Perinatal/Infant Health Overview
Perinatal and infant health is a central focus of the Division of Maternal and Infant Health (DMIH), which supports programs designed to ensure infants are born healthy and ready to thrive. The Women and Maternal Health and Perinatal and Infant Health Sections within DMIH oversee many programs including the Regional Perinatal Quality Collaboratives, Maternal Infant Health Program (MIHP), Infant Safe Sleep, Fetal Infant Mortality Review, Safe Delivery, and the Early Hearing Detection and Intervention program. MIHP provides Medicaid-funded home visits to women while pregnant and infants in their first year of life, and other infant health services focused on needs such as infant mortality prevention, safe sleep, and vision and hearing screening. Title V funds a variety of programs and initiatives related to perinatal and infant health, including projects related to sudden infant death syndrome, prenatal care outreach, PRAMS, and infant and maternal mortality reduction. MCH program staff also support regional perinatal quality collaboratives that use quality improvement methods to test strategies for improving maternal and infant health. Other federal funding is used to identify and meet the needs of this population, such as WIC (USDA), Universal Newborn Hearing Screening and Intervention (HRSA), and PRAMS (CDC). Perinatal and infant health is promoted through a network of partnerships, including those with health care providers, labor and delivery hospitals, universities, the Mother Infant Health and Equity Collaborative, and the Michigan Association for Infant Mental Health. For example, MDHHS staff serve as program liaisons or committee members to external organizations and initiatives and support communication between the Department and these partner organizations.
At the local level, local health departments (LHDs) expended Title V funds in three performance measures. One LHD selected NPM 3 (risk-appropriate perinatal care), expending 0.7% of LMCH funds, by collaborating with local birthing hospitals to coordinate care and refer to local programs. For breastfeeding (NPM 4) activities, 17 LHDs expended 9.7% of LMCH funds to facilitate breastfeeding support through groups, lactation consultants, staff development and breastfeeding promotion. Nine LHDs selected safe sleep (NPM 5), accounting for 7.8% of LMCH funds. LHDs provided safe sleep education before and after delivery, through faith-based liaisons and community outreach, and provision of safe sleep environments (e.g., pack-n-play).
Michigan’s approach to perinatal and infant health emphasizes implementing strategies that prevent maternal and infant morbidity and mortality, which are critical indicators of the degree to which a community takes care of its women and children. Focus areas include safe sleep and breastfeeding. In Michigan, the infant mortality rate has decreased from 7.5 deaths per 1,000 births in 2009 to 6.8 per 1,000 births (NVSS) in 2017. A similar trend has been documented nationwide. However, the risk doubles to 14.6 among non-Hispanic Black babies and is substantially greater (9.0) for babies born to mothers who are under 20 year of age. These data suggest that while the needs of women and children are being better prioritized in general, the needs of Black families and young families remain unmet. Another critical signal of wellbeing in the perinatal period and a factor in the health of infants is postpartum depression. From 2012 through 2017, the proportion of mothers reporting postpartum depression symptoms has remained constant at 13.5%, but this number jumped to 16.4% in 2018 (Michigan PRAMS). However, 20.1% of women with Medicaid prenatal care experienced depression symptoms postpartum compared to 12.7% for those without Medicaid, suggesting that women living with limited incomes face stressors around childbirth that women with greater resources are more protected from experiencing (PRAMS).
Risk-appropriate Perinatal Care (FY2019 Annual Report)
In FY2019, Michigan continued to build on its existing perinatal care system. These efforts included ongoing Regional Perinatal Quality Collaborative (RPQC) efforts in northern lower, west, southeast, southwest, Saginaw/Bay area, Thumb area and the Upper Peninsula of Michigan. Additionally, efforts began related to expansion into the Mid-Michigan and lower southeast areas of Michigan. Regional Perinatal Quality Collaborative efforts have served as the key drivers in addressing risk-appropriate care for mothers, infants and perinatal substance use. In FY 2019, Title V federal funding was used to support a portion of the Statewide Perinatal Quality Collaborative (PQC), as well as additional statewide maternal and infant health efforts. Focus remained on linking families to evidence-based prenatal and postnatal care models of CenteringPregnancy and CenteringParenting, as well as evidence-based home visiting, all of which have been proven to improve birth outcomes.
