Risk-appropriate Perinatal Care (FY 2020 Application)

The state priority need to support coordination and linkage across the perinatal to pediatric continuum of care was selected for the Perinatal/Infant Health domain, as a result of the five-year needs assessment process. The percent of very low birth weight (VLBW) infants born in a hospital with a Level III+ Neonatal Intensive Care Unit (NICU) (NPM 3) was selected as one of two measures to address this priority need.

Infants born prematurely and of VLBW or low birth weight (LBW) are at a greater risk of longer hospital stays, compromised health statuses, developmental delays and even death in comparison to their full-term, healthy weight counterparts. Black, Native American, Middle Eastern and Hispanic babies are particularly impacted by health inequities specifically related to gestation and birth weight. In 2017, 13% of all live births in Michigan occurred prior to 37 weeks gestation and 1.5% of all live births were born with VLBW. As was seen in 2016, the disparity between Black infants and White infants for prematurity, VLBW, and LBW is still apparent. Much like in 2016, the percentage of Black VLBW infants (3.1%) was triple that of White VLBW infants (1.1%) in 2017. The percentage of Black LBW infants (11.5%) was double that of White LBW infants (6.2%) in 2017[1]. This persistent disparity indicates the need for innovation and collective efforts to move the percentages in a downward trend.

The aim of the Michigan Regional Perinatal Quality Collaboratives (RPQCs) is to develop innovative strategies to regionally address the drivers of preterm birth rates, as well as VLBW and LBW. RPQCs ensure that their strategies closely align with the strategies and goals outlined in Michigan’s Mother Infant Health and Equity Improvement Plan (MIHEIP), which was drafted under the guidance of the Maternal Infant Strategy Group in 2019. The RPQCs are also tasked with addressing disparities in birth outcomes and health care inequalities through involvement of cross-sector local and statewide stakeholders, as well as implementing the MIHEIP utilizing the Population Health Model. Utilization of this model will allow the RPQCs to stratify the available data and tailor the implementation of evidence-based interventions to populations, or geographic areas, within the region that are identified as at risk for adverse birth outcomes. Several RPQCs have begun to address perinatal substance use through increased prenatal screening, increasing treatment capacity in their respective region and increased educational opportunities, including implicit bias and stigma reduction, related to Neonatal Abstinence Syndrome (NAS). Addressing the existing health inequities and disparities in Michigan will result in the overall reduction of Michigan VLBW, LBW and preterm birth rates. At the same time, striving to increase the percentage of preterm and VLBW infants born in a risk-appropriate care hospital will decrease the risk of neonatal, infant and maternal mortality.

Objective A: By 2020, support the implementation and evaluation of Regional Perinatal Quality Collaboratives (RPQCs) in all ten regions.

RPQCs have been launched in eight regional areas in Michigan. These areas have varied demographic composition and include rural and urban communities. Key stakeholders include, but are not limited to, the following: families, birthing hospitals, insurance payers, local health departments (LHDs), medical providers, health systems, home visiting programs and other community agencies. The two newest RPQCs were launched in the Saginaw Bay area and the Thumb area, both located on the east side of Michigan, in FY 2018 and FY 2019, respectively. In FY 2020, the final two RPQCs will be launched; one in the Lansing area and one in the far southeastern area of Michigan.

Regional Perinatal Quality Collaborative efforts in northern Lower Michigan are focused on increasing substance use screenings and treatment referrals of pregnant women, as well as establishing a sustainable home visiting program that is available to all pregnant/postpartum women and their infants, regardless of their insurance or income status. Substance use screening efforts achieved at two prenatal care sites in the region in FY 2019 are expected to fuel expansion of the screening tool use at other obstetric clinics in FY 2020. As a result of data stratification, the Region will identify and focus tailored efforts to populations/geographic areas identified most at-risk for perinatal substance use, as well as areas and populations experiencing a disproportionate number of infant and maternal deaths or morbidities. It is expected that the Region will work to implement additional evidence-based interventions, if indicated by the data.

Southeast Michigan has focused its RPQC efforts on increasing the utilization of evidence-based home visiting programs in Detroit to move the needle on infant deaths, especially those related to sleep-related causes. It is anticipated that information gathered in FY 2019 will encourage the collaborative to continue to expand the best practices to other home visiting agencies and birthing hospitals in the region. Additionally, the RPQC in this region continues to educate its members on implicit bias and health equity. Focusing efforts, including education, on implicit bias and health equity, especially related to policies and practices of member agencies, is only one step in addressing the root cause of disproportionate rates of infant mortality in this Region. Additional data stratification will highlight specific areas and populations in which the Region will need to focus efforts, including tailored implementation of evidence-based interventions.

