The domain of Perinatal/Infant Health sets the trajectory of the health of a child throughout the Life Course. NJDOH has identified the State Priority Need (SPN) of Reducing Black Infant Mortality and selected the related NPMs 4 (Breastfeeding) and 5 (Infant Safe Sleep) as a result of the Five-Year Needs Assessment process. NJ has implemented several evidence-based strategies related to NPM 4 & 5 which in turn will impact on several NOMs (1, 2, 3, 4, 5, 6, 8, 9, 9.5). Evidence-based strategies related to NPM 4 & 5 are listed in the Logic Model.

 

3.E.2.c.2.a - Annual Report - NPM 4:

4A) Percent of infants who are ever breastfed and

4B) Percent of infants breastfed exclusively through 6 months

 

Promoting breastfeeding has been a long-standing priority for FHS. Breastfeeding is universally accepted as the optimal way to nourish and nurture infants, and it is recommended that infants be exclusively breastfed for the first six months. Breastfeeding is a cost-effective preventive intervention with far-reaching effects for mothers and babies and significant cost savings for families, health providers, employers and the government. Breastfeeding provides biologically normal, appropriate nutrition and encourages normal, infant development; lack of breastfeeding increases the risk of disease and obesity. FHS has developed many strong partnerships to strengthen breastfeeding-related hospital regulations, promoting breastfeeding education, training and community support.

 

WIC’s 2019 Strategic Plan includes facilitating the creation of the New Jersey Breastfeeding Strategic Plan (NJBSP) with the NJ Breastfeeding Coalition (NJBC). The final report was scheduled to be released 2020 but due to the pandemic the plan had to be redrafted to include breastfeeding in COVID-19. NJBSP with recommendations of short- and long-term goals, objectives and strategies will be released in 2021 for review.

 

According to the Centers for Disease Control and Prevention (CDC) 2020 National Immunization Survey Breastfeeding Rate Report Card, New Jersey rates stayed about the same for newborns ever breastfed at 88.8% in 2016 and 88.7% in 2017 (NPM 4A), Breastfeeding rates  increased in four categories from 2016 to 2017: exclusive breastfeeding at 3 months increased from 43.7% to 46.9%; breastfeeding at 6 months increased from 60.2% to 63.5%; exclusive breastfeeding at 6 months increased from 22.8% to 27.7% (NPM 4b); and breastfeeding at 12 months increased from 38% to 38.6%. 

 

 

Table NPM #4	Born in 2010	Born in 2011	Born in 2012	Born in 2013	Born in 2014	Born in 2015	Born in 2016	Born in 2017
Percent of infants who ever breastfed	77.1	81.6	82.0	82.0	83.9	82.8	88.8	88.7
Percent of infants breastfed exclusively through 6 months	13.0	22.3	16.7	23.1	24.8	24.4	22.8	27.7

Notes - Source – the CDC’s National Immunization Survey.
http://www.cdc.gov/breastfeeding/data/NIS_data/

 

FHS has supported Baby-Friendly™ designation through training, technical assistance and mini-grants. The Baby-Friendly Hospital Initiative (BFHI) is a global program that was launched by the World Health Organization and the United Nations Children’s Fund to encourage and recognize hospitals and birthing centers that offer an optimal level of care for infant feeding and mother/baby bonding. BFHI recognizes and awards birthing facilities who successfully implement the Ten Steps to Successful Breastfeeding (i) and follow the International Code of Marketing of Breast-milk Substitutes (ii). Fourteen NJ hospitals have earned the “Baby-Friendly” designation. Two “Baby-Friendly” hospitals were added in NJ in 2019.

 

NJ hospitals participate in the Maternity Practices in Infant Nutrition and Care (mPINC) survey, which is a national survey of maternity care practices and policies conducted by the CDC every two years, beginning in 2007. In 2018, 42 of 50 (84%) eligible hospitals participated in the mPINC Survey and the total score was 80 (above the national score of 79). NJ tied with two other states, ranking 18 out of 53 in 2018.  The 2020 mPINC survey results have been collected and state reports will be released by the CDC when the data is finalized.

