Minnesota’s five-year comprehensive needs assessment identified reducing the infant mortality rate and racial and ethnic disparities in death rates as a significant area of need, and it is Minnesota’s perinatal/Infant health priority area.

Infant mortality is a multifaceted societal problem linked to factors that affect an individual’s physical and mental well-being, including maternal health, socioeconomic status, quality and access to medical care, and public health practices. It adversely affects families and communities, both socially and emotionally, resulting in negative symptoms such as depression, grief, and guilt.[1] Families suffer from long-term psychological distress, leading to partner separation or divorce.[2] Grieving parents also experience isolation from friends and family.

307 infants born in Minnesota in 2017 died before their first birthday.

Minnesota’s infant mortality rate has declined by 39% since 1990, from a high of 7.2 deaths per 1,000 live births to 4.4 in 2017. Despite Minnesota’s favorable infant mortality rate and ranking, the state’s overall rate disguises substantial variation by race/ethnicity – the burden of infant mortality is not shared equally across groups.

For infants born in 2017, Minnesota’s infant mortality rate was over two times greater for infants born to African American/Black mothers and three times greater for infants born to American Indian mothers than infants born to non-Hispanic white mothers. Stress from racism and discrimination causes changes in the body that can increase the rate of infant mortality.[3] The infant mortality rates among African Americans/Blacks in Minnesota vary greatly depending on the mother’s birth country. In 2017, infants born to U.S. born African Americans/Black mothers had an infant mortality rate double (10.3 per 1,000) that of infants born to foreign-born black mothers (4.9 per 1,000) and triple the rate of infants born to non-Hispanic white mothers (3.2 per 1,000).

Figure 1. Minnesota Infant Mortality Rate by Race/Ethnicity, 5-year averages, 2000-2017

Five-Year Strategies and Activities Moving Forward

The Infant Mortality Strategy Team identified strategies to address infant mortality and the racial and ethnic disparities by focusing on activities to address the root causes of infant mortality and promote protective practices like breastfeeding.

A logic model was developed to visualize our planned work and intended results (refer to Figure 2). A larger version of the logic model is included with the supporting documents for this application. The discussion below includes Minnesota’s plans for implementing the strategies during FY2021.

Figure 2. Minnesota Infant Mortality Logic Model

One of Minnesota’s aims is to accelerate infant mortality declines by addressing prematurity, SUIDS, and deaths related to congenital anomalies. As shown in Figure 2, these three causes of infant mortality make up 63 % of the state’s 350 to 380 infant deaths each year. The statewide measures also mask inequalities experience by Black, American Indian and other Minnesotans of color. For example, infants born to American Indian mothers—the population with the highest SUID rate in Minnesota—are approximately eight to eleven times more likely to die suddenly and unexpectedly before age one than infants born to white and Asian mothers, respectively.

Figure 3. Causes of Infant Mortality in Minnesota 2012-2016

Another Minnesota aim to reduce infant mortality is to increase breastfeeding. Racial and ethnic disparities in breastfeeding mirror the disparities in infant mortality found in Minnesota. Studies have shown that breastfed babies are much less likely to die from SIDS than infants who did not receive any breast milk (odds of death with no breastfeeding = 2.5 times higher than with any breastfeeding and 3.7 times higher than with exclusive breastfeeding ).[4]

The narrative plan below describes Minnesota’s activities for implementing the strategies during FY2021 related to SUIDs, birth defects, breastfeeding and prematurity.

Strategy A. Apply Culturally-Specific, Community-Based Best Practices

To address disparities among infants born to African American/Black and American Indian mothers, Minnesota will engage and build better partnerships with internal programs and external community partners working on infant mortality-related topics. As the Needs Assessment and Strategy Team recommended a shift in priorities for infant health, Minnesota will continue to develop new strategies and refine current ones to better meet the needs of communities.

Promoting Safe-Sleep Practices for All Infants

One of our main strategies to reduce infant mortality in FY2021 will be to focus on further reducing the incidence of sleep-related tragedies among infants in Minnesota by applying culturally specific community-based best practices. This will be accomplished by: 1) promoting consistent and inclusive safe sleep messaging statewide; and 2) collaborating with our community stakeholders to expand community-based infant mortality prevention and resources that are culturally specific to populations at greatest risk of experiencing an infant death.

Promote Infant Sleep Safety by Providing Consistent and Inclusive Safe Sleep Messaging

MDH and stakeholders plan to promote consistent and inclusive safe sleep messaging modeled from the American Academy of Pediatrics (AAP) safe sleep recommendations to avert preventable sleep-related tragedies during infancy. To accomplish this in 2021, MDH and its internal and external stakeholders will implement the following activities:

• Declare one week in the fall Infant Safe Sleep Week in Minnesota to include the Governor’s proclamation, a press release, coordination of TV and radio media coverage at a venue that implements safe sleep practices (e.g., a birthing hospital);
• Collaborate with partner organizations, other state agencies and safe sleep champions to communicate safe sleep practices, messages, facts, and data to the public on local radio stations; and
• Use social media (e.g., Facebook) to deliver safe sleep messages during safe sleep week. Our goal is to increase the number of safe sleep messages viewed on social media platforms during safe sleep week by 1.5% (at least 74,523 views).