The importance of comprehensive system linkages and quality improvement remain the driving force in Michigan’s efforts to improve maternal, infant and family health. In FY 2019, partnerships and collaborations were solidified and strengthened with many maternal and infant health partners, such as: Healthy Start projects; WIC clinics; Maternal, Infant and Early Childhood Home Visiting (MIECHV) Programs; local health departments (LHDs) receiving Title V funding; families; and Community Based Organizations (CBOs), such as Black Mothers Breastfeeding Association.
Objective A: By 2020, support the implementation and evaluation of Regional Perinatal Care Systems in five pilot communities or regions.
In FY 19, Regional Perinatal Quality Collaborative projects expanded to include eight of the ten Michigan-designated Prosperity Regions. Perinatal Quality Collaboratives are now located in southeast, west, northern lower, southwest, the Saginaw/Bay area, Thumb area and the Upper Peninsula of Michigan. Each regional project is charged with utilizing data driven decisions and quality improvement methodology aimed at improving maternal and infant health. All regions are required to review their respective birth outcome data (stratified by race, ethnicity, age and socioeconomic status) to identify inequities and gaps in care; both of which shape the focus of each region’s quality improvement project(s). Additionally, every region is to address the social determinants of health as the root cause of health inequity. Furthermore, each regional collaborative is to convene diverse cross-sector partners vested in improving maternal and child health outcomes, focus on relationship building with stakeholders and partners, and establishing authentic engagement of families and community members. Birthing hospitals, LHDs, Medicaid Health Plans, Healthy Start projects, evidence-based home visiting programs, Great Start Collaborative representatives, clinical care providers and community-based organizations are just a sample of the stakeholders and members of the Regional Perinatal Quality Collaboratives. The most important stakeholders, however, are the families residing in each region. Family input on the regional efforts, as well as barriers and inequities experienced, has been garnered in the form of focus groups, participation at regional collaborative meetings, as well as regional “town hall” meetings held in FY2019.
Southeast Michigan (inclusive of Wayne, Oakland and Macomb counties) is home to 24 of Michigan’s 80 birthing hospitals. Of these 24 birthing hospitals in southeast Michigan, ten have neonatal intensive care units (NICUs) and represent just under half of the NICUs in Michigan. In calendar year 2018, 45,233 (41%) of the births in Michigan occurred in southeast Michigan. In an effort to address areas of high infant mortality, the team designed its quality improvement project around increasing referrals and utilization of evidence-based home visiting from two prenatal care clinics and a NICU in the City of Detroit. These clinics, NICU, and home visiting agencies serve areas of the City that experience high rates of infant mortality. Expansion of this project into additional counties is expected in FY2020.
West Michigan contains 13 rural and urban counties, nine LHDs, 12 birthing hospitals, two NICUs and a reported 19,218 births in calendar year 2018. This regional quality collaborative has divided into two workgroups: one to increase substance use screening and referrals in pregnant women and one to increase utilization of evidence-based home visiting services. Building on the successes in FY2018, the team was able to expand use of the screening tool to an additional clinic and pilot co-locating home visiting staff in a WIC clinic as a strategy to increase referrals. The populations of focus for these two workgroups were identified through stratification of data and identification of certain geographic areas of the region with poorer birth outcomes and more cases of infant morbidity.
Northern Lower Michigan is made up of 21 counties, eight birthing hospitals, and one NICU. In calendar year 2018, 4,541 live births were reported. This region continued their work to increase substance use screening in pregnant women through an electronic screening tool, ensure women with Perinatal Substance Use Disorder (PSUD) are linked to appropriate providers for treatment, increase the number of obstetric providers trained in medication assisted treatment (MAT) and increase referrals and utilization of home visiting programs. Northern Lower Michigan identified a need for PSUD screening, based on data related to smoking in pregnancy, rate of Neonatal Abstinence Syndrome cases, and after surveying prenatal clinics on their current use of screening tools.
The Upper Peninsula is 16,377 square miles, has 15 counties, eight birthing hospitals, and one NICU. In calendar year 2018, 2,539 live births were reported. Recent Neonatal Abstinence Syndrome (NAS) data reflects the highest rates in Michigan are still occurring in the Upper Peninsula. Given these results, along with the high number of women who smoke while pregnant, the team decided to focus their efforts on increasing substance use screening in pregnant women, increase care coordination of PSUD treatment and obstetric care, reduce stigma related to care of babies with Neonatal Abstinence Syndrome (NAS), implement nonpharmacologic treatment of babies with NAS, and implement the Society for Public Health Education (SOPHE) Smoking Cessation and Reduction in Pregnancy Treatment (SCRIPT) program at several agencies throughout the region.
