local partners and provided materials that address the benefits of breastfeeding. Every perinatal provider and women in our local MCAH program received packets which included current best practices in breastfeeding/lactation.
- Santa Barbara County launched a unique breastfeeding promotion project via a public awareness campaign to promote breastfeeding with an emphasis on returning to work. The campaign displayed QR codes on topics including breastfeeding rights in the workplace, local community resources and support groups, nutrition and milk supply, and the overall benefits of human milk. The project was displayed at the Santa Maria Public Library in November 2021, Santa Barbara Public Library in March 2022, and at all five Santa Barbara County Public Health Department community clinics.
- Riverside County sponsored a Black Breastfeeding Week panel to promote and support Black women and birthing people’s breastfeeding efforts that was well attended by community members.
Local MCAH Challenge(s):
- The Dixie Fire and the State Mandated Emergency COVID lockdown prevented Plumas County nurses from providing face to face lactation consultations and education.
- Santa Barbara County reported several barriers to increasing breastfeeding duration. These included a cultural norm in the Hispanic community to supplement, formula companies sending advertising and free formula samples to clients, and early return to work. Though the Public Health Department provides free breast pumps through Lactation Services and companies friendly towards babies do exist, many clients are farm workers that are paid by how much they pick as a crew, or are in minimum wage jobs and do not feel comfortable, or may not have adequate time to pump at the workplace.
Local MCAH Success(es):
- TrueCare (San Diego) announced their success at fully implementing the “9 Steps” at their organization.
- Alameda County’s RBL provided technical assistance to clinics and outpatient settings serving WIC eligible families to implement the “9 Steps.”
Perinatal/Infant Focus Area 2: Improve healthy infant development through caregiver/infant bonding.
Perinatal/Infant Objective 1: Strategy 4:
Partner with birthing hospitals to support caregiver/infant bonding.
Activity:
CDPH/MCAH will disseminate information and resources on the importance of skin-to-skin care.
Narrative:
The Model Hospital Policy recommendations provide information on immediate postpartum support that includes offering the parent assistance in breastfeeding during the first hours after birth and protecting the first hours as a developmentally unique time to enhance parent and infant bonding and stabilization, regardless of feeding choice. The recommendations also include safe skin-to-skin care immediately after vaginal and cesarean births, encourage skin-to-skin for all parents and newborns, regardless of complications during the birth or feeding choice, and promote immediate, uninterrupted safe skin-to-skin contact to facilitate early breastfeeding behaviors and breastfeeding success.
CDPH/MCAH SIDS Program promoted the American Academy of Pediatrics Safe Sleep and Skin-to-Skin Care in the Neonatal Period for Healthy-Term Newborns in which skin-to-skin care and breastfeeding support is recommended for all mothers, as both are associated with a reduced risk of sudden infant death syndrome (SIDS).
Activity:
CDPH/MCAH will lead the development of social media posts and educational materials to raise awareness on the importance of infant/caregiver bonding.
Narrative:
The development of social media posts and educational materials was postponed to 2022-2023.
Local MCAH Program Examples:
Local MCAH programs supported efforts to support infant/caregiver bonding by partnering with community leaders to promote infant bonding, skin-to-skin training, and outreach activities to dads, partners, and caretakers.
- Alameda County hosts Café Dad Support/Educational groups that have positively impacted individual fathers and their families. With case management support from the Fatherhood Initiative program and attending Café Dad, fathers can build their capacity and skills to care for their children. Café Dad also partnered with Fathers Corps to help host the Virtual Fatherhood Summit of 2022. Café Dad hosted a “Dad and Me” event in partnership with the Oakland Athletics to celebrate fathers and their families. Café Dad continued to support fathers with gift cards to offset the rising cost of food and gas, as fathers are reporting that they are stretching their budgets to the limit.
Local MCAH Challenge(s):
Alameda County’s Café Dad groups were primarily for English-speaking fathers. As enrollment of Spanish-speaking fathers increased the focus shifted to creating a space for them. It was difficult recruiting and building the Spanish language Café Dad. However, during the fourth quarter of 2021-2022, Café Dad reached its goal of enrolling 15 Spanish-speaking fathers per group.
Perinatal/Infant Focus Area 3: Reduce Black infant mortality.