Provide Trainings on Safe Sleep, Bereavement, and Breastfeeding to Partners

Title V staff will partner with MDH FHV to provide safe sleep and bereavement training for public health nurses/home visitors and other health professionals working with families. The training will cover infant sleep safety and compassionate care to bereaved families adversely affected by the death of an infant or stillbirth. This training is an opportunity to remind home visiting staff and others of the AAP safe sleep recommendations so they can better communicate with families receiving home visiting and other services about infant sleep safety. Minnesota’s goal is to make safe sleep and bereavement training available to other professionals who work closely with families such as community health workers, doulas and allied health professionals.

All WIC staff in Minnesota are provided foundational training in breastfeeding management and support. In addition, we will provide the training Building Bridges for Breastfeeding Duration for WIC staff and community partners. More information on breastfeeding is in the section below.

Expand Community-Based Infant Mortality Prevention Education

Although MDH has its own safe sleep campaign, the agency also currently participates in the National Institute of Child Health and Development’s (NICHD) Safe to Sleep campaign, including NICHD’s safe sleep resources that target the general public, parents, caregivers, grandparents, racial/ethnic groups, and health care providers. MDH also develops state-specific safe sleep resources in multiple languages widely spoken in Minnesota, such as Hmong, Somali, and Spanish. Although many of these resources have been distributed widely and are well received, our campaign does not adequately target some of the hardest-to-reach populations and populations at greatest risk of experiencing a sleep-related SUID in our state, including fathers, immigrants, and homeless populations.

To ensure that Minnesota’s safe sleep campaign reaches these populations, we plan to collaborate with existing community-based infant mortality initiatives and programs serving families of color and American Indian populations such as Birth Equity Community Council (BECC), Early Childhood Family Education (ECFE), Head Start, and Tribal Health to further define strategies to support safe sleep practices. MDH will continue to use social media and other communication methods to focus on at risk groups and geographic hot spots with information education and resource that promoting safe sleep in multiple languages. As part of the planned work under the housing priority, we will intentionally include support for safe sleep to families, and specific strategies will developed over the coming year.

Reduce Disparities in Modifiable Risk Factors for Birth Defects

The Healthy Communities for Healthy Futures grant, a collaboration between the MCH and CYSHN Sections, aims to reduce disparities in modifiable risk factors of birth defects by allowing a community-driven innovative approach. The grant is grounded in the perspective that communities know what they need to address disparities. Grant applicants are encouraged to address system level factors for community-level approaches to reducing top risk factors for birth defects. Two grantees were selected to implement interventions for women of childbearing age to address diabetes, obesity, smoking, hypertension, substance misuse, intrauterine infections, chemical exposures, or maternal stress. The target populations for this work are groups experiencing health disparities in one or more of the risk factors listed above, including but not limited to People of Color, American Indian, disability, LGBTQ, rural, limited English proficiency, immigrant/refugee, and low-income communities. These grantees will begin work in the fall of 2020 and will pursue this important work for the next three years in diverse communities. Allowing this funding to work in collaboration with community led organizations to address social determinants of health will allow MDH to measure if this type of grant can allow broader structural change.

Culturally-Specific Support for Breastfeeding

Within MDH, staff will support collaboration with cultural partners to develop breastfeeding materials and expand outreach to targeted cultural groups including the Hmong, Karen, American Indian and Somali communities. Staff will increase sharing of the data relevant to each community.

In collaboration with the MBC, staff will provide financial and technical support to the Hmong Breastfeeding Coalition and the Indigenous Breastfeeding Coalition, to expand their capacity to conduct culturally specific breastfeeding activities. Minnesota aspires to foster community-created solutions to cultural and historical barriers to achieving breastfeeding goals. Strengthening connections with other community organizations, including the Twin Cities Regional Breastfeeding Coalition, the MNPQC, the Minnesota Perinatal Organization and the BECC is ongoing. Conversations will continue with African-American/Black advocates, including the Moving Health Equity Data to Action (MEDA) project coordinator, to identify needs and opportunities in our Black communities.

Minnesota WIC Peer Breastfeeding Support Program (PBSP) improves breastfeeding rates among the families it serves and reduces cultural disparities in breastfeeding. With increased funding in 2020, Minnesota WIC plans to expand PBSP to more local WIC agencies, as well as expand services in existing, underfunded peer programs to enable them to serve more eligible mothers. Timeline for applications has been delayed by the coronavirus pandemic.