Southwest Michigan is comprised of seven counties, eight birthing hospitals, and one NICU. In calendar year 2018, 8,915 live births were reported. In 2018, it was reported that only 57-72% of pregnant women began prenatal care in the first trimester. This data continues to be a key driver in the decision to work on increasing early entry into prenatal care in this region. Additionally, the team is exploring the implementation of universal referrals for home visiting services, in an effort to increase utilization of these services in the Region, and ensure all women and infants are linked to needed resources.
The Saginaw/Bay area is made up of eight counties, five birthing hospitals and one NICU. In calendar year 2018, 5,720 live births were reported. In the same year, 15-36% of pregnant women in this region reported smoking while pregnant, which are some of the highest numbers in the state. Given this data, the RPQC decided to focus their efforts on implementing SOPHE SCRIPT in several agencies throughout the Region. In addition, the team is exploring a CenteringPregnancy cohort for pregnant women with substance use disorder. The clinic where this cohort would receive care has an established CenteringPregnancy program and recently began offering the CenteringParenting program.
The Thumb area is made up of seven counties, eight birthing hospitals and two NICUs. In calendar year 2018, 8,792 live births were reported. In 2017, it was reported that this area of the state had the second highest NAS rates for Michigan at 1,936 per 100,000 live births. This data was a deciding factor in the Region’s efforts to implement an electronic substance use screening tool in two prenatal clinics, as well as ensure women who screened positive are linked to appropriate services and resources. It is expected that the Region will add additional areas of focus in FY2020, as the RPQC continues to grow.
Outreach to the Mid-Michigan and lower southeast areas in Michigan began in FY2019 with stakeholders in each region meeting to discuss operationalizing a Regional Perinatal Quality Collaborative. The Mid-Michigan area is comprised of three counties, two birthing hospitals and one NICU. In calendar year 2018, 4,972 live births were reported. Lower Southeast Michigan is made up of six counties, six birthing hospitals and two NICUs. In calendar year 2018, 10,035 live births were reported. These two areas of the state encompass the remaining prosperity regions not represented by an RPQC. Launching Regional Perinatal Quality Collaboratives in both the Mid-Michigan and lower southeast areas in Michigan ensures that all 10 prosperity regions are represented and therefore, will prove beneficial toward the overall improvement of maternal and infant health in Michigan.
Objective B: By 2020, increase Risk Appropriate Care for mothers and infants from baseline data indicators by 20%.
The ESM for this NPM, which aligns to this objective, is the number of CenteringPregnancy sites in Michigan. Ongoing support of this evidence-based strategy measure is a key component to assuring risk-appropriate care for Michigan mothers and infants. CenteringPregnancy is an evidence-based prenatal model that has proven health outcomes including reductions in preterm and low birth weight infants. The CenteringPregnancy model is patient-driven, resulting in a patient/clinician partnership that values the voices of women during pregnancy and interconception. MDHHS continues to be supportive of CenteringPregnancy, evidenced by the inclusion of the program into the state’s Mother Infant Health and Equity Improvement Plan (MIHEIP). To date, 15 CenteringPregnancy sites and three CenteringParenting sites have been established in Michigan.
In calendar year 2018, 88.6% of low birth weight (LBW) babies were born at hospitals offering neonatal intensive care units (NICU) or special care nurseries (SCN). In 2018, 9,096 babies were born with LBW at a hospital and of those, 8,055 were born at a facility with a NICU or SCN. In the same year, 89.5% of very low birth weight (VLBW) babies were born at hospitals offering a NICU. There were 1,470 babies born with VLBW in 2018 at a hospital, and of those, 1,315 were born at a facility with a NICU.
NICUs of Michigan most closely correlate with Level III nurseries and SCNs of Michigan most closely correlate with Level II nurseries. Based on data received from MDHHS Vital Statistics, the majority of LBW and VLBW babies were born at hospitals that best medically meet their needs. However, a deeper dive into the data and case abstraction may provide information as to why 11.5% of LBW babies are born at hospitals without NICUs and SCNs, why 10.5% of VLBW babies are born at hospitals without NICUs, and how we can ensure that going forward all LBW and VLBW babies are born at hospitals that best meet their needs.
Objective C: By 2020, expand quality improvement efforts related to the prevention and response of Perinatal Substance Use.
The MDHHS-supported Michigan Collaborative Quality Initiative is a voluntary quality collaborative of approximately 20 Michigan birthing hospitals. In FY 2019, the Michigan Collaborative Quality Initiative held monthly webinars to share best practices, discuss collaborative efforts and collected data to monitor improvements regarding NAS of infants cared for in Neonatal Intensive Care Units. The group also discussed implementing non-pharmacologic treatment of babies with NAS in the NICUs.
