II.E.2.c. Women/Maternal Health: Annual Report (10/1/2021-9/30/2022)
 

State Priority Need:

Access to high-quality, family-centered, trusted care is available to all Hoosiers.

 

National Performance Measure (2020 - 2025):

NPM 1: Well-Woman Visit: Percent of women, ages 18 through 44, with a preventive medical visit in the past year.

 

Evidence Based/Informed Strategy Measure (2020 - 2025): 

ESM 1.1: Number of Women who responded to PRAMS.

ESM 1.2: The percent of women receiving postpartum follow-up health care services within the first four to six weeks after delivery.

 

General Information

To increase the percentage of women who have an annual well-visit, MCH must better understand how many women are getting into well-woman care and their reasons for either continuing regular medical visits or not obtaining consistent care. Based on this knowledge, MCH can plan and work toward eliminating barriers to accessing trusted care. A top need from the five-year needs assessment demonstrated the urgency for an easier transition from labor and birth to postpartum care. Survey participants noted that postpartum care is either insufficient or too long after delivery for many women which makes the transition back to well-woman care after delivery challenging, especially when much of the attention is focused on babies.

 

MCH will aim to assist women in navigating their healthcare with supportive programming and policies to ensure women have easy access to regular, trusted, and respected care before, during, and after pregnancy. MCH has been working to increase the number of well-women visits through various avenues including surveillance, programming, and initiatives. Since the 2020, MCH has typically seen a maintenance of the percent of women with a preventative medical visit hovering around 75%. During the reporting year MCH did see a decrease in well-women visits to 73.3% not achieving the annual objective of 78.5%.

 

To better understand women’s experiences before, during, and after pregnancy, MCH utilized data from the Pregnancy Risk Assessment Monitoring System (PRAMS). Indiana PRAMS has undergone quite a bit of change during the reporting period. In 2021, a new Principal Investigator and epidemiology were hired. The staff turnover created a strain on the project timeline and implementation as it took time to get the new staff brought up to speed. These situations greatly affected PRAMS operations and response rates. This can be seen as the response rate decreased from 42.4% to 38.1% during this reporting period.

 

Despite the challenges, Indiana celebrated having five years of PRAMS data that can be used to drive programming and inform MCH initiatives. While Indiana has only met the CDC response rate threshold during one of those years (in 2018), the data is still weighted each year by the CDC and can still be utilized and shared with additional data caveat language understanding these limitations, PRAMS data shows that 90% of Hoosier women received a postpartum checkup when combining data from 2017 through 2021. Black or African American women reported the lowest percentage of women receiving a post-partum checkup (86%) and White women reported the highest percentage (91%). MCH recognizes the data caveats from not achieving the threshold and the importance of addressing the current response rate challenge and rethinking the implementation of PRAMS.

 

Increasing PRAMS Response Rate

The Indiana PRAMS Team implemented several new projects in order to increase the PRAMS response rate. Projects included strategically identifying and targeting under surveyed areas, social media campaigns, updating the website, and easier data analysis.

 

The first project included the creation of a map to strategically focus and identify ZIP Codes to increase response rates in those targeted areas. The MCH Surveillance Epidemiologist mapped PRAMS response rates based on the sampled woman’s residential address and whether she completed the survey or not. The map showed that the lowest response rates throughout the state were located in Marion County, home to Indiana’s capital city, Indianapolis, and where the Indiana Department of Health is located. As a result, the Indiana PRAMS team narrowed in on six specific ZIP Codes in Marion County with low response rates and high proportions of Non-Hispanic Black residents, a key demographic group for increasing PRAMS response rates. The Indiana PRAMS team located six Women, Infants, and Children (WIC) clinics that were located in those ZIP Codes to build collaborative partnerships and promote PRAMS. The Indiana PRAMS team met with state WIC staff to garner support and guidance, which was well received and resulted in a meeting with local WIC staff who operate clinics in the targeted ZIP Codes. The PRAMS team and local WIC staff met to discuss opportunities to display PRAMS materials in their waiting rooms and disseminate PRAMS information to WIC clients by directly handing out materials. The local WIC staff were supportive of these ideas to promote PRAMS. By building relationships with WIC staff in the areas that have low response rates, the PRAMS team is working to enhance PRAMS awareness and build an increased willingness, desire, and trust to respond to PRAMS surveys if sampled.

 

Another project to improve PRAMS response rates was a social media campaign to build PRAMS awareness utilizing social media platforms. MCH has had success in doing this for the Liv Mobile Pregnancy App and PRAMS sought to replicate those efforts. However, it was decided by the Office of Public Affairs that we could not pursue a media campaign during 2022 due to the heightened political climate around women’s health. The PRAMS team was disappointed by this news, but we are hopeful and optimistic something can be pursued again in the future.

