Required HRSA Performance Measures Selected for the California Perinatal/Infant Health Domain:

The Maternal, Child, and Adolescent Health Division of the California Department of Public Health (CDPH/MCAH) is including these measures at the beginning of each population health domain annual report to provide reviewers a quick reference to the following required HRSA Performance Measures: National Performance Measure (NPM), National Outcome Measure (NOM), and Evidence-based/informed Strategy Measure (ESM).

 

• NPM: Selected by CDPH/MCAH for each domain from the HRSA MCH Block Grant Performance Measure Framework.
• NOM: Designated automatically by HRSA to correspond to the selected NPM.
• ESM: Developed by CDPH/MCAH to track and drive improved outcomes for the Perinatal/Infant Health Domain.

 

Perinatal/Infant Health Measures:

 

NPM 4: Breastfeeding –

A) Percent of infants who are ever breastfed;

B) Percent of infants breastfed exclusively through 6 months.

 

National Outcome Measures:

NOM 9.1.	Infant mortality rate per 1,000 live births
NOM 9.3.	Post neonatal mortality rate per 1,000 live births
NOM 9.5.	Sudden Unexpected Infant Death (SUID) rate per 100,000 live births

 

CDPH/MCAH developed the below Evidence-based/informed Strategy Measure (ESM to track and drive improved outcomes for the Perinatal/Infant Health Domain.

 

ESM 4.1: Number of online views to the “Lactation Support for Low-Wage Workers” report.

 

Surveillance:

CDPH/MCAH monitored select quantifiable characteristics to track the health of California’s infants as part of its routine health surveillance efforts. The following indicators and measures, as listed in the table below, are continuously and systemically collected, analyzed, and interpreted to guide program planning, implementation, and evaluation of interventions. These indicators are analyzed by state, county, race/ethnicity, and other sub-state levels to identify specific improvement opportunities.

 

Select Perinatal/Infant Health Indicators and Measures	Data Source
Breastfeeding initiation and duration	Maternal and Infant Health Assessment (MIHA) Survey and Genetic Disease Screening Program, Newborn Screening Data
Infant mortality, including SUID/SIDS	California Birth Cohort File or California Comprehensive Master Birth and Death Files
Grief and bereavement services	SIDS Program Data
Infant safe sleep practices	MIHA
Preterm birth rate, including rate among infants born to non-Hispanic Black women	California Birth Statistical Master File (BSMF)

 

As part of California’s Title V State Action Plan, focus areas were identified in each population domain to help guide the work. Each year, the 61 Local Health Jurisdictions (LHJs) in California develop annual Scopes of Work (SOW) that contain activities that align with the Title V Action Plan and these focus areas.

 

The following graph shows the number of LHJs and the related focus areas in the Perinatal/Infant Health Domain that had activities the LHJs planned to implement in their 2022-2023 SOWs.

 

 

• 49 LHJs (80%) worked on Perinatal/Infant Focus Area 1: Improve healthy infant development through breastfeeding and caregiver/infant bonding via 76 SOW activities, in FY 2022-23.
• 50 LHJs (82%) worked on Perinatal/Infant Focus Area 2: Reduce infant mortality with a focus on reducing disparities via 124 SOW activities, in FY 2022-23.
• 19 LHJs (31%) worked on Perinatal/Infant Focus Area 3: Reduce preterm births via 27 SOW activities, in FY 2022-23.

 

Perinatal/Infant Priority Need 1:

Ensure all infants are born healthy and thrive in their first year of life.

 

Perinatal/Infant Priority Need 2:

Reduce infant mortality with a focus on eliminating disparities.

 

Perinatal/Infant Focus Area 1: Improve healthy infant development through breastfeeding.

 

Perinatal/Infant Objective 1:

By 2025, increase the percentage of women who report exclusive in-hospital breastfeeding from 70.2% (2018 GDSP) to 72.5%.

 

Story Behind the Curve:

Breastfeeding is linked to a reduced risk from many illnesses in children and mothers. Exclusive breastfeeding for the first six months of life is linked to health benefits for infants. Although breastfeeding initiation rates are high in the United States, most women do not breastfeed exclusively for the first six months and most of the challenges to exclusive breastfeeding are environmental.[1] Strategies like peer support, education, longer maternity leaves, lactation accommodation, transportation services, and breastfeeding support in the hospital, workplace, and community have been shown to increase rates of exclusive breastfeeding. Improvements in hospital policies have resulted in increases in breastfeeding rates.[2] From 2010 to 2020, California exclusive in-hospital breastfeeding rates rose from 56.6% to 70%, and population differences were reduced significantly. Recent data show that progress has slowed, and smaller but important disparities persist.[3] While the Baby-Friendly Hospital Initiative and similar policies improve maternity care, not all California women experience these policies and practices the same way. Sixty percent of mothers do not breastfeed for as long as they initially intended. Exclusive breastfeeding is influenced by factors including, but not limited to, issues with lactation and latching, concerns about infant nutrition and weight, lack of access to a lactation consultant, unsupportive work policies and lack of parental leave, cultural norms and lack of family support, and unsupportive hospital practices and policies.

 

CDPH/MCAH analyzes infant-feeding data for all maternity hospitals in the state. In 2020, 93.5% of California mothers began breastfeeding, but 30% of those mothers also fed their infants formula during their hospital stay.[4] Healthy People 2020 objectives limit in-hospital supplementation to approximately 14% of breastfed infants.[5] Though rates of exclusive breastfeeding in California have not declined, there has been a widening racial/ethnic gap rather than a stabilization across all populations. Despite significant increases in exclusive breastfeeding among all racial groups since 2010, disparities in breastfeeding rates persist in California. To make these data more accessible, CDPH/MCAH developed indicator-specific dashboards to meet the needs of our partners and stakeholders. In FY 2022-23, Breastfeeding Initiation was added to our available list of dashboards.[6] The dashboard includes any/exclusive breastfeeding shown by multiple stratifications and subgroups. Data from 2010 through 2021 are publicly available for viewing or download. Data for 2022 are forthcoming.