 

Breastfeeding rates on discharge (alone or in combination with supplemental formula) varied with the racial and ethnic composition of mothers. In 2019 Asian non-Hispanic women were most likely to breastfeed (76.4%) while black non-Hispanic women were least likely to breastfeed (67.1%). White non-Hispanic and Hispanic women initiated breastfeeding at 75.0% and 78.6% respectively.
 

The exclusive rates for 2019 were 41.9% for white non-Hispanic women, 29.8% for Asian non-Hispanic women, 25.1% for Hispanic women, and 24.4% for Black non-Hispanic women. These statistics underscore the importance of comprehensively evaluating and addressing healthcare delivery, access, culturally appropriate support and community involvement to combat disparities.

 

Further examination of the disparity in these rates will require State leadership in enforcement of hospital regulations regarding breastfeeding and in providing support for information of locally available breastfeeding promotional activities, protocols, and the cultural appropriateness of those services

 

WIC Services provide breastfeeding promotion and support services for WIC participants through grants to all 16 local WIC agencies. International Board Certified Lactation Consultants and breastfeeding peer counselors provide direct education counseling and support services, literature, and breastfeeding aids, which include breast pumps, breast shells and other breastfeeding aids. WIC staff conducts the Loving Support© Through Peer Counseling Breastfeeding Program. WIC breastfeeding staff conducts professional outreach in their communities and education to healthcare providers who serve WIC participants.

 

Existing FHS programs that promote breastfeeding and include performance measures for increasing breastfeeding include the Healthy Women, Healthy Families (HWHF) Initiative and the MIEC Home Visiting Program. The newly designed Healthy Women Healthy Families Initiative will include as one of its outcomes increasing exclusive breastfeeding. Additionally, in an effort to address the racial/ethnic disparity in breastfeeding rates, one of the interventions/strategies that will be a requirement in targeted municipalities include breastfeeding support groups for Black, non-Hispanic, women.

 

Close collaboration between Maternal and Child Health Services (MCHS), WIC Services (WIC), and the Office of Community Health and Wellness is ongoing. All three programs, in addition to the Office of Minority and Multicultural Health, have an interest in breastfeeding protection, promotion and support and have similar constituencies.

 

Throughout 2019 and early 2020, the New Jersey Breastfeeding Strategic Plan Steering Committee, consisting of NJDOH and Title V staff, with representatives from the New Jersey Breastfeeding Coalition and the Central Jersey Family Health Consortium met monthly to provide guidance and monitor the progress of the development of a statewide strategic breastfeeding plan. This project included completion of a statewide environmental scan of literature, laws, policies, data, trends, disparities and practices in the state that support or create barriers to breastfeeding initiation, duration, and exclusivity, especially with regard to WIC and SNAP participants. The project also included development and dissemination of surveys to pediatricians, obstetricians, family practice physicians, midwives, perinatal nurses, lactation consultants, childbirth educators, staff of Healthy Women Healthy Families, and analysis of the resulting data. Eight consumer focus groups were organized and facilitated in Atlantic City, Camden, Newark, New Brunswick, Phillipsburg, Trenton, Union City and Vineland to explore factors that support, influence or discourage breastfeeding among NJ families, especially persons of color and marginalized groups, including the WIC and SNAP populations. A diverse stakeholder group was created that included over seventy traditional and non-traditional partners in government, business, insurance, education, community organizations, and healthcare and across agencies and departments that met periodically to recommend policy environmental and system changes. Interviews of key informants and state experts was undertaken. Utilization of the data created by the above activities to inform a needs assessment and SWOT analysis of strengths, weaknesses, opportunities and threats regarding breastfeeding/lactation in the state. Recommendation of short and long term goals, objectives and strategies to accomplish the NJBSP mission. The final report was submitted in April 2020 for review by DOH. A section on COVID-19 and breastfeeding was then added and submitted to the DOH in August 2020. The DOH plans to formally release the NJBSP in August 2021 for National Breastfeeding Month.