Minnesota WIC and Title V staff will continue active participation on the Minnesota Breastfeeding Coalition (MBC) Steering Committee, and the group’s Equity and Access, Finance, Governance and Events Planning subcommittees. The coalition has statewide reach with local coalitions in all 87 Minnesota counties and is instrumental in policy, environmental, and systems change. We will foster connections with other community organizations pursuing policy, systems and environmental changes designed to improve perinatal health and breastfeeding and to reduce infant and maternal morbidity and mortality.

Additionally, WIC and Title V staff will collaborate with the MDH SHIP program to expand and support local breastfeeding coalitions, public health and WIC agencies mentoring of local businesses to achieve workplace, public health and employer designation as MDH Breastfeeding-Friendly facilities.

Addressing Prematurity

Babies born before 37 weeks represent just under 10% of all births in Minnesota, but prematurity remains one of the top causes of infant mortality, representing 25% of all infant deaths. Persistent racial and ethnic inequalities contribute to the overall rates of premature birth. In 2018, Native American (14%) and Black (10%) women have higher rates of giving birth prematurely than white women (9%). The effects of prematurity can be long lasting for the child, including difficulty breathing, developmental and learning delays, as well as the family who may experience feelings of guilt, anger and increased stress while caring for babies born prematurely. To address this important issue, Minnesota is implementing the Interventions to Minimize Preterm and Low birth weight Infants using Continuous quality Improvement Techniques (IMPLICIT) model to incorporate interconception care for the mother into well child visits to improve birth outcomes. In addition, the MNPQC has two active quality improvement efforts on premature birth prevention and hypertension in pregnancy, both of which contribute to improving outcomes for babies born before 37 weeks. These activities are described in the Women/Maternal Health Plan.

Strategy B. Improve Data Collection and Evaluation

Minnesota will improve data collection and evaluation as a strategy to reduce infant mortality. This will ensure availability of data for planning, programmatic, and policy decisions aimed at improving maternal and infant health outcomes in communities around the state. Evaluation will help with determining our progress in achieving our desired maternal and infant health outcomes. In the year ahead, staff will aim to accomplish the following activities:

Improve Data-Sharing

Minnesota has strict data privacy laws, which sometimes impede sharing infant health and mortality data among Divisions within a state agency, with other state agencies and with the public. Of particular concern are 1) not being able to share infant mortality data when there are fewer than twenty infant deaths in a population even when such data are needed for policy and programmatic purposes, and 2) not having access to data for births that occur to Minnesota residents out-of-state to include in the estimates of infant death rates. Not including all births in the calculations of infant death rates could grossly underestimate the state’s overall infant mortality rate, as well as race- and cause-specific death rates, including the SUID rate. In the next year staff the plans are to:

• Explore the possibility of removing barriers associated with sharing data with our partners when there are fewer than 20 infant deaths occur in a population;
• Aim to restore our privileges to access data for births that occur among Minnesota residents in neighboring states where most of the out-of-state births occur; and
• Continue our efforts with the Sudden Death in the Young Case Registry to share SUID data with all birthing hospitals around the state to help with improving training and infant sleep.

Establish a Fetal and Infant Mortality Review (FIMR)

In 2001, the infant mortality statute that required the Commissioner of Health to conduct Fetal and Infant Mortality Reviews in Minnesota (FIMR) was eliminated. Without the legislation in place, it will be difficult to access relevant information from important sources such as medical records, birth and death records, and coroner’s reports to understand fully the circumstances that may have contributed to infant deaths. Since 2014, staff have put forward legislative proposals to reinstate the FIMR without any success. In 2019, the proposal advanced to the Governor’s list of initiatives for funding considerations for the first time in six years; however, the proposal stalled due to the COVID-19 pandemic. If given the opportunity, staff will draft and submit another proposal to reinstate and fund the FIMR, but the economic downturn and increased pressures on state and local budgets may delay this request further. If the FIMR is reinstated with funding, staff will work swiftly to implement it.

Strategy C. Facilitate Policy and Systems Changes to Reduce Infant Mortality

MDH will make every effort to encourage policy and systems changes aimed at fostering optimal infant health outcomes in Minnesota. This includes increasing the number of safe sleep certified hospitals and breastfeeding friendly maternity centers around the state to ensure that providers are promoting best practices. Beyond safe sleep and breastfeeding, MDH will use FY2021 to consider future policy and systems change strategies recommended by the Strategy Team, including paid parental leave, expanding MA coverage to one-year postpartum, simplifying enrollment for Minnesota Health Care Programs, and increasing support for incarcerated pregnant people and parents.

