Exploring NAPPSS-IIN Project Insights and Future Visions: A Conversation About Safe Sleep and Breastfeeding

by Domonique Davis, Communications & Digital Strategy Manager

Aug 21, 2023

Domonique Davis: On this month's episode of Before Birth & Beyond, we're excited to be joined by summer 2023 NICHQ Communications and Digital Strategy interns Amalia Hirschhorn-Martinez and Katie McCormick. They will be speaking with members of the NICHQ team about our upcoming webinar, focused on infant safe sleep and breastfeeding messaging, and NICHQ's continued work to ensure health professionals and the communities they serve are supported with the necessary tools and resources to create safe sleeping environments. and improve breastfeeding and chestfeeding rates. Stay tuned for more.

Amalia Hirschhorn-Martinez: my name is Amalia Hirschhorn-Martinez, and my pronouns are she, her. Today, I'm joined by Dr. Stacy Scott, NICHQ's Project Director and Vice President of Health Equity Innovation. We're going to discuss NICHQ’s upcoming webinar titled "Their Stories are So Powerful: Community-Based Approaches to Infant Safe Sleep and Breastfeeding Promotion." This webinar will be held on August 23rd at 2:00 PM Eastern Time.

Thank you for joining me today, Dr. Scott. Would you mind taking a moment to introduce yourself?

Stacy Scott: I am Dr. Stacy Scott. I am Vice President for the Department of Health Equity Innovation. It's a fairly new department that was created to really help identify systems that overlook root causes of inequalities and really look at what are some of the roles of these barriers and challenges that we see in dealing with racism and other forms of oppression and how they impact community wellness.

So just a little bit. Our mission is to understand and address the critical components that serve as barriers and facilitators to equitable systems change. And our purpose is really to harness internal and external knowledge and bolster NICHQ’s, capacity to create a social justice and anti-racist systems of care.

Amalia Hirschhorn-Martinez: And can you tell us a little bit about the NAPPS-IIN Project and what your role was?

Stacy Scott: Yes. I served as the project director of NAPPS over the years, I first started out as the chair for the Wisdom Council, and I worked as a consultant and was really active in the work that we did around the community and as chance had it, I became an employee and eventually became the project director over the whole project.

NAPPS-IIN stands for the National Action Partnership to Promote Safe Sleep Improvement in Innovation Network, which we refer to as NAPPS-IIN. NAPPS was really aimed to make infant safe sleep and breastfeeding a national norm. We worked with aligning stakeholders to test what we refer to as safety bundles in multiple care settings to improve the likelihood that infant caregivers and families received a consistent evidence-based instructions about safe sleep and breastfeeding.

Amalia Hirschhorn-Martinez: And how do you feel that messaging around safe sleep and breastfeeding evolved, throughout this project? on what you've learned through the cohorts or how has this changed over the last few years?

Stacy Scott: It's been amazing what we were able to accomplish in the last five years of this project. We started out and again, working with hospitals and our usual partners in regards to promoting safe sleep and breastfeeding. But, as we went into our years four and five, we really sat back and took a long look on the importance of working with communities and with all the things happening around COVID and things of that nature, we were able to probably do some things outside of the box based on having to reset ourselves as a result of the pandemic, which for us, was positive. We were able to engage communities and community organizations. We were able to provide funding and support to help them build their capacity and look at quality improvement efforts in helping them to get the message out around safe sleep and breastfeeding.

Amalia Hirschhorn-Martinez: Can you elaborate on how leveraging community-based approaches can effectively address structural racism and promote breastfeeding and ensure safe sleep practices for mothers and infants.

Stacy Scott: Well, I think one of the big things that we did was really listen to the community. We were able to bring community to the table. And although our table probably was already set, we recognized that it was important and that was a missing piece to that. So we took a step back and we really said, okay, we need to hear from you.

And as a result, we were able to reposition ourselves. Look at our original aim statement and really adapt it based on the needs of our communities. We did take a look at structural racism and look at racial and ethnic disparities as well as geographic – from rural to urban. And looked at it from affirming care and a whole host of things that we had not started that journey with, in the beginning of this project.