Perinatal/Infant Objective 2:
By 2025, reduce the rate of infant deaths from 4.2 per 1,000 live births (2017 BSMF/DSMF) to 4.0.
Perinatal/Infant Objective 2: Strategy 1:
Lead research and surveillance related to fetal and infant mortality in California.
Story Behind the Curve:
Infant mortality is an important indicator of the overall health and well-being of a population. The infant mortality rate is regarded as a highly sensitive measure of population health because there is an association between the causes of infant mortality and other factors that influence the status of whole populations, such as economic development, general living conditions, social well-being, rates of illnesses, quality and access to medical care, public health practices, and quality of the environment. The infant mortality rate is measured as the number of infant deaths before one year of age for every 1,000 births in that population. About two-thirds of infant deaths occur before a baby is one month old, and the remaining third between two months and 12 months of life.
Although the infant mortality rate is decreasing in other ethnic/racial groups, the persistent infant mortality rate for Black infants has been alarming for decades, despite public health efforts to improve this crisis. Persistent differences in perinatal health outcomes for Black women and their babies are often attributed to their own failure to practice healthy behaviors during pregnancy, essentially placing the burden and blame on Black women and ignoring the larger structural factors that influence the lives of Black women and the health of their babies. Research documents that health behaviors alone cannot account for these disparities[6]. Some cases have found that Black women who do practice healthy behaviors have worse perinatal outcomes that White women who do not.[7] When the Black Infant Health Program (BIH) was established in 1989, efforts to address disparities in Black maternal and infant health focused on increasing Black women’s utilization of prenatal care. However, disparities have persisted despite increasing rates of prenatal care usage among Black women, and overall infant mortality rates have decreased, but the mortality gap between Black infants and their counterparts has not. Preterm birth, which is the leading cause of infant death, continues to increase for Black infants. The conditions of nearly every aspect of daily life are shaped by the structural factors of society such as economic development, general living conditions, social well-being, rates of illnesses, quality and access to medical care, public health practices, and quality of the environment. Structural or systemic racism is embedded in each of these levels and research has shown that structural racism negatively impacts the health of Black women, leading to chronic stress. Stress related to racism elevates cortisol and other stress hormones in a woman’s body, leading to several maternal health conditions, such as obesity, hypertension, and diabetes, which could increase her chances of having a preterm birth, an infant loss, or severe maternal outcomes.
CDPH/MCAH prioritized addressing racial disparities in the infant mortality rate and continued to enhance collaboration with BIH, the Perinatal Equity Initiative (PEI), and other state and local partners to support families with culturally appropriate strategies and resources.
Activity:
CDPH/MCAH will lead and funded the data collection and surveillance of Fetal and Infant Mortality Review (FIMR).
Narrative:
CDPH/MCAH continues to conduct fetal and infant mortality surveillance and review scientific literature to maintain currency with respect to both scientific methods and emerging issues. Black infant mortality rates continue to be two to three times higher than the rates for other groups statewide, and Black infants are slightly over twice as likely as White infants to die before reaching their first birthday. The infant mortality rate for Black infants was 10.2 per 1,000 births in 2020. This is the second straight year the rate has increased (8.4 in 2018; 9.5 in 2019; 10.2 in 2020) and is the highest among all racial/ethnic groups. The aggregated infant mortality rate remained at 4.2 infant deaths per 1,000 live births in 2018 and 2019 and decreased by 7.1 percent to 3.9 per 1,000 live births in 2020. The infant mortality rate for White infants was 2.7 per 1,000 in 2020, a decrease from 3.3 in 2019. The infant mortality rate also decreased for Hispanic infants from 4.9 in 2019 to 4.6 in 2020.
Activity:
CDPH/MCAH will lead the development and dissemination of data finding, reports, and presentations.
Narrative:
In partnership with UCSF for the MIHA 2022 Project, CDPH/MCAH is developing a comprehensive report on the health and well-being of Black mothers and infants in California.
Activity:
CDPH/MCAH will use local expertise and community input to review cases of infant deaths at local level and apply lessons learned.
Narrative:
This activity was paused during this reporting period and will be reassessed pending funding for SB 65.