Increase the Number of Safe Sleep Certified Hospitals

In the coming year, staff will work to increase the number of safe sleep certified hospitals in Minnesota by:

• Providing technical assistance to hospitals interested in receiving safe sleep certification.
• Developing kits with presentations and information about the certification program for community partners and Minnesota to use when recruiting hospitals for certification.
• Recognizing hospitals publicly that have become safe sleep certified during Safe Sleep Week in Minnesota.

Evidence-Based Strategy Measure

Safe sleep modeling occurs when hospitals develop, implement, maintain, and enforce a safe sleep policy that aims to prevent sleep-related injuries and deaths, and staff in turn serve as role models for safe sleep by intentionally conveying messages and cues to parents that promote sleep safety for infants. Because parents/caregivers tend to imitate the behaviors and practices they observe in the hospital later on at home, it is important that all birthing hospitals in Minnesota seek certification through the national certification program.

Because of the reasons stated above, Minnesota will continue to measure Minnesota hospitals with national Safe Sleep Hospital Certification as our evidence-based strategy measure (ESM) for the next five-year block grant cycle. More specifically, we will now be measuring the proportion of births that occur at safe sleep certified hospitals. More information on the measure, data sources, and potential limitations is included on the ESM detail sheet.

Increase the Number of MDH Breastfeeding-Friendly Designated Maternity Centers

With funding from Statewide Health Improvement Partnerships (SHIP), staff from the MBC will facilitate a 10-Step Learning Collaborative (10-SLC) to work on implementation of the Baby-Friendly Ten Steps. The 10-SLC brings together staff from hospitals across the state to work on a minimum of two steps, utilizing the MDH Breastfeeding-Friendly Maternity Center 5-Star Designation Program guidance and tools.

The Perinatal Hospital Leadership Summits (PHLSs) hosted by the MBC have helped increase the number of Baby Friendly Hospitals in the state. Staff will work with the MBC to develop alternative training opportunities for the audience that has attended past in-person leadership summits. Webinars and virtual meetings will be held during the fall of 2020 until in-person summits can be safely resumed.

Evidence-Based Strategy Measure

Most births in Minnesota occur in hospital settings. Maternity hospital practices and policies can undermine maternal and infant health by creating barriers to supporting a mother's decision to breastfeed. When hospitals become Baby-Friendly, they have the tools to give mothers the information, confidence, and skills necessary to successfully initiate and continue to breastfeed their babies. Women who get the support they need in the hospital are much more likely to continue once they return home.

Because of the reasons stated above, Minnesota will measure MDH Breastfeeding-Friendly Maternity Centers as our evidence-based strategy measure (ESM) for the next five-year block grant cycle. More specifically, we will now be measuring the proportion of births that occur at MDH Breastfeeding-Friendly Designated Maternity Centers. More information on the measure, data sources, and potential limitations is included on the ESM detail sheet.

National Performance Measures and Five-Year Objectives

Minnesota has chosen to continue to focus on NPM 5 - A) Percent of infants placed to sleep on their backs B) Percent of infants placed to sleep on a separate approved sleep surface C) Percent of infants placed to sleep without soft objects or loose bedding for the next five-year cycle beginning with FY2021. Recently released data from MDH’s SUID Case Registry for 2014-2018 show that infants born to African American/Black and American Indian mothers are eight to eleven times more likely to die suddenly and unexpectedly during sleep than infants born to white mothers.

Because breastfeeding exclusively is most protective against SIDS, Minnesota is also selecting NPM 4 - A) Percent of infants who are ever breastfed and B) Percent of infants breastfed exclusively through 6 months. If possible, mothers should exclusively breastfeed or feed with expressed human milk for 6 months, in alignment with recommendations of the AAP. The protective effect of breastfeeding increases with exclusivity. However, any breastfeeding has been shown to be more protective against SIDS than no breastfeeding. By 2025, Minnesota aims to reduce the overall SUID rate by 15% and reduce the SUID rates between whites and African Americans and American Indians by 15%.

[1] Murphy, S., Shevlin, M., & Elkit, A. (2012). Psychological consequences of pregnancy loss and infant death in a sample of bereaved parents. Journal of Loss and Trauma, 19(1), 56-69. doi: 10.1080/15325024.2012.735531

[2] Shreffler, K. M., Hill, P. W., & Cacciatore, J. (2012). Exploring the increased odds of divorce following miscarriage or stillbirth. Journal of Divorce and Remarriage, 53(2), 91-107. doi: 10.1080/10502556.2012.651963

[3] Kim, D., Saada, A. (2013). The social determinants of infant mortality and birth outcomes in western developed nations: A cross-country systematic review. Environmental Research and Public Health, 10(6), 2296-2335. Retrieved from: http://www.mdpi.com/1660-4601/10/6/2296/htm

[4] Hauck Fr, Thompson JM, Tanabe KO, Moon RY, Venneman, MM. Breastfeeding and reduced risk of sudden infant death syndrome: a meta-analysis. Pediatrics. 2011; 128(a):103-110.