Quality improvement efforts of the West Michigan RPQC have focused on increasing referrals and utilization of evidence-based home visiting programs, as well as on increasing substance use screening in pregnant women. Prior analysis of data revealed specific geographic locations in the region with a disproportionate number of infant morbidities. This data served as the initial basis of where to focus efforts in the Region. Results of these continued efforts, focused in both urban and rural areas of the region, will direct FY 2020 activities. Additional data stratification results shared with the Region will also direct FY 2020 efforts. 

The Upper Peninsula RPQC efforts have focused on increasing utilization of substance use screenings and treatment referrals of pregnant women, coordination of obstetric care and substance use treatment for women with Perinatal Substance Use Disorder (PSUD), continued education of staff on evidence-based treatments/interventions for Neonatal Abstinence Syndrome (NAS) and stigma reduction, and establishing a universal home visiting program that is available to all pregnant/postpartum women and their infants. Substance use screening efforts achieved at a prenatal care site in the region is expected to drive expansion of the screening tool to other prenatal care sites in FY 2020. PSUD and NAS have been a priority of this RPQC due to having the highest NAS rates in Michigan. As stratified data becomes available, the RPQC will analyze the results and identify any additional populations or geographic locations with disparate outcomes.

The RPQC of southwest Michigan recently re-focused its efforts and is currently working to increase referrals and utilization of evidence-based home visiting programs. Evidence-based home visiting programs are designed to serve specific subsets of the population that tend to experience higher rates of adverse outcomes. However, the region will further tailor efforts to the population/community identified in the data stratification process. Results of FY 2019 efforts are also expected to direct subsequent efforts in FY 2020.

Regional Perinatal Quality Collaborative efforts were initiated in FY 2019 in the Saginaw/Bay and Thumb areas of Michigan. In 2017, the Saginaw/Bay area had high percentages of pregnant women reporting smoking in pregnancy[2] and in 2016, the Thumb (and surrounding area) had the second highest NAS rate in Michigan2. This data helped shape the focus of each respective region’s quality improvement efforts in FY 2019 and will continue to steer their work in FY 2020. As with the other RPQCs, these regions will utilize stratified data to further define their population of focus, as well as to tailor implementation of evidence-based interventions.

All RPQC initiatives are to be inclusive of active and authentic family engagement. Input from families is valued and often garnered through in-person participation at regional meetings, focus group participation and patient feedback surveys. To further encourage authentic family engagement, in FY 2020 each RPQC is required to gather feedback from families at least twice during the fiscal year; whether it be through participation at regional meetings or through community events or groups.

In FY 2020, each funded RPQC will continue efforts aimed at the improvement of maternal, infant and family outcomes, as a means of decreasing the percentage of infants born prematurely, born with very low or low birth weights, and born exposed to harmful substances such as opioids, alcohol, and tobacco. The RPQCs will implement evidence-based interventions and other key strategies outlined in the MIHEIP through utilization of the Population Health Model. Each RPQC is expected to narrow their focus and tailor interventions to the populations in their region that are at greatest risk for adverse outcomes. The Population Health Model will guide each region in their continued efforts to address health disparities and inequities, especially as related to prematurity, very low or low birth weights and babies born exposed to substances. Furthermore, continued expansion of RPQCs to all regions within the state is planned for FY 2020.

Objective B: By 2020, increase Risk Appropriate Care for infants from baseline data indicators by 20%: Very Low Birth Weight (VLBW); Low Birth Weight (LBW); and prematurity.

The first strategy for this objective is to promote case management and care coordination for pregnant women in Michigan through evidence-based programming. MDHHS continues to support and promote CenteringPregnancy and CenteringParenting in Michigan. CenteringPregnancy is an evidence-based group prenatal care model that has been proven effective in decreasing the rate of preterm and low birth weight babies, as well as decrease racial disparities in preterm birth. The number of CenteringPregnancy sites in Michigan is the Evidence-based Strategy Measure (ESM) for this performance measure. To date, 14 CenteringPregnancy group prenatal care sites and one CenteringParenting site exist in Michigan. In addition, MDHHS promotes case management and coordination for women and infants through evidence-based home visitation programs. Evidence-based home visitation programs promote health care utilization and reduced risk for adverse birth outcomes such as VLBW, LBW, and premature births. MDHHS remains committed to promoting these evidence-based case management and care coordination strategies aimed at reducing inequities and decreasing poor outcomes for infants in FY 2020.

Participation in The American College of Obstetricians and Gynecologists (ACOG) Alliance for Innovation on Maternal Health (AIM) is the second strategy. By partnering with stakeholders and professional organizations, Michigan is working toward improved maternal morbidity and mortality outcomes, as well as reduced inequities in these adverse maternal outcomes. Addressing the health status of mothers is a key part of prevention efforts aimed at reducing the number of premature, very low and/or low birth weight babies. The work of MI-AIM will continue to lead the effort of improving maternal health of Michigan mothers in FY 2020.

