NPM 4A - Percent of infants who are ever breastfed

NPM 4B - Percent of infants breastfed exclusively through 6 months

 

Introduction: Breastfeeding

For the Perinatal/Infant Health domain, Hawaii selected NPM 4 (breastfeeding) based on the results of the 2015 Title V needs assessment. The first component of the 2020 Title V state breastfeeding objective is to increase the proportion of children who are ever breastfed to 92.0%. The 2019 indicator is from the 2016 National Immunization Survey (latest available data). The estimate for Hawaii (88.9%) failed to meet the annual objective of 91% but was higher than the national estimate of 83.8%. The current estimate for Hawaii has not changed significantly since 2011 (89.5%). There were also no significant differences among reported subgroups (birth order, educational attainment, household income, poverty level, marital status, maternal age, and race/ethnicity) based on the 2009-2011 aggregated data provided.

 

For the second component of the breastfeeding NPM, the 2020 Title V state objective is to increase the proportion of children who are breastfed exclusively through six months to 34.0%. In 2016 the estimate for Hawaii (33.2%) met the 2019 objective (33.0%), and was higher than the national estimate of 25.4%. The proportion of Hawaii children breastfed exclusively through six months increased since 2011 (from 26.4%). Higher risk groups were not assessed due to lack of federally available data.

 

Healthy People 2020 establishes breastfeeding initiation, duration, and degree of exclusivity as nationally recognized benchmarks for measuring success. Hawaii exceeds the 2020 objectives for both ‘ever’ breastfed and exclusively breastfed at 6 months.

 

Breastfeeding is a priority issue for Hawaii since the 2010 Title V needs assessment. Community stakeholders continue to recognize breastfeeding as a critical practice to improve birth outcomes, reduce infant mortality, and help the health and healing for mothers following childbirth. Hawaii’s efforts to improve breastfeeding rates are championed by two important state maternal and child health collaborative entities – the Hawaii Maternal and Infant Health Collaborative (HMIHC) and the Early Childhood Action Strategy (ECAS). Hawaii’s Title V agency, Family Health Services Division (FHSD) is a key participant in both initiatives.

 

Within FHSD, the Women, Infants, and Children (WIC) Services Branch is the lead program for breastfeeding, but works collaboratively with other Title V perinatal/infant health programs and community partners. WIC is the largest public breastfeeding promotion program in the nation, providing mothers with education and support. In addition, WIC trains other service providers working with pregnant women and new mothers to promote breastfeeding. WIC also uses breastfeeding peer counselors (BFPCs) to support WIC enrollees at a limited number of clinic locations.

 

Over the years, WIC and breastfeeding advocates established supportive breastfeeding laws in Hawaii. The challenge now is systematic promotion, enforcement and monitoring of the laws and policies. The key breastfeeding laws and legislation in Hawaii are:

• Hawaii Rev. Stat. § 367-3 (1999) requires the Hawaii Civil Rights Commission to collect, assemble and publish data concerning instances of discrimination involving breastfeeding or expressing breast milk in the workplace. The law prohibits employers to forbid an employee from expressing breast milk during any meal period or other break period.
• Hawaii Rev. Stat. § 378-2 (2000, Act 227) provides that it is unlawful discriminatory practice for any employer or labor organization to refuse to hire or employ, bar or discharge from employment, withhold pay from, demote or penalize a lactating employee because an employee breastfeeds or expresses milk at the workplace.
• Hawaii Rev. Stat. § 489.21 and § 489-22 provide that it is a discriminatory practice to deny, or attempt to deny, the full and equal enjoyment of the goods, services, facilities, privileges, advantages, and accommodation of a place of public accommodations to a woman because she is breastfeeding a child. The law allows a private cause of action for any person who is injured by a discriminatory practice under this act.
• Hawaii Sess. Laws. (2013, Act 249) requires specified employers to provide reasonable break time for an employee to express milk for a nursing child in a location, other than a bathroom, that is sanitary, shielded from view and free from intrusion. The law also requires employers to post notice of the application of this law in a conspicuous place accessible to employees.
• 2016 Session (Act 46) exempts from jury duty a woman who is breastfeeding or expressing breast milk for a period of two years from the birth of the child.

 

Although Hawaii’s overall breastfeeding rates compare relatively well to national averages, studies show lower rates are associated with low-income households particularly for exclusivity. Strengthening WIC breastfeeding programs provides a key opportunity to assure a healthy start in life for infants and improved health outcomes for postpartum mothers.