 

In January 2017, the State finalized new Hospital Licensing Standards that require hospitals to develop and implement evidence-based written policies and procedures for obstetrics, perinatal and postpartum patient services, newborn care, the normal newborn nursery, and emergency departments that address breastfeeding and supporting the needs of a breastfeeding mother and child from the point of entry into the facility through discharge. These Standards support the Ten Steps to Successful Breastfeeding and need strong enforcement.

 

The NJDOH will call attention to NJ’s 23.3% rate for hospitals supplementing breastfed infants with formula before two days of life; this is above the national average of 19.2% (with a Healthy People 2020 Target of 14.2%) and ranks NJ 46 out of 52 states (CDC’s Breastfeeding Report Card, 2020). In 2018 NJ was ranked 3rd worst out of 54 states. The Joint Commission Perinatal Care Core Measure on Exclusive Breast Milk Feeding (PC-05a) was retired in recognition of the decision some women make to not exclusively breastfeed despite recommendations. PC-05 continues as an accountability measure that is publicly reported on The Joint Commission’s Quality Check® website.

 

ESM 4.1 (Increase the Percentage of Births in Baby Friendly Hospitals) was selected for its positive impact on NPM #4 and NJ’s ongoing efforts to promote the Baby-Friendly Hospital Initiative and its ability to monitor breastfeeding rates from birth certificate data and the mPINC survey.

 

 

Annual Report NPM #5 (infant safe sleep)

 

Promoting infant safe sleep was selected as NPM #5 during the Five-Year Needs Assessment process for its importance in reducing often preventable infant deaths and its potential impact on improving NPMs 1, 2, 3, 4, 5, and 6. Sleep-related infant deaths, also called Sudden Unexpected Infant Deaths (SUID), are the leading cause of infant death after the first month of life and the third leading cause of infant death overall. Sleep-related SUID includes Sudden Infant Death Syndrome (SIDS), accidental suffocation and strangulation in bed and ill-defined and unknown causes. Due to the heightened risk of SUID when infants are placed to sleep on side or stomach sleep positions, health experts and the American Academy of Pediatrics (AAP) have long recommended the back sleep position, which has been called of the seven leading research findings in pediatrics in the last 40 years (Goldstein & Ostfeld, Pediatrics, 2017). Although, by definition, SIDS and ill-defined and unknown causes refer to deaths whose etiology has not been identified, the conditions that elevate risk are known. In 2011 and 2016, AAP expanded its recommendations to help reduce the risk of all sleep-related deaths through a safe sleep environment that includes use of the back-sleep position, on a separate firm sleep surface (room-sharing without bed sharing), and without loose bedding. Additional recommendations include breastfeeding and avoidance of overheating and of smoke exposure during pregnancy and after birth. These expanded, evidence-based recommendations for the first twelve months of life underlie the National Institute of Child Health and Development (NICHD) Safe to Sleep Campaign and that of the SIDS Center of New Jersey whose research contributed to the safe sleep policies of the AAP.

 

The selection of ESM 5.1 (Promote Infant Safe Sleep Environments) monitors and focuses attention on the complete safe sleep environment (Healthy Sleep) including back to sleep, no co-sleeping, and no soft bedding. Over a 10-year period there has been an upward trend in the use of back to sleep placement.

 

Table NPM #5

	2009	2010	2011	2012	2013	2014	2015	2016	2017	2018	2019
Percent of infants placed to sleep on their backs	65.7	67.4	68.9	70.1	69.5	70.8	70.5	69.4	75	73.4*	73.0*

*In 2017 the percent of infants placed on their backs surpassed the Health People 2020 NJ target of 74.1. The percentages for 2018 and 2019 fall within the standard error of measurement for 2017 and thus are comparable to 2017.

Notes - Source – NJ PRAMS.

https://www-doh.state.nj.us/doh-shad/query/selection/prams/PRAMSSelection.html.
 

