Breastfeeding (FY 2025 Application)

The American Academy of Pediatrics (AAP) recommends all infants are exclusively breastfed for six months to support optimal growth and development. Additionally, in 2022 the AAP published updated guidance supporting continued breastfeeding for two years or beyond, as long as mutually desired by mother and child. Breastfeeding has health benefits for infants and mothers, including significant benefits to the mental health of both mothers and babies. For infants, breastfeeding reduces risk of asthma, obesity, sudden infant death syndrome (SIDS), diabetes, ear infections, childhood leukemia, and some respiratory diseases. For mothers, breastfeeding can reduce feelings of anxiety and postnatal depression, reduce post-partum hemorrhage, and decrease the likelihood of developing breast, uterine and ovarian cancers. Human milk remains the optimal source of nutrition for the first months of life.

The Title V needs assessment revealed that breastfeeding is a critical maternal and child health (MCH) issue for Michigan’s mothers and infants. Needs assessment themes showed that families want more breastfeeding support and education and that families are having difficulty accessing breastfeeding support professionals and providers that support breastfeeding. During the Title V needs assessment, stakeholders identified the priority need to “create and enhance support systems that empower families, protect and strengthen family relationships, promote care for self and children, and connect families to their communities” as a way to achieve breastfeeding initiation and duration. The COVID-19 pandemic highlighted the need to ensure that emergency preparedness plans support access to human milk, especially in Black, Indigenous, and People of Color (BIPOC) communities that have been disproportionately impacted by COVID-19. MDHHS will continue to identify opportunities to expand collaboration with BIPOC-led organizations and communities that lead in addressing this health equity work, especially in relation to dismantling barriers to breastfeeding.

According to the National Immunization Survey (NIS), in 2020 Michigan’s initiation rate was 82.8% (CI 76.4-87.7). This meets the annual objective set of 82.7%. Michigan’s breastfeeding exclusivity rate through six months was 23.9%, and Michigan’s goal is to reach 41.1% by 2025.

Data from the Michigan Pregnancy Risk Assessment Monitoring System (MI PRAMS) can help inform Michigan’s strategies to reach its breastfeeding-related goals for Title V. PRAMS data through the 2021 birth year continue to tell a story of relatively static rates of initiation (88.4%), as well as 1-month (76.3%), 2-month (67.0%), and 3-month (56.9%) breastfeeding duration. PRAMS has shown that Michigan’s initiation rate had increased steadily from 2009 to 2014, rising from 73.2% to 84.3%. However, from 2014 through 2021, there has been a leveling out in breastfeeding initiation, with no significant increase nor decrease seen across these years. It is possible that 2021 initiation numbers (88.4%) reflect the start of an increase in initiation at the state level, but this cannot be determined reliably from a single year of data.

Across a time period where breastfeeding statistics have remained relatively static in Michigan (2016-2021), about nine in ten non-Hispanic white mothers initiated breastfeeding (88.5%; 95% CI: 87.3%-89.6%). Initiation was comparable for Hispanic mothers (87.8%; 95% CI: 83.6%-91.1%) and those in the non-Hispanic "Other" category (87.3%; 95% CI: 80.4%-92.0%), yet relatively lower for non-Hispanic Black mothers (75.1%; 95% CI: 73.7%-76.6%). Mothers from the non-Hispanic Asian and Pacific Islander subgroup had the highest proportion who initiated breastfeeding (95.6%; 95% CI: 90.8%-97.9%). By incorporating birth certificate information on maternal ancestry categories and also looking at paternal race/ethnicity/ancestry, we are able to describe two other groups. Initiation among mothers of Infants with Native American/American Indian/Alaskan Native ancestry was high, at 93.7% (95% CI: 88.5%-96.6%). The final group can likely only be found at sufficient numbers (for data analysis) in Michigan, which is mothers of infants with Middle Eastern/North African ancestry. Among these mothers, initiation was also high at 92.7% (95% CI: 88.5%-95.4%).

