The Safe Baby Program

The Florida Department of Health in Pinellas County (DOH-Pinellas) serves over 975,000 residents in a county situated on the West coast of Florida. DOH-Pinellas offers a range of services, including Clinical Health, School Health, Maternal Child Health and many others. The Maternal Child Health Division includes evidence-based programs such as Healthy Families, Nurse-Family Partnership, WIC (Women, Infants and Children) and Healthy Start. The Public Health Accreditation Board has accredited DOH-Pinellas as part of a statewide integrated health system since 2016. The department prides itself on its many community collaborations and for being a trusted resource for individuals and entities served. Some of the department's community collaborations and partners include Health in All Policies, Foundation for a Healthy St. Petersburg, Healthy Start Coalition of Pinellas County (HSC) and the Juvenile Welfare Board of Pinellas County (JWB). The department's community collaborations assist in enhancing all services provided to Pinellas County's population. In Pinellas County, approximately 83% of the population identifies as White, 11% Black and 10% Hispanic. Approximately 54% of the population is over the age of 45, while only 4% are 0-4yrs of age with the population under 24yrs decreasing by 3% based on the 2010 census. Recent data based on local hospital birth reports show steady declines in birth rates in the county since 2016.

DOH-Pinellas strives to serve a largely aging community while also providing needed services to an increasingly diverse population. For example, health equity has become a lens that the department looks through when creating new programs. This has enhanced conversations throughout the department and, as a result, collaborations have grown and flourished.

Adding the health equity lens to the discussion of infant mortality has highlighted the severity and complexity of addressing the issue.  However, it has also brought an impressive array of community organizations to the table to take a comprehensive approach to this problem.  A 2019 Tampa Bay Times article summarizes that health equity is a key risk factor affecting infant mortality. The article uses direct quotes from the Pinellas County Medical Examiner's Office to report that several risk factors associated with infant mortality, include the infant's gender, race, gestational age and environmental exposures. (Lane DeGregory article, Tampa Bay Times, 12/11/2019).

To address this issue the Juvenile Wellness Board (JWB), a primary funder of the Healthy Families Pinellas program and many other child-centered prevention programs in the county, established the Preventable Deaths Campaign. In reviewing preventable child deaths for the county, it was determined that in the last ten years, 76% of preventable child deaths between 2011-2019 were infant sleep-related, 17% were drowning-related and 7% were a result of inflicted head trauma. Members of the committee identified that families of infants who died before their first birthday were not enrolled in parent education or home visitation programs. It was thought possible to provide the basic education surrounding these topics to parents without the commitment of enrolling and engaging in a program. Further, it was hoped that ensuring all parents in the community receive education and resources to address those three significant causes of child death would decrease the mortality. 

In Pinellas County, 50% of eligible families with infants are enrolled in the Pinellas WIC program.  Since both WIC and Healthy Families are housed in the Maternal Child Health (MCH) Division of DOH-Pinellas, JWB funded an intra-agency collaboration to address the three leading causes of infant deaths in Pinellas County. Three Safe Baby Educators were hired and co-located full-time in three different WIC offices in the county.  Embedded into the WIC process, caregivers are referred to the Safe Baby staff while going through the WIC clinics. Meeting with the Safe Baby staff is a voluntary activity for families.  When they meet with the Safe Baby Educators, they receive educational materials to take home on safe sleep, choosing caregivers and Shaken baby syndrome. Educators meet with families for about 10-15 minutes each. Initial program objectives were to provide education to 2,500 caregivers. In the first year, starting July 2019, educators saw 2,609 caregivers. 

One of the main factors in the success of this program is its simplicity. Educators request minimal information from the caregiver before disseminating educational materials and potentially a Pack ‘n Play.  Time is allotted to the original appointment, so that no additional time needs to be requested for these services. Additionally, this program uses a well-defined, curriculum that is targeted and easy for families to understand.

The three leading causes of infant deaths in the county are unsafe sleep, drowning and intentional head trauma. DOH-Pinellas developed the Safe Baby program to address two of these items, safe sleep and shaken baby syndrome. The target population is prenatal moms and caregivers of infants under the age of 1 year. There were 7,419 births in 2020 and between July 2019 and June 2020, the program provided education on those two topics to 2,609 caregivers. Therefore, DOH-Pinellas provided 32% of caregivers with children under one year with safe sleep education and shaken baby syndrome information. In addition to the other programs that offer similar instruction in the county, we believe that the Safe Baby program has effectively reached the target population of parents and prenatal mothers not enrolled in home visiting parent education programs. Other parent education programs require parents to commit to home visiting or phone calls. These programs can be deemed intrusive by high-risk populations and too time-intensive for busy working families. Homelessness can also be a barrier to active participation in a program. This program seeks to reduce that difficulty.