 

To promote infant safe sleep (NPM #5), NJDOH has supported the evidence-based strategies of the American Academy of Pediatrics, the NICHD’s Safe to Sleep Campaign, the activities of the SIDS Center of New Jersey https://www.facebook.com/SID CenterNJ/, and  www.rwjms.rutgers.edu/sids, and the work of the Sudden Unexpected Infant Death Case Review Workgroup. To improve the surveillance of infant safe sleep practices, Family Health Services conducts the PRAMS survey which includes questions on infant safe sleep and participates on the SUID-CR Workgroup.

 

The SIDS Center of New Jersey (SCNJ) is a program funded by a NJDOH health services grant to Robert Wood Johnson Medical School (RWJMS), a part of Rutgers, The State University of New Jersey, New Brunswick and is based both at RWJMS and the Joseph M. Sanzari Children’s Hospital at Hackensack University Medical Center, Hackensack. SCNJ was established in 1988 through the SIDS Assistance Act. The SCNJ missions are to: 1) provide public health education to reduce the risk of sudden infant death, 2) offer emotional support to bereaved families, and 3) participate in efforts to learn about possible causes of and risk factors associated with sudden unexpected infant deaths, and best practices for providing safe sleep education.  Research by SCNJ faculty has contributed to the identification of risk factors and risk-reducing strategies.

 

The SCNJ develops novel safe sleep interventions and tools to educate providers and the public including parents, grandparents, physicians, nurses, the childcare community, hospitals, clinics, first responders, schools, social service agencies, home visiting programs, doulas, and faith-based communities.  It works with state, federal and national organizations to reduce infant mortality, the racial and ethnic disparities associated with SUID and the adverse antecedent social and health determinants that increase the vulnerability of infants to unsafe sleep environments. These factors include smoke exposure, preterm birth, the absence of breastfeeding, poverty, lifespan health, and implicit bias. The SCNJ's Infant's Bill of Rights supports collaboration among the many public health programs that address these issues and the shared goal of reducing infant mortality. SCNJ follows the guidelines of the AAP when providing risk reduction education. The Safe Infant Sleep guidelines of the AAP are intended to help families reduce the situational risks that are associated with Sudden Unexpected Infant Deaths. Research conducted by the SCNJ contributed to these recommendations and informs its safe sleep education programs. With the goal of changing behavior as well as knowledge, the SCNJ also evaluates educational methodologies and barriers to compliance and develops interventions designed to be respectful of generational, cultural and community concerns.  NJ rates of SUID are among the lowest in the US.  In 2018, New Jersey's SUID rate was 0.5 per 1000 live births, in contrast to the national rate of 0.9 and was third lowest among states. (CDC WONDER linked birth/infant death file).  Provisional New Jersey data for 2019 is on track to be similar.

 

NJ has participated in the Sudden Unexpected Infant Death Case Review (SUID-CR) Registry grant funded by the CDC since 2006. SUID-CR activities have standardized, and improved data collected at infant death scenes and promoted consistent case review, classification and reporting of SUID cases. NJDOH and SCNJ are represented on the multi-disciplinary SUID-CR Review Board which meets monthly as a subcommittee of the Child Fatality and Near Fatality Review Board (CFNFRB). The SUID-CR is staffed by the Department of Children and Families and is an important statewide surveillance system for unexpected infant deaths. The SUID-CR makes recommendations to the statewide CFNFRB concerning infant safe sleep and promotes SUID prevention activities which are included in the CFNFRB annual report.

