1. Samantha Sileno, CHES
Cathy L. Costa, MSW, MPH
Bureau of Maternal and Child Health
Baltimore City Health Department
The Safe Sleep Profile: Using Data to
Reduce Sleep-Related Infant Deaths in
Baltimore City
3. Baltimore City
622,000 residents
63% African American
28% White
5% Latino
3% Asian
1% Other
1/3 of households live below the
poverty line and have an income
less than $25,000/year
4. Baltimore City Infant Mortality
Rate (IMR), 2009
13.5 deaths per 1,000 live births
African American: 18.5 per 1,000
White: 3.5 per 1,000
Highest IMR in Maryland
4th highest IMR in the United States
More than 10 babies per month
5. Causes of Infant Death 2006–2009
44.9%
15.0%
5.9%
3.7%
2.7%
30.5%
Sleep Environment-Related
Congenital Anomalies
Accidents
Respiratory Infections
Homicides
Other
27.2%
15.6%
12.4%
11.0%
4.3%
4.1%
25.4%
Preterm/Low Birthweight
Sleep Environment-Related
Congenital Anomalies
Maternal Complications
Placenta, Cord, & Membrane Complications
Bacterial Sepsis
Other
All Infant Death Postneonatal Death
7. B’more for Healthy Babies Launch
10-year citywide infant mortality strategy
Coalition building across sectors
Coordination of efforts
Evidence-based, data-driven interventions
Major supporters
Office of the Mayor
Baltimore City Health Department
Family League of Baltimore City
CareFirst BlueCross Blue Shield
100+ partner organizations citywide
Broad support from foundations and city agencies
8. BHB Goals
Reductions in top 3 causes of infant mortality:
Preterm birth
Low birthweight
Sleep-related deaths
Improved life course outcomes:
Advocacy for self and family in health care setting
Self-efficacy for sustaining behavior change in the home
Family literacy as a way to increase income, quality of life
Resiliency in the face of adversity and trauma
9. BHB Conceptual Model
Policies and
Systems
Community
Mobilization
Mass Media
Improved
Triage
Increased
Coordination
Exposure to
Standardized
Messages
Increased
identification
of women at
risk
Improved
Referral
Ideational
factors
Increased Use of
Quality High
Impact Services
Improved
Behaviors
Improved
Birth and Life
Course
Outcomes
Service
Provider
Outreach
Project Outputs Short-Term Outcomes
Intermediate
Outcomes
Long-Term
Outcomes
10. B’more for
Healthy Babies
Co-Leaders:
Rebecca Dineen
(BCHD) & Gena
O’Keefe (FLBC)
Fetal-Infant Mortality Review
Child Fatality Review
Cathy Costa (BCHD)
Upton/Druid Heights
Patterson Park N&E
BabyStat Home Visiting Collaborative
Sharon Rumber (BCHD)
& Laura Latta (FLBC)
Communications Team
Johns Hopkins University
Center for Communication Programs
Evaluation and Data Team
Carson Research Consulting
& Jana Goins (BCHD)
Senior Medical Advisor
Stephanie Regenold (BCHD)
Task Forces
Safe Sleep
B’more Fit for Healthy Babies
Family Literacy
Teen Pregnancy Prevention
Substance Abuse
Provider Outreach
Trauma-Informed Care
Equity in Birth Outcomes
Baby Basics
Steering
Committee
(Office of
the Mayor)
BHB Organizational Structure
12. Child Fatality Review Data in the
Safe Sleep Profile
Yearly sleep-related death
mortality counts and rates
Age of mother
Age and sex of infant
Gestational age and birth weight
Number of siblings
Agency contact—social service,
home visiting, school, juvenile
justice, mental health, and
substance abuse systems
Sleep environment—
position, crib use, co-
sleeping, bedding
Prenatal and secondhand
smoke exposure
Supervisor at time of death
Day of week
Hospital of birth
13. Sleep-Related Infant Death:
Sleep Environment
13
19 20
12
17 19 19
26
14 14 14 16
12
3
1
2
2
4
1
2 1
1
1
0
5
10
15
20
25
30
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
NumberofDeaths
Unexpected Infant Deaths that Occurred During Sleep:
Cases Reviewed by Baltimore City Child Fatality Review
2002-2014
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.