The Title V state action plan continues to focus on reducing disparities in breastfeeding rates among women of color. In alignment with the plan, MDHHS has continued to prioritize using culturally responsive, evidence-based images and messages within public health campaigns to support the normalization of breastfeeding. Action plan strategies focus on increasing breastfeeding knowledge among maternal and infant health professionals who work with pregnant or postpartum women; offering free breastfeeding educational opportunities statewide through a webinar series and online breastfeeding training course; supporting and promoting access to breastfeeding support resources; normalizing breastfeeding in culturally responsive ways; and promoting community-driven resources that address common breastfeeding barriers. The evidence continues to support that babies born in Baby-Friendly designated hospitals are more likely to be breastfed. Therefore, increasing the percent of Baby-Friendly hospitals in Michigan remains the Evidence-based Strategy Measure (ESM) for this NPM. Title V funding supports breastfeeding promotion efforts, including social media activities.

Objective A: Increase the percent of infants who are breastfed exclusively until 6 months to 41.1% by 2025.

The first strategy is to provide MDHHS Maternal Infant Health (MIH) staff with an appropriate level of breastfeeding education. The free online course “Breastfeeding for Professionals Working with Families” was released in June 2023 and serves as a key resource to increase MIH staff knowledge on the health benefits of breastfeeding to parents and infants; common barriers to breastfeeding; root causes of breastfeeding disparities among racial and ethnic groups; information to support consistent messaging about breastfeeding; and community-based, culturally responsive breastfeeding resources to support both Michigan families and professionals. The training also discusses how to have honest and non-judgmental conversations about risk reduction strategies for safe sleep. This strategy, in tandem with the next two strategies, will help to achieve the state priority need by enhancing support systems that empower families, promote care for self and child, and connect families to resources in their communities. It also supports the strategy of promoting breastfeeding across programs within MDHHS. In 2025, this breastfeeding course will continue to be promoted to MCH professionals and partner agencies across the state. Going forward, the breastfeeding course will be updated as needed to reflect current guidance and recommendations.

Evidence demonstrates access to professional and peer support can increase breastfeeding duration. For the second strategy, MDHHS will continue to promote increased access to breastfeeding support professionals and peer counseling services in programs serving families. MDHHS will promote sources of breastfeeding support and disseminate the information to maternal and infant health programs and other partners through multiple communication modalities (e.g., newsletters, listservs, social media).

The third strategy, increase the percent of Baby-Friendly Hospitals in Michigan from 16% to 18%, is Michigan’s ESM for this NPM. Activities will focus on continuing to leverage and develop partnerships with organizations that promote and support hospitals’ ability to achieve and maintain Baby-Friendly designation. MDHHS will continue to encourage the benefits of Baby-Friendly designation and maintaining Baby-Friendly standards beyond designation through routine data collection, monitoring of practices, and quality improvement activities, which can support breastfeeding duration. In 2023, MDHHS worked with a community partner to develop a two-page resource that shared information about opportunities to support Michigan hospitals in achieving and maintaining the Baby-Friendly designation. This resource will continue to be promoted widely in FY 2025. Breastfeeding content will be included at the 2025 Maternal Infant Health Summit, which is broadly attended by MIH professionals, including hospital and clinic staff. Additionally, MDHHS will recognize hospitals that adopt breastfeeding-supportive maternity care and infant feeding as best practices. Michigan hospitals’ response to the COVID-19 pandemic has continued to place incredible strain on hospital resources in recent years and has impacted their ability to meet and/or maintain the Baby Friendly USA standards.

Objective B: To impact breastfeeding disparity, increase percent of non-Hispanic black women who initiate breastfeeding from 74.4% to 78.4% by 2025.

Disparities in breastfeeding initiation rates persist and this objective seeks to achieve more equitable health outcomes by addressing this disparity. PRAMS data will be used to measure and track the objective. The first strategy is to support training opportunities that improve the racial and cultural diversity of breastfeeding professionals. One example is the Great Lakes Breastfeeding Webinar Series hosted by the Michigan Breastfeeding Network. This webinar series provides monthly on-demand online training opportunities for professionals who serve families, at no cost to participants. The Michigan Breastfeeding Network has expanded the types of continuing education offered through the webinars and now provides contact hours for nurses, social workers, lactation consultants, community health workers, certified health education specialists, physicians, and dietitians. In 2025, it is expected that the webinars will continue to be hosted through an online learning platform that provides instant access to continuing education certificates after completion of the post-webinar evaluation. Not only do the webinars remove barriers such as travel and cost, but webinar topics have an intentional health equity focus.