Prior to FY 2019, maternal and infant health were siloed. Beginning in FY 2019, maternal and infant health efforts are addressed in the Mother Infant Health and Equity Improvement Plan (MIHEIP). This plan is the next iteration of the previous Infant Mortality Reduction Plan (IMRP). MDHHS is leading the MIHEIP effort and in 2018 held a series of “town hall” meetings at which stakeholders, including families, were provided an overview of the direction of the combined efforts. Attendees had an opportunity to offer feedback on the MIHEIP logic model. Additionally, in FY 2019 the MIHEIP was released for a public comment period in which families and other stakeholders offered comments on the final draft of the MIHEIP. Through various strategies, some of which are outlined above,the MIHEIP is focused on reducing health disparities, especially as they relate to the number of premature, very low and/or low birth weight babies in FY 2020 and beyond.

Objective C: By 2020, expand quality improvement efforts related to the prevention and response of Perinatal Substance Use via the Regional Perinatal Quality Collaboratives (RPQCs).

Three comprehensive strategies will continue to be utilized in FY 2020 to address Perinatal Substance Use, including addressing Neonatal Abstinence Syndrome (NAS). Perinatal Substance Use is a risk factor for preterm births and infants born with very low or low birth weights. In addition to the effects of alcohol and tobacco use, Michigan continues to have high NAS rates in several regions within the state. This is due to the opioid epidemic that Michigan continues to battle. All three strategies to address perinatal substance use will be guided by the RPQCs. In FY 2020, it is expected that at least four of the collaboratives will direct efforts on perinatal substance use and/or addressing NAS.

The first strategy is to promote opioid use disorder prevention and increase screening and identification of women (especially pregnant women and those of childbearing age) for opioid use disorder. Northern Lower Michigan, the Thumb area and the Upper Peninsula have implemented the use of electronic screening tools in prenatal clinics located within their respective region. West Michigan continues to implement a different evidence-based screening tool that is preferred by the region’s major health system. Patient feedback is also being collected and analyzed. Therefore, it is anticipated that in FY 2020, the results of these continued efforts will lead to an expansion across their respective regions to prevent, screen, and address perinatal substance use for all women of reproductive age. MDHHS will encourage the regions to utilize stratified data to identify areas in the Region with high numbers PSUD. Clinics identified as providing care to these women will be encouraged to implement an evidence-based screening tool, if not already doing so, and refer women who screen positive to appropriate treatment.

The second strategy builds upon the previous strategy: to enhance capacity to provide treatment for women identified as affected by opioid use disorder through cross-sector partnerships. Northern Lower Michigan identified a large gap in treatment options for individuals living in this 21-county region and is currently gearing up to offer expanded treatment capacity in the region’s most populated city. During the planning process, conversations have been inclusive of providers and community members. These efforts will carry over to FY 2020 with expectations that an additional prenatal care clinic will offer Medication Assisted Treatment (MAT). Additionally, the Upper Peninsula identified a cohort of pregnant women receiving MAT, but not attending their prenatal care appointments. Efforts are under way to create a care coordination system in which pregnant women on MAT, receive prenatal care and their MAT in a coordinated visit on the same day. It is expected that these efforts will carry over to FY 2020 and expand into a more comprehensive system of care.

As mentioned previously, NAS is also addressed under this objective. The third strategy aims to improve workforce development and training programs related to NAS, as well as maternal care for perinatal substance use both perinatally and postpartum. The Upper Peninsula has the highest NAS rate of any region in Michigan. Current efforts in this region have been focused on providing education and training on evidence-based NAS care and implicit bias/stigma reduction to birthing hospital staff, as well as prenatal care staff. These efforts are ongoing and are expected to continue in FY 2020. The Northern Lower Michigan region is also committed to training staff at birthing hospitals located in the 21-county region. Initial efforts have commenced and will continue into FY 2020. The Saginaw area on the east side of Michigan is also working to address NAS. Efforts in this area center around forming a dedicated workgroup and providing provider and other stakeholder (including court system/law enforcement staff) education. Having a standardized approach to NAS, as well as maternal screening and care for perinatal substance use, will decrease the number of mothers, infants and families impacted by substance use and will furthermore reduce the risk for preterm births[3] and infants born with very low or low birth weights.