To achieve breastfeeding equity in California, it is important to build on the foundation created by widespread adoption of supportive polices. Resources, quality improvement processes, and community partnerships are needed to ensure equitable structures and approaches are in place to meet the needs of California’s diverse families.

 

Perinatal/Infant Objective 1: Strategy 1:

Lead surveillance of breastfeeding practices and assessment of initiation and duration trends.

 

Activity:

CDPH/MCAH will lead breastfeeding data collection and surveillance in collaboration with Women, Infants, and Children (WIC), and University of California San Francisco (UCSF) on social disparities in health utilizing the Maternal and Infant Health Assessment (MIHA) Survey.

 

Narrative:

Development of the MIHA 2023 survey occurred from September 2022 through March 2023 and involved collaboration between subject matter experts, leadership from CDPH/MCAH and UCSF Center for Health Equity (CHE), and input from other CDPH programs, the Centers for Disease Control and Prevention (CDC), and key MCAH/MIHA data users. As in previous years, the survey included questions about breastfeeding intention, whether a mother has ever breastfed, breastfeeding duration, and supplementation. Additional questions included WIC participation, reasons for not enrolling in WIC prenatally, and benefits participants liked, including support for breastfeeding and help getting a breast pump. CDPH/MCAH supported UCSF CHE in MIHA data collection for the MIHA 2023 survey and had regular meetings to discuss data collection. CDPH/MCAH created indicator-specific data dashboards designed to serve the data needs of our partners and stakeholders. State-, county-, and/or regional-level indicator data are shown by various stratifications or subgroups and by year and includes a link to download the data. The Breastfeeding Intention and Duration Dashboard, based on MIHA data, was released during this reporting period and includes breastfeeding intention, ever breastfed, and any/exclusive breastfeeding at three months after delivery.

 

Activity:

CDPH/MCAH will lead the dissemination of breastfeeding data findings to increase in-hospital breastfeeding initiation in California.

 

Narrative:

To inform efforts to increase in-hospital breastfeeding initiation in California, CDPH/MCAH analyzes data collected by the California Newborn Screening Program. From these data, CDPH/MCAH publishes breastfeeding initiation rates by hospital, county, and the state overall. Historically, these data were provided via tables made available on the internet. However, with CDPH/MCAH’s development of a library of indicator-specific data dashboards, initiation data were transitioned to a new Breastfeeding dashboard that was designed and developed during this reporting period. The dashboard will be updated annually.

 

Local MCAH Program Examples:

• Humboldt County MCAH Staff presented on Breastfeeding Statistics to the Humboldt County Perinatal Community Coalition (PCC). MCAH staff discussed developing goals with the PCC to increase the breastfeeding initiation rates for Humboldt County.
  MCAH staff revised, posted online, printed, and distributed the 2023 Breastfeeding Resource Guide and coordinated with Partnership Health Plan to distribute breast pumps to local providers.
• San Benito County MCAH registered nurses, through a partnership with local Hazel Hawkins Memorial Hospital and the Baby-Friendly Task Force, are tracking monthly breastfeeding rates. All information is being disseminated at Healthy Mothers, Healthy Babies Coalition meetings. The lactation educator oversees monitoring and reporting for all breastfeeding activities at the local hospital and is continually pushing for higher rates of breastfeeding by discharge. Hazel Hawkins Memorial Hospital met or exceeded 80% exclusive breastfeeding for all but two months during July 2022 through January 2023.
• Ventura County’s success story of a first-time mom and her premature baby stands as a testament to the impactful work of public health nurses. Referred from the hospital’s NICU due to the baby’s prematurity, the mother ardently expressed her desire to breastfeed. The public health nurse began working with this mother to reach her goals. Through home visits and collaborative efforts, the public health nurse referred the client to a local International Board-Certified Lactation Consultant, enhancing the mom’s breastfeeding journey. The mother had initially provided the infant 25% breast milk. But with persistent support over two to three months the public health nurse empowered the mom to exclusively breastfeed her premature baby. This transformative achievement not only overcame challenges but also laid the foundation for a healthier future for both mother and child. During home visits, the public health nurse provided emotional support to this mother who continued to practice and work very hard to breastfeed, regardless of the difficulties and doubt she faced.

 

Perinatal/Infant Objective 1: Strategy 2:

Lead technical assistance and training to support breastfeeding initiation, including the implementation of the Model Hospital Policy or Baby-Friendly Hospital Initiative in all California birthing hospitals by 2025.

 

Activity:

CDPH/MCAH will partner with MCAH programs to include evidence-based breastfeeding guidance within their program curriculum.

 

Narrative:

CDPH/MCAH continues to partner with MCAH programs to include evidence-based breastfeeding guidance within their program curriculum.

 

Local MCAH Program Examples and Successes:

• In Alameda County, all EmbraceHer clients who are also patients of BElovedBIRTH Black Centering (BBBC) are provided education and support with breastfeeding through one prenatal and one postpartum BBBC group session, including International Board Certified Lactation Consultant (IBCLC) hands-on support. Participation in the BBBC groups helps clients build community and friendships among the other mothers in the group, many of whom are planning on breastfeeding their babies. The breastfeeding information and support received from the EmbraceHer case managers, BBBC cohort members, and lactation consultants encourages clients to breastfeed. In the future all EmbraceHer participants will be scheduled for a home visit with a lactation consultant within one week of giving birth to encourage continued breastfeeding and address any difficulties the client may be experiencing. Additionally, the BBBC team plans to use grant funds to support community members with the costs associated with becoming breastfeeding peer counselors to improve access to breastfeeding support for all EmbraceHer clients. Several Alameda County Maternal Paternal Child and Adolescent Health   nurses have completed breastfeeding trainings and several hold IBCLC certifications. All continue to promote breastfeeding to clients.
• In the Building Bridges nurse home visiting program, a client delivered premature twins at a local hospital, also in Alameda County. She spent many days in the NICU with the twins. During the hospital stay the twins received donor milk in addition to pumped breast milk. Mom became frustrated at times because she was not initially producing enough milk. During her home visit intake, she discussed with her nurse the desire to continue breastfeeding for at least a year. She was provided lactation support from the nurse at weekly home visits. Discussions on feeding positions, physiology, feeding challenges, storing milk, and infant feeding patterns were reinforced at home. Mom became more confident and was able to continue feeding the twins for several months.

