How did NYC implement the Safe Sleep Initiative to reduce child fatalities?

Bernice entered the hospital room in the post-partum unit, congratulating the family on their newest addition before introducing herself as a community coordinator there to talk with them about safe sleep. Her approach — a combination of warmth, compassion, and authority on the topic — immediately put the family at ease. As Bernice demonstrated safe sleep techniques, such as placing the child on her back in an empty crib, she encountered some anticipated resistance from the infant’s grandmother, who expressed that her own children had slept on their stomachs without issue. After acknowledging the grandmother’s experience and sharing her own personal history of engaging in similar sleep practices with her children, Bernice explained that new research over the past decade has revealed the risks associated with bed sharing, excessive bedding, and putting infants to sleep on their stomachs. She kept the tone positive and strengths-based throughout the conversation, describing the reasoning behind why families should follow such guidelines. By the end of her visit, the family, including the grandmother, were receptive to modifying their behaviors in support of safe sleep practices.

Bernice’s approach reflects what research supports: handing out a flyer about safe sleep isn’t enough to change behaviors, since parents, and especially mothers, tend to follow the parenting traditions endorsed by family members they trust. This is particularly true in high-risk neighborhoods that have a history of mistrust with government agencies. In fact, in some instances, Safe Sleep campaigns that relied on information-sharing only served to widen the racial disparities between white and non-white infant fatalities. While general information campaigns may change the behaviors of white and middle-class parents, that same behavior change does not occur with families of color living in high-risk neighborhoods. What does work is a combination of public awareness, intensive engagement in the community, and education of parents and family members who influence parents.

No silver bullet

Instead of adopting a single intervention, New York City has implemented a constellation of interwoven strategies that work.

Meeting families where they are

The NYC Administration for Children’s Services’ (ACS) Safe Sleep Initiative knew that solely sharing information with families does not lead to behavioral change, especially in high-risk communities with a history of mistrust of public agencies. According to Dale Joseph, assistant commissioner, Office of Community Partnerships at ACS: “Information sharing alone is not sufficient; this work needs to be about real behavioral change. It’s not about passing out a flyer — it’s about building a relationship so trust grows and the community sees what we’re trying to do.”

The Citywide Stakeholders Coalition takes a multipronged approach to community engagement. Since every community is different, safe sleep community coordinators map out the unique strengths and opportunities in each area and identify which partners are most likely to care about and be connected to this issue. To start, they build upon existing relationships with community organizations. The faith-based community has been a critical ally in this work, given its scope of influence, credibility, and influence on young parents who hold its advice in high regard. The local business community can reach a large and diverse audience and has assisted by putting up safe sleep ads in places of business. In addition, hospitals are a safe and trusting place to engage with expectant and new mothers during a time when they are most motivated to learn how to safely care for their infants. The Safe Sleep Initiative has also trained community-based agencies and other service provider staff who work directly with families on a regular basis.

Not every group was initially receptive to the safe sleep recommendations, and some posed resistance to their citywide adoption. For example, breastfeeding advocates were concerned that some safe sleep practices ran counter to the importance of mother-infant bonding and attachment. These concerns have led to continued dialogue among the coalition members about developing a common language and agenda that all of the stakeholders are comfortable advocating for.

The community coordinator positions within the ACS Safe Sleep Unit are critical to authentic engagement. Each of the five coordinators is assigned to high-risk neighborhoods, becoming intimately acquainted with their borough where they develop collaborative relationships, engage the community, and build credibility with residents. They emphasize the importance of being nonjudgmental and building trust in the community so parents don’t feel as if child welfare workers are trying to catch them doing something wrong, but rather view them as a resource. Their community engagement strategies include grassroots organizing and education activities located in the core of the neighborhood, such as hosting a table in community centers, presenting at events, and visiting hospital rooms, among others. Community coordinators continually search for new creative ways to engage with residents and have discovered that new fathers are a captive audience who are eager to learn how to keep their babies safe.

Community coordinators are sensitive to the cultural needs of the diverse populations they serve and committed to always explaining the why behind the recommended behavior change. However, one challenge that the coordinators face is the myriad of languages spoken by the families they serve. Although two of the community coordinators are bilingual in Spanish, there are many other languages in the community, and coordinators don’t always have access to an interpreter.

