Baltimore City’s Baltimore City’s

Crib ProgramCrib Program A Baltimore City Health Department/First Candle

Partnership

Stephanie Strauss Regenold, MD, MPH

Senior Advisor, Babies Born Healthy Initiative

Bureau of Maternal & Child HealthBaltimore City Health Department

Consultant, First Candle

stephanie.regenold@baltimorecity.gov

stephanie.regenold@firstcandle.org

BaltimoreBaltimore

BaltimoreBaltimore

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

Infant Mortality Rate Infant Mortality Rate (IMR)(IMR)

National average: 6.86 National range: 4.89 (Asian & Pacific Islanders)--

13.63 (Non-Hispanic Blacks) Healthy People 2010 target goal: 4.5

BaltimoreBaltimore IMR 12.8 [ranks 4th highest in the nation] IMR Non-Hispanic Blacks 18.0

PostneonatalPostneonatalInfant Mortality Infant Mortality

RateRate

Death of an infant one month to one year of age

Leading cause nationwide: SIDS

Leading cause in Baltimore: SIDS

Unexpected Infant Unexpected Infant Death During Death During

SleepSleep 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)

Unsafe Sleeping Unsafe Sleeping EnvironmentEnvironment

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)

Unexpected Infant Deaths that Occured During Sleep: Baltimore City, 2002-2008

13

19 20

1217

19 20

3

01

2

2

4 0

0

5

10

15

20

25

2002 2003 2004 2005 2006 2007 2008

Nu

mbe

r of

Dea

ths

Unsafe sleep environment confirmed Unsafe sleep environment not confirmed*

* Deaths for which the evidence did not indicate an unsafe sleep environment, however, data on unsafe sleep risk factors may have been missing or unknown. Baltimore City Health Department analysis of data from cases reviewed by the Baltimore City Child Fatality Review.

Unsafe Sleeping Unsafe Sleeping EnvironmentEnvironment

Identified in 91% of infants dying unexpectedly during sleep:

>75% bedsharing

>75% soft bedding

>60% bedsharing and soft bedding

Triple Risk ModelTriple Risk Model

Critical

Development

Period

Vulnerable

Infant

Outside

Stressors

SIDS -prone/side sleeping-bed sharing-soft bedding-smoke exposure-overheating-infection

-first 6 months of life

possible brainstem abnormality-

(Filiano & Kinney, 1994, 2001)

The ABC’s of Safe The ABC’s of Safe Sleep InitiativeSleep 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

The ABC’s of Safe The ABC’s of Safe Sleep InitiativeSleep 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

Safe Sleep for Safe Sleep for InfantsInfants

Alone

On my Back

In a CribTM

Safe Sleep Safe Sleep Snap ShirtsSnap Shirts

Safe Sleep Safe Sleep Enclosure CardEnclosure Card

Crib DistributionCrib Distribution

Coordinated by the BCHD

Cribs distributed by Baltimore HealthCare Access

and Baltimore City Home Visiting Programs

Baltimore HealthCare Baltimore HealthCare AccessAccess

Maternal & Infant Health Maternal & Infant Health Improvement ProgramImprovement 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.

Baltimore Home Visiting Baltimore Home Visiting Programs for High Risk Programs for High Risk

Pregnant Women & Pregnant Women & InfantsInfants

• 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

Baltimore City Health Baltimore City Health DepartmentDepartmentSafe Sleep Safe Sleep

CoordinatorCoordinator 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

Determined by each Determined by each distributing agencydistributing agency

Eligibility criteria

Timing of crib delivery (usually 36+ weeks)

Follow up

Crib DistributionCrib 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

FundingFunding

Proceeds from sale of infant safe sleep snap shirts nationwide through partnership with First Candle

Donations (local businesses, BHCA)

MCH Title V (budget modifications)

OutcomesOutcomes

>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

EvaluationEvaluation 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 %).

ChallengesChallenges

Sustainability/funding

Equitable distribution of cribs

Effectiveness of “giveaway” program

Need for effective SIDS/SUDI messages

Thank you!Thank you!

Questions??