 

The Hawaii Title V breastfeeding strategies were derived from the 2011 Surgeon General’s Call to Action to Support Breastfeeding and are generally accepted by Hawaii breastfeeding stakeholders including Breastfeeding Hawaii, the ECAS, the HMIHC, the Perinatal Action Network, Healthy Mothers Healthy Babies, and the March of Dimes.

 

The Hawaii strategies include strengthening peer counseling programs, partnering with community-based organizations to bring WIC breastfeeding services to underserved populations, and collaborating/networking on statewide planning. A review of the AMCHP and MCH Evidence Center research supports Hawaii’s strategies: the WIC Peer counseling program and activities such as workforce training of home visiting program staff to promote breastfeeding.

 

Strategies to address the objectives and NPMs are discussed below.

 

Strategy 1: Strengthen programs that provide mother-to-mother support and peer counseling.

 

One of WIC’s core services is to provide breastfeeding education and support to participants. Breastfeeding services include: providing guidance, counseling, and breastfeeding educational materials to families before baby arrives; facilitating access to healthy and varied foods; direct engagement with mothers and families to ensure longer participation in the program; provision of breastfeeding aids such as breast pumps and breast pads; and availability of trained staff in varying roles.

 

WIC mothers are strongly encouraged to breastfeed their infants unless it is contraindicated for medical reasons. All WIC staff are trained to promote breastfeeding and provide the necessary support new breastfeeding mothers and infants need for success. Federal WIC program regulations require State WIC programs to create policies and procedures to ensure breastfeeding support and assistance is provided throughout the prenatal and postpartum period, particularly when the mother is most likely to need assistance.

 

WIC provides additional services through a Breastfeeding Peer Counseling (BFPC) Program, which conducts monthly group sessions for pregnant and breastfeeding WIC moms to address breastfeeding concerns and provide one-on-one support to those interested. Hawaii WIC uses the US Department of Agriculture’s (USDA’s) Loving Support© model, an evidence-based curriculum, to assure the success of the program.

 

Feedback collected from WIC mothers indicates a high level of satisfaction with the program, particularly the camaraderie shared in the group meetings which is the primary aim of the program: to provide mothers with a trusted friend who has breastfed. Peer Counselors become part of a mother’s “Circle of Care,” providing basic breastfeeding information, monthly contacts during the pregnancy and postpartum period, and referrals to designated resources when issues fall beyond their scope of practice. The program is currently located at four WIC offices at community-based organizations, as well as three state-run WIC offices. A total of four peer counselors currently service all seven sites. The program is located only on Oahu.

 

Funding for the BFPC Program comes from USDA and is managed by the WIC Services Branch. Each local office recruits peer counselors and must follow the protocols as outlined in the Loving Support© model. Recruitment and retention of peer counselors can be challenging since the positions are part-time and applicants normally seek full-time employment.

 

The strength of the BFPC Program is in the support mothers receive from their peers. In 2019 seven ‘baby showers’ group events were completed by BFPCs. These events are meant to allow moms to learn and network with other mothers around breastfeeding as well as other aspects of family life. This support leads to increased breastfeeding duration and exclusivity.

 

To reinforce breastfeeding promotion (and other important health messages), WIC staff refer clients to the Healthy Mothers Healthy Babies “Text4Baby” service. The service sends enrollees free text messages on prenatal care, baby health, breastfeeding and parenting tips throughout pregnancy and baby’s first year of life.

 

ESM 4.1 is the measure for this strategy: the percent of WIC infants ever breastfed. The numerator is calculated using the number of unduplicated WIC infants who were marked as currently breastfeeding (or if not currently breastfeeding, marked as having previously breastfed). The denominator is the sum of all unduplicated WIC infants. WIC anticipates reporting data for breastfeeding exclusively at 6 months in next year’s report. Issues with the new data system are being addressed.

 

Strategy 2: Partner with community-based organizations to promote and support WIC breastfeeding services.

 

WIC partners with community-based organizations to promote and support breastfeeding. Over the past 15 years, WIC gradually transitioned its service provision from stand-alone state-operated clinics to contracting WIC services with community-based organizations like the Federal Qualified Health Centers. These organizations specialize in providing an array of services to low-income and underserved populations, hire staff that often reflect the diverse cultural groups found in these communities, and have access to language translation resources. Thus, WIC offices located in these organizations may be more effective in reaching WIC clients and providing services, including breastfeeding support.

 

WIC also works in conjunction with other Title V programs serving high-risk pregnant women by offering breastfeeding education and training to staff, service contractors, and community partners. These programs include the Maternal and Child Health Branch state-funded Perinatal Support Services program, the Hawaii Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program, and the associated MIECHV Hawaii Home Visiting Network.