Success(es):
The infant mortality data dashboard based on state and county-level data for 2007-2018 was released in May 2022. Otherdashboards in the Perinatal/Infant domain published as of June 30, 2022 are Births, Preterm Birth, Low Birthweight and Neonatal Abstinence Syndrome. Fetal Mortality and Breastfeeding dashboards were in progress as of June 30, 2022.
Perinatal/Infant Objective 2: Strategy 2:
Fund the implementation of local fetal infant review programs to identify state and local strategies to reduce infant mortality.
Activity:
CDPH/MCAH will lead in the standardization of FIMR process, including sampling, data collection, and Case Review Team (CRT) recommendations.
Narrative:
CDPH/MCAH funded 15 LHJs to conduct FIMR activities. Senate Bill (SB) 65, also known as the California Momnibus Act, was signed into law in 2021. SB 65 shifts data collection and protocols from historically funded FIMR counties to counties meeting specified mortality rates. CDPH/MCAH identified opportunities for program improvement while planning for changes in funding allocations and changes in which counties will be required to participate in FIMR. In anticipation of general funds allocation for SB 65, CDPH/MCAH will only continue funding to the 15 LHJs until June 30, 2023. Starting July 1, 2023, LHJs will no longer be required to conduct FIMR activities for state contractual purposes. During this final year of funding, the 15 LHJs have been directed to conduct Enhanced Safe Sleep activities in place of normal FIMR activities. Each LHJ is being provided technical assistance this final year to help them comply with this new contractual agreement.
Activity:
CDPH/MCAH will partner with local FIMR programs to support the assessment of fetal and infant deaths in local communities and supported local FIMR programs to organize community members to develop a plan of action to address the factors that lead to fetal and infant deaths.
Narrative:
CDPH/MCAH continued to partner with local FIMR programs to support a community-based, action-oriented process to review fetal and infant deaths and make recommendations for system-level changes to prevent similar deaths in the future. FIMR teams operated at the LHJ level to examine medical, non-medical, and systems-related factors and circumstances contributing to fetal and infant deaths.
Each local FIMR site obtained fetal and infant death notifications through the Child Death Review Teams (CRT) in each county and/or through vital records. Each FIMR program then sampled death files to review for case reports to present the information to the CRT.
The CRT reviewed and made recommendations to the Community Action Teams (CAT) to propose and implement strategies to prevent fetal and/or infant deaths. Examples of CAT efforts included the following:
- Health Advisory from Fresno County Public Health directed at local OB providers regarding current COVID treatment and management of pregnant persons, along with encouraging OB provider to have patient discussion regarding postpartum contraception options.
- Public Service campaign on poisoning prevention measures during National poisoning prevention week of March 21-26.
- Public Service campaign on water safety posted to county social media during Water Safety month in May.
- Recommendation that local providers continue safe sleep education and parenting during well-child visits.
The following activities were paused during this reporting period and will be reassessed pending funding for SB 65:
- For non-FIMR counties, CDPH/MCAH will develop guidelines for LHJs on best practices when an infant death occurs.
- CDPH/MCAH will compile and disseminate best practices/recommendations from Community Action Teams (CAT) statewide.
Local MCAH Challenges:
Several Local MCAH programs reported that key staff redirection, retirement, or replacement impacted FIMR activities. Within MCAH departments, FIMR work has been re-structured after being on hold due to staff deployment for COVID. Maintaining relationships with county hospitals and the staff providing data for chart reviews is difficult when those partners retire or move to other jobs. Coordination with the Coroner’s Office requires establishing roles, responsibilities, and workflows; coroner office staff may not attend FIMR review. Establishing new members for the Case Review Team is difficult.
Perinatal/Infant Objective 2: Strategy 3:
Lead the California SIDS Program to provide grief and bereavement support to parents, technical assistance, resources, and training on infant safe sleep to reduce infant mortality.
Activity:
CDPH/MCAH will continue tracking sudden, unexpected infant deaths from local health jurisdictions.
Narrative:
All documentation received was given a case number and saved in an annual state database. State and county-level data was updated as new vital statistics data files became available.
Activity:
CDPH/MCAH will lead the dissemination of data finding, reports, and presentations for local SIDS programs.
Narrative:
CDPH/MCAH Epidemiology team shared SIDS/SUIDS data on the infant mortality data dashboard to provide easier access to more timely data.