The Regional Perinatal Quality Collaborative of northern lower Michigan, as mentioned above, implemented quality improvement efforts aimed at increasing the number of prenatal substance use screenings and conducted brief interventions and referrals via the innovative use of handheld technology while patients waited at prenatal appointments. These efforts expanded to additional clinics within the Region in FY2019, and are slated to continue, and further expand, in FY2020. The Thumb area began piloting the innovative screening technology, referenced above, in FY2019 and will continue into FY2020. The Upper Peninsula will begin implementation of the previously referenced screening technology in FY2020. West Michigan has implemented a paper version of an evidence-based screening tool at three clinics and plans to continue and expand the project in FY2020. All Regional Perinatal Quality Collaborative projects have also been instrumental in ensuring that education and outreach efforts to address Perinatal Substance Use have occurred in the forms of SOPHE SCRIPT training, use of Finnegan scoring of infants to identify NAS, nonpharmacologic treatment for infants with NAS and linking to supportive resources, such as evidence based home visiting programs.
MDHHS continues to work to align maternal and infant health efforts both internally and with external partners. These efforts have resulted in increased communication and more streamlined efforts to positively impact the lives of those affected by Perinatal Substance Use Disorder (PSUD). Specifically, this partnership led the MDHHS Office of Recovery Oriented Systems of Care (OROSC) to provide funding for the Regional Perinatal Quality Collaborative in the Saginaw/Bay region, with the caveat that quality improvement efforts must focus on PSUD. As mentioned above, this area of the state has high NAS rates, as well as high rates of reported smoking in pregnancy. As MDHHS continues to build and strengthen partnerships, it is expected that additional opportunities and programs positively impacting those affected by PSUD will be supported and developed.
Breastfeeding (FY 2019 Annual Report)
Breastfeeding is a natural way to feed and provide nutrition to infants, and research shows that it provides many short- and long-term benefits to both mothers and babies, including significant benefits to the mental health of both mothers and babies. Michigan continues to promote and fund breastfeeding initiatives and education. Breastfeeding initiation continues to rise in Michigan. PRAMS data indicate that in 2004, 71% of mothers in Michigan initiated breastfeeding. By 2017, that rate increased to 87.7%. While initiation rates were stable from 2004-2009, from 2009-2017 sustained growth in initiation occurred, from 73.2% to 87.6% of mothers, gaining 14.5% across eight years. PRAMS 2018 data show a slight dip to 86.9% initiation rate.
From 2009-2014 initiation grew from 64.9% of black mothers to 77.3% (+12.4%), almost identical to the change from 74.5% to 86.3% among white mothers (+11.8%). However, from 2014 to 2017, initiation among black mothers has remained unchanged (77.3% to 77.2%) compared to increases among white mothers (86.3% to 90.1%). MDHHS continues to seek ways to better support breastfeeding and to increase initiation among non-Hispanic black mothers. Starting in 2016, PRAMS asked mothers why they did not initiate breastfeeding. Among mothers who chose not to initiate, the top reasons included not wanting to breastfeed, not liking breastfeeding and having other children to care for. Mothers completing the survey could choose multiple reasons. Non-Hispanic black mothers reported more reasons for not initiating than non-Hispanic white mothers.
Families and consumers have significant input into local breastfeeding activities through breastfeeding coalitions and peer support groups. For example, families and consumers were invited to participate in Regional Town Hall Meetings at which breastfeeding was discussed among other maternal and infant health topics.
MDHHS is currently operating under Michigan’s first Breastfeeding State Plan published in the fall of 2017. The Plan set a common agenda necessary for a collaborative approach among an array of stakeholders: state, local and tribal government; health care professionals and organizations; employers; childcare providers and educational institutions; community organizations; and most importantly, individuals and families. The Plan’s five key strategies to achieve breastfeeding goals are the elimination of disparities; advancing breastfeeding rights through education of policy makers and support of laws that protect breastfeeding families; building community support through the work of breastfeeding coalitions and increased access to breastfeeding support; changing organizational practices; and strengthening individual skills. In order to focus internal efforts and limited resources, MDHHS breastfeeding partners (i.e., WIC, maternal and infant health and obesity prevention) identified key strategies:
- Increase training opportunities to improve the number, availability, and racial and cultural diversity of trained breastfeeding professionals.