Breastfeeding (FY 2020 Application)

The percent of infants who are ever breastfed and percent of infants breastfed exclusively through six months (NPM 4) was selected as the second of two measures to address the priority need to “Support coordination and linkage across the perinatal to pediatric continuum of care” in the Perinatal/Infant Health domain. Breastfeeding is a natural way to feed and provide nutrition to infants, and research shows that it provides many short- and long-term benefits to both mothers and babies. Therefore, Michigan continues to promote and fund breastfeeding initiatives and education. The publication of Michigan’s first Breastfeeding State Plan in the fall of 2017 set the common agenda necessary for a collaborative approach among an array of stakeholders: state, local and tribal government; health care professionals and organizations; employers; child care providers and educational institutions; community organizations; and most importantly, individuals and families. The Breastfeeding Plan’s strategies strive to address the social determinants of health and resultant health inequities, and work to address health disparities in breastfeeding and infant mortality. Michigan’s five key strategies to achieve breastfeeding goals are the elimination of disparities; advancing breastfeeding rights through education of policy makers and support of laws that protect breastfeeding families; building community support through the work of breastfeeding coalitions and increased access to breastfeeding support; changing organizational practices; and strengthening individual skills.

To focus efforts internally, MDHHS breastfeeding partners (i.e., WIC, Maternal and Infant Health, and Obesity Prevention) identified three priority strategies:

1. Increase training opportunities to improve the number, availability, and racial and cultural diversity of trained breastfeeding professionals.
2. Work with community partners to develop and support interventions to address disparities in breastfeeding rates.
3. Increase the number of Baby-Friendly hospitals.

Breastfeeding support has been identified as a supporting intervention in Michigan’s new Mother Infant Health and Equity Improvement Plan. In FY 2019 and FY 2020, MDHHS will also focus on supporting community development and implementation of breastfeeding initiatives contributing to the Improvement Plan.

Michigan’s state-level breastfeeding work group continues to meet to enhance communication and goal alignment among state-level programs and partners. The group uses a collaborative tracking tool to document progress towards achieving the goals of the state plan and to identify issues that are more easily solved through collaboration.

To improve breastfeeding rates and reduce disparities, Michigan is focused on increasing access to breastfeeding professionals and educated peers, increasing the number of Baby-Friendly hospitals, and providing support to community level breastfeeding initiatives. Barriers include funding limitations to support local and state breastfeeding efforts and a lack of local data from mothers and families to determine actual barriers to breastfeeding. Title V funds do not directly support the work outlined below, but the Breastfeeding Coordinator is housed within the Division of Maternal and Infant Health.

Objective A: Increase percentage of Baby-Friendly designated birthing hospitals to 26% by 2020.

Michigan’s evidence-based strategy measure (ESM) is to increase the percent of Baby-Friendly designated hospitals. The purpose of the Baby-Friendly Hospital Initiative (BFHI) is to assist hospitals in providing mothers with information, confidence and skills needed to start and continue to breastfeed their babies. Although there is general support for the Baby-Friendly initiative in Michigan, the state’s birthing hospitals struggle to move forward on the Baby-Friendly pathway. As of March 2019, 16 out of 83 Michigan birthing hospitals have received the Baby-Friendly designation and many more are on the pathway. The current percent of Baby-Friendly hospitals is 19.3% and progress is being made towards the goal of 26% by 2020.

Three strategies will be implemented to impact this objective. The first strategy is to support Michigan birthing hospitals’ individual goals to continue movement along the Baby-Friendly pathway. MDHHS staff will work with communities and hospitals as part of the Improvement Plan implementation as well as reaching out to hospitals to determine their Baby-Friendly status and any support that can be offered. The second strategy will continue and expand breastfeeding supportive practices by providing trainings and/or materials to at least 15 birthing hospitals. Examples include WIC-supported Building Bridges, Coffective trainings and materials, 310 Connect collaborative support, and promoting the Mother Baby Summit. The third strategy will assist key partners who influence maternal and infant health to develop and implement one specific strategy that supports efforts to increase the number of Baby-Friendly hospitals. These partners will be internal such as home visiting programs and external such as statewide health care associations or councils.

Objective B: Reduce the disparity in breastfeeding initiation between non-Hispanic white women and non-Hispanic black women from an average of 12.1% to 11.9% by 2020.

According to PRAMS data, Michigan’s gap in breastfeeding initiation between non-Hispanic white women and non-Hispanic black women has decreased over time but has been inconsistent. The average gap between white and black women was 11.5% in 2012-2014, 12.2% in 2013-2015, 9.9% in 2014-2016, and 11.1% 2015-2017. For this reason, this objective will remain at 11.9% by 2020.

Michigan’s first strategy is to increase training opportunities to improve the number, availability and racial and cultural diversity of trained breastfeeding professionals. MDHHS collaborates with and supports the Great Lakes Breastfeeding Webinar series which offers breastfeeding-specific training every month, without cost to participants. The webinar provides contact hours for nurses, social workers, lactation consultants and dietitians. This free, easy-to-access education removes barriers to obtaining advanced training and diversifies and strengthens Michigan’s lactation workforce.  Webinar topics use a health equity lens and challenge viewers to approach breastfeeding support from that perspective. MDHHS will also focus on increasing breastfeeding support training opportunities among programs and organizations that interact with moms, including home visitors.