CDPH/MCAH will partner with the California SIDS Program to provide training on grief and bereavement support to support families impacted by SIDS, SUID, and other sleep related infant deaths.
CDPH/MCAH will lead the California SIDS Program by increasing awareness, promoting safe sleep education, identifying risk factors, and providing resources.
Narrative:
CDPH/MCAH hosts two annual events to share up-to-date data on SIDS/SUID with all participants and collaborators to keep them apprised of current SUID/SIDS trends. The Annual SIDS Spring Training and the Annual SUID/SIDS Conference provided training on grief support to families impacted by SIDS, SUID and other sleep related deaths.
CDPH/MCAH in collaboration with the California State University, Sacramento, hosted the annual SIDS Spring Trainings via Zoom. These trainings were intended for public health staff and other professionals who interact with families when an infant dies suddenly and unexpectedly. These trainings addressed current theories and research trends, roles, and responsibilities of professionals at various levels, grief, and bereavement support. The Spring Training included sessions on “Back to Basics: The Home Visit” which discussed Safe Sleep Strategies; “Managing Compassion Fatigue While Providing Compassionate Bereavement Support”; and “Promoting and Supporting Safe Sleep in Less Than Perfect Situations” and a Parent Panel.
CDPH/MCAH in collaboration with the California State University, Sacramento, and the State SIDS Advisory Council, hosted the 41st Annual SUID/SIDS Conference via Zoom. This annual conference focused on providing education and research about SUID/SIDS, supporting our families in areas of grief and bereavement, and supporting strategies that promote a safe infant sleep environment and meets the needs of families. Sessions included: “SIDS Parents Networking and Discussion”, “SIDS and The Triple Risk Model”, and “Update on Biological Vulnerabilities and Risk Reduction Strategies”, “Reaching Beyond the Parents to Provide Grief Support to the Extended Family” and “The Forgotten Survivors: SIDS Siblings”.
Activity:
CDPH/MCAH notified California birthing hospitals and licensed midwives of their responsibility to disseminate SUID/SIDS risk reduction information to parents or guardians of newborns upon discharge.
Narrative:
The California Health and Safety Code Section 1254.6 (HSC § 1254.6), requires all hospitals in California to provide SIDS/SUID risk reduction information to all parents or guardians of newborns, upon discharge from the hospital or surrounding a community birth by a licensed midwife. RPPC Coordinators along with SIDS Coordinators reached out to birthing hospitals and licensed midwives to provide this updated, informative letter. Included in the letter are links to AAP Policy Statement which is endorsed by CDPH/MCAH and the California SIDS Advisory Council. In addition to the AAP recommendations, the CDPH/MCAH developed “Infant Safe Sleep Strategies”, a document which supports a family-centered approach to sharing risk reduction and infant safe sleep information, while promoting breastfeeding.
Activity:
CDPH/MCAH will lead and fund local MCAH programs (CHVP, AFLP, BIH, and IHP) to provide SUID/SIDS risk reduction and infant safe sleep education and resources to pregnant and parenting women.
Narrative:
Some AFLP agencies educate program participants on safer sleep practices and are part of local coalitions dedicated to safer sleep.
Local MCAH Program Examples:
- Kern County increased the distribution of Safe Sleep awareness through community outreach events and in onboarding new hospital nursing staff.
- San Bernardino County prepared a Safe Sleep video in conjunction with the County of San Bernardino Children’s Network for dissemination within the community to inform all viewers of current standards and practices for safe sleep and raise awareness of the importance of safe sleep environments for infants.
- Los Angeles’s BIH Program participants who completed prenatal group received bassinets to help provide a safe sleeping space for their new babies.
- The City of Pasadena’s MCAH and WIC programs continue to communicate on a regular basis to collaborate on young children’s health initiatives. Although COVID-19 response significantly impacted service delivery, staff were able to maintain close relationships despite the disruption in in-person services. WIC staff have conversations with parents/caregivers who have shared that their infants sleep on their tummies or and answer parent questions on safe sleep. Staff were prompted to remind/inform clients about back to sleep for SIDS prevention. Currently, WIC clients take a class called “Let’s Talk Newborn Feeding” in which it lists “less risk of SIDS” as a benefit of breastfeeding.