• Modoc County trained two public health nurses in lactation education to support new moms. Additional promotion of these services led to several postpartum moms reaching out for support. One mom was assisted to get her baby to latch with a nipple shield when the baby was very small, and eventually was able to go straight to the breast. Another mom who received support with her first baby came back for support with her second baby.
• San Joaquin County Nurse Home Visitor Success Story: My client is a 42-year-old mother of a one-year-old infant with Down’s Syndrome. Mom was born in another country and is very grateful for her new life in the United States. Her infant has been exclusively breast milk fed from birth despite cardiac issues. When her infant was about 4 months old, Mom verbalized that she had difficulty breastfeeding in public due to her modesty and cultural upbringing. Made aware of the benefits of breastfeeding for at least 6 months and ideally a year, Mom mainly stayed at home due to her feelings of discomfort of breastfeeding in public. I encouraged Mom to join La Leche League Support Group on Facebook, speak to a breastfeeding specialist at WIC and provided strategies to comfortably breastfeed while away from home. My client’s baby has been exclusively breastfed for a year now and has managed to breastfeed in her van when outside of the home.
• Tuolumne County participated in the Breastfeeding Coalition Walking Event on August 10, 2022, to increase awareness of breastfeeding in the community and to support breastfeeding individuals. There were over 50 community attendees, well above past years, including two invited clients.

 

Activity:

CDPH/MCAH will lead the completion and dissemination of the Model Hospital Policy and partner with Regional Perinatal Programs of California (RPPC) directors and WIC Regional Breastfeeding Liaisons (RBLs) to provide technical assistance.

 

Narrative:

CDPH/MCAH continued dissemination of the finalized fourth edition of Providing Breastfeeding Support: Model Hospital Policy Recommendations. The Nutrition and Physical Activity (NUPA) Coordinator continues to work with RPPC contractors and WIC RBLs to promote the Model Hospital Policy and accompanying online breastfeeding resources.

 

Activity:

CDPH/MCAH will lead technical assistance and breastfeeding quality improvement initiatives with RPPC birthing hospitals to support local MCAH work efforts.

 

Narrative:

RPPC Contractor Perinatal Advisory Council: Leadership, Advocacy, and Consultation hosted a discussion on breastfeeding laws and compliance to share resources for the implementation of the Model Hospital Policy and to support collaboration across hospitals and programs to comply with health and safety codes related to infant feeding by 2025. RPPC Directors reported facilities' plans for becoming compliant. While 32% will follow the Model Hospital Policy, approximately 17% will follow an alternative process, including many hospitals that will not be renewing their Baby-Friendly designation.

 

 

Activity:

CDPH/MCAH will promote best practices to support health care workers in their efforts to educate families on the importance of the Ten Steps to Successful Breastfeeding through Family Health Outcomes Project (FHOP) trainings/webinars for local MCAH programs.

 

Narrative:

This activity has been paused as we identify resources to support trainings.

 

Perinatal/Infant Objective 1: Strategy 3:

Partner to develop and disseminate information and resources about policies and best practices to promote breastfeeding duration, including lactation accommodation within all MCAH programs.

 

Activity:

CDPH/MCAH will continue to partner with FHOP, California WIC Association (CWA), and the California Breastfeeding Coalition (CBC) to develop a training for community health centers on how to adopt the “9 Steps to Breastfeeding Friendly: Guidelines for Community Health Centers and Outpatient Care Settings” (PDF).

 

Narrative:

This activity has been paused as we identify resources to support trainings.

 

Activity:

CDPH/MCAH will continue to partner with local MCAH Directors, local health jurisdiction Breastfeeding Coordinators, and WIC RBLs to develop and disseminate information to communities and businesses on lactation accommodation laws.

 

Narrative:

CDPH/MCAH continues to partner with various stakeholders and MCAH programs to disseminate information and resources about policies and best practices to promote breastfeeding duration, including lactation accommodation. Additionally, CDPH/MCAH updated the local health jurisdiction breastfeeding coordinators email distribution list, which includes WIC directors working closely with WIC RBLs.

 

Activity:

CDPH/MCAH will continue to partner with the CWA and CBC on the dissemination and education of the Low Wage Worker Lactation Accommodation Brief developed with the Childhood Obesity Collaborative Innovation and Improvement Network.

 

Narrative:

CDPH/MCAH released the Lactation Support for Low-Wage Workers resource in 2021. This resource will be reassessed in the future to determine the need for potential updates.

 

Activity:

CDPH/ MCAH will continue to provide training, technical assistance, and resources to American Indian Maternal Support Services (AIMSS) programs to promote breastfeeding among American Indian women.

 

Narrative:

The DHCS AIMSS grant manager regularly shares resources, training, and toolkits that encourage healthy dietary practices from CDPH/MCAH with DHCS/AIMSS programs. DHCS/AIMSS clients are referred to WIC services either through their OBGYN or the AIMSS coordinator. Some clinics have WIC staff come to the clinics for a day either weekly or monthly. Family Spirit curriculum now has a new module called Nurture and hosted quarterly/monthly training for all clinic members to learn about how to deliver this module that addresses healthy infant feeding and growth in the first year of life to help reduce early childhood obesity. AIMSS programs have access to resources such as the California Infant Feeding Guide, WIC educational materials, and Comprehensive Perinatal Services Program (CPSP) resources. Effective lactation support is provided to all clients in the AIMSS program through local WIC departments, hospitals, and lactation consultants. Celebrating breastfeeding awareness month is encouraged at each clinic and they receive resources in advance to write an article and share resources with their communities.

 

Perinatal/Infant Focus Area 2: Improve healthy infant development through caregiver/infant bonding.

 

Perinatal/Infant Objective 1: Strategy 4:

Partner with birthing hospitals to support caregiver/infant bonding.

 

Activity:

CDPH/MCAH will support and promote clearer guidelines on skin-to-skin care and Kangaroo Mother Care through MCAH local programs and RPPC Directors.