The second strategy to reduce the gap in disparities is to facilitate community efforts in local communities to improve breastfeeding rates among women of color. MDHHS will focus on at least two communities to explore and identify reasons and solutions for lower breastfeeding rates among women of color. Breastfeeding data will be used to identify communities and strategies. MDHHS will engage locally with professionals, stakeholders and community members to brainstorm possible reasons and solutions and support community-driven solutions as appropriate.

The third strategy is to learn—from statewide experts and community members—approaches to address the specific breastfeeding support needs of non-white women. MDHHS will strategize ways to be better supportive of groups who provide support and protection of mothers who face disparities in breastfeeding initiation and duration. The MDHHS strategy will include an analysis of breastfeeding data but will also focus on cultivating relationships in communities. The State Breastfeeding Coordinator will meet with and learn from community groups such as breastfeeding coalitions, birth and postpartum Doulas, hospitals, birthing centers, Black Mothers Breastfeeding Association and other breastfeeding support groups that represent women of color. The goal of the meetings will be relationship building, community engagement and identification of community-driven approaches that can be supported by MDHHS.

Safe Sleep (FY 2020 Application)

In Michigan’s original five-year plan, the priority area to “Foster safer homes, schools and environments with a focus on prevention” was linked to promotion of infant safe sleep environments through the following two-part SPM:

1. The percent of infants put to sleep alone in their crib, bassinet or pack and play and;
2. The percent of infants put to sleep without objects in their crib, bassinet or pack and play.

HRSA added two Pregnancy Risk Assessment Monitoring Survey (PRAMS) measures to the original NPM that previously only measured the percent of infants placed to sleep on their backs. Given this change, Michigan converted its original SPM to the new NPM for the FY 2019 Title V application. Michigan did not choose “infants being placed to sleep on the back” as an original performance measure because the state exceeds the Healthy People 2020 goal of 75.9%. 

While Michigan exceeds the Healthy People 2020 goal for back sleeping, parents are continuing to practice infant sleep behaviors that put infants at risk, which is confirmed by data from the Michigan PRAMS. PRAMS data for 2016 show that the percentage of parents and caregivers practicing these behaviors have decreased compared to 2015. However, it is important to note that all PRAMS states began asking different safe sleep questions in 2016, so it is difficult to compare these questions over time. The proportion of Michigan mothers meeting Michigan’s NPM is lower than in prior years, except for back sleeping, but the measurement now provides a more comprehensive picture of infant sleep practices.

In 2016, 83.2% of Michigan infants were usually sleeping on their back. In addition, 34% of infants were placed to sleep on a separate approved sleep surface. In prior years, this measure was based on only two sleep risk factors—does the infant sleep in his or her own crib and does the infant sleep with other people. Starting in 2016, this measure is based on five different sleep risk factors: always or often 1) sleeps alone in own bed; 2) in a crib, bassinet or pack and play; 3) does not sleep on a twin or larger mattress; 4) does not sleep on couches, sofas, armchairs; and 5) does not sleep in a car seat or swing. Asking about whether infants sleep in a car seat or swing—a new question—has had an especially large impact on this measure. Also, in 2016, many more mothers report that their infants have at least one soft item in the sleep space. This increase may be due to changes in the wording of the question regarding blankets (any blanket versus only plush or thick blankets). The proportion of infants sleeping with no soft objects (pillows, bumpers, blankets, toys) is 51.8%. Although the number is lower than the number reported in the past, in 2016 Michigan had the highest proportion of mothers reporting that their infants do not sleep with soft objects (compared to 28 other PRAMS states reporting this data).

Another important source of data is from the Centers for Disease Control and Prevention (CDC) Sudden Unexpected Infant Death (SUID) Case Registry. It is a statewide, population-based surveillance system that tracks all sleep-related infant deaths and contains comprehensive information about the circumstances associated with the infants’ deaths as well as information about the case investigation. Data is collected through local, county-based Child Death Review teams. In Michigan, 1.3 sleep-related infant deaths occur per every 1,000 live births [Centers for Disease Control and Prevention (CDC) SUID Case Registry – 2010 to 2017, Michigan Public Health Institute, 2019]. Between 2010 and 2017, an average of 142 babies died each year in Michigan due to sleep-related causes (n=1,136 total cases).