- Contra Costa County’s SIDS Program provides safe sleep education materials to MCAH staff and other units within the division and outside of the division (including perinatal nursing, hospital, foster care, Child and Family Services, and more). The SIDS Coordinator is available to provide safe sleep advice or technical assistance to the Public Health Division and to the community as a whole. All perinatal home visitors in Family, Maternal, and Child Health are trained in safe sleep and discuss safe sleep with their clients.
- Humboldt County planned Safe Sleep media campaign with a radio ads and social media posts. Distributed 150 gift bags for new mothers to local birthing facilities with sleep sacks and safe sleep brochures in English and Spanish.
- Napa County MCAH took a team approach to promote and disseminate information and resources related to SIDS/SUIDS risk factors and reduction strategies by partnering with Children’s Welfare Services) and hosting a quarterly Safe Sleep Educational training. One of our MCAH Perinatal Outreach Educators became a Safe Sleep Ambassador with Cribs 4 Kids and began distributing Safe Sleep Educational material at community outreach events this year. The CWS trainings became part of the CWS new employee onboarding process. We are also exploring funding to provide parents with a safe sleep playpen or bassinet for those that are co-sleeping due to crowded housing.
Local MCAH Challenge(s):
Many LHJs reported very high turnover rate of SIDS Coordinators along with long delays in hiring new SIDS Coordinators.
Perinatal/Infant Focus Area 4: Reduce preterm births.
Perinatal/Infant Objective 3:
By 2025, reduce the percentage of preterm births from 8.7% (2017 BSMF) to 8.4%.
Perinatal/Infant Objective 3: Strategy 1:
Lead research and surveillance on disparities in preterm birth rates in California.
Story Behind the Curve:
A major contributor to infant mortality is preterm birth.[8] Preterm birth (live birth that occurs prior to 37 weeks of pregnancy) is the most frequent cause of infant death in the United States1 and has lifelong consequences for surviving infants. In 2019, California had the sixth lowest preterm birth rate in the nation at 8.95 per 100,000.[9]
Within California there are large racial/ethnic disparities in preterm births, with Black and Hispanic infants most likely to be born early (2016). The deaths of Black infants are also more likely to be related to preterm birth (44.7%) than those of Hispanic (35.5%) or White infants (34%).[10]
The reasons for health disparities are complex. The known causes of poor birth outcomes such as lack of prenatal care, smoking, alcohol, drugs, and chronic medical conditions do not completely explain Black/White disparities in infant mortality. A recent study exploring the relative contribution of factors to preterm birth disparities in California (2005-2010) concluded that maternal individual factors, neighborhood conditions, and air pollution explain roughly 39.3% of the Black/White disparities, while the remaining 60% remained unexplained. Social conditions such as racism, poverty, lack of social support, discrimination, and other sources of stress may account for this unexplained variance.[11] These social, economic, and racial stresses can occur across a woman’s entire lifespan, potentially impacting subsequent generations. Given the complexity of the pathways to preterm birth, a comprehensive strategy centered on improving birth outcomes for people of color is needed.
Some evidenced or practice-based strategies for reducing preterm birth in people of color include promoting adequate birth spacing, helping women quit smoking, and providing high-quality and culturally appropriate care for women during pregnancy. SB 65 was signed into law in 2021 and addresses racial preterm birth rate disparities through interventions such as Medi-Cal reimbursement for doula care and investment in a Black, Native American, and other peoples of color doula and midwifery workforce.
Activity:
CDPH/MCAH will lead and fund the data collection and surveillance of preterm births including disparities in race/ethnicity.
Narrative:
CDPH/MCAH continued to monitor preterm birth rates and review scientific literature to maintain currency with respect to both scientific methods and emerging issues. Data from the California birth file revealed that for Objective 3, the percentage of preterm births decreased from 8.9% in 2019 to 8.8% in 2020. This is the first decline after the percentage increased for five straight years. By race/ethnicity, both the percentage of American Indian and Alaska Native (AIAN) preterm births and Black preterm births was 1.7 times more than the percentage of White preterm births (12.7% and 12.6%, respectively, compared to 7.5%) in 2020. The next highest percentage was in Pacific Islander births (9.8%), followed by Hispanic (9.0%), Multi-Race (8.9%), and Asian (8.3%) births.