 

The PRAMS Team spent considerable time updating the PRAMS website so that it is more informational to people who may be sampled, more user-friendly for requesting PRAMS data, and more visually appealing to invite increased traffic to the site. The PRAMS Team researched other state PRAMS sites to learn from other successes and then created brand new visuals showing how people are randomly sampled to participate in PRAMS and how their stories shape the work and direction of MCH.

 

The MCH Surveillance Epidemiologist also created an efficient and easy way to sort and search through over four years of PRAMS quotes, a rich source of qualitative data, that participants leave at the end of their surveys. In the past, these quotes were not organized or easily accessible for use. To remedy this, the Surveillance Epidemiologist created a new SAS code that reads through all submitted quotes and can pick out specific key words, sort them, and print them in an output that is easy to use. This will allow colleagues to utilize PRAMS quotes as qualitative data in presentations, educational materials, website updates, and grant applications. Using PRAMS data increases buy-in for PRAMS from partners and builds awareness of PRAMS – both of which can increase PRAMS response rates and strengthen the PRAMS program.

 

Postpartum Follow-up Care

MCH also utilized the PRAMS data to assist in reviewing the landscape of postpartum follow-up health care services within the first four to six weeks. Keeping in mind the data caveats from not achieving the threshold to have weighted data, MCH saw an increase from 87.8% to 90.0%.

 

Home Visiting Support Services

MCH continued to support women receiving postpartum follow-up health care services through home visiting support services. IDOH can track the percentage of mothers enrolled in home visiting who receive a postpartum visit with a healthcare provider within eight weeks of delivery. MCH will ensure that home visitors have access to training and education about postpartum care. Home visitors benefit from being knowledgeable about the benefits of postpartum care to share that information with mothers served. The home visiting programs ensure that staff are receiving training and education about postpartum care and how to define a postpartum visit. MCH is committed to increasing the home visiting program data through a Maternal, Infant, Early, and Childhood Home Visiting (MIECHV) Program and My Healthy Baby.

 

LIV Mobile Pregnancy App

MCH continued to promote postpartum care among women and encouraged them to own their healthcare journey through the LIV Mobile Pregnancy App. This is for those planning, pregnant, or are parents to utilize and download to their phone. LIV can help individuals navigate services near them, includes interactive features, send appointment reminders, and more. The LIV App is available in both an English and Spanish version.

 

ESM 1.3: Percentage of mothers enrolled in Home Visiting prenatally or within 30 days after delivery who received a postpartum visit with a healthcare provider within 8 weeks (56 days) of delivery.

 

Home Visiting Investment

MCH continued to partner with state agencies in the coordination of home visiting services within other systems. Specifically, MCH invests in Nurse-Family Partnership (NFP), with state and federal funding, including the Maternal Infant and Early Childhood Home Visiting (MIECHV) Program. The overall vision of Indiana’s investment in home visiting is to improve health and developmental outcomes for children and families. Nurse Family Partnership is an evidence-based community health program with years of evidence showing significant improvements in the health and lives of first-time moms and their children. The NFP model engages women early in pregnancy aiming to improve pregnancy outcomes through engagement in preventive health practices, improve child health and development, and improve families’ economic self-sufficiency. NFP serves mothers and infants for two years postpartum and will continue to advocate and be an essential proponent for getting women into essential postpartum care. Implementation of NFP began in 2011 and has expanded to reach 46 of the 92 counties in Indiana. In August of 2022, the state legislators increased the state investment in NFP to expand programming statewide. MCH is committed to maintaining and increasing the current home visiting service capacity to ensure that more clients have access to home visiting. 

 

Currently, across four active implementing agencies, Indiana has a total funded NFP capacity of approximately 2,600 families. With the strengthened state investment in NFP services, the IDOH funded capacity will increase by more than 1,600 families. From 10/1/2021-9/30/2022, a total of 1,723 families were served in the Indiana NFP programming. In Fiscal Year 2022 Title V directly supported the NFP Lake County implementation which served a total 240 clients with a total 2,619 completed home visits by a team of 8 full time nurse home visitors.  Since the implementation of NFP in Indiana, more than 8,000 families have been served to date.

 

The percentage of women who had an annual visit within 30 days after delivery continues to exceed the MCH goals set for the Title V Block Grant. The 10/1/2021 - 9/30/2022 data is representative of two local implementing agencies receiving MIECHV funding that tracks the percentage of mothers enrolled in home visiting who receive a postpartum visit with a healthcare provider within eight weeks of delivery. In FY22, 250 women were enrolled in home visiting prenatally (or within 30 days after delivery) and remained enrolled for at least eight weeks. Of those women, 123 received a postpartum visit with a healthcare provider within eight weeks of delivery. This represents 49.2% of eligible women receiving this service. While this is a decrease from the previous two years of reporting on this measure, it is significantly above the identified goal of 26.75%. MCH will continue to work in identifying the key barriers to postpartum care and providing support for families to receive this essential healthcare.