 

Narrative:

CDPH/MCAH SIDS Program promoted the American Academy of Pediatrics (AAP) Safe Sleep and Skin-to-Skin Care in the Neonatal Period for Healthy-Term Newborns (2022) in which skin-to-skin care and breastfeeding support is recommended for all mothers, as both are associated with a reduced risk of SIDS. Information and guidance were shared with all local MCAH programs.

 

Activity:

CDPH/MCAH will lead the development of social media posts and educational materials to raise awareness about the importance of infant/caregiver bonding.

 

Narrative:

The development of social media posts and educational materials was postponed to a later date.

 

Activity:

CDPH/MCAH will support and expand gender sensitivity in lactation promotion to include breastfeeding.

 

Narrative:

CDPH/MCAH continues to utilize gender inclusive language in the materials developed and resources available on our website Hospital Breastfeeding Policy Resources under “Transgender and Gender Nonbinary People.”

 

Activity:

DHCS/AIMSS programs will provide education materials, resources, and training on infant bonding that are culturally appropriate.

 

Narrative:

AIMSS programs provide evidence-based, culturally appropriate infant bonding education to their clients and teach the bonding effects breastfeeding provides. Curriculum titled Family Spirit teaches clients lessons on reading infant cues, infant behavior, understanding and responding in a timely manner, and the importance of bonding. The Family Spirit curriculum optimizes local assets and resources to welcome new infants and encourages discussions on attachment and bonding, beliefs, and practices.

 

Activity:

DHCS/AIMSS programs will continue to utilize CPSP, Healthy Spirit, and other culturally appropriate educational materials for American Indian infants.

 

Narrative:

AIMSS Programs continues to utilize resources from CPSP, Indian Health Service, CDC, Family Spirit, National Institute for Children’s Health Quality, and other American Indian-specific trainings and resources.

 

Perinatal/Infant Focus Area 3: Reduce Black Infant Mortality.

 

Perinatal/Infant Objective 2:

By 2025, reduce the rate of infant deaths from 4.2 per 1,000 live births (2017 BSMF/DSMF) to 4.0.

 

Story Behind the Curve:

Infant mortality is an important indicator of the overall health and well-being of a population. The infant mortality rate is regarded as a highly sensitive measure of population health because there is an association between the causes of infant mortality and other factors that influence the status of whole populations, such as economic development, general living conditions, social well-being, rates of illnesses, quality and access to medical care, public health practices, and quality of the environment. The infant mortality rate is measured as the number of infant deaths before one year of age for every 1,000 births in that population. About two-thirds of infant deaths occur before a baby is one month old, and the remaining third between two months and 12 months of life. Although the infant mortality rate is decreasing in other ethnic/racial groups, the persistent infant mortality rate for Black infants has been alarming for decades, despite public health efforts to improve this crisis. Persistent differences in perinatal health outcomes for Black women and their babies are often attributed to their own failure to practice healthy behaviors during pregnancy, essentially placing the burden and blame on Black women and ignoring the larger structural factors that influence the lives of Black women and the health of their babies. Research documents that health behaviors alone cannot account for these disparities.[7] Some cases have found that Black women who do practice healthy behaviors have worse perinatal outcomes than White women who do not.[8]

 

When the Black Infant Health Program (BIH) was established in 1989, efforts to address disparities in Black maternal and infant health focused on increasing Black women’s utilization of prenatal care. However, disparities have persisted despite increasing rates of prenatal care usage among Black women, and overall infant mortality rates have decreased, but the mortality gap between Black infants and their counterparts has not. Preterm birth, which is the leading cause of infant death, continues to increase for Black infants. The conditions of nearly every aspect of daily life are shaped by the structural factors of society listed above, and structural or systemic racism is embedded in each of these. Research has shown that structural racism negatively impacts the health of Black women. Chronic stress related to racism elevates cortisol and other stress hormones in a woman’s body, leading to several maternal health conditions, such as obesity, hypertension, and diabetes, which could increase her chances of having a preterm birth, an infant loss, or severe maternal outcomes. CDPH/MCAH prioritized addressing racial disparities in the infant mortality rate and continued to enhance collaboration with BIH, the Perinatal Equity Initiative (PEI), and other state and local partners to support families with culturally appropriate strategies and resources.

 

Perinatal/Infant Objective 2: Strategy 1:

Lead research and surveillance related to fetal and infant mortality in California.

 

Activity:

CDPH/MCAH will lead and fund the data collection and surveillance of fetal and infant deaths, including disparities in race/ethnicity.

 

Narrative:

CDPH/MCAH continues to conduct fetal and infant mortality surveillance and review scientific literature to maintain currency with respect to both scientific methods and emerging issues. Black infant mortality rates continue to be two to three times higher than the rates for other groups statewide, and Black infants are nearly three times as likely as White infants to die before reaching their first birthday. The infant mortality rate for Black infants was 8.6 per 1,000 live births in 2021, a decrease after consecutive increasing years in 2019 and 2020 (8.4 in 2018; 9.5 in 2019; 10.2 in 2020). The overall state infant mortality rate was 4.1 per 1,000 live births, a 5.1%increase from a record low rate of 3.9 per 1,000 live births in 2020. The infant mortality rate for White infants was 3.0 per 1,000 live births in 2021, an increase from a record low rate of 2.7 in 2020. The infant mortality rate also slightly increased for Hispanic infants from 4.6 in 2020 to 4.7 in 2021.

 

Activity:

CDPH/MCAH will lead the development and dissemination of data findings, reports, and presentations related to fetal and infant mortality in California and inform CDPH/MCAH programs about existing disparities in infant mortality.

 

Narrative:

CDPH/MCAH continued to develop and update data dashboards to disseminate findings. The fetal mortality dashboard contains maps, bar charts, and trend charts using state and county-level data for 2007-2021. The infant mortality dashboard contains maps, bar charts, and trend charts using state and county-level data for 2007-2020. Both dashboards include several categories to show disparities among various subgroups. The dashboards are publicly available and accessible to all CDPH/MCAH programs.