- Develop and promote interventions to address disparities in breastfeeding rates.
- Increase the number of Baby-Friendly hospitals.
Challenges toward implementing the strategies outlined in FY 2019 Title V state action plan included staff turnover in the State Breastfeeding Coordinator position which is primarily responsible for implementing the plan. A new coordinator was hired in March 2019, six months into the fiscal year. The coordinator prioritized professional orientation and training and received her Certified Lactation Consultant (CLC) certification in Fall 2019.
Objective A: Increase percentage of Baby-Friendly designated birthing hospitals to 26% by 2020.
Michigan’s evidence-based strategy measure (ESM) is the percent of Baby-Friendly designated hospitals. The purpose of the Baby-Friendly Hospital Initiative (BFHI) is to assist hospitals in providing mothers with information, confidence and skills needed to start and continue to breastfeed their babies. Progress toward meeting this objective has slowed. While the percent of Michigan birthing hospitals with Baby-Friendly status did increase from 14.3% in 2016 to 18.8% in FY 2019, it is unlikely to increase to 26% in 2020. While there is general support for the Baby-Friendly initiative in Michigan, our birthing hospitals struggle to move forward on the Baby-Friendly pathway due to time, cost and competing priorities. Not reflected in the percent of hospitals to achieve Baby-Friendly are the important steps Michigan hospitals are taking to improve breastfeeding-friendly practices outside of the designation.
The first strategy to achieve our goal was to determine each Michigan birthing hospital’s individual goal to continue movement along the Baby-Friendly pathway. This strategy was not achieved due to staff turnover in the State Breastfeeding Coordinator position. The second strategy was to continue the work of QI Jumpstart, a collaborative network of hospitals working on quality improvement and training. The QI Jumpstart did continue to meet in FY 2019 without additional MDHHS funding and continues to provide a collaborative environment for hospitals to move along the Baby Friendly pathway.
The third strategy was to promote breastfeeding supportive practices in at least 20 birthing hospitals through trainings and support of the annual Mother Baby Summit. The Mother Baby Summit was held on November 8, 2019 and numerous MDHHS staff attended the meeting. MDHHS supports a breastfeeding webinar series that offers educational topics and training and continuing education for social workers, nurses, lactation consultants, and dieticians. Hospitals have participated in all twelve webinars held in FY 2019 with an average of 162 participants identifying as hospital staff. The MDHHS WIC Division hosted four Building Bridges trainings in FY 2019 with a cumulative 184 people attending. Building Bridges is a highly acclaimed training that promotes collaboration between hospitals, WIC programs and community partners in providing lactation support services. MDHHS also hosted the Maternal Infant Health Summit in March 2019 and included a presentation on Breastfeeding and Safe Sleep. Registration shows that 17 people attended the presentation including 12 that self-identified as nursing staff.
The fourth strategy focused on assisting key statewide partners who influence maternal and infant health to develop and implement one specific strategy that supports efforts to increase the number of Baby-Friendly hospitals. Coordinated effort on this strategy was hindered due to staff turnover in the State Breastfeeding Coordinator position. However, thanks to the work of statewide partners elevating the importance and positive outcomes from breastfeeding, breastfeeding support is being prioritized by several statewide partners. The Michigan Council for Maternal and Child Health (MCMCH) which has long advocated for breastfeeding support, continues to recognize its importance via its policy agenda. MCMCH and the Michigan Chapter of the American Academy of Pediatrics produced a maternal and infant health fact sheet which acknowledged the positive impact of breastfeeding.
Objective B: Reduce the disparity in breastfeeding initiation between non-Hispanic white women and non-Hispanic black women from an average of 12.1% to 11.9% by 2020.
According to PRAMS data, Michigan’s gap in breastfeeding initiation between non-Hispanic white women and non-Hispanic black women has decreased from an average of 15.3% in 2009-2011, to 12.1% in 2013-2015. To further reduce the gap in disparities, Michigan worked to provide and promote training opportunities to improve the number, availability and racial and cultural diversity of trained breastfeeding professionals. MDHHS continued to work with state-administered programs to provide a base level of competency. The State Breastfeeding Coordinator convenes a state-level workgroup with representatives from various programs and departments including WIC, Safe Sleep, Home Visiting, Medicaid, Children’s Special Health Care Services, Chronic Disease and others. The purpose of the group is to coordinate breastfeeding related efforts and provide consistent breastfeeding information within MDHHS programs. Staff share training opportunities that can be promoted in statewide programs including the Great Lakes Breastfeeding webinars.