According to the CDC SUID Case Registry, three in four sleep-related infant deaths in Michigan occurred in an unsafe sleep location, including adult beds (48%) and couches or chairs (15%). Only 21% of infants who died of sleep-related causes were placed to sleep in a crib, bassinet or portable crib. A crib, bassinet or portable crib was not present in the home in 15% of the deaths. Of the infants who die of sleep-related causes in Michigan, 58% of deaths occur while an infant is sharing a sleep surface with an adult(s), another child(ren), and/or an animal(s).

Significant racial disparities exist among sleep-related infant deaths. In Michigan, Black infants are 3.4 times more likely to die of sleep-related causes than White infants (2.7 sleep-related infant deaths per 1,000 live births for Black infants compared to 0.8 per 1,000 live births for White infants, CDC SUID Case Registry – 2010 to 2017, Michigan Public Health Institute, 2019). Compared to White infants, infants whose race was categorized as other (other includes American Indian, Asian, Pacific Islander, and multi-racial infants) are more than twice as likely to die of sleep-related causes (1.8 sleep-related infant deaths per 1,000 live births when “Other” is listed as the race compared to 0.8 per 1,000 live births for White infants).

Looking within Michigan, there is disparity for the proportion of NHW (85.4%) and NHB (66.2%) mothers whose infants were usually placed to sleep on their backs. The disparity gap (85.4% - 66.2%) is 19.2%. At the national level, there is a slightly larger disparity gap (21.5%) in this measure when comparing NHW (83.8%) to NHB (62.3%) mothers. There is almost no disparity for the proportion of NHW (35.7%) and NHB (34.8%) mothers whose infants slept on a separate approved sleep surface and whose infants slept without any soft objects or loose bedding (NHW 52.8% versus NHB 51.8%). At the national level, there is a notable disparity in both these measures when comparing NHW (35.3% for sleeping on a separate sleep surface and 45.7% for sleeping with soft objects) to NHB (27.0% for sleeping on a separate sleep surface and 37.5% for sleeping with soft objects).

Two of Michigan’s safe sleep objectives relate to how babies are put to sleep. The strategies to address these two objectives are combined, since the safe sleep behaviors are so closely related. Although infants being placed to sleep on their back was not singled out as a specific objective, all strategies and activities will promote the key messages to parents and caregivers: infant sleeps alone and without objects on the back, in a crib, bassinet or pack and play. The strategies developed to meet these objectives involve ensuring community level partners are trained on infant safe sleep and have the support and tools to educate families by having non-judgmental, culturally sensitive conversations about infant safe sleep practices. A challenge to this work is ensuring that families receive the information early, at every touchpoint and are receiving consistent, accurate messages about the safest way to sleep their baby.

Objective A: Increase percent of infants put to sleep on a separate approved sleep surface to 37.5% by 2020. (Changed from 81.8% to 37.5% due to changes in PRAMS data as noted above.)

Objective B: Increase percent of infants placed to sleep without soft objects or loose bedding to 57.1% by 2020. (Changed from 87.4% to 57.1% due to changes in PRAMS data as noted above.)

The first strategy is to support the safe sleep activities of local health departments (LHDs) and the Inter-Tribal Council of Michigan to increase the capacity of communities to implement infant safe sleep education, awareness and outreach activities to promote infants being placed on their backs and alone with no objects in their cribs, bassinets or pack and plays. This strategy will be accomplished through the provision of mini-grants to communities identified as having high numbers of sleep-related infant deaths. In addition to high numbers of deaths, many of these communities also experience significant racial disparities among the deaths. In FY 2020, 15 LHDs and the Inter-Tribal Council of Michigan will be offered such grants. Grant funds can be used for educational activities, community outreach efforts and expanding community awareness of infant safe sleep. A portion of the grant funds can be used to purchase pack n plays or sleep sacks. Each community uses a local advisory council to guide activities. In FY 2020, coordination with Regional Perinatal Quality Collaboratives will continue to be encouraged, as well as requiring that activities align with the Mother Infant Health and Equity Improvement Plan (MIHEIP). Activities are to be data-driven and culturally relevant to at-risk, high-risk families in the community. Many mini-grantees involve parents and caregivers in funded activities as parent educators, speakers and outreach workers. They will also be encouraged to utilize the MIHEIP Ambassador Program.

The second strategy to increase the percent of infants put to sleep safely is to support providers who educate families on infant safe sleep and facilitate new partnerships to make it possible for families to receive infant safe sleep education at all potential touchpoints. This work includes continuing to facilitate new collaborations with non-traditional partners so the message spreads in communities that may not have been reached previously. Non-traditional partners often have greater acceptance in high-risk communities—communities that bear the burden of health disparities—due to increased levels of trust and their ability to reach community members who are not being served in traditional health or human services settings. This approach has the potential to impact racial disparity as many of the populations that are disproportionately affected by sleep-related infant deaths may have strong connections with non-traditional community partners.