 

Perinatal/Infant Objective 2: Strategy 2:

Support local fetal infant mortality review (FIMR) programs by expanding and implementing infant safe sleep strategies and engaging community action team members in efforts to reduce the number of sudden unexpected infant deaths.

 

Activity:

CDPH/MCAH will support local FIMR programs to implement enhanced safe sleep practices and organize community action members to develop a plan and engage community action teams in efforts to reduce the number of sleep related deaths and implement culturally appropriate infant safe sleep strategies.

 

Narrative:

The FIMR Program for this reporting period was unique in that the FIMR Programs did not conduct normal FIMR Program activities for the 15 funded local health jurisdictions (LHJ), but instead implemented enhanced safe sleep practices within their respective LHJs.

 

CDPH/MCAH FIMR Program’s focus for the year was on the development and implementation of the California FIMR+ Program. CDPH/MCAH FIMR funding and LHJs have remained the same since 2004. Changes in infant mortality rates since that time have led to the LHJ allocations no longer being aligned the mortality burden and disparities. The refreshed FIMR Program considered several factors that influenced direction of the program which included qualitative and quantitative data such as infant mortality rates, disparities, local capacity, and program challenges; estimated staffing needs and associated costs; LHJ eligibility (e.g., data indicators, capacity) and the support of department, division, and local leadership. The outcome of the review resulted in the selection of two LHJs who were identified as fitting all selection criteria for funding and a more robust allocation. Implementation began on July 1, 2023. The two LHJs will help CDPH/MCAH better quantify the costs and impact of the California FIMR+ program, which is based on the National FIMR model and seeks to leverage local BIH and PEI programs and partners to enhance support for families experiencing a loss, as well as bi-directional information sharing and systems improvement.

 

Activity:

CDPH/MCAH will compile and summarize strategies, best practices, and lessons learned from local FIMR Programs.

 

Narrative:

CDPH/MCAH provided funding to 15 LHJs. The focus of the FY 2022-23 FIMR funding was to engage the Community Action Team (CAT) to develop a plan and engage community members in efforts to reduce the number of sleep related deaths and implement culturally appropriate infant safe sleep strategies. In addition to addressing local SIDS requirements, each LHJ funded for FIMR implemented activities that expanded safe sleep efforts while addressing disparities in their community and utilizing culturally appropriate resources. Key activities include one or more of the following:

 

• Work with external partners to expand safe sleep training for nurses, caregivers, and childcare providers.
• Promote and support safe sleep education and engage hospitals to support the implementation of HSC § 1254.6 regarding the requirement that hospitals provide safe sleep information upon discharge.
• Conduct a public awareness campaign to help decrease infant mortality in the community.

 

Below are examples of FIMR-funded enhanced safe sleep activities conducted by LHJs.

 

Local MCAH Program Examples:

• San Bernardino County (SBC) Department of Public Health (SBCDPH) Fetal and Infant Mortality Review (FIMR) Community Action Team (CAT) has updated the “Sudden Unexplained Infant Death in San Bernardino County” online story map to expand safe sleep health education for county residents. The SUID story map consists of an overview of the SBC SIDS/SUID program, SUID rate by county comparison, SIDS rate map by SBC county Supervisorial Districts, a SUID hot spot map, a SUID rate by race/ethnicity comparison chart to highlight disparities, and information for the county Safe Sleep for Infants Program. The SUIDs story map may be viewed here. In addition, SBCDPH FIMR produced a safe sleep data brief to include descriptive statistics consisting of safe sleep facts, leading causes of infant death by race/ethnicity in SBC, estimated percentage of infant bed sharing by race/ethnicity, sleep position by race/ethnicity, and SIDS risk and protective factors by race/ethnicity.
• Los Angeles County Department of Public Health FIMR Program provided training to the following:

• 25 childcare providers on safe sleep environments for all infants both at home and in childcare settings. Participants committed to implementing safe sleep policies/practices and share information with staff and clients.
• 25 students and two staff at a high school in Paramount City. Students committed to share information with family and friends.
• 24 pregnant women and mothers in partnership with Paramount Community Center. Participants committed to follow safe sleep recommendations.
• 20 WIC staff in Service Planning Area 6. Staff committed to share information with WIC clients.
• In addition, 60 birthing hospitals in LA County provided SIDS safe to sleep information and materials to families and labor and delivery staff. Through the Regional Perinatal Program of California (PAC/LAC), each facility received data pertaining to their facility to highlight practices that may need more training and improvement. PAC/LAC also evaluated birthing hospitals safe infant sleep interventions, policies, educational materials, and discharge planning.

 

Perinatal/Infant Objective 2: Strategy 3:

Lead the California SIDS Program to provide grief and bereavement support to parents, as well as technical assistance, resources, and training on infant safe sleep to reduce infant mortality.

 

Activity:

CDPH/MCAH will continue to lead and track reporting of sudden unexpected infant deaths (SUID) from local health jurisdictions (LHJ).

 

Narrative:

All documentation related to sudden unexpected infant deaths received was assigned a case number and saved in an annual state database. Tracking of risk factors present at the time of death are noted as well as services provided by the local SIDS Program.

 

Activity:

CDPH/MCAH will continue to lead the dissemination of data findings, reports, and presentations for local SIDS programs.

 

Narrative:

The CDPH/MCAH Epidemiology team shared SIDS/SUID data on the infant mortality data dashboard to provide easier access to more timely data. State and county-level data was updated as new vital statistics data files became available.

 

Activities:

CDPH/MCAH will continue to partner with the California SIDS Program to provide training on grief and bereavement support for families impacted by SIDS/SUID, and other sleep-related infant deaths.

 

CDPH/MCAH will continue to lead the California SIDS Program by increasing awareness, promoting safe sleep education, identifying risk factors, and providing resources.

 

CDPH/MCAH will continue to support and promote the 2022 AAP Recommendations for a Safe Infant Sleeping Environment, endorse dissemination of the Safe to Sleep education campaign materials, and lead the development of safe sleep strategies that address SIDS and other sleep-related causes of infant death.