MDHHS partners with and provides support to the Great Lakes Breastfeeding webinar, a project of the Michigan Breastfeeding Network, which offers breastfeeding-specific information every month, at no cost to participants. The webinar provides contact hours for nurses, social workers, lactation consultants and dietitians. This free, easy-to-access education allows all providers the ability to receive advanced training, which diversifies and strengthens Michigan’s lactation workforce. Topics have a strong health equity focus. FY 2019 topics were well-received with webinar attendance between 476 and 897 each and representing an average of 35 states. The webinars continue to be popular with WIC, hospitals, health departments and home visitors. In FY 2019, MDHHS worked with the Michigan Breastfeeding Network to obtain funding from maternal and child health partners in Region V (Ohio and Wisconsin) to support the webinars and to move toward regional collaboration.
Due to the staff turnover in the State Breastfeeding Coordinator position, MDHHS has just begun to refocus on building partnerships with communities that have lower breastfeeding rates among women of color. The Coordinator has started attending local breastfeeding collaboratives, Regional Town Hall meetings and Michigan Breastfeeding Network quarterly meetings to build relationships and learn more about the communities and their needs. MDHHS is hoping to explore projects to support specific communities in FY 2020.
Safe Sleep (FY 2019 Annual Report)
In Michigan’s original five-year plan, the priority area to “Foster safer homes, schools and environments with a focus on prevention” was linked to promotion of infant safe sleep environments through the following two-part SPM:
- The percent of infants put to sleep alone in their crib, bassinet or pack and play.
- The percent of infants put to sleep without objects in their crib, bassinet or pack and play.
HRSA added two Pregnancy Risk Assessment Monitory Survey (PRAMS) measures to the original NPM, that previously only measured the percent of infants placed to sleep on their backs. Given this change, Michigan converted its original SPM to the new NPM for FY 2019. Michigan originally did not choose “infants being placed to sleep on the back” as a performance measure because it exceeded the Healthy People 2020 goal.
Michigan’s safe sleep strategies and activities promote three key messages to parents and caregivers: infants should sleep 1) alone, 2) on the back, and 3) in a crib, bassinet or pack and play. These behaviors are critical to the prevention of sleep-related infant death. Of the leading causes of infant death, sleep-related causes are considered the most preventable. In FY2019, Title V federal funding was used for activities that support Michigan’s safe sleep work, including PRAMS, infant mortality communication, Fetal Infant Mortality Reviews, and funding to local health departments to support community-based safe sleep efforts.
Data from PRAMS for birth year 2017 show that the percentage of mothers placing infants to sleep alone in their crib, bassinet, or pack and play and the percentage of mothers putting infants to sleep without objects in their crib, bassinet or pack and play has increased compared to 2016. Parents placing infants to sleep on their back remained relatively stable between 2016 and 2017.
In birth year 2017, 83.3% of Michigan mothers placed their infants to sleep on their backs; this is a stable trend as compared to 2016. In birth year 2017, 39.2% of infants were placed to sleep on a separate approved sleep surface, which has increased compared to 2016. Prior to 2016, this measure was based on only two sleep risk factors—does the infant sleep in his or her own crib and does the infant sleep with other people. Starting in 2016, this measure is based on the combination of five different sleep risk factors: always or often 1) sleeps alone in own bed; 2) in a crib, bassinet or pack and play; 3) does not sleep on a twin or larger mattress; 4) does not sleep on couches, sofas, armchairs; and 5) does not sleep in a car set or swing. Asking whether infants sleep in a car seat or swing—a new question—has had an especially large impact on this measure. The proportion of infants sleeping with no soft objects (pillows, bumpers, blankets, toys) increased from 51.8% in 2016 to 58.3% in birth year 2017.
In FY 2019, MDHHS continued its work to identify the touchpoints where a family could and should receive infant safe sleep information. For example, MDHHS built upon connections with existing partners, such as the Women, Infants and Children (WIC) Program, home visiting programs, child welfare, and the Regional Perinatal Quality Collaboratives and explored ways to enhance partnerships with others such as Early On®, MDHHS Tobacco and Immunization Divisions, and Children’s Special Health Care Services.
Challenges exist in ensuring that families receive consistent infant safe sleep messages at all potential touchpoints. For example, families may sometimes receive inconsistent messages from health care providers and family members, who may have been taught and used outdated infant sleep techniques.
