2020 Annual Report

SPM 2 - Percent of infants placed to sleep on their backs

Objectives:

• Increase the number of NM birthing facilities trained by the NMDOH in safe sleep education protocols from 3 to 15 by 2020.
• Transition at least five NM birthing facilities to report standardized statistics for Shaken Baby Education to the NMDOH in 2019.
• Leverage existing program partners to increase the number of home visitation and perinatal case management programs trained in Safe Sleep and Shaken Baby education from 5 to 15, statewide by 2020.

Strategies

• Create an incentive program to award hospitals with Safe Sleep certification.
• Develop and track a data collection protocol for Shaken Baby Syndrome Education at NMDOH; tie use of protocol to certification to incentivize hospitals.
• Participate in an evaluation of Shaken Baby and Safe Sleep Education delivered by NMDOH.
• Draft and present a statewide, multi-sector Safe Sleep Strategy Plan by 2020.

Safe Sleep/ Sudden Unexpected Infant Death - SUID Prevention

Background - Definitions and program activities

Sudden Unexpected Infant Death (SUID) includes deaths of infants which are either unexplained after thorough case investigation (i.e., SIDS ICD-10 R95, Unknown ICD-10 R99) or explained by Accidental Suffocation or Strangulation in Bed (ICD-10, W-75). All cases are reviewed in field investigation and autopsy to assess sleep environment-related risks and prevention factors. New Mexico joined the Centers for Disease Control and Prevention (CDC) Sudden Unexpected Infant Death (SUID) Registry in 2009, and in 2011 the NMDOH Office of Injury Prevention and MCH Epidemiology began formally planning and implementing safe sleep prevention plans. SUID rates initially decreased slightly in 2010-2014, but five-year moving averages indicate a slow increase to about 1 death per 1,000 live births through 2019 (Figure 1). Rates are about twice as high among male infants compared to female.  By ethnicity, rates are 2.7 deaths per 1,000 for Black/African American infants, 1.0 per 1,000 among Native American infants and .8 per 1,000 among Hispanic and non-Hispanic white babies (NMVR, NM-IBIS, 2010-2019).

Safe Sleep Interventions

NMDOH Title V and the Children Youth and Families Department have offered webinar trainings for birthing hospitals, perinatal case management, midwifery, and WIC nutrition programs since 2012.  These trainings informed initial strategies to work with perinatal clinicians and hospital staff responsible for policy development and regulations at clinical or facility settings. We developed trainings in collaboration with Dr. Michael Goodstein, a nationally recognized neonatologist and board member of Cribs for Kids, who we later contracted to train New Mexico hospital staff in safe sleep hospital policy and procedure development (Oct. 2014). Title V and Office of Injury Prevention work with UNM Prevention Research Center professionals to train hospital staff in AAP safe sleep recommendations and to assess current practices. All three programs also collaborated on legislation, statewide strategic planning, and environmental scans of program policies and practice across the state.

The panel for the NM Sudden Unexpected Infant Deaths (SUID) Registry is managed by the NM Office of the Medical Investigator. The panel is active and included ongoing representation from OIP and Title V. Dr. Lori Proe, Office of the Medical Investigator (OMI) pathologist, led the death review panel with participation from lead field investigator, Rebecca Tarin. The team was rounded out by NMDOH staff to develop recommendations for the annual child fatality review.  Nicholas Sharp, the Title V MCH Epidemiologist/Evaluator, participated in the SUID panel and contributed to the recommendations for policy or program applications. He evaluated SUID registry data and developed a survey of NM birthing hospitals to assess their understanding and practice AAP guidelines.

The Early Child Education and Care Department opened in July 2020 as the “umbrella” for virtually all child development and childcare operations statewide.  It is anticipated that the creation of the new department will significantly centralize and standardize trainings available to educate parents, grandparents, home visitors and health professionals about all aspects of safe sleep and safe pregnancies.

NMDOH Title V child health staff positions were vacant from July 2020 forward, but the application year plans reflect our anticipation of filling the health educator mortality prevention coordinator and the Child Health Manager in 2021. Although safe sleep did not rise out of the public input or needs assessment priorities, the work is still important, and with more diverse engagement we expect it to be more impactful over the next few years.

Objective- Increase the number of NM birthing facilities trained by the NMDOH in safe sleep education protocols from 3 to 15 by 2020.