Utilizing the public health approach of empowering community members to develop the solutions for problems that affect them, the Health Department leverages community residents with influence to take on the role of safe sleep ambassadors through the Champions Pilot Project. This project engages community members through Neighborhood Health Action Centers1 to recruit and train grandparents and other trusted community residents to demonstrate safe sleep practices. The training employs a newly created safe sleep curriculum and educational materials, which they then use to educate their own informal networks as well as provide trainings in public gathering spaces. Currently, 80 ambassadors have educated 150 families in the Brooklyn community. Champions also connect families to local resources on breastfeeding, social services, and the Health Neighborhood Action Centers.

A visible “home” for the initiative

Various NYC agencies had been engaged in safe sleep activities for more than a decade and the partnership between city agencies has evolved over time. Once Mayor Bill de Blasio established and funded the Safe Sleep Initiative in 2015, a clear governance structure was put in place and the collaboration became more formalized. The Department of Health and Mental Hygiene (DOHMH) and ACS led the development of a common agenda and language. The mayoral funding was key to the success of the project, as it allowed the creation of the Safe Sleep Unit and the five community coordinator positions.

This city-led collaboration has consistently emphasized that the safety of infants is the collective responsibility of all of the city agencies. It also framed and unified priorities, strategies, and messaging to effectively promote key infant safe sleep practices citywide. City agencies and community-based partners made a commitment to work together to address conditions that serve as barriers to safe sleep, such as housing, access to healthcare, and other resources that, when provided, allow families and children to thrive.

Integrating into existing programming

Multiple city agencies have now adopted their own practices and policies to promote safe sleeping practices. For example, DOHMH integrated safe sleep education and crib distribution into its existing home visiting programs offered to young and low-income mothers. The city’s two home visiting programs — the Newborn Home Visiting Program and the Nurse Family Partnership — provide home visits to mothers regardless of age or immigration status in high-risk neighborhoods in Brooklyn, Harlem, and the Bronx, as well as any mothers residing in homeless shelters, prisons, foster care, or juvenile justice facilities.

The home visitor works with the family to assess any barriers — practical or philosophical — to safe sleep and then develops solutions in partnership with them. Inadequate housing continues to be a major barrier for families who desire to engage in safe sleep practices. Many families do not have the room for a crib or are lacking the financial resources to deal with housing quality issues such as lack of heat or pests. The home visitors focus on parental concerns, problem-solve with families, and provide tools and tips to help keep their infants safe. The home visitor may help the family address housing quality issues, provide a pack ‘n play that can be folded up and stored when not in use, or work with the family to re-organize furniture and streamline belongings to make room for a crib.

Department of Homeless Services (DHS) has recently adopted a new safe sleep policy for families with infants living in NYC’s shelters. New staff training requirements on how to effectively deliver the safe sleep message to families are being implemented. The policy outlines staff responsibilities at the different touch points in the system, from showing videos and providing educational materials at intake to installing cribs and conducting weekly inspections for shelter residents. With the new policy in place, DHS will now need to focus on barriers to implementation. For example, DHS provides standard cribs at all of its shelters; however, the crib guard rails are too high for new mothers recovering from a C-section to reach down and pick up their baby. Many parents are provided with a portable playpen to help address this issue.

All of us have to work together to ensure success. We have all touched these families in some way – we are working with the same families. This is not just a single agency program, all of the city agencies have to take ownership of a piece of this.

– Dale Joseph, Assistant commissioner, Office of Community Partnerships

Learning about what works

Coalition members were proactive in learning from other jurisdictions that had successfully reduced deaths due to unsafe sleep practices. They invested time and resources to travel to Baltimore, Maryland, and Rochester, New York, to learn from their Safe Sleep teams about what components were essential to success. Recommendations from those teams — being data driven, building strong partnerships, and focusing on the influencers in the community — were brought back to NYC for integration and adaptation into its model. ACS also partnered with Casey Family Programs to provide two annual Safe Sleep symposiums, which brought together more than 200 health, human services, and child welfare experts to discuss ways in which existing safe sleep education and practices could be enhanced for greater citywide impact.

Finally, ACS and DOHMH were diligent in learning what could be improved upon, and solicited community feedback to test the effectiveness of new messaging and imagery.2 Community residents emphasized that the materials should be conveyed in a nonjudgmental tone and focus on the positive, recommendations that were subsequently integrated into the initiative’s informational materials and videos.

2 See