 

Strategy 3: Collaboration and networking.

 

Hawaii has an active state breastfeeding coalition, Breastfeeding Hawaii (BH), that works to promote, protect and support breastfeeding through collaboration of community efforts around outreach, legislation, policy enforcement, education, and advocacy. The state WIC breastfeeding coordinator is a board member of BH, and serves as a liaison to CDC’s Division of Nutrition, Physical Activity and Obesity and the United States Breastfeeding Coalition.

 

As noted earlier, efforts to improve breastfeeding rates are championed by two important state maternal and child health entities: the Hawaii Maternal and Infant Health Collaborative (HMIHC) and the Early Childhood Action Strategy (ECAS). Under the auspices of both organizations a state breastfeeding plan was developed in 2018 that identified project priorities.

 

ECAS continues to convene/staff monthly HMIHC workgroup meetings that focused on implementation of the breastfeeding priorities:

• Provide guidance regarding insurance reimbursement for lactation support workers who are not primary care providers,
• Create a breastfeeding toolkit for pediatricians and obstetricians and
• Develop and launch a campaign to communicate consistent messaging regarding breastfeeding aimed at the whole family.

 

Broad stakeholder involvement is a key factor of success for this effort. Other participants included: Breastfeeding Hawaii, Healthy Mothers Healthy Babies, March of Dimes, University of Hawaii Office of Public Health Studies, University of Hawaii School of Nursing and Dental Hygiene, University of Hawaii John A. Burns School of Medicine, American Academy of Pediatrics – Hawaii Chapter, Kona Community Hospital, Hawaii Public Health Institute, Early Head Start and Head Start, Family Support Hawaii, BAYADA Home Care, La Leche League, Hawaii Mothers Milk, Family Hui Hawaii, Federally Qualified Health Centers (FQHC), and Tripler Army Medical Center.

 

Despite Hawaii’s excellent breastfeeding initiation rate, the CDC’s Maternity Practices in Infant Nutrition and Care report shows that birthing facilities in Hawaii still have opportunities for improvement. The report is based on a survey of hospital practices conducted every two years. Areas for improvement include appropriate use of breastfeeding supplements, inclusion of model breastfeeding policy elements, provision of hospital discharge planning support, and adequate assessment of staff competency. Since the benefits of breastfeeding are dose-related, duration and degree of exclusivity need to be reviewed as well. The DOH Chronic Disease Prevention and Health Promotion Division leads the Baby-Friendly Hospital Initiative which is supported by the breastfeeding workgroup. Discussions continued with Hawaii’s two largest labor and delivery hospitals to improve Baby-Friendly practices.

 

The Breastfeeding State Plan and its Logic Model focuses on four strategic areas: (1) leadership, (2) messaging & training, (3) laws & policies, and (4) support for families needed at critical junctures during the prenatal/postpartum period. Although there are no dedicated funds to implement the Plan, it serves as a guide to align existing breastfeeding efforts conducted by individual organizations and agencies. Without dedicated staffing, it is challenging to monitor and support plan progress.

 

Current Year Highlights for FY 2020 through April 2020

Here are some highlights of current breastfeeding activities for FY 2020 including the impacts & changes from the early days of the COVID pandemic in Hawaii.

 

WIC breastfeeding services continued through FY 2020 including BFPC services. The ECAS breastfeeding workgroup continued meeting to implement project priorities.

 

WIC services are significantly impacted by COVID. With the March Stay at Home orders, most WIC staff at state clinics and local community organizations moved to telework. All WIC clinics were closed for in-person visits and services for WIC enrollees were provided remotely via phone. Fortunately, Hawaii WIC was in the process of implementing an eWIC (electronic benefits) program to replace the issuing of paper checks for food purchase, reducing the number of required in-person clinic visits.

 

Due to the unprecedented closure of many Hawaii businesses and resulting increase in new unemployment filings, WIC saw an increase in new client enrollments for March/April. Prior to COVID, Hawaii WIC was following the national trend of decreasing WIC enrollment numbers.

 

WIC BFPC services are provided remotely via text and phone. Group events are suspended and staff are considering other methods to convene WIC moms to encourage networking.

 

The ECAS BF Workgroup meet via Zoom. A list of BF resources and information specific to COVID-19 is being compiled.

 

Review of Action Plan

A logic model was developed for NPM 4 to review the alignment between the strategies, activities, measures and desired outcomes. By working on these strategies, the Hawaii Title V program plans to meet the breastfeeding objectives for ESM 4.1 and NPM 4 to increase the percentage of infants breastfed.