The second strategy is to promote breastfeeding promotion campaigns to normalize breastfeeding in culturally responsive ways. At a minimum, in FY 2025 social media messages promoting breastfeeding will be identified and used on MDHHS social media channels. These social media messages will aim to integrate community voice by reflecting the input and preferences shared by community-based organizations. MDHHS will also work with partners to recognize observances such as, but not limited to, Breastfeeding Awareness Month, Indigenous Milk Medicine Week, Black Breastfeeding Week, and Asian American, Native Hawaiian and Pacific Islander Breastfeeding Week. Through non-Title V funding sources, MDHHS will also continue to work with the Genesee County Health Department to increase breastfeeding rates within the City of Flint and Genesee County. Past work with Genesee County has supported efforts to develop breastfeeding education animated “shorts” and print materials using evidence-informed curriculum to provide tailored breastfeeding education via social media and local advertising.

The final strategy will be to promote breastfeeding educational resources that focus on common breastfeeding barriers at the dyad. Resources were developed through a partnership with local BIPOC-led breastfeeding support organizations to address latch, milk supply, and pain, which were identified through PRAMS data as top reasons for stopping breastfeeding. The content in these resources was determined by community organizations and the families they serve to better address the needs of families. These resources will continue to be promoted widely with Maternal and Infant Health partners for statewide use.

Safe Sleep (FY 2025 Application)

Infant deaths from sleep-related causes continue to be a persistent concern. The Title V NPM for safe sleep is linked to Michigan’s state priority need to “create and enhance support systems that empower families, protect and strengthen family relationships, promote care for self and children, and connect families to their communities.” The MDHHS Infant Safe Sleep Program (ISS Program) is housed in the Division of Maternal and Infant Health and provides training, technical assistance, and resources to professionals and families in Michigan. It also oversees ISS grants to local agencies.

In Michigan, sudden unexpected infant deaths (SUID) are a leading type of death for infants 1-12 months old (2020-2022 Michigan Resident Infant Death File, Division for Vital Records & Health Statistics, MDHHS), with suffocation being the most common cause of SUID. Statewide 1.3 sleep-related infant deaths occur per 1,000 live births [Centers for Disease Control and Prevention (CDC) Sudden Unexpected Infant Death (SUID) Case Registry – 2010-2021, Michigan Public Health Institute (MPHI), 2023] and there is no clear trend showing either an increase or a decrease in the state rate. Rates across the state vary widely, with some jurisdictions experiencing rates as high as 3.5 and some as low as 0.6 (CDC SUID Case Registry – 2010 to 2021, MPHI, 2023).

Significant racial disparities exist among sleep-related infant deaths. In Michigan, non-Hispanic Black (NHB) infants are 4.0 times more likely to die of sleep-related causes than non-Hispanic white (NHW) infants. Compared to NHW infants, American Indian infants are 2.6 times more likely to die of sleep-related causes (CDC SUID Case Registry – 2010 to 2021, MPHI, 2023).

Additionally, data show infants born preterm and low birth weight babies are also at increased risk for sleep-related infant deaths. Pre-term infants experience a sleep-related infant death rate 2.5 times higher than infants born at 37 weeks or greater gestation. Moreover, infants born with low birth weight have a 3.1 times greater risk of dying due to sleep-related causes as compared to infants with a birth weight of 2,500 grams or higher (CDC SUID Case Registry – 2010 to 2021, MPHI, 2022).

Most sleep-related infant deaths are preventable with safe sleep practices. Data from the Michigan Pregnancy Risk Assessment Monitoring Survey (PRAMS) often take several years to reach statistically significant change. Since 2016, there has been a clear and sustained improvement in back sleeping in Michigan since that time (81.9% in 2016 to 86.5% in 2021). About 2/3 of Michigan mothers in 2021 report that their infants were usually placed to sleep in a space without soft or loose bedding or objects (64.1%). As with back sleeping, this measure has shown sustained improvement since 2016 (51.8%). Across the last three years, the measure of a separate approved sleep surface has been somewhat resistant to change, remaining just above 40% (41.3% in 2021), but this remains an improvement from 2016 (34.0%).  As this single performance measure is a composite of five different component measures, Michigan will be taking a closer look at all five components (infant always or often sleeps alone; sleeps in a crib; does not sleep on a couch or sofa; does not sleep in a car seat or swing; does not sleep on a twin or larger mattress) to see where future improvements may be found. Michigan has seen a notable and sustained improvement in the proportion of mothers who are not sleeping their infants in car seats or swings (from 47.4% in 2016 to 56.9% in 2021), but smaller year-by-year changes in other components seem to be offsetting changes in the composite measure.