Activity:
CDPH/MCAH will lead the dissemination of data findings, reports, and presentations related to preterm birth rates in California.
Narrative:
CDPH/MCAH continued to develop and update data dashboards to disseminate findings. The preterm birth data dashboard contains maps, bar charts, and trend charts using state and county-level data for 2007-2019 and was published in May 2022.
Activity:
CDPH/MCAH will support the development and dissemination of the California Black Maternal and Infant Health Report.
Narrative:
CDPH/MCAH partnered with UCSF Center for Health Equity to develop a comprehensive report, Centering Black Mothers, on the health and well-being of Black mothers and infants in California. The report focuses on linking Black maternal and infant health inequities to racism and other social determinants of health. The development of the report is a collaboration with Black female academics as co-authors and the advice of Black women who are leaders in their community. CDPH/MCAH management and staff members provided input on the report’s development and structure, as well as reviewed multiple drafts of report chapters and the complete report. The graphically designed report will be submitted for internal MCAH review in Fall 2022 with anticipated release in 2023.
Perinatal/Infant Objective 3: Strategy 2:
Lead the implementation of the Black Infant Health (BIH) Program to reduce the impact of stress due to structural racism to improve Black birth outcomes.
Activities:
CDPH/MCAH will support local BIH MCAH programs’ dissemination of public awareness campaigns to State partners and stakeholders.
CDPH/MCAH will partner with local health jurisdictions to actively recruit and increase the number of Black women participating in BIH programs and connect them to appropriate resources.
CDPH/MCAH will partner with professional organizations to provide education materials related to preterm birth reduction strategies to pregnant Black women.
Narrative:
BIH implements an evidence-informed intervention that uses a group-based approach to enhance the importance of advocacy and empowerment to combat the negative effects of structural racism on physical and mental health. Participants get to meet, interact, and build a sisterhood with other Black women. Group sessions are complemented with client-centered life planning, goal setting and referrals to services for participants and their families. This powerful combination serves to help women enhance life skills, learn proven strategies to reduce stress techniques such as meditation and yoga and build social support. Ultimately, this two-pronged approach impacts not only participants themselves, but future generations of Black women, infants and families.
Perinatal/Infant Objective 3: Strategy 3:
Lead the implementation of the Perinatal Equity Initiative (PEI) to increase perinatal equity in California.
Activity:
CDPH/MCAH will lead learning collaborative cohorts to promote statewide sharing of best practices to decrease the infant mortality rate and collaborated with experts to support successful implementation of legislated interventions.
Narrative:
The PEI oversaw monthly discussions and collaboration between LHJs and DHCS to facilitate a smooth implementation of SB 65. SB 65 will provide doula care for Medi-Cal enrollees by January 2023 and invests in the midwifery workforce. Recognizing the need to grow a culturally congruent birthing workforce, some LHJs are assisting doulas in obtaining training and certification. Other counties are offering scholarships for midwifery training.
Activity:
CDPH/MCAH will support implementation of the PEI interventions at the local level.
Narrative:
The PEI continues to promote the use of a variety of interventions by the 11 PEI-funded counties that are broadly described in budget legislation as appropriate strategies to support Black infant health not offered in current programming through the established Black Infant Health (BIH) program. While the BIH program is considered the core effort to address the health impact of chronic exposure to racism, the PEI program provides additional support through an array of interventions designed to work in parallel with the BIH intervention model.
Activity:
CDPH/MCAH will support accountability for programmatic outcomes using a Results Based Accountability model.
Narrative:
The PEI also collects data on birthing outcomes and utilizes this information to determine the adequacy of services and referrals, to explore external factors contributing to adverse birth outcomes, and to support sites’ performance measures for programmatic efforts to improve outcomes.
Activity:
CDPH/MCAH will support local MCAH programs development of public awareness campaigns with PEI funds.
Narrative:
In June 2022, the BIH and PEI Programs held their first virtual joint BIH/PEI Perinatal Equity Conference. The conference was well attended and included LHJ PEI staff and their community advisory board members. A panel on the role of Fathers and Partners was enthusiastically received, leading to a burgeoning effort to find ways to normalize the participation of the fathers/partners of participants’ children across all PEI interventions.
