Creation and Expansion of a Community Portable Crib Program

Austin Public Health is an accredited public health department with jurisdiction over all of Travis County, Texas, which includes the City of Austin, with a total population of 1.2 million. Travis County is one of the fastest growing areas in the country, and the City of Austin is ranked as the 11^th most populated city in the United States.  Travis County is ethnically and linguistically diverse.    In 2019, 49.1 percent of Travis County residents were non-Hispanic White, 33.9 percent were Hispanic/Latinx, 8.3 percent were Black/African American, and 7.9 percent were Asian.  In Travis County, 31.4 percent of residents speak a language other than English at home.  (US Census, American Community Survey, 2018 5 Year Data Profile).

Accidental suffocation or strangulation in bed (ASSB) is the leading cause of injury death for infants under 12 months of age in Travis County and the City of Austin.

APH convened the Austin Travis County Safe Sleep Coalition to identify strategies to reduce ASSB deaths.  The coalition included partners from hospitals, Federally Qualified Health Centers, fire and police departments, The Travis County Medical Examiner's office, medical emergency services, the State Department of Family Services, Center for Child Protection, and the Maternal Infant Outreach Program.  Four committees were created:  Clinical Policy, Practice and Education Committee; Resource Committee; Branding and Messaging Committee; and the Community Education Committee. 

Through the Resource Committee, the Coalition developed a program to provide a safe sleep environment to families who did not have a safe place for their infant to sleep and who could not afford one.  Since the program's inception in October of 2019, APH has provided a total of 921 cribettes for 917 babies in 904 families through October 31, 2022.  In addition, APH has supplied families receiving cribs in a hospital setting (newborns) a sleep sack to discourage the use of blankets.

Processes were developed to implement the crib program in a multitude of locations.  Initially, cribs were provided to area hospitals and Federally Qualified Health Centers (FQHC) and has been expanded over the course of three years. 

The crib program was successful in meeting the objectives that had been established for the group. All of the following objectives were met:

·       To provide a safe sleep environment for those who cannot afford one and to gather data about those families to get a better sense of community needs.

·       To have families use the portable crib instead of co-sleeping.

·       To evaluate whether the cribs help families practice safe sleep.

APH was able to provide funding for the first year of the program and in the second year of the program, we received supplemental funding from the United Way.  Fortunately, funding for the crib program has been identified in APH Chronic Disease and Injury Prevention operational budget for ongoing sustainability.  

The public health impact of this practice is quite impressive.  Of the crib recipients who commented on where their baby would or currently is sleeping, 278 recipients said baby would have slept in unsafe environment if not for the crib distribution.  This included co-sleeping, with mom, in an adult bed, in a car seat, among other unsafe sleep environments.  By providing a safe place for their infant to sleep, we have eliminated one barrier that may have resulted in families bed sharing or placing their infant in an unsafe sleep environment. 

Twenty-one percent (22%) of cribs were given out in zip codes that had been identified as possibly high-risk for accidental suffocation deaths (78753 and 78723). We also identified 14 zip codes that received more portable cribs than the other 38 zip codes, which will help with outreach, education, and community support.

Because the Austin-Travis County community has a large percentage of Spanish speaking families, the Coalition made sure to create all materials in both Spanish and English.  The crib video was provided by Cribs for Kids in English, and we had it translated to include Spanish subtitles. Sixty-four percent (63%) of crib recipients were Spanish speaking and six percent (6%) spoke something other than Spanish or English.  In 2022, as two refugee service providers came on board with the program, we recognized the need for education in the Pashto language.  APH worked with the Department of State Health Services and one of the refugee organizations to recreate the video with a voiceover in Pashto.

The crib program was intended for those who could not afford a crib and was promoted through partners that help families without health insurance or government assistance programs. The program was successful in reaching individuals in highest need of cribs.  Ninety-five percent (92%) of families given a crib were also receiving some form of government assistance. Cribs were also provided to individuals experiencing homelessness and individuals residing in shelters for domestic violence.

The crib program began in 2019 and has continued and grown through the pandemic.  This program has been identified as a sustainable change that will impact hundreds of infants each year. APH continues to facilitate the safe sleep coalition and the crib program continually looking at ways to improve safe sleep.