 

In 2018, The SIDS Center of New Jersey developed a unique and free app, SIDS Info, for ioS and android devices, with the goal of enhancing the education of parents and providers about safe infant sleep and enabling parents and others to have direct access to this information. This novel and interactive tool contains graphics, English and Spanish text and voiceovers to eliminate language and literacy challenges, and a menu of additional resources.  It gives nurses, physicians, childcare specialists, case workers and other providers a new way of reviewing the information with parents. Providers also help families download the app to their phone, ubiquitous in all population groups, to serve as an enduring resource for a generation of parents familiar with accessing information in this manner. The app can reduce the need for print material, can be automatically updated, and is more accessible and enduring than flyers.  It can be shared remotely with others caring for an infant. Under a "Keep It Up!" strategy, pediatricians also are encouraged to review the app with families at well-baby visits to compensate for a decline in compliance over time. Rural communities and others with limited access to health resources, and parents concerned about visiting health care providers during the COVID-19 pandemic, are able to access this tool directly. SIDS Info, which received a Public Health innovation Award from the NJDOH, has been accepted as a resource by the NICHD Safe to Sleep Campaign® and as an Emerging Practice in the Innovation Hub of the Association of Maternal and Child Health Programs.  In 2019, faculty of the SCNJ announced release of a second app, Baby Be Well®, developed in a collaboration of Rutgers University and volunteers of Microsoft.  It is intended to extend interest in accessing the information throughout the first year, through multiple design strategies, providing an additional resource to compensate for reductions in compliance over time.  These tools are now widely used in NJ and other states. Other educational strategies used by the SCNJ include webinars in English and Spanish specific to provider groups, grandparent education through faith-based community programs, hospital-based staff education through its "Nurses LEAD the Way!" initiative and tool kit, a high-school education program with established efficacy to create trusted student ambassadors who inform their community, and participation in the community-based outreach programs of Nurture NJ.  To make its flyers, other resources and live and on-demand webinars directly accessible to the public, the SCNJ posts them on its social media platform:  https://www.facebook.com/SIDSCenterNJ/ and its website:  www.rwjms.rutgers.edu/sids.

 

Through the multiple evidence-based strategies in NJ to promote infant safe sleep and the consistent message to place infants to sleep on their backs, according to NJ PRAMS, NPM #5 has been slowly improving from 60.6% in 2004 to 75% in 2017 which exceeded the NJ Healthy People 2020 goal of 74.1%. At 73%, the data for 2019 falls within the standard error of measurement of 2017 and thus is comparable to the previous year, The NJ SUID rate has also declined from 1.13 per 1000 live births in 1990-1992 to 0.5 per 1000 live births in 2018, according to NJSHAD and NCHS. The NJ SUID rate falls well below the national rate of 0.9 and is among the lowest in the US. Racial and ethnic disparities in NPM 5 persist throughout the US and are being addressed through more targeted educational messages using home visitor staff in DCF and the MIEC Home Visiting Program. The SCNJ provides safe sleep education to these programs and also addresses racial disparity in the application of safe sleep practices and in the adverse antecedent social and health risk factors that affect SUID. 

 

Annual Report – SPM #1 (The percentage of Black non-Hispanic preterm births in NJ)

 

The selection of SPM #1 (The percentage of Black non-Hispanic preterm births in NJ) during the Five-Year Needs Assessment process recognizes the persistence of racial/ethnic disparities in healthy birth outcomes in NJ. Infants who are born preterm are at the highest risk for infant mortality and morbidity. The percentage of black preterm births was selected to begin to address the underlying causes of black infant mortality and the racial disparity between preterm birth rates.

 

	2009	2010	2011	2012	2013	2014	2015	2016	2017	2018	2019
Annual Indicator	14.0	13.2	13.0	12.7	12.8	13.3	13.3	13.6	13.1	13.5	13.8
Numerator	2,298	2,105	2,021	1,986	1,930	1,983	1,879	1,852	1,774	1,835	1,803
Denominator	16,402	15,945	15,586	15,692	15,064	14,864	14,169	13,634	13,530	13,643	13,043

Notes - Source - Birth Certificate data from the SHAD system

https://www-doh.state.nj.us/doh-shad/

 

See Chart 5 Low Birthweight by Race/Ethnicity attached as Supporting Document #3.

 

Maternal and Child Health Services has a long history of efforts to combat persistent perinatal health disparities.  Despite years of improving pregnancy outcomes programs and appointments of task forces dedicated to addressing disparities in healthcare, these disparities continue. 