 

My Healthy Baby Initiative

My Healthy Baby is a collaboration between the Indiana Department of Health, the Indiana Family and Social Services Administration (FSSA) and the Indiana Department of Child Services (DCS). This initiative is building a network of services and support to wrap our arms around moms and babies to create healthier outcomes for both. It was established by House Enrolled Act 1007, which was signed into law by Gov. Eric Holcomb in 2019. My Healthy Baby connects pregnant women on Medicaid to home visiting providers in their own community. A family support provider offers free, personalized guidance and support to the woman during her pregnancy and for at least the first 12 months after her baby’s birth. My Healthy Baby referred women to perinatal home visiting programs and offered many areas of support including positive parenting, child development, maternal and child health resources, access to social supports, and family economic self-sufficiency. My Healthy Baby referred 4,962 clients to home visiting programs during the 12-month period from October 1, 2021, through September 30, 2022.

 

Increased Medicaid Coverage

Throughout the pandemic, it was essential that pregnant women had adequate access to health insurance. It was even more critical that they were covered during the postpartum period. During the ongoing federal public health emergency, no coverage in Indiana was discontinued, which means new mothers could stay on Medicaid beyond the 60-day postpartum limit. This order stood as long as the public health emergency declaration was in place. Fortunately, IDOH and state legislatures worked throughout the pandemic to expand postpartum Medicaid coverage. Hoosier mothers will be able to stay on Medicaid for up to 12 months after giving birth under a new coverage expansion starting in April 2022. 

 

State Priority Need:

Reduce preventable deaths in the MCH population with a focus on reduction and elimination of inequities in mortality rates.

 

State Performance Measure (2020 - 2025):

SPM 1: Reduce maternal mortality rates and disparities by promoting best practices in clinical care.

 

In order to measure the maternal mortality rates within Indiana, MCH uses the Alliance for Innovation on Maternal Health (AIM) Patient Safety Bundles. These bundles help measure the number of birthing hospitals around the state implementing the Obstetric Hemorrhage Bundle. MCH utilizes this performance measure to also implement programming within our partner division of Fatality Review and Prevention, to reduce violent deaths, to increase access to mental health, and to utilize the Perinatal Quality Collaborative.

 

Alliance for Innovation on Maternal Health Bundles (AIM)

MCH continued working with the American College of Obstetricians and Gynecologists (ACOG) to reduce maternal mortality and morbidity through evidence-based patient safety bundles under the Alliance for Innovation on Maternal Health (AIM). The Indiana AIM Collaborative has made considerable strides in enrollment, quality improvement, and data improvement in patient safety bundle implementation. To date, IDOH has successfully implemented the Obstetric Hemorrhage bundle and the Severe Hypertension in Pregnancy bundles. By September 30, 2022, 100% of delivering facilities in Indiana were enrolled in Severe Hypertension in Pregnancy Bundle with 98% of delivering facilities enrolled in the Obstetric Hemorrhage bundle. This success in enrollment was due to the continued work from the MCH nurse surveyor team and Indiana AIM team to monitor goals and outcomes for each facility while simultaneously encouraging continuous quality improvement. Data submission remained steady at above 80% for all quarters and there has been a steady increase in education for both bundles regarding education for providers and nurses. MCH will continue to implement new AIM bundles in response to the annual Maternal Mortality Review Committee (MMRC) report to align with recommendations and needs of pregnant and postpartum Hoosiers.

 

Indiana has continued to strive for improvement in quality and care to support delivering facilities around the state. The Indiana AIM Team participated in two communities of learning (COLs) which included the AIM Data Support COL (January 1, 2022 to August 31, 2022, and the Quality Improvement COL (September 1, 2021- August 31, 2022). Each series not only provided presentations from the top experts in each field of patient, hospital, and data improvement, but also provided hands-on learning opportunities and support to participants. Additionally, the two Indiana AIM State Leads traveled to Rockville, Maryland from September 6-8, 2022, to participate in the Annual AIM Meeting which brought together other state leads, PQC leaders, and experts in the maternal health field for an immersive learning and networking experience. From this meeting, Indiana made genuine connections with other states who faced similar barriers and problems to work together to find a solution.

 

While participating in each of the COLs, the Indiana AIM Team also provided technical assistance and continuing education opportunities to the Indiana AIM Collaborative. Each month the Indiana AIM Team hosted speakers and experts in the clinical field to present on subjects related to Severe Hypertension in Pregnancy or Obstetric Hemorrhage during a join webinar for the enrolled facilities. There was a high number of participants in each webinar because each facility was focused on providing the highest standard of care for each pregnant and postpartum patient. In addition to the monthly educational webinars, the Indiana AIM Team also held biannual webinars to review the data improvement and quality of the collaborative. Prior to these data webinars, each facility received an individual hospital report which summarized their progress, barriers, and areas for improvement in their enrolled bundle(s). Then during the data webinar, the Indiana AIM Team would discuss collaborative-wide successes, areas for improvement, and how the state of Indiana compared to states of similar demographic characteristics (such as other Midwestern states). 