Data show that the behaviors described above do impact deaths. One example is when looking at sleep location. According to the CDC SUID Case Registry, three in four (74.7%) sleep-related infant deaths in Michigan occurred in an unsafe sleep location, including adult beds (49.9%) and couches or chairs (14.1%). Only 22.2% of infants who died of sleep-related causes were placed to sleep in a crib, bassinet, or portable crib. Of the infants who die of sleep-related causes in Michigan, 57.5% of deaths occur while an infant is sharing a sleep surface with an adult(s), another child(ren), and/or an animal(s) (CDC SUID Case Registry – 2010 to 2021, MPHI, 2023).

The disparity gap in back sleeping was relatively constant through 2014. Starting in 2014, a seven-year period was observed in which back sleeping remained statistically unchanged among Black mothers. In combination with modest improvements among white mothers, this has resulted in a widening disparity gap for back sleep. According to 2021 PRAMS data, there is a disparity gap of 19.8% for the behavior of infants usually being placed to sleep on their backs between Non-Hispanic white (NHW) and Non-Hispanic Black (NHB) individuals , 91.3% and 71.5%, respectively. There are also growing and/or persistent disparities in some safe-sleep performance measures that have just recently become clear upon examination of the 2020 and 2021 PRAMS data. In 2016, the proportions of NHW and NHB mothers sleeping their infants on separate approved surfaces and in spaces without loose objects or bedding were about equivalent. A single digit disparity gap opened in 2017-2018 and grew to double digits for each measure by 2020. Now, in 2021, there remains a 16.1% disparity gap of infants being put to sleep without soft objects or loose bedding (68.8% for NHW as compared to 52.7% for NHB). NHW mothers also reported a higher proportion of infants sleeping on a separate approved sleep surface (44.0% for NHW compared to 38.7% for NHB; disparity gap 5.3%) which is close to the average disparity gap (6.0%) seen for this measure across 2016-2021. These disparities all reached statistical significance.

However, the difference in sleep behaviors by NHW and NHB infants does not account for all differences in sleep-related infant death rates between the two groups. It is important to note that social determinants of health (SDOH) and systemic policies and practices rooted in racism and oppression drive these disparities and interfere with a family’s ability to practice infant safe sleep behaviors and ultimately to achieve optimal health.

Objective A: Increase the percent of infants put to sleep on their backs from 84.9% in 2019 to 92.3% by 2025.

Objective B: Increase the percent of infants put to sleep on a separate approved sleep surface from 40.6% in 2019 to 53.5% by 2025.

Objective C: Increase the percent of infants placed to sleep without soft objects or loose bedding from 63.1% in 2019 to 80.9% by 2025.

Objective D: Increase the percent of non-Hispanic Black infants put to sleep on their backs, put to sleep on a separate approved sleep surface, and put to sleep without soft objects or loose bedding.

The strategies to address Michigan’s safe sleep objectives are combined and will promote key messages to parents, caregivers, and providers: infant sleeps on the back, alone and without objects in a crib, bassinet or pack and play. Activities will be designed to increase the behaviors by all families, while focusing specifically on decreasing the disparity for NHB families and other historically disadvantaged groups including American Indians.

The first strategy is to support safe sleep activities of Local Health departments (LHDs) and the Inter-Tribal Council of Michigan (ITC) by offering grants to increase the capacity of those communities to implement infant safe sleep education, awareness, and outreach activities, with a focus on populations within their jurisdiction that experience high rates of sleep-related infant death and disparity. In FY 2025, five LHDs and ITC will be offered grants. The jurisdictions served by the five LHDs account for 51% of the sleep-related infant deaths in Michigan and all experience significant racial disparities among the deaths. Grantees, as experts in their own communities, are given the latitude to design, direct and conduct their work.

As SDOH are known to contribute to infant outcomes, the grantees will be asked to explore how to address SDOH impacting families they serve and to consider how to address upstream causes of disparity. As part of grant requirements, grantees will continue to be required to have an advisory team to guide their work. That advisory team will be required to include members that can address SDOH. In addition, grantees will continue to be required to include community members on their advisory team. Grantees will be asked to document their efforts obtaining input and feedback from families.