Local MCAH Program Examples:
Riverside County - Feedback from the Community Advisory Board (CAB) and through the Results Based Accountability (RBA) data system was obtained and monitored with the purpose of increasing OB provider and the community’s awareness regarding the high rates of infant mortality in the Black Community and efforts to address this disparity. Selected interventions were implemented by community-based organizations and measured by the RBA scorecard data system which measures CAB activities, community program outcomes, and data collected from media campaign efforts. Through the efforts of the PEI CAB, there has been an effective media campaign increasing awareness of Black maternal and infant mortality in Riverside. Additionally, through a regionalized approach, Riverside and San Bernardino met to collaborate on these issues and plan the first ever Perinatal Equity Summit.
Perinatal/Infant Objective 3: Strategy 4:
Lead the implementation of the Community Birth Plan (CBP), being piloted in Los Angeles, to build community systems to galvanize health care, public health sectors, and communities to collaboratively reduce Black preterm birth.
This activity is no longer being tracked by CDPH. Connections to the work Los Angeles County is doing to decrease Black preterm birth is done via the BIH and PEI programs.
Perinatal/Infant Objective 3: Strategy 5:
Lead the development and dissemination of preterm birth reduction strategies across California.
Activity:
CDPH/MCAH will facilitate the process of incorporating preterm birth reduction strategies in all MCAH programs (CHVP, AFLP, BIH, and CPSP).
Narrative:
CDPH/MCAH facilitated Maternal/Infant Domain Meetings with all MCAH programs to identify and share strategies used to reduce preterm birth. Programs described how they address the following factors that affect preterm birth: access to health care, attending prenatal visit attendance, managing chronic health conditions, environmental exposures, gestational diabetes, healthy weight, and hypertensive disorders. Strategies used by MCAH programs to address factors that affect preterm birth include Doula Services, Group Sessions, Case Management, Education and Outreach, Referral and Research and Surveillance. CDPH/MCAH programs will continue to use these preterm birth reduction strategies across California.
Many AFLP agencies provide support to program participants related to healthy eating, pre/postnatal care, immunizations, nutrition, obesity prevention, exercise, and cooking.
Activity:
CDPH/MCAH will develop and disseminate culturally appropriate social media messages about preterm birth reduction strategies for populations with high preterm birth rates.
Narrative:
CDPH/MCAH postponed the development and dissemination of culturally appropriate social media messages about preterm birth reduction strategies to coincide with Prematurity Awareness Month in November 2022.
Local MCAH Program Examples:
- The City of Pasadena MCAH is a collaborative partner on the San Gabriel Valley African American Infant Maternal Mortality (SGV AAIMM) Task Force. Project staff have facilitated and presented at several events tailored to Black pregnant and birthing people. Staff also participated in the SGV AAIMM Black Breastfeeding week, Black Mental Task Force Wellness, and SGV Group Holiday Health Fair. They also attended conferences and workshops on maternal mental health, Medi-Cal access, domestic violence, and positive parenting.
- Solano County participated with the Solano HEALS community coalition to implement a project to decrease rates of prematurity and low birth weight in Solano County for African American infants. The project included holding community meetings on infant mortality disparities, providing race/equity training to community partners that serve African Americans, and sharing information on African American mental health.
[2] Differences in Exclusive Breastfeeding Rates in US Hospitals According to Baby-Friendly Hospital Initiative Designation and Area Deprivation Index Category
[4] CDPH In-Hospital Breastfeeding: Statewide, County and Hospital of Occurrence by Race/Ethnicity: 2020
[6] Goldenberg RL, Cliver SP, Mulvihill FX, et al. Medical, psychosocial, and behavioral risk factors do not explain the increased risk for low birthweight among black women. Am J Obstet Gynecol. Nov 1996;175(5):1317
[7] Liu B, Xu G, Sun Y, et al. Association between maternal pre-pregnancy obesity and preterm birth according to maternal age and race or ethnicity: a population-based study. Lancet Diabetes Endocrinol. Sep 2019;7(9):707-714. doi:10.1016/s2213-8587(19)30193-7
[10] Reynen D, Troyan J. Surveillance of Black Infant and Maternal Health in California; Presentation to stakeholders during Black Infant Health Program Conference in Sacramento, CA on April 10-11, 2018. Sacramento, CA: California Department of Public Health, Maternal Child and Adolescent Health Division;2018
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