The same risk factors that increase the risk for infant mortality can also cause a barrier for caregivers who want to obtain resources and enroll in educational programs. Some of these risk factors are systemic, such as areas with high poverty rates, low air quality in both homes and the environment and substance misuse. Additionally, the family culture can be a factor that causes a significant barrier. Going against the advice given by grandmothers and great-grandmothers is often a high mountain to climb.” Parent education programs address these factors over time while building rapport, supporting the family and providing resources for usually 2-5 years. This approach works for families enrolled in long-term home visiting initiatives. However, a review of local infant deaths showed that the infants that died due to unsafe sleep were not enrolled in home visiting parent education programs. This program works by providing targeted education to caregivers and offering Pack ‘n Plays as incentives. Prenatally, and after a baby is born, many entities, including the use of the Healthy Start Infant Risk Screen, hospital staff, Ob/Gyn practices, police and community agencies affirm the same message. What sets Safe Baby apart is that the information is provided to the family when stress levels are low, no buy-in is required and additional information is not requested. Caregivers are not asked about personal risk factors and there is no intrusiveness.   Safe Baby is available to all Pinellas County families. The department simply wants to ensure all babies stay safe and make it to their first birthday. 

There is a bilingual Safe Baby Educator on staff to ensure and encourage access to service.  In the past, when there was not a bilingual educator, the Spanish speaking population still had access to in-house interpreters in Spanish and other languages and they were provided with Spanish educational materials.  Participants are only asked to share basic demographics reducing a barrier for individuals who are hesitant to use public resources.  The Safe Baby program operates out of three locations which are in the North, Mid and South areas of the county. The locations are all on bus routes; therefore, reducing transportation as a barrier.  

In addition to access to the Safe Baby program itself, Safe Baby staff also facilitates connections and reconnections with parenting programs housed in DOH-Pinellas. These programs include Healthy Families, Nurse-Family Partnership and the Healthy Start program. Because all these programs are within the DOH-Pinellas Network, Safe Baby staff can see if a parent is part of one of the programs. For example, if a program has lost contact with their home visitor - Safe Baby staff can provide updated contact information if the family is still interested in the program and another touch point. The Safe Baby staff has emerged as a mini resource and referral stop for families and staff at DOH, particularly WIC staff where they are housed. Even if a family was not on the initial appointment sheet for Safe Baby or walk-ins, WIC staff regularly bring families to Safe Baby educators for needed information and community connections. If families are interested, Safe Baby staff also make direct referrals to our internal programs. These referrals help supplement the decline in referrals we have seen due to downward trends in births in the last five years. 

The Safe Baby staff interview every caregiver to determine the sleeping arrangements for the baby. If there is a barrier to the plan, they assist with problem-solving. If the caregiver cannot purchase a Pack ‘n Play or crib, they are offered a free Pack ‘n Play on-site to bring home the same day. If they do not have transportation to get it home, they can return to retrieve it or one of our home visitors can deliver it. In addition, if they are a part of a parent education program, the program provides a Pack ‘n Play and is often a way for the family to reconnect with their home visitors. If an infant is in the home, it is always a priority to ensure that the family does not go home without a safe sleep option for that night. Family needs take center stage and programs work together to meet the need. In the first year of operation (July 2019 - June 2020), the program distributed 61 Pack ‘n Plays. When Pack ‘n Plays are distributed, families are shown how to put up and take down the portable crib. Additionally, fitted sheets are provided to the families. Forty-six of the Pack ‘n Plays were distributed out of the St. Petersburg office, where it is known that St. Petersburg's population is 22% Black and has 13% of persons living in poverty. This supports the program in directly addressing health inequities and disparities in infant deaths in this community. 

The Safe Baby program highlights the ability of DOH-Pinellas to work with internal collaborators and community partners in a variety of ways to address health equity issues in new and creative ways. Its streamlined model, setup, implementation period, and ongoing adjustments due to COVID-19 this year highlight the model's malleability and the partners' commitment to do whatever is needed to meet this community's needs. The Safe Baby educators are in the WIC office and are a supervisory unit in the Healthy Families program. Both entities are DOH-Pinellas programs. JWB, a long-term collaborating community agency with DOH-Pinellas, fully funds the Safe Baby and Nurse-Family Partnership programs. Pre-COVID-19, the program's flexibility also allowed its staff to go out to community outreach events representing both DOH-Pinellas and the Sleep Baby Safely initiative of JWB. The ability of DOH-Pinellas to get out in the community and showcase such diverse client-centered services goes above and beyond the community's preconceptions of a "Health Department." 