In FY 2020, efforts to collaborate with and support faith-based organizations will continue. Technical assistance will be provided from the MDHHS Infant Safe Sleep Program and the MDHHS Office of Community and Faith Engagement. Additional non-traditional partners will be explored in FY 2019 through the work of the MIHEIP Ambassador Program and if feasible, those avenues will be implemented in FY 2020. Other areas of collaboration that will continue in FY 2020 include home visiting programs (such as the Maternal Infant Health Program and Healthy Start Programs); Medicaid Health Plans; MDHHS Immunizations; Women, Infants and Children (WIC); MDHHS Child Welfare Programs including Child Protective Services (CPS); MDHHS Breastfeeding; MDHHS Tobacco; MDHHS Health Disparities Reduction and Minority Health Section; MDHHS Early On®; and MDHHS Children’s Special Health Care Services.

Efforts to support birthing hospitals to educate families on infant safe sleep will continue as research has shown that when health care providers, including nurses, are educated on infant safe sleep, they share that information with families; in turn, families are more likely to follow recommended infant safe sleep practices. The evidence-based or -informed strategy measure (ESM) implemented in FY 2019 was to increase the number of birthing hospitals trained on infant safe sleep. In January 2019, the MDHHS Infant Safe Sleep Program began to offer birthing hospitals the training “Infant Safe Sleep: The Basics and Beyond” with one nursing contact hour awarded. In FY 2020, efforts to ensure that birthing hospitals are trained on infant safe sleep will continue, as well as exploring other ways hospitals can be supported. In FY 2019, the trainings will be conducted at hospitals throughout the state, upon request, with some focus on birthing hospitals in southeast Michigan. In FY 2020, a more targeted approach will be taken, and focus will be on birthing hospitals in southeast Michigan in order to reach the most concentrated number of births in the state and hospitals in areas of the state that experience health disparities. Hospitals with special care nurseries and neonatal intensive care units (NICUs) will also be targeted because babies born with lower birth weights and/or premature are at higher risk of sleep-related infant death. A continued challenge to providing training to birthing hospitals is not being able to reach all staff due to staff turnover and staff being unable to attend in-person trainings due to scheduling conflicts. To address this challenge, the Infant Safe Sleep Program is in the process of developing a video version of the training.

The third strategy is to develop and disseminate safe sleep messages that are based in best practices and families’ experiences. This strategy was refined in FY 2018 to align with one of the major activities in a grant awarded to the MDHHS Infant Safe Sleep Program from the Michigan Health Endowment Fund (MHEF) in December 2016. This strategy was informed from the results of focus groups, conducted in FY 2018, to identify preferences for safe sleep message type and delivery. Focus group results, innovative infant safe sleep research and programming were shared with the MDHHS media team. Several meetings were held and preliminary recommendations were reviewed in January 2018. It was determined that additional community input, including input from communities that experience health inequities, was needed before moving forward with the development of new safe sleep messages and educational products. In FY 2019, the Infant Safe Sleep team is contracting with two community-based agencies to obtain the needed additional community input and to develop prototype materials. After initial development of messages and methodologies, market testing will be done so that refinements can be made prior to large scale dissemination. In FY 2020, these messages and educational products will be disseminated statewide to our community partners. The goal is that improved messaging and methodologies will translate to increased use of safe sleep practices among high-risk populations and, ultimately, reduce the number of deaths in addition to reducing the racial disparity.

As a fourth strategy, the MDHHS Infant Safe Sleep Program will continue to develop and disseminate tools for providers to have effective, non-judgmental, and culturally-sensitive conversations about safe sleep. This includes providers who work with pregnant and parenting families in programs that reach those populations including home visiting, WIC, child care, child welfare, CPS, and prenatal care. Staff at state and local levels will continue to provide training to these provider groups at state and local events. An online safe sleep training for providers working with families (formerly called Infant Safe Sleep for Health Care Providers but renamed Infant Safe Sleep for Professionals Working with Families) will continue to be available, offering continuing education credits for social workers, nurses and certified health educators. A second online safe sleep training will also continue to be available and is a required training for child care providers licensed by the Department of Licensing and Regulatory Affairs.

A focus for FY 2020 is to continue to promote the Helping Families Practice Infant Safe Sleep (Safe Sleep 201) training for home visitors and child welfare workers that will be launched (in person and online) in FY 2019 and a three-part motivational interviewing and safe sleep webinar series also released in FY 2018. The objectives of these trainings are to address how to have more effective conversations with families around safe sleep, start where the family is at to address the challenges families face in following the guidelines, and reduce the risks in the sleep environment while educating families that following the AAP recommendations is the safest way for baby to sleep. In addition, starting where the family is at and listening to a family’s voice on their situation, as the Safe Sleep 201 training promotes, supports using a health equity lens when having conversations with families.