15. Sleep-Related Infant Deaths in Baltimore City by
Age of Infant 2009–2014 (N=102)
10%
62%
23%
6%
Less than 1 month 1–3 months 4–6 months 7–12 months
0%
10%
20%
30%
40%
50%
60%
70%
PercentageofallSRIDs
Age
16. Sleep-Related Infant Deaths in Baltimore City by
Gestational Age at Birth, 2012–2014 (N=44)
Gestational Age
PercentageofSRIDs
17. Sleep-Related Infant Deaths in Baltimore City by
Maternal Age 2009–2014 (N=102)
17%
39%
24%
13%
8%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
15-19 years 20-24 years 25-29 years 30-34 years 35+ years
18. Sleep-Related Infant Deaths in Baltimore City by
Infant Siblings 2009–2014 (N=102)
17%
35%
31%
13%
3%
0%
5%
10%
15%
20%
25%
30%
35%
40%
0 1 2-3 4+ Unknown
Number of Siblings
19. Sleep-Related Infant Deaths in Baltimore City
Supervisor at Time of Incident by Year
2009–2014 (N= 102)
0%
10%
20%
30%
40%
50%
60%
70%
80%
Mother Father/Partner Grandparent Other
2009
2010
2011
2012
2013
2014
20. Sleep-Related Infant Deaths in Baltimore City by
Unsafe Sleep Environment Factor
2009-2014 (N=102)
.
81%
72%
44%
57%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Sleeping outside
crib/bassinet
Bed-sharing Not on back Unsafe bedding/toys
Unsafe Sleep Environment Factor
21. Sleep-Related Infant Deaths in Baltimore City by
Crib Use 2009–2014 (N=102)
19%
41%
22%
19%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Crib in home and being
used
Crib in home but not
being used
No crib in home Unknown
Crib Use
22. Sleep-Related Infant Deaths in Baltimore City by Reported
Tobacco Smoke Exposure
2010–2014 (N=75)
56%
53%
48%
44%
46%
48%
50%
52%
54%
56%
58%
Prenatal exposure (mother smoked
during pregnancy)
Postnatal exposure (secondhand
smoke at home)
Both pre- and postnatal exposure
Smoke Exposure
23. Sleep-Related Infant Deaths in Baltimore City by
Agency Contact 2012–2014 (n=43)
Agency Contact 2012
(n=14)
2013
(n=17)
2014
(n=13)
Primary caregiver had history of maltreatment as victim
with CPS
4 5 3
Primary caregiver had history of maltreatment as
perpetrator with CPS
2 9 4
Finding of substantiated abuse or neglect related to the
death by CPS
1 1 2
Previous substantiated abuse or neglect of baby 1 2 0
Caregiver known to BMHS (BHSB) 7 9 7
Caregiver known to BSAS (BHSB) 1 3 2
Post-loss contact made by HCAM 7 3 8
Prenatal Risk Assessment received by HCAM 10 6 5
Mother had Medical Assistance 12 11 11
25. SLEEP SAFE’s First Five Years
• Over 4,000 providers from 220 venues
received safe sleep training
• 1,800 visitors to the safe sleep toolkit
• April 2014 Safe Sleep Summit for hospital
providers
• All birthing hospitals show the safe sleep
video with 95% of 2014 nurse home
visiting clients reporting seeing the video
prior to postpartum discharge
26. SLEEP SAFE: Phase I
Mass media campaign
Social marketing
Video
Community outreach and saturation of messaging
Provider training and toolkit
Policy and systems interventions
Mayoral proclamation
Hospital policies/MOUs
Portable crib program
27. Bus and bus shelter ads
Billboards
Flyers, posters, door hangers, rack
cards, magnets, onesies
Radio spots
News coverage on TV and radio
SLEEP SAFE Social Marketing
28.