 

First Lady Tammy Murphy has made reducing black infant mortality a top priority, committing to improving the well-being of women and infants. The First Lady has traversed the state over the past three years meeting with stakeholders to better understand the depth of the crisis, and to raise awareness that New Jersey's black infants are three times more likely than white infants to die before their first birthday. The First Lady launched Nurture NJ, a multi-pronged, multi-agency campaign focused on reducing maternal and infant mortality and morbidity and ensuring equitable maternal and infant care among women and children of all races and ethnicities. The Nurture NJ campaign is dedicated to ensuring equitable maternal and infant care among women and children of all races and ethnicities.  This past January 2021, the Nurture NJ 2021 Strategic Plan was unveiled with a goal of reducing New Jersey’s maternal mortality by 50% over the next five years and eliminate racial disparities in birth outcomes. This strategic plan supports the First Lady’s platform to make New Jersey “the safest and most equitable place in the nation to deliver and raise a baby”.

 

Through the Healthy Women Healthy Families (HWHF) Initiative, implemented in July 2018, efforts continue to be targeted to reduce the Black Infant Mortality (BIM) Rate in New Jersey.  Specific BIM reducing activities including Centering Pregnancy and Centering Parenting programs, Doula, breastfeeding support and Fatherhood initiatives are being implemented in the cities with the highest BIM rates in NJ. Centering groups faced an initial pause due to in-person restrictions, but within a few months many groups were able to resume using a virtual platform. After pandemic restrictions were modified, in-person groups also resumed following certain guidelines. The Doula Pilot Program was a three year state-wide program that ended June 2021, which included the three community-based grantees working in 12 regions.  Additionally through this program, doula care proves to reduce black infant mortality in 8 municipalities (Atlantic City, Camden, East Orange, Irvington, Jersey City, Newark, Paterson, and Trenton).  The bridge funding will provide support to the community doulas trained through the Doula Pilot Programs as they transition and enroll in NJ FamilyCare Medicaid fee-for-service and the Manage Care Organization’s process to become Medicaid providers.  A RFA was issued for the creation of a Doula Learning Collaborative (DLC), which was awarded to Health Connect One.  The focus of the DLC is to reduce maternal and infant mortality and eliminate racial disparities in health outcomes by providing training, workforce development, supervision support, mentoring, technical assistance, direct billing, and sustainability planning to grow the community doula workforce. Community Health Workers and supervisors are receiving breastfeeding education through an initiative by the NJDOH. The” Breastfeeding in Color” training focuses on women of color and was developed to address issues of disparities, focusing on reproductive justice and addressing inequities in human lactation. Fatherhood success continues with a total of 207 fathers graduating from the program since inception three years ago, with alumni still staying involved.

 

The Colette Lamothe-Galette (CLG) Community Health Worker Institute was established through a NJ Department of Labor Apprenticeship program to create a standardized community health worker training and certification program, resulting in a robust CHW workforce. This has allowed the state to educate an emerging and critical component of its workforce – creating a needed infrastructure to support CHWs and enhance CHW skill sets and lead sustainable efforts to support this indispensable workforce. Graduation of the initial cohorts has already begun, with new cohorts continuously being enrolled.

 

In collaboration with the CLG-CHW Institute, the Epidemiology Laboratory and Capacity (ELC) grant emphasizes the prevention of disease and enhanced detection for COVID19. The ELC focused on hiring and training CHWs to assist in contact tracing efforts; assisting with the surveillance of vulnerable populations; implementing prevention strategies with vulnerable, diverse populations; and providing alternative testing and vaccine sites for COVID-19. The COVID Community Corps and Vaccine Ambassador Programs also support these efforts.

 

Efforts for safe sleep education and practices continue through the SIDS Center of NJ and Rutgers State University involving a) outreach and education, and b) providing linkages that will address some of the social determinants that literature and research as well as focus groups conducted by FHS have identified as contributors to mortality. Intentional focus continues on municipalities that were identified as having the highest Black Infant Mortality Rates as well as high proportion of Black, NH women in need of these services.