The goal of the Safe Baby program is to provide education on the three leading causes of child preventable deaths in Pinellas. The DOH-Pinellas' Healthy Families program received the funding to fully implement this program. The program worked with DOH-Pinellas' WIC program to determine the location of Safe Baby offices. The Safe Baby offices were set up with examples of a safe sleep environment. The offices are also fully stocked with educational materials on the three subjects. There are also toys and books to occupy older children while topics are discussed with the caregivers to create a family-friendly environment. Safe Baby Educators also have materials on hand from the Healthy Families Resource Specialist and hand out community resource materials and activities that are appropriate and as needed for the families. The Sleep Baby Safety campaign provides the Safe Sleep education for the program. Shaken baby syndrome and choosing safe caregivers education is provided by educational handouts already in use in the Healthy Families program.

The target population is provided by the WIC Staff daily and Safe Baby staff can see the family queue throughout the day. WIC staff was instrumental in getting the Safe Baby program access to information in the WIC system. The Safe Baby staff identifies any appointments scheduled for the day that are prenatal moms or families with an infant under one year. Pre-COVID-19, Safe Baby staff would then give the highlighted list back to WIC staff to send clients to Safe Baby staff within the WIC process. Since COVID-19, WIC has not seen many clients in office, so Safe Baby staff make outreach phone calls to all identified individuals and provide the same education and resources. The program is also still distributing Pack ‘n Plays to families in need. 

The budget for the program is as follows:

Salary for Safe Baby Educators ($27,040 x3) = $81,120

Salary for Program Supervisor (added duties) = $4,000

Fringe benefits for all of the above = $47,335

Routine Travel = $1,000

Office Supplies = $6,000

Pack 'n Plays ($60 x 60) = $3,600

Training = $1,000

Educational Supplies = $600

TOTAL for this program model: $144,655 

The flexibility and simplicity of the Safe Baby program makes it easily transferrable to other Local Health Departments (LHDs). There is potential to have existing staff do a portion of Safe Baby as part of their positions. The only additional funding needed would be money for Pack' n Plays and to purchase additional educational materials. Although, we believe some of the program's success comes from the fact that Safe Baby educators are not associated with a formal curriculum or formal programs in the eyes of the public. Incorporating Safe Baby with other programs also potentially affects access to services and health equity. 

The short-term results are clear. The program has increased the number of families receiving education and having safe sleep options in their homes. DOH-Pinellas has also gained an additional user-friendly service to provide to families. This additional resource for families has undoubtedly increased positive public perceptions of DOH-Pinellas. The Safe Baby program communicates clearly to caregivers that the program's primary goal is for families to be safe and healthy.

With the shift to providing services via phone calls and virtual visits during COVID-19, the program has increased the amount of education offered. Since the start of the 2021 fiscal year, the program has provided education to 1,569 caregivers and distributed 6 Pack' n Plays. Data is collected by daily and monthly cumulative reports submitted by Safe Baby staff, and the data's quality is checked for accuracy monthly by the supervisor. Per DOH-Pinellas and Healthy Families policy, the Pack' n Play distribution is documented by receipts obtained for inventory purposes.

Because of COVID-19 and the current virtual status of the WIC program, it will take 2-3 years to determine any long-term effects of the Safe Baby Program. The program keeps a record of the number of caregivers provided with education. Our larger goal of preventing infant deaths is difficult to correlate directly to Safe Baby because of the far-reaching community collaborations of the Preventable Death Campaign. We can determine if preventable infant deaths decline in the coming years, it could point to the success of the Safe Baby Program. Some parents need to hear the information multiple times; perhaps some need to hear it from someone they feel is a trusted source. In the future, we would like to cross-reference any infant deaths that do occur and determine if the caregivers of those children were provided with Safe Baby education. That would be a strong indicator of the direct positive effects of the program.  

The malleability of the program will make it sustainable. JWB has been the funder of the Healthy Families program (and other prevention programs) since its inception in 1992. The Safe Baby Program does not require a large budget and can be a small offshoot of another program as it currently is with Healthy Families. We do not see the funding source changing long-term if the program remains effective and continues to provide education to parents. DOH-Pinellas and JWB see the value of the potential direct impact of saving infants' lives.  

Co-location also helps keep costs low. The current budget would need to remain stable to sustain the program. If the funding were to shift up or down program services could easily be adaptable. When Safe Baby staff resume seeing clients face-to-face, there is a potential for Pack ‘n Play costs to rise. The program would be able to pull from other line items within its own budget to maintain the demand.  

To conclude, this program exemplifies the effectiveness of a small, targeted program that works within already established successful programs and uses data gathered and agreed upon by the community. Over 4,000 families have received education on the three leading causes of infant deaths in two years, and community collaborations have been built and reinforced. Health equity for the highest risk populations has been addressed.   DOH-Pinellas continues to provide unique services to a diverse community fostering community collaborations and innovative, simple strategies to tackle complex issues for our families.