 

Maternal Mortality Review Committee

The Indiana Maternal Mortality Review Committee (MMRC) was formalized in July 2018 following passage of IC 16-50, which required the multi-disciplinary review of pregnancy-associated deaths in Indiana and secured protections for the confidentiality of the process. The MMRC was developed with guidance from the Centers for Disease Control and Prevention (CDC) Division of Reproductive Health’s Building US Capacity to Review and Prevent Maternal Deaths program and is modeled after other well-established MMRCs in the United States. Coordination for the MMRC and related activities is under the purview of IDOH’s Division of Fatality Review and Prevention (FRP). IC 16-50 was edited during a special legislative session by SB 1, which was added to create further prohibition of abortions in Indiana and made changes to the MMRC requirements. Indiana MMRC has taken these into consideration and made the necessary changes required.

 

The Indiana MMRC includes representation from a broad range of physicians and nurses from multiple specialties (Obstetrics and Gynecology, Cardiology, Pulmonary Medicine, Anesthesiology, Pathology, Maternal-Fetal Medicine, Public Health), along with social workers, coroners, health advocates, and other allied health professionals. These volunteers extensively review pregnancy-associated deaths to identify opportunities for prevention. As the goal of the review is identifying systems level changes and not assigning individual blame, the names of patients, medical providers, and involved institutions are not disclosed during the process. During the last year, Indiana MMRC has done a full evaluation of the members of the MMRC by sending out applications, required by all members, dictating their skills and role with the MMRC.

 

In 2019, FRP was awarded funding through the CDC project entitled Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM). This grant and the associated technical assistance have allowed for the expansion of efforts already underway to systematically identify and collect relevant information pertaining to pregnancy-associated deaths, review the findings, and make data-driven recommendations. Indiana MMRC continues to maintain this grant and began the fourth grant year.

 

The Indiana MMRC is currently continuing its work to identify and review all deaths of women within one year of pregnancy and childbirth. Deaths occurring in 2021 will be completely identified and reviewed by late spring 2023. FRP has been concurrently identifying and gathering records for deaths which occurred in 2022 to facilitate the beginning of that cohort’s review immediately following the completion of 2021 deaths. FRP has also been concurrently identifying 2022 cases to continue timely and accurate reviews. The fourth annual Maternal Mortality Review (MMR) report will be completed and released in Summer of 2023.

 

The release of the third annual MMRC report identified that the pregnancy-associated and pregnancy-related mortality rate was much higher than what was seen the previous two years. While the majority of pregnancy-associated deaths (59.8%) occurred six weeks or more post-partum, 66.7% of the deaths determined to be pregnancy-related occurred either during pregnancy or within the first week post-partum. These findings suggest women are most at risk for dying from a pregnancy complication or other condition aggravated by pregnancy either during pregnancy or in the first week following childbirth. However, their risk of dying from other causes, including injury or other medical conditions, is highest six or more weeks out from childbirth.

 

The race-specific ratios are different between 2018, 2019, and 2020, with 2020 data showing a Black, non-Hispanic rate twice that of White, non-Hispanic women. 2018 and 2019 data also indicate that Black, non-Hispanic women have a higher mortality rate than White, non-Hispanic women, but the difference is not as large as what was seen in 2020. This large difference is likely due to the ratios being considered unstable, because of the small numbers in one-year data. As the MMRC collects more data through continual review of all maternal deaths, they can also continue to make more targeted, evidence-based recommendations for preventing similar deaths and reducing maternal mortality in Indiana.

 

The report also identified data collected from three years, showing a slight disparity with Black, non-Hispanic women experiencing 128.8 pregnancy-associated deaths per 100,000 live births, compared to 91.6 for White, non-Hispanic women. The ratios for Hispanic women and women of other races are much lower. Again, take caution when interpreting these ratios, as they are still based on quite small numbers, and are all considered unstable ratios. These ratios may still fluctuate quite a bit from year to year, and the MMR staff will continue to include to evaluate the average ratios as more review data is collected in the coming years.

 

FRP continued to evaluate and expand the types of records and information that can be accessed to understand each woman’s history and each touchpoint or type of service/care she received.  The MMRC has been working to incorporate more records into the review process that provide a full picture of both medical and social events that could have impacted outcomes. FRP has continued working with FSSA and Medicaid data and has collaborated to create a more cohesive process to obtain these records. Unfortunately, Indiana MMRC has hit a snag regarding the Division of Mental Health and Addiction. Indiana MMRC lost engagement with the person responsibility for Division of Mental Health and Addiction and has continued to seek out another person to engage with to continue to receive records.  However, Indiana MMRC has made up for this loss by pushing to gather these records on their own. The addition of mental health resources has allowed MMRC to evaluate the mental health challenges and provide educated recommendations and MMRC would like to see this continue. FRP continues to work on engaging DCS, WIC, local jails, the Department of Correction, substance use treatment providers and more.