 

Narrative:

The goal of the California SIDS Program is to reduce the number of SIDS/SUID deaths by prioritizing helping families/caregivers cope with SIDS/SUID deaths, educating about the importance of safe sleep environments, and engaging in family-centered conversations to reduce risk of all sleep-related deaths. The SIDS program also offers education about this difficult topic, support services and training for health professionals, and counseling for parents and caregivers who may have lost a baby to any form of SUID.

 

While there is no known cause of SIDS, the SIDS program is committed to using data about SIDS/SUID to carry out strategies and interventions to reduce infant death, including outreach and education about best practices for infant safe sleep to lower potential for SIDS and sleep-related suffocation, asphyxia, and entrapment among infants.

 

As mandated by California Health and Safety Codes, California’s 61 LHJs are required to implement the California SIDS Program, with a goal of reducing the number of SIDS/SUID deaths in their communities and implementing outreach and education activities for families and organizations to support an infant safe sleep environment. Given each LHJ’s unique community demographics, size, income, and access to health care, local programs are tailored to the communities they serve. LHJs:

 

• develop and distribute SIDS/SUID literature at community events;
• adhere to the AAP Safe Sleep Recommendations;
• assess and support families’ needs by providing safe sleep products such as bassinets, Baby Boxes, portable cribs;
• provide grief and bereavement support to parents and caregivers who suffer a SIDS/SUID loss;
• work with infant day care centers in collaboration with Department of Social Services; and
• ensure that Labor and Delivery hospitals in California provide safe sleep information and guidance to all parents and caregivers of newborns.

 

The California SIDS Program, in collaboration with the California State University, Sacramento (CSUS) and California SIDS Advisory Council, convenes the Annual Spring Training and the Annual California SIDS/ SUID Conference.

 

The Annual Spring Training on SIDS/SUID is part of CDPH/MCAH’s ongoing efforts to increase public awareness and provide education about SIDS/SUID and other sleep-related infant deaths. This training focuses on providing information to professionals who encounter SIDS/SUID cases in their jobs including coroners, coroner investigators, childcare program analysts, childcare providers, emergency department personnel, EMTs, fire personnel, health educators, hospital staff, law enforcement officers, MCAH health care professionals, paramedics, nurses, social workers, SIDS Coordinators, and health professionals involved with SIDS/SUID. Topics discussed at the training included “The Relevance of Culture to the SIDS Experience” and “You’re a new SIDS Coordinator – Now What?”

 

The Annual SIDS/SUID Conference focuses on providing support to parents and family members who have been affected by SIDS/SUID, and information to professionals who encounter SIDS/SUID cases in their jobs, to allow them to better understand the experience of parents and families, and to provide insight into what can be done to reduce the risk of SIDS/SUID in their communities. The annual conference is intended for parents and family members who have lost an infant suddenly and unexpectedly, as well as professionals listed above. Topics discussed at the annual conference included “SIDS & The Triple Risk Model: an update on biological vulnerabilities and risk reduction strategies”; “Reaching Beyond the Parents to Provide Grief Support to the Extended Family”; “Boatwright Award/Fostering Engagement in the SIDS Community”; “The Forgotten Survivors: SIDS Siblings” (panel discussion).

 

Activity:

CDPH/MCAH will support and notify California birthing hospitals and licensed midwives of their responsibility to disseminate SUID/SIDS risk reduction information to parents or guardians of newborns upon discharge.

 

Narrative:

In accordance California Health and Safety Code Section 1254.6 (HSC § 1254.6), which requires all hospitals in California to provide SUID/SIDS risk reduction information to all parents or guardians of newborns, upon discharge from the hospital or in the event of a home birth by a licensed midwife, a CDPH MCAH letter was updated and released in October 2020 and sent as a reminder to all birthing hospitals and licensed midwives. This resource letter is posted on the CDPH/MCAH SIDS website. MCAH intends to update the letter every four years for use by local MCAH Programs and the Regional Perinatal Program of California whose purpose is to support birthing hospital staff with education, evidence-based standards and practice policies.

 

Activity:

CDPH/MCAH will lead and fund local MCAH programs to provide SUID/SIDS risk reduction and infant safe sleep education and resources to pregnant and parenting women.

 

Narrative:

Upon referral to the BIH program, every woman, whether they elect to participate in the program or not, is provided culturally congruent materials about SUID/SIDS risk reduction and infant safe sleep resources. Participants in the program receive additional information through the group curriculum and case management. For the Perinatal Equity Initiative (PEI), 11 local PEI programs distribute culturally appropriate resources, provide education that promotes safe sleep, and makes referrals to education resources that fit their needs. Many local programs have partnered with others in their counties to provide pack and play cribs to participants as an alternative to co-sleeping.

 

CHVP-funded evidence-based home visiting programs provide safe sleep education, guidance, and resources to pregnant and newly parenting participants, as appropriate. Additionally, local programs funded through the federal Maternal, Infant, and Early Childhood Home Visiting grant are required to measure and report on the percentage of infants enrolled in home visiting that are always placed to sleep on their backs, without bedsharing or soft bedding among infants less than one year old during the reporting period.

 

All birthing facilities with an RPPC site visit report that they provide safe sleep and SIDS /SUIDS education and information including the 2022 AAP updates as part of discharge. Many hospitals report receiving Cribs for Kids Gold or Silver Safe Sleep designation. RPPC Directors may also share the National Institutes of Health resource for parent education in multiple languages, and samples of the Safe Sleep Policy for hospitals that don't have one. RPPC encourages hospitals to include safe sleep practices in annual nursing competencies. Though all hospitals share the AAP's stance and promote its use, discussions during birth hospital site visits sometimes raise the challenge of AAP leaving no "wiggle room" regarding co-sleeping and staff have difficulty teaching this evidenced-based stance as co-sleeping is promoted in some patient populations they care for.

