Baltimore City’s Crib Program A Baltimore City Health Department/First Candle Partnership Stephanie Strauss Regenold, MD, MPH Senior Advisor, Babies Born Healthy Initiative Bureau of Maternal & Child Health Baltimore City Health Department Consultant, First Candle stephanie.regenold@baltimorecity.gov stephanie.regenold@firstcandle.org

Baltimore Map for orientation—east and then up I95 from Charlottesville

Baltimore Population 636,000 [ranks 18th in the nation] 21.5 % below poverty level African Americans comprise 65% of the population; Latinos <3% 9,350 births/year Some background: Population 7/05 US Census Bureau Births BCHD IMR Big Cities Health Inventory: The Health of Urban America 2007, National Association of County and City Health Officials, Benbow, N., editor. Washington, DC, 2007. Model Behavior January 2007

Infant Mortality Rate (IMR) National average: 6.86 National range: 4.89 (Asian & Pacific Islanders)-- 13.63 (Non-Hispanic Blacks) Healthy People 2010 target goal: 4.5 Baltimore IMR 12.8 [ranks 4th highest in the nation] IMR Non-Hispanic Blacks 18.0 National average is for 2005; 6.78 in 2004 Current US rate ~50% higher than the Healthy People’s goal Baltimore is 18th in size, 4th in infant mortality

Postneonatal Infant Mortality Rate Death of an infant one month to one year of age Leading cause nationwide: SIDS Leading cause in Baltimore: SIDS Not only is SIDS the leading cause of postneonatal infant mortality: it is the 3rd leading cause of infant mortality in the nation; 2nd leading cause of infant mortality in Baltimore Model Behavior January 2007 5

Unexpected Infant Death During Sleep Infant (<1 year of age) Cause of Death as determined by Medical Examiner: SIDS, SUDI, or Asphyxia due to overlay ICD-10 Code:--R95 (SIDS) --R99 (other ill-defined and unspecified causes of mortality) -- W75 (accidental suffocation and strangulation in bed) What we did at the health dept with our epidemiologists—looked at all sudden and unexpected infant deaths that occurred during sleep These were the codes—most were determined to be SIDS or SUDI; coded as SIDS Model Behavior January 2007 6

Unsafe Sleeping Environment Bed-sharing—infant sleeping in a bed or couch with another person; or Placing infant to sleep on stomach or side; or Soft bedding, toys, or soft objects under or around the infant during sleep; or, No crib available or improper use of crib; or Smoking in house (never sole risk factor) Then we categorized according to risk

CFR Identified 132 infant deaths that occurred 2002-mid 2008 BCHD epidemiologists looked at sleep related deaths Categorized according to risk—this was the categorization: Infant, SIDS, SUDI, asphyxia, R99 (unspecified); W75 (accidental suffocation and strangulation in bed)

Unsafe Sleeping Environment Identified in 91% of infants dying unexpectedly during sleep: >75% bedsharing >75% soft bedding >60% bedsharing and soft bedding

Triple Risk Model SIDS Critical Development Period Outside Vulnerable -first 6 months of life SIDS possible brainstem abnormality- (Filiano & Kinney, 1994, 2001) -prone/side sleeping -bed sharing -soft bedding -smoke exposure -overheating -infection Outside Stressors Fern’s talk covered: Sudden Infant Death Syndrome (SIDS) is the sudden death of an infant younger than 1 year of age that remains unexplained after a thorough case investigation, including: performance of a complete autopsy examination of the death scene review of the infant’s and family’s clinical histories Vulnerable Infant

The ABC’s of Safe Sleep Initiative In response to Baltimore City’s CFR 2004 Recommendations Partnership between Baltimore City HD and First Candle Developed with grant funding from the Abell Foundation, Babies Born Healthy (DHMH), the CJ Foundation for SIDS and March of Dimes, with in-kind support from First Candle Evolved into partnership Model Behavior January 2007

The ABC’s of Safe Sleep Initiative ABC’s of Safe Sleep logo and message developed by the BCHD and used for educational campaign Sale of infant snap shirts through First Candle Free crib program City-wide educational campaign included radio ads, bus shelter ads, posters, flyers Model Behavior January 2007 12

Alone Safe Sleep for Infants On my Back In a CribTM The message Model Behavior January 2007