 

 

The strategies address several service levels toward promoting breastfeeding from enabling to population-based, system building efforts that impact a mother’s ‘circle-of-care’ as illustrated in the graphic below from the USDA National Breastfeeding Campaign.

 

 

Challenges Encountered

While Hawaii has many dedicated breastfeeding advocates and partners, efforts to develop strategies and sustain their implementation in the community are difficult due to the lack of a Statewide Breastfeeding Coordinator to serve all families, including those not serviced by WIC.

 

Recruitment and retention of staff for the BFPC program also continues to be a challenge. Reasons for peer counselors leaving the program have varied, including returning to school, deciding to stay home with a new baby, need for higher salary/full-time work, and moving out-of-state.

 

Hawaii WIC data show the majority mothers stop breastfeeding between the first 2-4 weeks after hospital initiation. The primary reason mothers cite is not having enough milk. Additional data collection is needed to determine if moms’ responses are due to true milk insufficiency or formula supplementation. Such information would greatly inform the breastfeeding support offered by the BFPC, which could be critical to ensuring mothers’ continuation of the practice.

 

State policies that impact a mother’s ability to increase her duration and degree of exclusivity also need to be implemented. Paid family leave is supported by the current state Administration, but legislation has not successfully passed.

 

Overall Impact

The FHSD WIC Services Branch breastfeeding promotion program can access a large high-risk population of pregnant women and young mothers to help promote and support breastfeeding in Hawaii. The Hawaii WIC program services nearly half the births in the state. Despite loss of staffing, WIC state offices and community contractors continue to promote breastfeeding to clients, as well as provide training/resources to WIC contractors and other community organizations serving pregnant women and new mothers.

 

The Affordable Care Act helped promote breastfeeding by requiring breast pump coverage through medical plans. This can assist mothers with lengthening the duration of exclusive breastmilk feeding, especially as new mothers return to work or school.

 

Additionally, Title V leveraged resources of key partners to provide leadership, staffing, and funding to sustain community-based activities beyond WIC. For example, the coordinator for the ECAS and HMIHC helped to convene breastfeeding stakeholders, coordinate statewide planning, and access national technical assistance resources. The Strategic Plan will be key in seeking resources for breastfeeding efforts such as reinstituting a State Breastfeeding Coordinator position.

 

Other Title V programs serving high-risk pregnant women also offer an opportunity to promote breastfeeding through education, workforce training, and support services. Partner programs include the MCH Branch Perinatal Support Services program and the Hawaii Home Visiting Network convened by the MIECHV program. In addition, the Title V Early Childhood Comprehensive Systems (ECCS) coordinator ensures breastfeeding is integrated into state systems planning and services where appropriate. For example, breastfeeding promotion is included in the Executive Office on Early Learning (EOEL) Early Childhood Strategic plan for the state.

 

NPM 5A - Percent of infants placed to sleep on their backs,

NPM 5B - Percent of infants placed to sleep on a separate approved sleep surface,

NPM 5C - Percent of infants placed to sleep without soft objects or loose bedding

 

Introduction: Safe Sleep

For the Perinatal/Infant Health domain, Hawaii selected NPM 5 based on the results of the 2015 Title V needs assessment. The 2020 Title V state objective is to increase the proportion of infants placed to sleep on their backs to 82.0%. The latest Pregnancy Risk Assessment Monitoring System (PRAMS) data from 2016 showed Hawaii below the 2019 state objective (77.9%), but similar to the national estimate of 78.4%. Hawaii did meet the Healthy People 2020 Objective for safe sleep (75.9%). Although the 2016 survey showed a slight decrease from the 2015 indicator, the difference is not statistically significant. State targets for this objective were updated through 2025 after reviewing trend data and consulting with program staff, reflecting an approximate 5% improvement over 5 years.

 

Looking at this objective over time, the proportion of infants placed to sleep on their backs increased significantly since 2007 (71.7%). Analysis of Hawaii PRAMS 2012-2016 aggregated data revealed Native Hawaiian mothers (72.9%) were less likely to place their infants on their back compared to Filipino (81.2%), White (85.3%), Chinese (86.3%), and Japanese (88.3%) mothers. Mothers that were under 20 years of age (69.4%) and 20-24 years of age (72.8%) were less likely to place their infants on their back to sleep, compared to mothers that were 25-34 (81.8%) and 35 years or older (83.6%). Mothers at or below 100% FPL (76.8%) and those between 101-185% FPL (76.7%) were less likely to place their infants on their back to sleep, compared to those at 301% and greater FPL (85.6%).