In FY 2019, a new ESM was implemented to increase the number of Maternal Infant Health Program (MIHP) agencies that have staff trained to use motivational interviewing with safe sleep. However, the ESM will be changed to require the Helping Families Practice Infant Safe Sleep (Safe Sleep 201) training instead of the three-part motivational interviewing and safe sleep webinar series. The change was for several reasons: 1) the Safe Sleep Safe Sleep 201 training is based on the principals of motivational interviewing; 2) it is offered online and in-person; and 3) the online version is interactive, closed captioned, and connected to Learning Management System to document completion of the course. Increased skills by MIHP providers on how to have more effective conversations with families around safe sleep will increase the likelihood that families will follow the safe sleep guidelines. MIHP agencies serve approximately 20,000 pregnant moms and 13,000 infants on Medicaid annually. Targeting MIHP providers allows the most high-risk mothers and families to be reached.

Support for professionals will also be continued through the email list for professionals working with families around the issue of infant safe sleep and the quarterly webinars that were established in FY 2017.

The final strategy for this objective is to support promotion of protective factors related to infant safe sleep (i.e., smoking cessation, breastfeeding, immunizations). Outreach to other MDHHS programs that will be continued in FY 2020 include Medicaid Health Plans (to help ensure prenatal care), MDHHS Immunizations (to help ensure infants are immunized), WIC and MDHHS Breastfeeding (to ensure breastfeeding is supported), and MDHHS Tobacco (to help reduce smoking among pregnant mothers and families).

Work that started in FY 2017/2018 to support the number of local health departments implementing the Society for Public Health Education (SOPHE) Smoking Cessation and Reduction in Pregnancy Treatment (SCRIPT) Program will be continued. The MDHHS Infant Safe Sleep Program will continue activities such as provide/participate in a quarterly call to support local health departments implementing SOPHE SCRIPT; connect with MDHHS Tobacco to ensure the appropriate supports for tobacco dependence treatment are in place; and provide support as needed and as feasible to help health departments obtain training and implement SOPHE SCRIPT or other tobacco dependence treatment programs.

Family input is another component of program activities. One parent regularly attends quarterly meetings of the Michigan Infant Safe Sleep State Advisory Committee and several others are active promoters of infant safe sleep in their communities. Parents are on the distribution list for the meetings and/or are in contact with the MDHHS Infant Safe Sleep Program about their interest in becoming involved. It is hoped that family/parent involvement will be expanded in FY 2020, and staff will be able to provide the necessary supports to increase this important aspect of the program. The Infant Safe Sleep Program plans to utilize the MIHEIP Ambassador Program to gain more family input and extend the program’s reach.

Objective C: Reduce the gap between non-Hispanic white women and non-Hispanic black women in following safe sleep guidelines by 2020.

The intended outcome of reducing the gap between non-Hispanic white women and non-Hispanic black women in following safe sleep guidelines is to reduce the unacceptable racial disparity that exists in sleep-related infant deaths in Michigan. Starting with birth year 2016, Michigan began using the phase 8 PRAMS questionnaire that has updated language on some sleep measures. Because of this change, we can report disparity gaps in all the performance measures but cannot make direct comparisons to past years of survey data (2015 and back). The current disparity rates are noted in the introduction to this section. Changes will be tracked over time as more data are collected using the new phase of PRAMS in subsequent years.

Each strategy noted above for Objectives A and B will integrate the need to address health equity and racial disparities. Approaches will vary but may involve allocating more resources to areas that experience greater racial disparity and gaining a better understanding of messages and methodologies that may be more effective with different racial or ethnic groups. In addition to the approaches integrated with the strategies above, additional strategies will be implemented in FY 2020.

The first strategy is to provide training and support to LHDs on health equity. In FY 2018, a training session on health equity was provided to the LHDs that received mini-grant funds. Continued training, technical assistance and support is planned for FY 2019 and beyond, not only from the MDHHS Infant Safe Sleep Program, but also from the MDHHS Health Disparities Reduction and Minority Health Section. The second strategy is to dedicate at least one infant safe sleep webinar annually to the topic of health equity. The challenge in this strategy is to provide webinars that educate participants on health equity but also provide strategies they can use in their work. The third strategy is to send at least one message on the topic of health equity via the Infant Safe Sleep for Professionals listserv per quarter.

[1] All data are from the MDHHS Division of Vital Records and Health Statistics (accessed March 15, 2019).

[2] MDHHS Division of Vital Records and Health Statistics

[3] Opioid use and opioid use disorder in pregnancy. Committee Opinion No. 711. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017;130: e81–94