 

Local MCAH Program examples:

• Solano County provided the Solano County Dream Center. These are safe sleep materials to put into the welcome packet of all clients who are pregnant and/or a parent of an infant.
• Sutter County distributed safe sleep materials to 887 new parents after the birth of their baby. 74 families were visited on the postpartum floor and 38 families received a CPSP-approved crib and safe sleep promotional materials (sleep sack, board book), along with personalized one-on-one safe sleep education. Safe sleep educational materials and flyers were offered and distributed to participants at community outreach events including Public Health's Haunted Health Fair and Cultural Celebration, the Live Oak Fall Festival, the Yuba City Summer Stroll, World Breastfeeding Week Latch-On event, and at the monthly Help Me Grow screening events. All local CDPH and CPSP providers received safe sleep information. Local MCAH staff attended SIDS trainings through CDPH/MCAH. A Safe Sleep social media campaign was conducted on the county’s public health Facebook page in collaboration with local (First 5) Sutter County Children and Families Commission using the NIH Safe to Sleep social media toolkit. The SIDS Awareness Month social media campaign was successful with 1,159 impressions. Some families who received cribs and one-on-one safe sleep education reported that they learned new information about safe sleep recommendations and intended to follow them.
• Ventura County disseminated safe sleep educational material in various social media platforms during SIDS Awareness Month. A “Clear the Crib Challenge Video” was recorded and shared with numerous members of the community. More than 200 parents and family members in Ventura County viewed the video which promoted a safe sleep environment. The county’s Public Health Community Health Nursing team took the #CleartheCrib challenge to help raise awareness about safe infant sleep environment.

 

Activity:

The DHCS/AIMSS programs will continue to be provided grief and bereavement support through training, resources, and educational materials to support American Indian families experiencing infant mortality.

 

Narrative:

AIMSS program participants are provided culturally congruent grief and bereavement support materials and education using both Family Spirit and CPSP curriculum in addition to other resources to address SIDS/SUID and other sleep related infant deaths.  

 

Activity:

The DHCS/AIMSS programs will be provided training, educational materials, and resources for American Indian safe sleep education utilizing best practices.

 

Narrative:

AIMSS programs receive resources on Recommendations for Safe Infant Sleep, including those with American Indian focus, from various sources. Healthy Native Babies Project hosted a three-part webinar series focused on addressing safe infant sleep in American Indian and Alaska Native communities. Programs were invited to attend 2022 SIDS/SUID Annual Spring Training online hosted by CDPH/CSUS and resources/recordings were shared after the event. The AIMSS grant manger also shared highlights with the programs.

 

Perinatal/Infant Focus Area 4: Reduce preterm births.

 

Perinatal/Infant Objective 3:

By 2025, reduce the percentage of preterm births from 8.7% (2017 BSMF) to 8.4%.

 

Perinatal/Infant Objective 3: Strategy 1:

Lead research and surveillance on disparities in preterm birth rates in California.

 

Activity:

CDPH/MCAH will lead and fund the data collection and surveillance of preterm births, including disparities in race/ethnicity.

 

Narrative:

CDPH/MCAH continued to monitor preterm birth rates and review scientific literature to maintain currency with respect to both scientific methods and emerging issues. Data from the California birth file revealed that for Objective 3, the percentage of preterm births rose 4% in 2021 to 9.14%, up from 8.75% in 2020. The 2021 rate is the highest reported since at least 2007 (9.14%), when measurement of gestational age changed to obstetric estimate. By race/ethnicity, the percentage of Black preterm births was 1.7 times higher than the percentage of White preterm births (12.71% compared to 7.63%) in 2021. The next highest percentage was in Pacific Islander births (11.51%), followed by American Indian and Alaska Native (10.45%), Multi-Race (9.84%), Hispanic (9.36%), and Asian (9.01%) births.

 

 

Activity:

CDPH/MCAH will lead the dissemination of data findings, reports, and presentations related to preterm birth in California.

 

Narrative:

CDPH/MCAH continued to develop and update data dashboards to disseminate findings. The Preterm Birth Dashboard contains maps, bar charts, and trend charts using state and county-level data for 2007-2021.

 

Activity:

CDPH/MCAH will support the development and dissemination of the California Black Maternal and Infant Health Report.

 

Narrative:

CDPH/MCAH partnered with UCSF Center for Health Equity, Black Women for Wellness (an organization focused on empowering the health and well-being of Black women), and a statewide group of Black women leaders and academics to develop the report, Centering Black Mothers in California: Insights into Racism, Health, and Well-being for Black Women and Infants. This comprehensive report presents data on a range of health outcomes from before pregnancy to the time just after pregnancy and provides an evidence base to link structural racism and other societal and community factors with Black maternal and infant health inequities. Quotes from Black birthing people remind readers of the personal stories behind the data. The purpose of the report is to inform efforts, in California and beyond, to advise policy and program development, community action, and health care access and quality that will promote racial equity and bolster opportunities to be healthy among Black women, other Black birthing people, and their families.

 

CDPH/MCAH management and staff members provided input on the report’s development and structure, as well as reviewed multiple drafts of report chapters, and supported the review of the report at multiple levels of state government. CDPH/MCAH Outreach and Communications supported the graphic design of the report and the CDPH/MCAH dissemination plan and implementation, which included a webpage, e-blast, and the development of a social media toolkit.

 

The report was released in September 2023, and was presented at the California Black Birth Equity Summit, the CDPH Office of Health Equity Advisory Committee Meeting, and an MCAH Townhall. A proposal has been submitted for the presentation of the report development process and results for the upcoming Association of Maternal & Child Health Programs meeting in Oakland, California.

 

Perinatal/Infant Objective 3: Strategy 2:

Lead the implementation of the Black Infant Health (BIH) Program to reduce the impact of stress due to structural racism to improve Black birth outcomes.

 

Activity:

CDPH/MCAH will continue to lead and fund state and local BIH Program.

 

Narrative:

CDPH/MCAH funded 15 LHJs and their 26 service areas across the state of California where over 90% of the Black births occur to implement the BIH Program. The program consists of 10 prenatal and 10 postpartum group sessions with complimentary one-on-one support. Each service area has a public health nurse and mental health professional to ensure participants’ mental health and medical needs are supported throughout their time in the program.

 

Activity:

CDPH/MCAH will support local MCAH programs’ development of a public awareness campaign through BIH funds.

 

Narrative:

CDPH/MCAH funded Fresno and Long Beach BIH programs to lead the statewide campaign for all BIH programs. Additionally, funding was provided for each LHJ to develop resources specific to their communities.