Since 2020, the COVID-19 pandemic has changed how LHDs and ITC conduct safe sleep activities. They had to be creative in overcoming the challenges the pandemic presented and many of their solutions have remained a permanent part of their programming, such as continuing to offer virtual options for events. They will be encouraged to continue to be creative in their efforts to meet program objectives.

The second strategy is to continue to support agencies in implementing and/or updating existing safe sleep policies or protocols so that families interacting with those agencies receive up-to-date infant safe sleep education; have access to tangible resources for safe sleep; and are given referrals to supportive programs such as home visiting, WIC and lactation support. The support to agencies will continue to be customized to fit their needs and will include access to recommendations that outline how agencies serving families can support infant safe sleep. Success at connecting with agencies in the last several years has been challenging, particularly due to other competing program needs. The ISS Program will continue to recruit agencies, including agencies serving historically marginalized and underserved populations. ISS Program staff will continue to provide support to other federal and state programs including the Maternal Infant Health Program (MIHP), the Maternal, Infant, and Early Childhood Home Visiting program (MIECHV), and WIC to support and enhance infant safe sleep education and awareness with staff and clients. The ESM tied to this strategy will continue to count the number of agencies supported and provided technical assistance in implementing or updating a policy.

The third strategy is to provide education and share tools with providers on how SDOH impact safe sleep and how to have client/patient centered conversations regarding safe sleep. This includes trainings (i.e., virtual, online and in-person) for providers who work with pregnant and parenting families in programs such as home visiting, WIC, childcare, child welfare, CPS, emergency medical services and prenatal care. In FY 2025, motivational interviewing concepts and risk reduction techniques will continue to be included in trainings conducted with professionals who work with families. The trainings help professionals better understand the challenges a family may face in following the guidelines by having honest and open conversations; equip professionals to help the family evaluate their current risk and explore strategies for risk reduction; and identify needed supports. The ESM to require all new MIHP staff to take the online Helping Families Practice Infant Safe Sleep training will continue in FY 2025. In FY 2023, MIHP agencies served approximately 11,300 adults and 14,515 infants on Medicaid. Focusing on MIHP providers allows mothers and families at higher risk to be reached.

In 2022 the ISS program established a partnership with MDHHS Bureau of Emergency Preparedness, EMS and Systems of Care to implement an Infant Safe Sleep Certification Program for EMS Agencies and Fire Departments. The program requires the fire departments and EMS agencies to train providers as well as connect with local safe sleep contacts to access supportive services for families. This program will continue in FY 2025. The High Touch, High Tech (HT2) e-screening tool delivers a brief motivational intervention, notifies the healthcare provider, and helps connect families to additional supports. Its expansion to include screening for safe sleep knowledge and behaviors continues to be available. Opportunities to expand and enhance this project will continue to be explored in FY 2025.

Support for professionals will also be continued through the email listserv and webinars. Resources for infant safe sleep and infant care will continue to be available through the Infant Safe Sleep website and the MDHHS Clearinghouse. Images used in educational materials will continue to reflect the diversity of families in Michigan and most materials are offered in a variety of languages. Other languages will be added as necessary. The ISS Program will continue to explore how to develop safe sleep messaging that resonates with families and can include information about risk reduction.

Another strategy is to provide professionals and families with guidance on protective factors (i.e., smoking cessation, breastfeeding, immunizations) and evidence-based programs (i.e., community-based doula support, home visiting) to enhance the overall health and well-being of moms and babies. Information on protective factors is incorporated into safe sleep messaging and educational materials when possible. In FY 2025, the Infant Safe Sleep and Breastfeeding Programs will continue to integrate their work more closely. Quarterly calls with MDHHS programs such as Immunizations, WIC, Tobacco, and Home Visiting will maintain collaborations that work to infuse infant safe sleep into all aspects of work with families.

The final strategy is to continue to recruit hospitals to work with the Infant Safe Sleep Program to explore ways each hospital can educate and support families of infants, including NICU infants, to support their practice of safe sleep behaviors after discharge. The model hospital policy/procedure document and audit forms will continue to be utilized in this work. The support provided to each hospital will be customized to fit the needs of the hospital. The ESM tied to this strategy will track the number of hospitals that have been supported. A challenge with this ESM is the competing priorities of a hospital setting. Hospital staff invested in safe sleep may not have the administrative support needed to implement changes.