While two distinct objectives for infant safe sleep have been identified, the strategies to address them are combined since the safe sleep behaviors are so closely related. Although infants being placed to sleep on their back was not singled out as a specific objective, all strategies and activities will promote the key messages to parents and caregivers: an infant sleeps alone and without objects on the back, in a crib, bassinet or pack and play.
Objective A: By 2020, increase the percent of infants put to sleep alone in their crib, bassinet or pack and play by 4%.
Objective B: By 2020, increase the percent of infants put to sleep without objects in their crib, bassinet or pack and play by 4%.
In FY 2019, activities occurred within six strategies for Objectives A and B:
- Support safe sleep activities of local health departments and the Inter-Tribal Council of Michigan.
- Support providers who educate families on safe sleep.
- Develop and disseminate safe sleep messages based in best practices and families’ experiences.
- Develop and disseminate tools for providers to have effective, non-judgmental, and culturally sensitive conversations about safe sleep.
- Support promotion of protective factors (i.e., smoking cessation, breastfeeding, immunizations).
To continue and further expand a program initiated in 2013, funding in the form of mini-grants was provided to 15 local health departments (LHDs) and the Inter-Tribal Council of Michigan in FY 2019. The LHDs and Inter-Tribal Council of Michigan represent Michigan communities with the highest numbers of Sudden Unexpected Infant Deaths (SUIDs). Grant funding is provided in the amount of $22,500 for all grantees, except for Wayne County ($45,000) and the City of Detroit ($90,000) due to the higher number of SUIDs in these communities. The mini-grants allow communities to develop local programming which is culturally relevant and informed by the community. For example, activities range from providing safe sleep education sessions at home or in a community setting; purchasing billboards; providing group classes; conducting community awareness events; creating public service announcements (PSAs); and promoting protective behaviors such as breastfeeding and smoking cessation. A portion of the grant funds can be used to purchase pack and plays or sleep sacks. In FY 2019, grantees provided infant safe sleep education to nearly 5,800 individuals (parents, caregivers, professionals and community members) through classes and workshops. Over 12,000 people were provided infant safe sleep information at community events such as health fairs. Analysis of pre/post test scores of people who attended classes and workshops revealed that infant safe sleep knowledge and intention to practice safe sleep behaviors increased after attendance. Providing technical assistance to the infant safe sleep grantees is another critical component of this work, as the grantees provide education for local groups such as hospitals, home visiting collaboratives, childcare centers, and community agency staff.
The third strategy was to develop and disseminate safe sleep messages that are based in best practices and families’ experiences. Much of this work was funded through a Michigan Health Endowment Fund grant awarded in December 2016. The results of focus groups with parents and individuals that provide support (e.g., grandmothers, aunts, uncles, and other caregivers) was the beginning of this work in FY 2018. In FY 2019, the Infant Safe Sleep Program contracted with the Inter-Tribal Council of Michigan (ITC) and the Greater Detroit Area Health Council (GDAHC) for additional community-based advising. With the results of focus groups with families, ITC expanded their infant safe sleep education to be more comprehensive. A series of five videos for the Power of Your Newborn training and a podcast, Serving Native American Families, will be available to the public and the ITC home visiting team.
GDAHC began by identifying some of the key agencies that provide services to families with high risk for experiencing infant mortality in southeast Michigan, to speak with staff about their experiences in working with this population. Next, a brief survey was created for clients regarding their preferences on messaging formats. GDAHC participated in several community events where the primary audience was parents and families of infants and toddlers. In addition, GDAHC hosted five focus groups with parents and grandparents. Feedback from the focus groups and the community venues served as the sources of data for the final safe sleep messages and materials.
The fourth strategy, to develop and disseminate tools for providers to have effective, non-judgmental, and culturally sensitive conversations about safe sleep, is part of ongoing programmatic efforts. Program staff provide in-person training at conferences and professional trainings. All trainings address challenges families have with following the safe sleep guidelines and how professionals can have open, non-judgmental conversations to support their efforts. An in-person and online version of a “Safe Sleep 201” training for home visitors and child welfare workers is available. This training is based on the principals of motivational interviewing and teaches professionals how to have more effective conversations with families around safe sleep: start where the family is at to address the challenges families face in following the guidelines, and reduce the risks in the sleep environment while educating families that following the AAP recommendations is the safest way for baby to sleep. The training also encourages professionals to include family members and other caregivers in the conversation to address the issue of when family members provide outdated advice.