Safe Sleep Snap Shirts The vehicle—available in English and Spanish Model Behavior January 2007

Safe Sleep Enclosure Card

Crib Distribution Coordinated by the BCHD Cribs distributed by Baltimore HealthCare Access and Baltimore City Home Visiting Programs First Candle marketed and sold the snap shirts; BCHD used that money Model Behavior January 2007 16

Baltimore HealthCare Access Maternal & Infant Health Improvement Program Serves as the single point of entry for Prenatal Risk Assessments and Infant Identification Forms to identify high-risk pregnant women and infants. Initial outreach services are provided by Family Advocates who refer lower risk women to supportive services including community-based home visiting programs. a non-profit agency of the Baltimore City Health Department created in 1997 in response to State legislation governing the roles of local health departments in the Medicaid Managed Care Program known as HealthChoice. Mission has expanded to include services to special populations such as those in need of Addiction Support, the Homeless, Immigrants, and the uninsured and underinsured. Served as main distributor of cribs—they have since designated a safe sleep coordinator for their agency Model Behavior January 2007 17

Put in clinic waiting rooms, DSS offices, WIC sites, hospital units, etc

Baltimore Home Visiting Programs for High Risk Pregnant Women & Infants Baltimore City Health Department Maternal & Infant Nursing Program Baltimore City Healthy Start Healthy Families Bon Secours BCHD Healthy Homes The Family Tree People’s Community Health Center WORK ON THIS SLIDE—COMPLETE AND PUT DESCRIPTIONS IN THE NOTES Variety of programs and who they serve: Model Behavior January 2007 19

Baltimore City Health Department Safe Sleep Coordinator Tracks number of cribs distributed, number in stock Trains all home visiting advocates in Infant Safe Sleep with yearly updates Develops educational materials for crib recipients Meets monthly with home visiting programs and BHCA Provides inservice training to hospital staff (nurses, physicians, social workers), clinics, public agencies (social services, detention centers), and other organizations Trouble shoots Began as one person—now one is tracking cribs and I am doing trainings Keeps track of cribs Keeps advocates trained—for example, most advocates were teaching about SIDS—we are working on emphasizing safe sleep Sees what is going on with home visiting programs for example, requests came from multiple families in one apartment building Model Behavior January 2007 20

Determined by each distributing agency Eligibility criteria Timing of crib delivery (usually 36+ weeks) Follow up Model Behavior January 2007 21

Crib Distribution Family referred by home visiting program, BHCA triage, or from posters Crib delivered by BHCA Safe Sleep Liaison or by home visiting advocate Crib set up with family member Safe sleep education given/reinforced Receipt of Crib (waiver) signed by receiver Posters in various clinics, hospitals, ed’s Model Behavior January 2007 22

Funding Proceeds from sale of infant safe sleep snap shirts nationwide through partnership with First Candle Donations (local businesses, BHCA) MCH Title V (budget modifications) Snap shirts now smaller percentage of funding source First Candle: national non-profit headquartered in Baltimore Formerly SIDS Alliance Promotes safe pregnancies and the survival of babies through the first years of life Organization supports programs of research, education, advocacy and grief support for families in need Particular focus on reducing the incidence of SIDS, SUID and stillbirth nationally Model Behavior January 2007 23

Outcomes >2,500 cribs distributed since 2006 Better identification of high risk pregnant women Infant safe sleep message recognized in a variety of venues around the city Unsafe sleep recognized as major and preventable cause of infant mortality Distributed about 750-- 1,000 cribs/year Women call about cribs who might not otherwise contact BHCA In prisons, DS offices—people are aware of the abc’s Model Behavior January 2007 24

Evaluation Pre & post test questionnaires at time of crib delivery inconsistent Observational survey by M&I nurses 100 M&I clients—no difference in use of crib between those received by Crib Program and those received privately Very few infant deaths among home visiting program population (<2 %). Ultimately SIDS/SUDI rates Model Behavior January 2007 25

Challenges Sustainability/funding Equitable distribution of cribs Effectiveness of “giveaway” program Need for effective SIDS/SUDI messages Babies are still dying sleep-related deaths INSERT CARTOON BEFORE THIS SLIDE Model Behavior January 2007 26

Thank you! Questions?? Model Behavior January 2007 27