Program website:  http://www.austintexas.gov/page/safe-sleep

All families are affected by ASSB, however Black/African American families are at higher risk.  In addition, babies under the age of 6 months are at greatest risk for ASSB. Through the APH report Accidental Suffocation and Strangulation in Bed Deaths, APH found 90% of ASSB deaths occurred within the first six months of life and that there were two zip codes with a higher proportion of these deaths.  The target population is families with infants living within Travis County with a total population of 1.2 million. Families without a safe place for their baby to sleep and are receiving government assistance (such as WIC or Medicaid) or with incomes below 200% poverty level are eligible for the program

Causes of ASSB death include misinformation and lack of knowledge of the updated AAP safe sleep recommendations.  Lack of a safe sleep environment has also been identified as a possible reason for families not practicing safe sleep. Prior to the launch of the crib distribution program the only practice used to address the problem in Travis County was through organizations providing their own safe sleep education to families. This did not address the structural cause of families potentially not having a safe sleep environment in which to place the baby for sleep, nor the need for a standardized approach to safe sleep education. 

APH implemented the program through partnership with organizations that work with families needing assistance.  The coalition agreed on using a standardized safe sleep educational brochure available in both English and Spanish.  Furthermore, the Cribs for Kids® instructional video on assembling the portable crib was professionally translated and added as closed-captioned text in Spanish.  A video created by the Texas Department for Family Protective Services (DFPS) with a clear image of safe sleep was one piece of the education being used, which also contained closed captioned text in Spanish.  As Austin began to receive many refugees from Afghanistan, we identified a need to make a voiceover of this video into Pashto and worked in partnership with DFPS to create the video in 2022.

Upon execution of the program, APH initially partnered with two hospitals and two FQHCs.  Over the course of the past two years, we have incorporated into the program another hospital, one newborn nurse home visiting program, one maternal infant outreach program, one county-based program, two refugee service organizations and five neighborhood centers.  Every new partner must attend a safe sleep training provided by APH which includes standardized safe sleep education.  Once the organization has completed this training, they receive cribs and  bilingual safe sleep brochures from APH.  Before giving a portable crib to a family, staff with the partner organization must provide the standardized education and brochure.

Current American Academy of Pediatrics guidelines state that a crib, bassinet, portable crib, or play yard that conforms to the safety standards of the CPSC is the recommend sleep environment for infants.  Several studies have shown that when provided with a safe sleep environment for their children, families will utilize this choice.

 By providing education along with cribs for families, we have developed a standard of care in hospitals and FQHCs and broken access barriers for a safe place to sleep to those with a lower income.

Accidental suffocation or strangulation in bed (ASSB) is the leading cause of injury death for infants under 12 months of age in Travis County and the City of Austin.  In 2018, Austin Public Health produced a report covering five years of data extracted through case review of medical examiner reports and found there of the 41 ASSB infant deaths in the City of Austin between 2013 – 2017, most incidents (73%) occurred in an adult bed. The coalition identified the creation of a crib program for families who could not afford one as a way to help reduce these deaths.   

Initially, APH convened the Austin Travis County Safe Sleep Coalition to identify strategies to reduce ASSB deaths.  The coalition included partners from hospitals, Federally Qualified Health Centers, fire and police departments, The Travis County Medical Examiner's office, medical emergency services, the State Department of Family Services, Center for Child Protection, and the Maternal Infant Outreach Program.  One goal was to establish four committees to work on the various strategies to reduce ASSB deaths.  Four committees were convened:  Clinical Policy, Practice and Education Committee; Resource Committee; Branding and Messaging Committee; and the Community Education Committee.  APH worked closely with the Resource Committee, to develop the crib distribution program, in collaboration with the Ascension Dell Children's Medical Center, Community Care Clinic, People's Community Clinic, St. David's Medical Center and Ascension Seton Medical Center. 

Through the Safe Sleep Coalition Resource Committee, processes were developed to implement the crib program in a multitude of locations.  Initially, the program was a pilot providing cribs to area hospitals and Federally Qualified Health Centers (FQHC).  Over the course of three years, it has been expanded to include neighborhood centers, a newborn nurse home visiting program, county-based family program, two refugee service organizations and five neighborhood centers.  

APH included partners that work closely with our priority populations, and we continue to engage with the Maternal Infant Outreach Program (MIOP) as a partner in the crib distribution program.    MIOP provides peer support to African-American/Black women who are pregnant or post-partum and services are provided by Community Health Workers. Ten percent (10%) of cribs were given to Black or African American recipients.  Twenty-two percent (22%) of cribs were given out in zip codes that had been identified as possibly high-risk for accidental suffocation deaths (78753 and 78723). We also identified 14 zip codes that received more portable cribs than the other 38 zip codes, which will help with outreach, education, and community support.