In FY 2019, a new evidence-based or -informed strategy measure (ESM) was implemented to increase the number of Maternal Infant Health Program (MIHP) agencies that have staff trained to use motivational interviewing with safe sleep. As noted in the FY 2020 application, the ESM was changed to require the Helping Families Practice Infant Safe Sleep (Safe Sleep 201) training instead of the three-part motivational interviewing and safe sleep webinar series. In FY 2019, 83 out of 85 MIHP agencies completed the training.
In addition, efforts to support birthing hospitals to educate families on infant safe sleep continue. The related ESM is to increase the number of birthing hospitals trained on infant safe sleep. When health care providers, including nurses, are educated on infant safe sleep, families are more likely to follow recommended infant safe sleep practices. In FY 2019, the MDHHS Infant Safe Sleep Program trained nearly 800 nurses and other hospital staff at 20 birthing hospitals in the state. Additionally, an Infant Safe Sleep Resource Book and Picture Ring was provided to staff at the 20 birthing hospitals, home visitors, WIC offices, school-based health centers, and Children’s Protective Services workers. Challenges to providing training to birthing hospitals include connecting with the hospital to schedule the training and not reaching all staff due to turnover and scheduling conflicts. In addition, hospital administrative procedures may prevent staff from implementing best practices related to infant safe sleep.
In FY 2019, over 700 individuals attended an in-person safe sleep training and over 10,000 individuals completed one of the three online infant safe sleep trainings. Providers are also supported with access to free educational materials to use in their work with families; nearly 356,000 educational items were distributed by MDHHS in FY 2019. During FY 2017, an infant safe sleep email listserv for professionals was established and by the end of FY 2019 had grown to over 2,600 members. A quarterly webinar series on infant safe sleep was established in FY 2017 and has continued since that time.
The final strategy for this objective is to support promotion of protective factors related to infant safe sleep (i.e., smoking cessation, breastfeeding, immunizations). Outreach to other MDHHS programs that continued in FY 2019 included MDHHS Immunizations (to help ensure infants are immunized); WIC and MDHHS Breastfeeding (to ensure breastfeeding is supported); and MDHHS Tobacco (to help reduce smoking among pregnant mothers and families). Support for local health departments and other partners implementing the Society for Public Health Education (SOPHE) Smoking Cessation and Reduction in Pregnancy Treatment (SCRIPT) Program was also continued. In conjunction with MDHHS Tobacco, the MDHHS Infant Safe Sleep Program continued to host a quarterly call to support local health departments implementing SOPHE SCRIPT as well as other smoking cessation activities. In addition, the Infant Safe Sleep Program hosted a SOPHE SCRIPT training. Representatives from 14 agencies across the state attended and learned effective techniques to engage and assist pregnant and postpartum women in quitting and staying quit. In addition, resource materials on Smoking and Safe Sleep were created in conjunction with MDHHS Tobacco. These materials included a handout and bulletin board kit on how smoking affects a baby’s health and increases the risk of sleep-related infant death. The bulletin board kits were provided to all WIC offices and nearly 300 other partners across the state.
Objective C: Reduce the gap between non-Hispanic white women and non-Hispanic black women in following safe sleep guidelines by 2020.
In FY 2019, activities occurred within three strategies for this objective:
- Provide training and support to local health departments on health equity.
- Dedicate at least one infant safe sleep webinar annually to the topic of health equity.
- Send at least one message on the topic of health equity via the Infant Safe Sleep for Professionals list per quarter.
The intended outcome of reducing the gap between non-Hispanic white women and non-Hispanic black women in following safe sleep guidelines is to reduce the unacceptable racial disparity that exists in sleep-related infant deaths in Michigan. For each strategy noted above for Objectives A and B, the Infant Safe Sleep Program took steps to address health equity and racial disparities as part of those strategies. In addition, the Infant Safe Sleep Program implemented specific strategies to ensure health equity was kept at the forefront.
The first strategy is to provide training and support to LHDs on health equity. In FY 2019, a training session on health equity was provided to LHDs that received mini-grant funds. Continued training, technical assistance and support is planned for FY 2020 and beyond. The second strategy was to dedicate at least one infant safe sleep webinar annually to the topic of health equity. In May 2019, the Infant Safe Sleep Program hosted the webinar “Serving Native American Families.” A challenge with this strategy is to provide webinars that educate participants on health equity while also providing concrete strategies they can use in their work. The third strategy was to send at least one message on the topic of health equity via the Infant Safe Sleep for Professionals listserv per quarter. In FY 2019, six messages sharing information and resources on the topic of health equity, including training opportunities, were sent via the Infant Safe Sleep for Professionals Listserv.
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