 

Indiana MMR team continued to work on incorporating informant interviews and interviews with family or loved ones into the process. The goal of these interviews continues to be to understand the women’s perceived experiences and well-being during pregnancy or in the time leading up to death. It has continued to be an issue that the official records do not provide the whole story, and these interviews provide valuable insight into how a woman was feeling and what she may have experienced during this time. To achieve this, Indiana MMRC has maintained the contract with the Grassroots Maternal Child Health Leadership Training Project. Grassroots trains and mentor's women to help their neighborhoods improve pregnancy and infant development outcomes. They work to make change at the community, organizational, and policy levels, while meeting the needs of women, infants, and families in their neighborhoods by linking them to services. These community leaders and the FRP nurse consultants have received appropriate training for conducting family interviews and will ultimately embed these qualitative data into the pregnancy-associated death case presentations. This critical addition to the case narratives has helped the Indiana MMRC better understand the experiences of women who died, as well as their families, friends, and communities who endured the loss of a pregnant or recently pregnant woman. By hearing stories directly from those closest to the women who died, recommendations generated by the committee can be informed by the individual circumstances leading to pregnancy-associated deaths. The MMR team has continued to send notifications to families of the deceased and has conducted 5 interviews this year.

 

Community Vital Signs

During the past year, the Division of Fatality Review and Prevention (FRP) has worked to incorporate the Community Vital Signs (CVS) Project into the MMRC process. The project was developed by a team at Emory University with support from Centers for Disease Control and Prevention, Division of Reproductive Health Maternal Mortality Prevention and focuses on incorporating causes of inequity within a community into the MMRC conversation through summarizing community resources, experiences, and exposures in the place in which the decedent lived. The goal of using the CVS is to provide evidence-based data and link it to actionable recommendations. FRP has worked on incorporating the CVS into the narrative that opens each case review and sheds light on the resources a woman had access to during the last year of her life. These indicators do not describe the individual choices or behaviors of the decedent, but instead were selected to reflect the maternal health risk environment including the supply and demand for health services, as well as social, economic, and environmental factors that are hypothesized to shape reproductive and perinatal health.

 

Suicide and Overdose Fatality Review 

Under the purview of FRP, the Suicide and Overdose Fatality Review (SOFR) Program began in 2018 as a pilot program in three counties. Since then, the program has expanded to 23 functioning teams, with six more in the formation phase. The local expertise of the SOFR team membership has been a critical addition to the MMRC work because there is a high burden of suicide and overdose death among maternal mortality in Indiana. MMRC members have been identified through SOFR teams and coordinated case identification and records sharing processes have been established. As additional SOFR teams are created and prevention efforts are recommended through the MMRC, the joint efforts of both programs will be critical for information dissemination and guidance for evidence-based best practices.

 

Maternal Deaths Due to Violence Prevention

Improvement in clinical care was also the focus when providing the educational opportunity to reduce maternal mortality from intimate partner violence (IPV). As part of the State, Local, Territorial, and Trible (SLTT) Partnership grant, which was awarded to the Indiana Department of Health’s Division of Maternal and Child Health (MCH) and Division of Fatality Review and Prevention (FRP), IDOH MCH collaborated with the Indiana University School of Medicine (IUSM) to deliver a cost-free tele-education course for healthcare and social service providers around the state. The IUSM Extension for Community Healthcare Outcomes (ECHO) program is focused on connected primary care teams from local areas to multi-disciplinary specialist teams to improve treatment, quality, and knowledge for various health conditions and populations. During the Maternal Mortality Prevention and IPV ECHO the hub team of experts present short didactic presentations around a particular sub-topic on IPV, and the participants can present de-identified patient cases to specialists or expert teams who then mentor the providers as they learn to manage patients with complex conditions. The hub team of experts included specialists such as healthcare providers from the community and a variety of settings to include clinical care, trauma-informed care, psychiatry, law and law-enforcement, and community advocacy and training. IUSM and MCH scheduled seven didactic presentations for participants around the state to register. The first ECHO for this subject was held on July 11, 2022, with over 100 participants. The final ECHO session is scheduled to end on October 10, 2022, with a scheduled second round of the same subjects to reach even more providers on a different meeting cadence.