Amalia Hirschhorn-Martinez: How do you feel that the limitations presented in the study impacted the overall findings and conclusions of the research?

Stacy Scott: Of course anytime you think about limitations, I mean there’s some standard things that unfortunately in doing this kind of work we experienced. Of course, we did everything via Zoom because of the pandemic. And, it would've been nice to be able to go into the communities.

However, I have to be honest that I don't know had the pandemic not happened, if we wouldn’t have had the ability to redirect the funds in the way we did to be able to leverage the community. A lot of that money that we had was designated for travel, and thanks to our funders, we were able to redistribute it in a way that could really impact the community in a positive way. We, of course, also looked at the community as a whole, and, even though we focused on communities of color – rural areas limitation was in that. Because of how we did all of the work we did, virtually, we were not able to have that up-and-close type of personal relationships with various communities. So those were some of the things that we did really look at. And then also how we broadly characterized what community-based organizations were. And so that gets into a whole lot about what is considered authentic community engagement, but we do feel that we've done a great job to the best of our ability to engage the community at all levels.

Amalia Hirschhorn-Martinez: If given the opportunity to study are there any changes that you would have made to address some of these issues, or equity-based issues.

Stacy Scott: For us, we were following traditional lines of quality improvement. That I think that what we would have done is that we would have started with the communities first. I look at the cohorts of our projects. We'd worked with hospitals in our first cohort, which was Cohort A. We looked at hospitals and other birthing organizations such as doctor's offices in Cohort B, our second cohort, and then C, we finally were able to reach out to communities. If I had to do it again, I would've had the communities be first. I think it's important to establish that network of communities. Help build their capacity which we know they're capable, but being able to build their capacity would've been important.

And helping them to prepare them to be able to partner with their hospital partners and other healthcare providers throughout their communities, I think would've been a plus.

Amalia Hirschhorn-Martinez: In what manner can themes derived from the community listening sessions be utilized to shape future directions of initiatives concerning safe sleep and breastfeeding work at NICHQ?

Stacy Scott: Well, of course, I don't want all of the work and the learnings that we have gotten to be in vain. I think it's important that we continue to champion the things that we were able to begin working in this project. Of course, education is key. We are looking at dissemination of information, relationship building, and support. Really looking at our client-provider relationship being able to give people a platform to continue to talk about the work they do.

I, I'm very proud of that.  Working with the healthcare professionals, we really kind of talk amongst ourselves, but being able to give people the opportunity, the people that are on the front line, that are ground zero, the opportunity to share as far as their challenges, as well as successes, and really looking at best practices, I think is so very important.

Amalia Hirschhorn-Martinez: How did you acquire the feedback specifically? Was the research you gathered from the community-based approaches conveyed through providers or the community members themselves?

Stacy Scott: It's probably all of the above. When we look at who our targeted communities that we worked with were really community-serving organizations. That were not necessarily people that they served, but we looked at them as being able to give a voice to the community organizations that were not your atypical.

 Be it hospitals or medical centers or doctor's offices, but these were people that were part of community-serving organizations, be it a church. Being a neighborhood health center that were there doing the work and that we looked at them as our constituents.

We wanted to hear from them their lived experiences of being out there and doing this work. And of course, in collecting some of the data that they collected was also information that they got from who they served. But we wanted to look at this as an opportunity to be able to tell the stories of all of those people that are out there doing this work and attempting to make a difference to save babies lives and promote breastfeeding.

Amalia Hirschhorn-Martinez: Dr. Scott, if you have anything else to add.

Stacy Scott: I just want to put out there that we should never not listen to our community partners. A lot of times, we get caught up in the profession and things of that nature. You know, we look at all of the recommendations that come out. We await them, but to be able to hear from people. And to get a true understanding on, again, the challenges and the barriers, as well as the successes in getting people to heed.