 

The Hawaii 2016 PRAMS survey provided first-time benchmark data for the two new Title V safe sleep national measures (NPM 5B and 5C) which assess whether infants are placed on an approved sleeping surface and placed with soft objects or loose bedding that may endanger infant safety. The 2016 data showed that only 20.3% of Hawaii infants were placed to sleep on a separate approved sleep surface, significantly lower than the 2016 national estimate of 31.8%. Approved surfaces would be a separate crib, bassinet, or pack and play, and not a mattress or bed, couch, sofa, armchair, swing or car seat. Also, only 31.6% of Hawaii infants were placed to sleep without soft objects or loose bedding, a significantly lower proportion than the national estimate of 42.4%. For this indicator, unsafe items include sleeping with a blanket, toys, cushions, pillows, or with crib bumper pads. Higher risk groups for both measures are not able to be reported at this time, due to small numbers.

 

From a population standpoint, Hawaii child death numbers remain small (165 in 2018). Non-natural deaths due to external factors such as an accident or violence-related causes are even smaller (42 in 2018). Despite the small numbers, infant sleeping conditions continue to emerge as possible factors in several Child Death Review (CDR) cases each year. Hawaii CDR recommendations continue to promote safe sleep activities.

 

The 2015 Title V needs assessment confirmed the importance of providing safe sleep education and training to parents and childcare providers. The Hawaii Maternal and Infant Health Collaborative (HMIHC) and Early Childhood Action Strategy (ECAS) also identified the promotion of safe sleep practices as an important priority to improve birth outcomes and reduce infant mortality. Specifically, the HMIHC identified two priority strategies to achieve the objective of decreasing infant mortality in the first year of life: 1) Foster safe sleep practices for all who care for infants; and 2) Provide professional development and training opportunities for caregivers of infants.

 

Although safe sleep is part of the Title V Maternal and Child Health Branch (MCHB) program efforts, implementation of the strategies occurs through collaboration across the Family Health Services Division (FHSD). MCHB provides general support and leadership through its Parenting Support Programs (PSP) and Safe Sleep Hawaii (SSH), a statewide partnership that promotes life-saving safe sleep techniques, policies, and education for parents, health professionals, and other caregivers. The CSHN Branch nurse manager for the Newborn Metabolic Screening program also worked with the Perinatal Nurse Managers Task Force (PNMTF), which represents all birthing hospitals, to integrate safe sleep into hospital practice.

 

There is no dedicated funding source for Safe Sleep staffing or program activities. Title V-funded staff provide leadership and overall support for safe sleep program efforts. The supervisor for the Family Strengthening and Violence Prevention (FSVP) Unit under the MCHB serves as the Title V program lead for safe sleep. The FSVP supervisor oversees family violence prevention and parenting support programs. The position was vacated in 2018, and filled recently in March 2019.

 

Under this new leadership, Title V safe sleep strategies were updated to reflect the most up-to-date data and accomplishments. The strategy to have all Hawaii birthing hospitals formally adopt safe sleep was completed, so the strategy was deleted and the related strategy measure (ESM 5.1) was inactivated. The workforce development strategy which originally targeted birthing hospital staff was generalized, to expand training to a broader range of healthcare and service providers through the development of partnerships. A new strategy was added, with an accompanying ESM 5.2, focusing on outreach to non-English-speaking communities. The new strategy was added based on data findings and input from service providers that work with multi-cultural families.

 

A review of the AMCHP and MCH Evidence Center research indicates that targeting caregivers with education is supported by some evidence of effectiveness. Hawaii’s other two strategies are also recommended as best practices for Title V agencies.

 

The safe sleep strategies and activities are discussed below.

 

Strategy 1: Assure competent workforce through partnerships & training

 

Originally this strategy focused on identifying safe sleep competency training needs for birthing hospital professionals, but was broadened to support workforce training for providers that work with families of young children using evidence-based/informed information/trainings.

 

The PNMTF continues to focus on assuring a competent hospital workforce and keeping regular staff trained on the most recent safe sleep environment recommendations, and also recognizes the need to provide training opportunities for new nurses. Although none of Hawaii’s birthing hospitals include safe sleep as a formal workforce competency, the topic is discussed with families at discharge and included on the hospital discharge checklists. Hospitals use various means to promote safe sleep education including creation of safe sleep committees and providing information at regular staff skills fairs. In addition, safe sleep remains a standing agenda topic at some hospital staff meetings to assure consistent messaging and encourage staff to access safe sleep trainings for nurses on the National Institute of Child Health and Human Development website. The CSHNB nurse on the PNMTF serves as the hospitals’ safe sleep subject matter expert and provides technical assistance and training on safe sleep environment policy and protocol development, as well as guidance on related issues.