 

As part of another strategy to improve clinical care to reduce maternal deaths due to violence, MCH also began a partnership with the Centering Healthcare Institute (CHI) which is the non-profit known for employing a well-known model of group prenatal care, CenteringPregnancy. CenteringPregnancy is a group prenatal care model that seeks to support pregnant patients around the same gestational age through group health visits, facilitated group education, and opportunities for community building. Benefits from CenteringPregnancy and other group prenatal care models include reduced premature births, reduction in low-birthweight deliveries, improved breastfeeding and immunization rates, and decreased caesarean sections. MCH began working on an agreement to grant funds to CHI to provide project management and implementation support to five clinical facilities to pilot a CenteringPregnancy and CenteringParenting model with a supportive lens for IPV. MCH sees the opportunity to implement an upstream approach to support the clinical facilities in improving the overall health of pregnant and postpartum persons which can have benefits on the social and structural determinants of health which may reduce the incidence of maternal deaths due to IPV. This agreement is expected to be executed by December 31, 2022.

 

MCH and FRP continued to make significant advancement in the Reduce Maternal Deaths due to Violence project through the work of case completion. As part of this project, FRP had set a year one goal to improve the “completeness” of cases reviewed by the Maternal Mortality Review Committee (MMRC) to improve the overall quality of case reviews and recommendations by the committee. By increasing the case completeness, the members of the MMRC will have the adequate level of information for deciding cause of death and the opportunities to prevent similar deaths in the future. For the first year, FRP set the goal to reach at least 65% of case completeness for each case record. By the end of the project year, FRP reached the goal, with the members rating 65% of cases reviewed were complete.

 

Maternal Mental Health

MCH was awarded the State Maternal Health Innovation (MHI) and Data Capacity grant from the Health Resources and Services Administration (HRSA). As response to the critical needs of mothers and birthing persons in Indiana, through the State Maternal Health Innovation (MHI) and Data Capacity grant, MCH will increase the support and capacity for maternal mental health and postpartum care. This will be achieved through establishing a Maternal Health Task Force (MHTF) and Community Advisory Committee (CAC) that will guide state and project staff to identify areas of need and develop a maternal health Strategic Plan. The Strategic Plan will strive to improve data and surveillance through collecting qualitative data in a digital story platform, improving data quality and AIM implementation through strengthening the workforce, improving current data usage for racial and ethnic data, promoting continuous quality improvement among participating AIM hospitals, and employing innovative strategies by piloting the AIM safety bundle, Postpartum Discharge Transition, with a Stepped Care Model for mental health in five sites.

 

Severe Maternal Morbidity

MCH was also awarded the State Perinatal Quality Collaborative (PQC) agreement from the Centers for Disease Control and Prevention (CDC) respectively this year. Indiana continues to struggle with high rates of infant and maternal mortality and morbidity. In 2021, the infant mortality rate was 6.7 deaths per 1000 live births with significant disparities, especially in non- Hispanic Black populations. In 2021, the non-Hispanic Black infant mortality rate was 13.2 deaths, compared to 5.4 non-Hispanic White infant deaths, and 8.1 Hispanic infant deaths per 1000 live births. Overdose, both accidental and unknown intent, was overwhelmingly the leading cause of death, accounting for 30.4% of pregnancy-associated deaths in 2020. With the State Perinatal Quality Collaborative (PQC) agreement, Indiana goal is to improve collection and access to rapid, population health data, to address Indiana’s perinatal morbidity and mortality more nimbly. Indiana will utilize its ‘three-legged stool’ of a PQC—IPQIC, IHA, and IDOH to (1) collect data through a dashboard (2) review the data continuously in order to (3) deploy Continuous Quality Improvement (CQI) projects within facilities. To begin, the implementation team will leverage the deployment of the AIM- Care for Pregnant and Postpartum People with Substance Use Disorder toolkit. Through the life of the project, the team will expand CQI efforts in ‘level 0’ facilities and standalone emergency departments and include other AIM bundles.

 

Levels of Care

In September 2019, IDOH promogulated the Perinatal Level of Care (PLoC) rules which designate both neonatal and maternal units in a delivery facility. By September of 2021, IDOH has received 100% birthing facilities PLoC applications, and in the years since, MCH survey team has traveled the state surveying and designating all delivery facilities. The survey team has seen marked improvement in the quality of care delivered when comparing gap analysis results from 2015 to the results of facilities’ surveys.

 

Every hospital has successfully been designated; however, the survey team has begun hospital recertification. So far in this reporting period, 19 out of 19 Level III/III birthing facilities have submitted their application for their hospital recertification. The MCH Clinical Team continued to work in partnership with the Indiana Perinatal Quality Improvement Collaborative MCH’s Clinical Team worked through considerable challenges and problem solving to help facilities navigate through the designation process. Not only were hospitals dealing with considerable barriers due to COVID pandemic, staffing shortages on the units as well as on transport teams made it difficult for many facilities. The Clinical team worked with each facility individually to understand their unique challenges and strengths. The team used tools such as remote chart reviews, flexible scheduling, and the increasing use of tele-health to evolve MCH’s survey process.