Not only just here, but the message around breastfeeding and safe sleep is so very important. And I'm glad and honored that we here in NICHQ had an opportunity to be able to share the lived experiences of people on the ground level. And we do hope that we can continue or encourage other people to receive these messages and insight from our community partners.

Amalia Hirschhorn-Martinez: Thank you so much Dr. Scott for taking the time to share your insights with me and everyone today. It was a pleasure having you on before birth and beyond.

Stacy Scott: Thank you so much for the opportunity to be able to share.

Amalia Hirschhorn-Martinez: Again. The webinar is scheduled for Wednesday, August 23rd at 2:00 PM Eastern Time. You can find more information and a registration link in our show notes and a recording will be shared right after the webinar. Thank you.

Domonique Davis: Stay with us to hear Katie McCormick discuss findings from the NICHQ-led study "Community-based Approaches to Infant Safe Sleep and Breastfeeding Promotion. A Qualitative Study," published in BMC Public Health with Dr. Meera Menon who shares insight as the publications lead author and a new mother.

Katie McCormick: Hi, Meera. Thank you so much for joining me to talk about the publication. Why don't you introduce yourself and, what you do at NICHQ?

Meera Menon: Yeah, happy to. And thanks for speaking with me, Katie. So, my name is Meera Menon. I am an Associate Director of Research and Evaluation at NICHQ.

At NICHQ, I help oversee our Department of Applied Research and Evaluation, including managing a fantastic team of researchers, and I also lead evaluation research activities related to NICHQ's project work.

Katie McCormick: regarding the NAPPSS project, and how it's centered on making safe sleep and breastfeeding a national norm, can you summarize what the publication is about?

Meera Menon: So, this publication was actually related to our direct project work on the NAPSS-IIN project. The original project was really focused around making safe sleep and breastfeeding a national norm, but within the hospital setting. As we really got into the work, we realized that it needed to start with the community and we needed to listen to the community really understand community needs, what's really working well, the [00:18:00] strengths, but what barriers exist and what those working within the community, identified they need to support safe sleep and breastfeeding. This publication was really around addressing that gap. We conducted a series of community-based focus groups, which we called “listening sessions,” with community-based providers who are working directly in their respective communities around promoting safe sleep and breastfeeding. And we did these, listening sessions to really understand what their needs were, and what we could do to support them with the NAPPS-IIN project. We heard a lot of different things related to both the struggles of providers doing this work in the community as well as what parents directly were experiencing within the community as well.

Katie McCormick: I also found it super interesting that you interviewed healthcare providers. Instead of, going straight to community members or, patients, do you think it would have been any different if you had talked to them instead of healthcare providers?

Meera Menon: We talked to community members that were directly working with, [00:19:00] different populations. So, you know, they could have been doulas, home visitors, community-based health workers. directors of nonprofits that, do work related to safe sleep and breastfeeding.

I think there might have been, in our sample, I'd have to double-check, maybe one or two medical providers directly, but most people were community-based individuals that were directly working with community members.

Katie McCormick: When considering barriers to infant safe sleep and breastfeeding, what is a particular barrier that you think holds greater potential for a breakthrough or progress?

Meera Menon: It's tricky because I think we've been working on these topics for a really long time, those working in public health, but one of the things that I've realized, especially as I've become a parent myself, is really that to make real headway in safe sleep and breastfeeding, and really improve rates, reduce disparities, we need to look at this as a systems level problem and not an individual level problem.

So a lot of times these initiatives tend to focus like individual behavior, like promoting, safe sleep, promoting breastfeeding at the individual level, but really ignore the fact that there are systems in place that make it really challenging for parents to engage in these behaviors.

We don't have a robust family leave policies in this country. There is not really a lot of medical support for parents who intend to breastfeed or who might need to go an alternate route as well. It's not the easiest answer, but I think that's the place where we really make the most headway is looking at systems-level solutions rather than treating, improving safe sleep and breastfeeding at the individual level.

And I think that's something that also was pretty apparent in the paper as well. You know, there was a lot of discussion around individual-level behavior, but there was also this recognition that, what is the context that parents are in and what is sort of the overlying situation that they're coming into and how does that impact the decisions they make around safe sleep and breastfeeding?