Costs for the program are approximately $25,000 in Cribs for Kids® cribettes, $3,000 for wearable blankets, as well monthly storage unit rental agreement. This serves approximately 300 families per year.

APH had three main goals for this program:

·       To provide a safe sleep environment for those who cannot afford one and to gather data about those families to get a better sense of community needs.

·       To have families use the portable crib instead of co-sleeping.

·       To evaluate whether the cribs help families practice safe sleep.

An evaluated of the crib program was completed using the crib referral form with quantitative data such as demographics, address, information on government assistance and household size.  Additionally, qualitative data included a question regarding Where does or would your baby sleep?” Of the 917 recipients, 639 commented unknown”, while 278 said baby would have slept in unsafe environment if not for the crib program.  This included co-sleeping, with mom, in an adult bed, with parents, with siblings, in a car seat, and other unsafe sleep environments.  By providing a safe place for their infant to sleep, we have eliminated one barrier that may have resulted in families bed sharing or placing their infant in an unsafe sleep environment. 

The referral form also allowed us to identify that twenty-two percent (22%) of cribs were given out in zip codes that had been identified as possibly high-risk for accidental suffocation deaths (78753 and 78723) from the APH Accidental Suffocation and Strangulation in Bed Death report. Additionally, we identified 14 zip codes that received more portable cribs than the other 38 zip codes, which will help with outreach, education and community support.

Sixty-three percent (63%) of crib recipients were Spanish speaking and six percent (6%) spoke something other than Spanish or English.  This amplifies the message that we need to continue education and outreach in Spanish and other languages.

In 2022, as two refugee service providers came on board with the program, we recognized the need for education in the Pashto language.  APH worked with the Department of State Health Services and one of the refugee organizations to recreate the educational video with a voiceover in Pashto.  We decided this form of education was most likely to make an impact as many of the refugees could not read or write. 

The crib program was intended for those who could not afford a crib and was promoted through partners that help families without health insurance or government assistance programs. The program was successful in reaching individuals with the highest need.  Ninety-two percent (92%) of families given a crib were also receiving some form of government assistance such as Medicaid or WIC.  A few cribs were also provided to individuals experiencing homelessness and individuals residing in shelters for domestic violence.

In January of 2022 with the help of an intern, APH completed a follow up phone survey of 30 recipients who received their portable crib from three months prior (October 2021).  There was a total of six questions measuring sleep position, sleep surface, location of the cribette and how often it was used.  Of the 30 recipients, 27 (90%) said they were using the portable crib provided by APH.  All of them (100%) were using the portable crib in the parent's bedroom.  Fifty-seven percent (57%) were using the portable crib all of the time and thirty-seven percent (37%) were using it most of the time.  Ninety percent (90%) of those surveyed were placing their baby on the back to sleep.

APH has a contract with Cribs for Kids and identified annual funding to continue the crib program, which is in its fourth year.  Funding includes storage unit costs as well as cribettes and shipping.  There have been price increases due to tariffs since inception of the program, however we have been able to update the contract and secure funding eveyr year for the cribs.  The program has seen a continued increase in partnership, although we lost participation from one partner due to inadequate staffing at their organization.  We hope to bring this partner back into the program once adequate staffing has been reestablished. 

APH has a full-time staff member responsible for the crib program, which includes providing partner training, attaining educational materials, ordering and receiving the cribettes at the storage unit and helping deliver cribs to various partner locations.  A system has been put in place for partner organizations to schedule regular pick up of the cribettes from the storage unit.  There are a few partners who are not able to pick up cribettes themselves, therefore APH has implemented delivery of the cribs via personal vehicle as well as using City of Austin facilities vehicles. 

Each partner must provide a referral form for every cribette given through either encrypted email, fax or in person delivery.  Upon implementation of the program, many forms did not make it to APH in a timely manner.  Through meetings with partners, we have established a successful process to receive forms on a regular basis.  Some forms came back with incomplete infomration and we identified a way for organizations to QA the forms before coming to APH.

Not every partner has the capacity to implement the crib program in the same way and APH had to find solutions for each individual partner organization to make the program successful. For example, some of the neighborhood centers only have capacity to store five cribs at a time, whereas one of the hospitals moves up to 25 cribs a month.  The refugee centers not only need APH to deliver the cribs, but also requested the education in another language, which we were able to do.  Flexibility in working with partners has been key to the success of the program.