 

Justice-Involved Mothers and Infants

In September 2020, IDOH partnered with IU Richard M. Fairbanks School of Public Health to support Grassroots Efforts to Improve Indiana’s MCH Outcomes. The funding supported the creation and development of Mothers on the Rise (MOTR), which aims to create a system to serve mother/baby pairs transitioning from the Leath Nursery Unit at the Indiana Women’s Prison to their home community. Mothers on the Rise worked with each mom/baby dyad to provide education, help create a resume and think about job placement upon release, provide clothing, hygiene supplies, and infant care supplies, connect them with food banks, link them to necessary mental health services, prenatal services, or women’s health care, and aid with the BMV or legal help. The aim of the project is to provide equitable services to formerly incarcerated women, who have experienced socioeconomic and/or racial health, education and financial disparities across their life course. MOTR paired each dyad released from the women’s prison to a community navigator who supports the mom and baby in attending well child visits and securing social services like Section 8 housing.

 

This past year, MOTR has further developed goals for the program and has expanded on their objectives. This expansion on the objectives better provides an update on program success. The MOTR Team hosted a quarterly retreat with IDOC transitional healthcare team, MOTR staff, and early childhood education professionals to plan our next steps to improve parenting and bonding practices in the nursery unit. Throughout this first year the program has faced various challenges including, keeping up with the number of times mothers have had to change their contact information, transportation and housing barriers, and toxic partnerships. Addressing these barriers requires MOTR to rely mostly on partnerships, forming new alliances in communities, and recruiting community navigators. MOTR has partnered with the IU McKinney School of Law to provide legal aid and services to the women. Through this partnership, 10 women have filled out the forms to request assistance. Another great success MOTR had surrounds their ability to assist and secure safe housing to prevent mother/baby pairs from homelessness. Through MOTR’s first year of transformative work, no mother-baby pair had to be separated and not a single mother returned to the justice system.

 

State Priority Need:

Reduce preventable deaths in the MCH population with a focus on reduction and elimination of inequities in mortality rates.

 

State Performance Measure (2020 - 2025):

SPM 2: Prevent the use of substances, including alcohol, tobacco, and other drugs among youth and pregnant women.

 

The statewide needs assessment survey showed substance use as the second highest need (behind mental health) for communities across the state. Inevitably, women who use substances may become pregnant, and MCH is committed to ensuring they have access to optimal healthcare throughout and after their pregnancy. As MCH improves the ability to screen and identify women using substances during pregnancy, we hope to grow in our capacity to provide further treatment and care for all families. MCH received positive cord data directly from hospitals and is analyzed by our MCH epidemiologists. MCH utilizes the number of birthing hospitals who report this cord data to assist in measure the preventing the use of substance in pregnant women. During the reporting period, there was 84.5% of hospitals reporting the data. This is not only an increase from the previous year of 81%, but also meets the annual objective of 84%.

 

Perinatal Substance Use Taskforce

MCH continues to work closely with the Indiana Perinatal Quality Improvement Collaborative’s (IPQIC’s) Perinatal Substance Use (PSU) Taskforce. Through this taskforce, MCH has the opportunity to work closely with participating birth hospitals and focus on best practice implementation for PSU and Neonatal Abstinence Syndrome diagnosis and surveillance. The intention is to move this taskforce from a focus on data collection to data-guided action by way of a heightened emphasis on prevention for future work. To use data to guide future prevention efforts, the MCH Epidemiology Team conducted a bias analysis utilizing the PSU data collected from participating hospitals and Vital Records birth worksheets. The analysis incorporated race and ethnicity data from birth records and PSU screening data as reported by the hospitals. The results showed that hospitals that had a higher proportion of Non-Hispanic Black births also had a higher screening percentage, while hospitals that had a higher proportion of Non-Hispanic White births had a lower screening percentage. The association for Non-Hispanic Black births was found to be statistically significant. This was the first-ever analysis of this kind within our work and has been used to spur conversations with the hospitals about bias in screening for substance use and to build an emphasis on prevention.

 

Additionally, IPQIC’s PSU task force has worked on completing the toolkit for the Care for Pregnant and Postpartum Persons with Substance Use Disorder bundle from the Alliance for Innovation of Maternal Health (AIM). The PSU taskforce was divided into sub task force to review the previous toolkit released and identify gaps and areas to support hospitals during implementation. Each sub task force focused on one of the five R’s of the bundle which included Readiness for every unit, Recognition & Prevention for every patient, Response for every event, Reporting and Systems Learning for every unit, and Respectful, Equitable and Supportive Care for every unit, provider, and team member. The final draft of the toolkit was reviewed by the entire PSU taskforce on August 15, 2022. Once approved and accepted by the IPQIC’s leadership, the toolkit will be ready for implementation.