 

Safe Sleep Hawaii (SSH)

SSH is the statewide coalition that promotes safe sleep efforts. The group focuses on developing appropriate and consistent parent education materials and general awareness messaging for safe sleep practices, following the current version of the American Academy of Pediatrics (AAP) Evidence-Based Recommendations for a Safe Infant Sleeping Environment at Birthing Hospitals, Child Care Centers, and Child Care Providers.

 

SSH has a diverse membership (see Table 1 below) with representation from government, non-profit, for-profit, and grass-roots organizations and sectors, as well as families who are committed to preventing infant mortality through safe sleep practices. In-person SSH meetings are held quarterly and ad-hoc teleconferences are scheduled as needed.

 

Table 1: Safe Sleep Hawaii Coalition Membership

ORGANIZATION	COUNTY
Adventist Health Castle	Honolulu
Child and Family Services	Statewide
Department of Health – Maternal Child Health	Statewide
Department of Health – FHSD	Statewide
Department of Health – Public Health Nursing	Statewide
Department of Human Services	Statewide
Hawaii AAP (American Academy of Pediatrics)	Statewide
Hawaii Primary Care Association	Statewide
Healthy Mothers Healthy Babies	Statewide
Kaiser Permanente	Statewide
Kapiolani Medical Center for Women and Children	Honolulu
Keiki Injury Prevention Coalition	Statewide
March of Dimes	Statewide
Military (Navy)	Statewide
PATCH (People Attentive to Children)	Statewide
Private Citizens	Honolulu
Queens Medical Center	Honolulu
Shriners Hospital for Children	Statewide
Waianae Coast Comprehensive Health Center	Honolulu
Wilcox Medical Center	Kauai

 

The Title V lead for safe sleep is responsible for managing the service contract for the SSH Facilitator, coordinating the efforts relating to safe sleep within FHSD, and acting as the point-of-contact for all safe sleep related inquiries and activities.

 

The SSH Facilitator contract is state funded and the position is filled by a Registered Nurse whose responsibilities include:

• convening SSH quarterly meetings;
• identifying relevant safe sleep materials and opportunities;
• maintaining SSH membership and LISTSERV;
• convening the sub-committee on identifying AAP-approved on-line training courses for caregivers at childcare facilities;
• providing ad-hoc safe sleep advice; and
• coordinating a yearly Safe Sleep Summit.

 

The SSH Facilitator is also contracted by the DOH Injury Prevention and Control Section (non-Title V) to convene the State Keiki (child) Injury Prevention Coalition (KIPC), thus integrating safe sleep into overall statewide child injury prevention efforts.

 

Safe Sleep Policy for Licensed Child Care Facilities

The Department of Human Services (DHS) Child Care Program is a key agency partner in the promotion of safe sleep workforce training. The Child Care Program is responsible for the licensing of child care facilities statewide, and implements a policy requiring all child care facilities to have a written operational safe sleep policy, review these policies with staff, and undergo annual training on safe sleep practices. There is emerging evidence to support the effectiveness of mandatory child care provider education. SSH initially assisted DHS to develop training materials and continues to monitor implementation of the program.

 

Strategy 2: Inform, Educate, Empower. Develop appropriate and consistent parental education and general awareness safe sleep messages.

 

This strategy focuses on identifying decision-makers, key partners, and resources to develop safe sleep messages for parents and others who care for infants.

 

Data to Inform Program Planning/Policy

To encourage the use of data to inform program planning, an Infant Safe Sleep Fact Sheet was developed using data from PRAMS and the Child Death Review (CDR) program. This fact sheet provides general information on Sudden Unexpected Infant Deaths (SUID), Sudden Infant Death Syndrome (SIDS), and data trends, and highlights the importance of creating a safe sleep environment. This fact sheet is accessible via the HI-PRAMS website (http://health.hawaii.gov/fhsd/home/hawaii-pregnancy-risk-assessment-monitoring-system-prams/). This fact sheet was shared with PRAMS steering committee members, the SSH, the CDR program, and other key stakeholders. Plans are to update the fact sheets with 2016 data and conduct further data analysis include examining correlations between co-sleeping, substance use/abuse, and breastfeeding.