 

Activity:

CDPH/MCAH will increase the identification of Black women who are at risk for a preterm delivery and connect them to appropriate resources.

 

Narrative:

Risk factors for preterm delivery are included in the BIH assessment and participants who fall into this category are assigned to the public health nurse at that location to ensure they are connected to resources as quickly as possible.

 

Activity:

CDPH/MCAH will partner with professional organizations such as the American College of Obstetricians and Gynecologists and March of Dimes (MOD) to provide education materials related to preterm birth reduction strategies to pregnant Black women.

 

Narrative:

CDPH/MCAH partners with MOD, which is a member of the Preconception Health Council of California Executive Team, to identify and share preterm birth prevention strategies and resources.

 

Perinatal/Infant Objective 3: Strategy 3:

Lead the implementation of the Perinatal Equity Initiative (PEI) to support local initiatives to support birthing populations of color.

 

Activity:

CDPH/MCAH will lead learning collaborative cohorts to promote statewide sharing of best practices to decrease the infant mortality rate.

 

Narrative:

CDPH/MCAH continues to host eight PEI learning collaborative calls specific to each intervention implemented by funded counties. These calls allow counties to discuss best practices, successes, and challenges implementing each intervention. In addition to inviting subject matter experts to the learning collaborative calls, participants also discuss new topics, current events, and new strategies.

 

Activity:

Collaborate with experts to support successful implementation of legislated interventions.

 

Narrative:

CDPH/MCAH continues to holds bi-monthly learning collaborative meetings with the 11 funded PEI counties. County subcontractors attend these meetings to also share and learn strategies that are being applied in other regions of the state.  CDPH/MCAH collaborated with the LHJ’s to develop its first PEI Celebration.   Community experts were invited to participate in the virtual event and served as guest speakers. These community experts worked as panelist and described their efforts and the challenges experienced with implementing this program.

 

Activity:

CDPH/MCAH will continue to support implementation of the PEI interventions at the local level.

 

Narrative:

CDPH/MCAH learning collaborative meetings provide PEI counties a platform to partner to build and learn strategies for implementation of their interventions. County subcontractors also attend these meetings to provide updates on lessons learned. PEI counties work with their local Community Advisory Boards to decide on and develop interventions. These meetings help to ensure that the interventions match the needs of the communities.

 

Activity:

CDPH/MCAH will continue to support local MCAH programs’ development of public awareness campaigns with PEI funds.

 

Narrative:

CDPH/MCAH maintains regular monthly discussions with counties on their public awareness campaigns and strategies used to highlight the PEI programs. These strategies include promoting community events where local PEI programs have vendor booths and distribute educational materials to community members. Programs may also include sharing birthing experiences and using these experiences to promote a change of practice at birthing facilities, educate community members about the issues, and empower more healthy lifestyles. The PEI team assists with distributing marketing materials to collaborative contacts through announcement emails and social media posts.

 

Perinatal/Infant Objective 3: Strategy 4:

Lead the development and dissemination of preterm birth reduction strategies across California.

 

Activity:

CDPH/MCAH will support and facilitate the process of incorporating preterm birth reduction strategies in all MCAH programs.

 

Narrative:

CDPH/MCAH addressed topic-specific maternal and infant health activities, including MCAH’s role in reducing preterm births. Various subject matter experts were identified within CDPH/MCAH to identify and discuss strategies used by the program. As a result of the meeting, a matrix of strategies was developed to identify specific programs and activities that contribute to efforts to reduce preterm births.

The BIH curriculum includes preterm birth reduction strategies for participants of the program. Local staff also present these strategies at public awareness events throughout the year to share this information more widely and host awareness events during Prematurity Awareness Month.

 

Activity:

CDPH/MCAH will lead, create, and disseminate social media toolkits that address preterm birth.

 

Narrative:

CDPH/MCAH Outreach and Communications Unit collaborated with the CDPH Office of Communications team to create social media messages for Prematurity Awareness Month. The social media was shared with local and state partners and posted on the CDPH platforms.

 

Activity:

CDPH/MCAH will disseminate preterm birth prevention strategies, resources, and best practices to stakeholder groups.

 

Narrative:

CDPH/MCAH partnered with March of Dimes (MOD) to identify and share preterm birth prevention strategies and resources. For example, MOD’s vast web library of information on prenatal education risk-reduction strategies; signs and symptoms of preterm labor; the Supportive Pregnancy Care program that provides prenatal education and social support, and fosters an environment that nurtures positive experiences for both patient and provider; and promotion of access to health care coverage to improve maternity care and infant health outcomes.

 

California is fortunate to be home to one of six MOD research centers that are dedicated to finding causes of and treatments for preterm birth. In California, MOD has a center at Stanford as well as a secondary site at UCSF. MOD research grants are broadly aimed at translational and actionable science that leads to interventions.

Activity:

CDPH/MCAH will disseminate consumer-facing resources and education materials via the MCAH website.

 

Narrative:

CDPH/MCAH Outreach and Communications Unit disseminated information and education materials on perinatal and infant health via the MCAH website.

 

 

[1] CDC Facts: Key Breastfeeding Indicators

[2] Differences in Exclusive Breastfeeding Rates in US Hospitals According to Baby-Friendly Hospital Initiative Designation and Area Deprivation Index Category

[3] CDPH In-Hospital Breastfeeding Initiation Data

[4] CDPH In-Hospital Breastfeeding: Statewide, County and Hospital of Occurrence by Race/Ethnicity: 2020

[5] AAP Policy Statement: Breastfeeding and the Use of Human Milk

[6] CDPH Breastfeeding Initiation Dashboard

 

[7] Goldenberg RL, Cliver SP, Mulvihill FX, et al. Medical, psychosocial, and behavioral risk factors do not explain the increased risk for low birthweight among black women. Am J Obstet Gynecol. Nov 1996;175(5):1317

[8]Liu B, Xu G, Sun Y, et al. Association between maternal pre-pregnancy obesity and preterm birth according to maternal age and race or ethnicity: a population-based study. Lancet Diabetes Endocrinol. Sep 2019;7(9):707-714. doi:10.1016/s2213-8587(19)30193-7