29. SLEEP SAFE Video
All eight city birthing hospitals
to postpartum mothers
Waiting areas in clinics, WIC,
and Department of Social
Services
Home visiting 1:1
Jury duty
Central booking
Community saturation
31. Videos and discussion guides
Patient materials
Training and CMEs
Grand rounds
Rattle ‘n’ Roll!
Provider Training & Toolkit (cont.)
32. Established single point of entry for triaging all
pregnant women
Provide in-home safe sleep education and crib set
up
Links to other services (home visiting, car seats,
WIC, Medicaid enrollment, etc.)
Portable Crib Program
33. SLEEP SAFE: Phase II
Smoking campaign—JUST HOLD OFF
Focus on fathers—primary cargivers in 25% of
sleep-related infant deaths, 2010-2012
Focus on grandmothers—key influencers and
often present
Focus on Spanish-speaking families
40. Cathy L. Costa, MSW, MPH
Infant Mortality and Child Fatality
Review Director
Bureau of Maternal & Child Health
Baltimore City Health Department
cathy.costa2@baltimorecity.gov
410-396-1562
Thank You! SLEEP SAFE
Samantha Sileno, CHES
Centers for Disease Control and
Prevention Public Health Associate
Bureau of Maternal & Child Health
Baltimore City Health Department
ypl0@cdc.gov
410-396-1567
41. Contact Information
Cathy L. Costa, MSW, MPH
Infant Mortality and Child Fatality Review Director
Bureau of Maternal & Child Health
Baltimore City Health Department
cathy.costa2@baltimorecity.gov
410-396-1562
Samantha Sileno, CHES
Public Health Associate, CDC
Bureau of Maternal & Child Health
Baltimore City Health Department
samantha.sileno@baltimorecity.gov
410-396-1567
Editor's Notes
There are several reasons why we believe that a theory-based approach to evaluation is important. First, the theory helps us to identify what we need to be tracking. Second, it broadens our measure of success beyond the long-term measures. Third, because the theory explicitly links project activities to the outcomes, it helps us to attribute improvements in the outcomes to the project activities. Finally, it provides us with a more detailed understanding of how the project worked.
Let me explain our understanding of this project’s theory and, using it, explain the point’s from the previous slide. EXPLAIN MODEL BY WORKING BACKWARDS.
Address each high impact area using an integrated model of policy, service, community, and individual behavior change:
Policy: improved access to services; standardized messaging
Services: Improved screening/referrals/counseling on key topics
Community: Outreach to link women to services and create healthier social norms; community-based programs to provide support
Individual: Behavior change resulting from improved policy environment and services & community and family supports
Over 2009–2014, 72% of SRIDs were to infants 3 months or younger. 6% of SRIDs have been to infants 7 months or older.
Over 2012–2014, 42% were born less than full term (less than 39 weeks).
Later term 41-42
Term 39-40
Post term->42
Early term 37-38
Preterm 32-37
Very preterm 28-32
Over 2009–2014, 56% of SRIDs (54 of 89 cases) were to mothers 24 years old and younger, compared with 42% of all births being to mothers 24 years old and younger.
Over 2009–2014, ~80% of SRIDs have been to mothers with 1 or more previous children.
Over 2009–2014, 81% of confirmed SRIDs occurred while sleeping outside crib/bassinet; overall. 72% occurred while bed-sharing. In 44% the infant was not on his/her back. In 57%, there was unsafe bedding/toys.
Note: Sleep position and unsafe bedding/toys was not consistently recorded for 2009 SRIDs; the 2009 cases (27) were not included.
Over 2009–2014, 19% confirmed SRIDs occurred while sleeping in a crib/bassinet. 41% occurred where a crib was present but not being used. 22% occurred in homes without a crib. In 19% of cases it was unknown whether a crib was in the home.
Over 2010–2014, in 56% of confirmed SRIDs, mothers smoked during pregnancy; in 53%, the infant was exposed to secondhand smoke; and in 48%, both were reported.
Emphasis on prenatal safe sleep education
Standardized hospital protocol for postpartum education, parent contract
Safe sleep education prior to NICU discharge
Early pediatric visit (2-4 days of life)
Keep providers informed
This clinic poster is one of several materials developed under the campaign.