It sometimes feels like culture follows some of the federal-state policies that are underlying it. So, you know, the fact that a lot of parents return to work when their infants are essentially newborns still and it makes it really hard to continue breastfeeding relationship. If there are with that setting, with those work hours, et cetera. There have been some big headway with, policies to support breastfeeding, but what does that actually look like in practice and how does that look like for a baby, for example, that might not take a bottle and like, how does that parent, continue a breastfeeding relationship in that regard.

So if also they work full-time, I think it's a little bit of both where I do think that social policy might be leading the way to what culture is, but it's also hard to say it's a little bit chicken, egg, sometimes.

Katie McCormick: As a new mother, do you see any changes that you would have made due to your new role, not only as a researcher?

Meera Menon: It's interesting because just given my new role as a mother, I don't know if I would have made any specific changes to this. paper or findings because our findings were really driven by the voices of the respondents in the study and the community members that were participating.

I think there's a much deeper appreciation for what that lived experience looks like and speaking just for myself, I have an understanding for how difficult and challenging it is for parents around making decisions for safe sleep and breastfeeding or how difficult and challenging it is to, reach certain milestones, like six months exclusive breastfeeding, one year exclusive breastfeeding.

When you're directly living it's really easy to see how challenging it is. That lived experience provides me a little bit more empathy in the situation and understanding that, really what some of these challenges are and some of the decisions I made, I made because I have all of this knowledge and understanding around, safe sleep and breastfeeding. But what does that look like for someone who doesn't have that?

Katie McCormick: What do you hope healthcare providers take from this publication? And then also what do you hope parents, or anyone experiencing it personally, take from it overall?

Meera Menon: That's a really good question. From the provider perspective, I would again go back to my whole idea that it's not an individual-level behavior.It's a systems-level problem, so taking that lens and when you're looking at one specific patient, it's not just their own individual decision-making. It's the larger system and context they live in. And with that I think a lot of providers, and this is a big focus of the NAPPSS project, should try to engage in compassionate conversation around some of these decisions with patients. So one of the products of the NAPPS-IIN project was these conversational modules where really it was around using shared decision-making strategies to talk to patients and understand the decisions behind their, choices.

Also related to that is specifically with the safe sleep space. I think parent providers tend to really focus on abstinence-based approaches to safe sleep. And this paper really highlighted the fact that, that doesn't work and we know that abstinence-based approaches don't work. So it shouldn't be a conversation about not discussing the alternative. There is, increasingly, other big organizations such as the Academy of Breastfeeding Medicine, talking more about risk mitigation as an approach. And ultimately working to like the full standard, gold standard in infant sleep practices, but understanding that's not where everyone's going to be and what are the small steps that providers can take to encourage parents, to make the decisions that match their situation the best?

Katie McCormick: And then also like patients or anyone who's living with a newborn or such.

Meera Menon: With that, I feel like the answer is a lot less complicated than to providers and I think it's just to give yourself grace and understand that this is just a season of life and things will change.

But I also think that the burden shouldn't be on the patient in this situation. Instead of placing everything on the patient, there needs to be a more equal decision-making, and getting support from the provider. You should feel free to advocate and have these conversations, but that often assumes that the patient's in a place of privilege. And we can’t assume that always, and especially a postpartum person, might just really be at their wits end in many places.

I hope that if parents look at this or newly postpartum individuals look at our findings, it would just be to understand that there is a sort of shared experience around, this time that a lot of parents are going through, and the really nice thing about this paper is that it's open access. It's pretty broadly available to anyone who is interested in the topic. So hopefully, parents can look at it if there aren’t other ways to put themselves to sleep if they're not tired already. All jokes aside, I think that it's helpful to know that there are a lot of other people going through the same situation.

Domonique Davis: To learn more about the naps in project or to register for NICHQ's August 23rd webinar about safe sleep and breastfeeding messaging. Check out the show notes or visit