1. 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

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

3. 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.
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4. Infant Mortality Rate (IMR)
National average: 6.86
National range: (Asian & Pacific Islanders) (Non-Hispanic Blacks)
Healthy People 2010 target goal: 4.5
Baltimore
IMR [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

5. 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
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6. 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
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7. 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

8. 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)

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

10. Triple Risk Model SIDS Critical Development Period Outside Vulnerable
-first 6 months of life
SIDS
possible brainstem abnormality-
(Filiano & Kinney, 1994, )
-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

11. 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
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12. 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
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13. Alone Safe Sleep for Infants On my Back In a CribTM The message
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14. Safe Sleep Snap Shirts The vehicle—available in English and Spanish
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15. Safe Sleep Enclosure Card

16. 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
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17. 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
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18. Put in clinic waiting rooms, DSS offices, WIC sites, hospital units, etc

19. 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:
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20. 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
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21. Determined by each distributing agency
Eligibility criteria
Timing of crib delivery (usually 36+ weeks)
Follow up
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22. 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
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23. 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
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24. 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 ,000 cribs/year
Women call about cribs who might not otherwise contact BHCA
In prisons, DS offices—people are aware of the abc’s
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25. 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
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26. 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
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27. Thank you!
Questions??
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