 

Fetal Alcohol Spectrum Disorder

As a result of the collaboration among DCS, FSSA, MCH and IPQIC, a plan of care template was developed to address appropriate linkage to resources and supports for all pregnant patients. While modeled after the CAPTA required Plan of Safe Care, the template expands linkages to community resources and provides for postpartum care continuity. The template has been piloted at a Level III hospital in Northern Indiana. The plan has also been incorporated into the resource materials for Indiana's PSU Hospital Collaborative.

 

Building on the work of the IBDPR related to documenting prenatal alcohol exposure, IPQIC worked with its PSU task force to assess the reliability of the ETOH and the cost connected to additional cord tissue testing. IPQIC also collaborated with the state Children's Commision to look at the challenge of identifying older children who had been potentially exposed to alcohol but never received a diagnosis. These children too frequently identified with cognitive and behavior issues with no documentation of prenatal exposure. As a result of these issues, effective October 1, 2023 the cord tissue panel that the PSU Hospital Collaborative is implementing will include alcohol testing.

 

Tobacco Cessation

MCH has made many efforts to address the high rates of tobacco use during and after pregnancy. MCH has partnered with the Division of Tobacco Prevention and Cessation (TPC) to release an opportunity for five pilot OB/GYN clinics to implement the evidence-based model, Clinical Effort Against Secondhand Smoke Exposure (CEASE). CEASE addresses family tobacco uses in a routine and effective manner, with a mission to educate, encourage, and support individuals to choose a smoke-free lifestyle through the 3A model of tobacco cessation, Ask-Assist-Refer.

 

Additionally, MCH and TPC has worked together to develop a three-tiered tobacco cessation program to pilot throughout Indiana. The three-tiered approach adopts the Ask-Advise-Refer intervention, integrates a referral system to the Indiana Tobacco Quitline into the sites electrotonic medical records, and, lastly, funding for the Tobacco Treatment Specialist (TTS). The letter of intent was released mid-August 2022 and five pilot sites were awarded September 2022, with a grant start date of October 1st, 2022.

 

Other Substance Prevention Collaboration

Members of the Title V program, including the MCH Director, Clinical Director, and members of FRP participated with partners at the Division of Mental Health and Addiction on a PRISM project through ASTHO. The Promoting Innovation in State & Territorial MCH Policymaking (PRISM) Learning Community has provided regular technical assistance and capacity building over the past twelve-months to support and advance policy implementation within states and territories to equitably address substance misuse and addiction and mental health disorders in women, children, and families within the context of the COVID-19 pandemic. Indiana was able to use the technical assistance time to meet more closely with our partners in the Family and Social Services Administration to learn more about their Plans of Safe Care initiatives and the Indiana Pregnancy Promise Program.

 

In 2019, Indiana’s Office of Medicaid Policy and Planning was awarded a Centers for Medicare and Medicaid (CMS) grant to address opioid use disorder in pregnant patients. The Indiana Pregnancy Promise Program is a free, voluntary program for pregnant Medicaid members who use opioids or have used opioids in the past. Through partnerships with the state’s managed care entities (MCEs) The Pregnancy Promise Program connects individuals to prenatal and postpartum care, other physical and mental health care, and treatment for opioid use disorder. The Pregnancy Promise Program provides support during the prenatal period and for 12 months after the end of pregnancy. Support encompasses not only access to case management, recover services, but also priority in other state funded services such as high-quality pre-k. Through these supports and relationships, the Pregnancy Promise Program provides hope to parents and babies and sets a strong foundation for their future. The project director the program continued to serve on IPQIC and the MMRC. The MCH Director continued to serve on the board for the Pregnancy Promise program. In this reporting year, the program continued to build partnerships and infrastructure to refer pregnant people to resources across Indiana. They have successfully leveraged the Managed Care Entities (MCEs) and the Indiana 211 system to connect pregnant people to services. Pregnancy Promise began enrollment on 7/1/2021 and by 9.30.2022 there were 310 enrollees. 200 enrolled in the prenatal period and 110 in the postpartum period.

 

The MCH Director continued to work with NACCHO and CityMatCH on the Alignment for Action Learning Collaborative with Bartholomew County. This partnership seeks to examine how state and local health departments can more collaboratively learn and work together to align strategies for population health improvement. Specifically, the state is learning from Bartholomew County how they implemented a FIMR program that essentially eliminated safe sleep related deaths in their community. The Title V program will take those learnings and spread and sustain to other counties with similar projects. Additionally, Bartholomew County is working to build prevention and intervention strategies related to substance use disorder in pregnant people. These learnings are especially important as Bartholomew County is considered ex-urban and rural. Its population is similar to many other counties within the state where these strategies may be replicated. The Title V program is grateful for the opportunity to forge new and strengthen existing partnerships as a result of this opportunity.