 

Partnering on Parent/Family Educational Tools

The safe sleep educational materials for families and providers were developed in partnership with the DHS Child Care program are now widely disseminated for general safe sleep promotion to many Hawaii programs and agencies serving families. The materials include:

• AAP-recommended guidelines regarding safe sleep environments;
• a letter from a family, “Don’t let a preventable infant death happen…,”; and
• a poster that can be displayed in the infant’s home, in pediatrician offices, or used as a training tool.

The goal was to provide families with helpful materials that could begin dialogues about safe sleep practices with everyone who cares for their children, whether family or not. To ensure the guide was “parent-friendly,” the materials were tested with DHS First-To-Work (FTW) program families and revised based on input.

 

The guides have been used by the DHS Child Care program as well as by early childhood programs such as Women, Infants and Children (WIC), Child Abuse and Neglect Prevention programs, Home Visiting Programs, and birthing hospitals throughout the state. The guides were also used with crib distribution programs sponsored by the Title V’s MCHB. MCHB’s Parenting Support Programs help to store and provide ongoing distribution of the Safe Sleep Guide for Parents statewide.

 

Promotion of Safe Sleep Environments

Nurse educators who conduct childbirth classes at birthing hospitals provide education to parents about safe sleep environments. Two hospitals use the safe sleep posters in their birthing rooms to stress the importance of providing a safe sleep environment for infants. Nurses report that the poster is a valuable teaching tool when educating family members about safe sleep.

 

Another valuable educational tool is the Safe Sleep Hawaii video. The video includes personal family stories about the importance of adhering to safe sleep recommendations, and supports the educational information presented on safe sleep practices and environments. A copy of the Safe Sleep Hawaii video is available for birthing hospitals to play on their internal video sites (http://www.safesleephawaii.org/). The largest maternity hospital in the state requires parents to view the video prior to discharge.

 

Pack ‘n Play Distribution

There are several small program efforts to promote safe sleep environments for families with minimal financial resources. Hawaii’s Healthy Mothers, Healthy Babies has a “Cribs for Kids®” program targeting low-income families through referrals from community agencies. Parents without a safe sleep environment for their child, and who are willing to participate in a one-hour educational session, can receive safe sleep information and a free Pack ‘n Play (PNP) portable crib. Some of the birthing hospitals also have their own PNP distribution programs for low-income, at-risk families.

 

DOH sponsored an effort to distribute play yards called “Play yards for Keiki.” This initiative provided a safe sleeping environment to families that did not have a safe sleeping environment for their infant child. Participants of this program must meet eligibility criteria and complete safe sleep educational trainings.

 

In May of 2019, the DOH funded a new crib distribution initiative administered by the Keiki Injury Prevention Coalition (KIPC) called “KIPC Crib Distribution.” This program sought to build on the “Play yards for Keiki” initiative and assure those families most in need received a play yard. Eligibility criteria focused on supporting low-income families that were unemployed or receiving government assistance such as Temporary Assistance for Needy Families (TANF). The “KIPC Crib Distribution” program implemented agreements with its distribution sites (e.g., Kauai District Health Office, YWCA, Parents and Children Together, etc.) to improve efficiency.

 

Strategy 3: Expand outreach to non-English-speaking families and caregivers through translation of educational materials and safe sleep messages.

 

Hawaii is a state with a high immigrant and diverse ethnic population, including many English as a second language (ESL) speakers. These populations also bring diverse traditional and cultural practices for infant sleep, sometimes including co-sleeping. To expand outreach to these groups, Title V MCHB partnered with the Department of Human Services (DHS) and the Office of Language Access (OLA) to translate the Safe Sleep Guide for Parents into the most common second languages spoken in Hawaii households.

 

A workplan and budget was developed for the project. Ongoing activities include identifying the languages for translation, coordinating with translators, selecting a design and printing company to complete the project, and distribution of the final products. A new ESM 5.2 was developed to assure completion of this project: The number of languages Hawaii safe sleep educational materials are currently available for the community.

 

Current Year Highlights for FY 2020 through April 2020

In October of 2019, Safe Sleep Hawaii held its annual Safe Sleep Hawaii Summit. The Summit was funded by the MCHB. The plenary speaker was Dr. Rachel Moon, an internationally recognized expert in SIDS and post-neonatal infant mortality. Dr. Moon currently serves as Division Head of General Pediatrics at the University of Virginia. Her presentation focused on the causes of sleep-related infant deaths and methods to prevent these types of deaths, including interventions and skillsets needed to promote behavior change with families and caregivers to create safe sleep environments for infants. The Summit also featured a panel discussion compromised of professionals who provide infant safe sleep education, describing the common issues and challenges they encounter. Breakout sessions focused on practical skills to address difficulties working with families through realistic scenarios. The 2020 Summit Planning Group is rethinking plans for an in-person conference, given the gathering and travel restrictions brought about by COVID-19.