The NMDOH Office of Injury Prevention (OIP) and MCH Epidemiology collaborated to expand a scope of work for hospital safe sleep education and continue the work through a contract with the UNM Prevention Research Center. Theresa Cruz, PhD, is the Project Director/PI overseeing trainings with University of New Mexico delivery and nursing staff which has expanded to cover eight facilities across the state. Beginning with the largest facilities, UNM Hospital and Lovelace in Albuquerque, the program added two southern facilities, Memorial Medical Center and Mountainview Hospital in Las Cruces, Dona Ana County, and Gerald Champion (Otero County) in 2019. In 2020, Christus St. Vincent in Santa Fe, Gallup Indian Medical Center and Northern Navajo Medical Center in Shiprock (San Juan County) were trained. GIMC and NNMC are both Indian Health Services hospitals, and they serve a population of mostly Navajo families who have been over-represented in the NM SUID cases.  A total of eight hospitals have been trained, but the goal to reach 15 (about half of NM birthing facilities) will continue to move forward. Hospital trainings were modified to an electronic, web-based curriculum during COVID which will be used with and without in-person trainings after the course of the pandemic.

During the reporting period, we surveyed NM birthing hospitals to measure their understanding and practice of AAP guidelines with delivering families. We found that among 15 responding hospitals, 63% had a safe sleep policy governing their activities. One-half of the facilities had only offered a one-time training to staff, 40% trained staff annually, and 10% had a training every two years. The concepts directly taught to parents and caregivers varied. While 100% taught people to avoid co-sleeping/bedsharing and to keep soft items out of the sleep space, 88% taught breastfeeding or about avoiding over-bundling or over-heating infants. Just 75% encouraged room sharing or taught parents to keep siblings in solitary sleep surfaces.

Community Programs

NMDOH and CYFD programs research and The Office of Injury Prevention has representation on the Consumer Product Safety Commission (CPSC) and circulates recall notices and articles biweekly to alert the public on recalls of defective sleeping products. Notices from CPSC, Safe Kids Worldwide, and Kids in Danger help alert public health programs and community-based organizations about defective products designed for infants, toddlers and children.

Many Mothers, a volunteer-staffed maternal support program serving families in Santa Fe and Rio Arriba Counties, provides prenatal and postpartum support to pregnant women, stay-at-home fathers, and families with babies, six months or younger. The program started offering Baby Boxes or Travel Bassinets to promote safe sleep with clients beginning in 2018. Many Mothers also partners with Tewa Women United YVK Doula Program in Española to provide baby boxes to families prenatally or at delivery. The doula program’s experience with Baby Box products has been positive among Latino and some (northern Pueblo) Native American families, and doula staff also encourage clients to view short video trainings to obtain more information and resources on safe sleep. However, there are no evaluation plans among partnering organizations to assess the use of baby boxes or bassinets, and that is a gap still needing attention in the statewide safe sleep strategic plan.

Some communities continue to decline distribution of the boxes, since they may seem uncomfortable for sleep or culturally inappropriate, as shared by the Navajo Nation service area or Navajo Area Indian Health Service (IHS) families.  Prenatally, and at delivery, families do receive safe sleep and breastfeeding education/promotion in the Navajo IHS service area, but they are not offered a specific sleeping product. Families are encouraged to place their infants on firm mattresses in a supine position, and this is aligned with cradle boarding and cultural practices. Breastfeeding is strongly encouraged by health promotion and lactation staff in IHS hospitals, which were also the first facilities in New Mexico to achieve Baby-Friendly Hospital Initiative (BFHI) breastfeeding designation.  By strengthening and building upon optimal breastfeeding initiation, SUID prevention efforts will become more effective. Breastfeeding is a primary preventive aspect of safe sleep that sometimes gets lost in sleep environment promotion, and it is essential that it remain in focus.

Statewide safe sleep strategy development strategies

To promote coordinated efforts in safe sleep education, Title V staff drafted a statewide, multi-sector Safe Sleep Strategic Plan in 2019. Evaluator Nicholas Sharp drafted the plan, which was developed with input from the NMDOH Tribal Liaison, the Child Fatality Review SUID Registry staff, Title V program and UNM partners.  The NM Children’s Cabinet Executive Director, Mariana Padilla, was consulted for support in the implementation of the statewide plan, and Cabinet Secretaries from each state agency have convened to review the current activities and plans for inter-agency coordination.

The SUID panel drafted their 2019 prevention recommendations based on death review findings. Title V staff and OIP staff worked together to align Title V strategies and objectives with the findings applied to the recommendations.

In 2020, MCH Epidemiology Title V staff worked with tribal partners through MCH coalitions and with a student from the College of Population Health to review cultural competencies and articulation n the strategic plan development. With that assessment, a new draft of the strategic plan was released, and a quarterly planning group meets to discuss and act upon the recommendations and focus areas of the plan.  As with many public health efforts, however, the composition of participants can be compromised by competing demands and desires for efficiency. The group was primarily DOH, CYFD, UNM academic staff, and only in 2021 has the participation expanded to include vital partners from the NM Breastfeeding Task Force, the Indian Affairs Department and tribal WIC programs. An invitation is pending with the DOH office of community health workers, Office of African American Affairs and with community-based programs led by people of color.

Objective- Transition at least five (5) NM birthing facilities to report standardized statistics for Shaken Baby Education to the NMDOH in 2019

The legislation for Shaken Baby Syndrome (SBS) was enacted during the report year, and it mandated that every birthing facility in New Mexico educate families about SBS prevention before discharge.  The law was based on strong evidence from a nationally researched model, locally replicated at the University of New Mexico.  The 2018 SBS education law requires DOH-approved education for staff and families delivering at every birthing facility.

Rules governing the SBS mandatory reporting were promulgated in 2020 along with other traumatic brain injury rules. It is not clear whether Title V MCH staff or the Office of Injury Prevention staff will be required to perform an evaluation, but it is our goal to provide impact evaluation on the education provided to families at delivery. Because our Title V Health Educator position is vacant, Family Health Bureau has not pursued the evaluation design or hospital reporting, and the Office of Injury Prevention (OIP) is accountable for all aspects of the work.  

FHB/Title V staff analyzed a 2019 bill introduced on safe sleep education which closely resembles the current SBS education law; however, the safe sleep bill did not pass in 2019 or 2020.  We are still exploring the feasibility and impact of introducing that bill in futures legislative sessions.

Objective: Leverage existing program partners to increase the number of home visitation and perinatal case management programs trained in Safe Sleep and Shaken Baby education from 5 to 15, statewide by 2020.

A NMDOH OIP Health Educator developed a Train-the-Trainer education model for safe sleep and general home safety for families interacting with Child Protective Services (CPS), starting in 2017.  CPS used web-based trainings to continue safe sleep education for all staff throughout 2018 and 2019, with approximately 1200 additional staff trained in safe sleep, shaken baby prevention and safe home trainings via e-learning modules.

The Safe Sleep presentation produced by NMDOH circulated electronically throughout the state to home visitor and other caregiving programs during 2019 and early 2020. The slide deck for Department of Health Safe Sleep presentations was updated and approved in March 2020, however it is unclear how much the information has been shared among home visiting programs or other perinatal programs across the state, since the pandemic ensued.

Title V and OIP staff presented on Safe Sleep for over one hundred WIC providers in March 2020 at the New Mexico Breastfeeding Conference, however the event was virtual due to the COVID-19 pandemic. In addition, 38 providers from the Indian Health Service did receive Safe Sleep training at the Tribal PRAMS conference held at Isleta Pueblo in February 2020.

Figure 1. Sudden, Unexpected Infant Death (SUID) Rates, 5-Year Moving Time Periods, NM 1999-2019

Appendix of Strategic plan recommendations coming out of the SUID panel, 2020:

1. Provide ongoing and expanded safe sleep education for parents, grandparents, home visitors and health professionals
   1. Legislation should require birth hospitals to provide one-on-one instruction on safe sleep to all birth, foster, and adoptive parents prior to a newborn’s discharge from the hospital.
   2. Birth hospitals, Ob-Gyn providers and pediatricians should be linked with state, county, or community resources that can provide free “baby boxes” bassinets, cribs, or other safe sleep surfaces when needed prior to the newborn going home.
   3. The Early Childhood Education and Care Department (ECECD), with consultation and material from NMDOH, should be tasked with providing trainings for statewide home visiting and daycare staff regarding all aspects of health and safety for newborns and toddlers, with Safe Sleep guidelines being the priority.
2. Increase statewide participation in home visiting programs.
   1. Ob-Gyn providers, birth hospitals, and pediatricians should be primary points of contact for referrals to home visiting services.
   2. ECECD will be tasked with keeping providers up to date on the local home visiting services available in their respective counties for their referral to local parents.
3. Improve opportunities for mandated reporters and community providers to initiate a face-to-face response from CYFD Protective Services or home visiting professionals when there are concerns about unsafe sleep or related risk factors.
   1. Under a differential response track, circumstances leading to assessment and follow-up from the agency could include:
      1. Caregivers whose infants are discharged from a birthing hospital with a “Plan of Safe Care” as required by the Child Abuse Prevention and Treatment Act as amended by the Comprehensive Addiction and Recovery Act (CARA) of 2016 will be offered home visiting services.
      2. Caregivers with previous CPS involvement will receive in-home safe sleep assessments and education.
4. Revise procedures and practices around safe sleep for foster care and respite care providers, per CYFD Protective Services Division.
   1. All CYFD field staff; licensed placement agency staff; prospective foster parents, adoptive parents, and respite care providers licensed through CYFD or a CYFD-regulated private agency should participate in annual safe sleep training based on American Academy of Pediatrics recommendations.
5. Improve investigation of SUID deaths and remove barriers to thorough data collection at the death scene.
   1. All Field Deputy Medical Investigators, including law enforcement/tribal police partners, should be routinely trained in SUID death investigations.
   2. Provide translation services for parents/caregivers whose first language is not English, to complete thorough interviews and doll reenactments with law enforcement and Field Deputy Medical Investigators.

These strategies and recommendations will be continuously updated and inform FY21-22 plans to keep infants safe in sleep environments.