 

The DOH, DHS, and OLA began implementation on the joint venture to translate the Safe Sleep Guide for Parents. This workgroup reviewed several sources of data including Census data, requests for language interpretation services by DHS entitlements programs, and PRAMS data, to help identify cultural groups/languages that appear to have an increased risk for sleep-related infant mortality. Through this process, eleven languages were selected for translation: Chuukese, Ilocano, Japanese, Korean, Marshallese, Samoan, Spanish, Simplified Chinese, Tagalog, Traditional Chinese, and Vietnamese.

 

The Safe Sleep Guide was translated into the identified languages using OLA resources, and the workgroup selected a graphic designer to format the documents. The translated text and design layouts were reviewed by focus groups of native speakers to ensure the translations were correct, and information and graphics were appropriately displayed in a readable and understandable manner. Next steps include printing the translated materials and finishing the distribution plan that includes website development and social media.

 

Review of the Action Plan

A logic model was developed for NPM 5 to review alignment among the strategies, activities, measures, and desired outcomes. The strategies were revised to reflect:

• all birthing hospitals successfully adopting and implementing safe sleep policies;
• expansion of workforce training to providers beyond the hospital; and
• translating safe sleep education materials into languages other than English.

By working on the three strategy areas, Hawaii plans to increase the percentage of infants placed safely to sleep. The activities associated with each of the three strategies directly correlate with short-term outcomes and will impact longer-term outcomes (NPM 5 and NOMs 9.1, 9.2, 9.5). Short term outcomes include:

• Parents and families increase awareness, capacity, and self-efficacy specific to safe infant sleep, including non-English speaking groups.
• Development of families and parents as advocates for safe sleep.
• Provider training opportunities are identified; providers are trained and prioritize safe sleep when meeting with families.
• Hospital protocols are developed, strengthened, and institutionalized.

ESM 5.1 was inactivated since it was completed in FFY 2018 with all birthing hospitals becoming compliant with AAP protocols. A new ESM 5.2 was created to assure completion of the new strategy to expand availability of safe sleep educational materials through language translation for Hawaii’s diverse ethnic populations.

 

 

Challenges Encountered

COVID-19

Due to social distancing recommendations discouraging face-to-face meetings, Safe Sleep Hawaii is arranging for remote meetings only. Providers of Safe Sleep education are challenged to rethink service delivery, given the new restrictions. For example, the KIPC crib distribution program funded by DOH requires parents to complete an in-person class or meeting with an educator on safe sleep. New options are being explored for virtual learning.

 

Addressing Co-Sleeping

Co-sleeping is a common practice in Hawaii. Initiatives such as ‘Pack and Play’ distribution and education through the Cribs for Kids Program have proven effective nationally with high risk populations. However, addressing local/cultural beliefs and a general acceptance of co-sleeping is challenging. The practice may be attributed to the State’s ethnic/cultural diversity, as well as economic constraints related to the State’s high cost of housing which contributes to the sharing of small dwellings and/or multi-family living arrangements. Data indicate certain ethnic groups, young mothers, and low-income families are particularly at risk. Targeted outreach to diverse cultural populations is a key strategy for future prevention education activities.

 

Education Dissemination

FHSD will continue to engage with other Title V programs (e.g., WIC and Home Visiting), birthing hospitals, FQHCs, DHS benefit programs, as well as other “non-traditional” partners such as pre-schools and churches, to expand educational efforts to a broader audience. With translated safe sleep materials, SSH will also expand community partnerships to reach broader multi-cultural populations.

 

Overall Impact

By working with key stakeholders to address this issue, parents, families, caregivers, and the medical community have increased knowledge and understanding of creating a safe sleep environment for infants. Program activities successfully addressed safe sleep through a multi-pronged approach consisting of advocacy, policy development, workforce training, education, supporting safe sleep champions, and grass roots programs/initiatives. These activities, combined with input from parents and families, and the leadership provided by the PNMTF, SSH, and Title V were successful in mobilizing Safe Sleep efforts. PRAMS data shows stable safe sleep rates comparable to the U.S. for infant positioning. However, 2016 PRAMS data show Hawaii below national estimates for the two Title V safe sleep measures regarding approved sleep surfaces and the dangers of soft bedding. More effort is needed to increase awareness about these topics.

 

Crib distribution programs that are paired with education help families provide the necessary physical environment to create safe conditions as specified by AAP guidelines. These efforts are targeted toward vulnerable families in need.