III.E.2.c. Women/Maternal Health: Annual Report 2024 (10/1/2022-9/30/2023)

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.

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 the baby.  

 

To better understand women’s experiences before, during, and after pregnancy, The Maternal and Child Health Division (MCH) utilized data from the Pregnancy Risk Assessment Monitoring System (PRAMS). PRAMS previously outsourced the implementation of Indiana’s surveys but encountered issues with response rates falling below the minimum threshold, with a continuous decline over time. Reaching the minimum response rate would ensure that findings from Indiana’s PRAMS data are representative of the state and enable the data to drive the creation of additional programs for mothers and infants. During this reporting period, Indiana PRAMS has undertaken major changes to increase the number of respondents. This includes moving the operations of PRAMS in-house with the assistance of Title V funding, implementing the new Phase 9 of the survey, and a complete overhaul of Indiana PRAMS materials to accompany the new implementation.

Increasing PRAMS Response Rate

Starting July 2023 operations officially moved inhouse with the first distribution of surveys beginning August 2023. The full operations and responsibilities of PRAMS are now maintained within MCH, spanning the programs, systems building, and epidemiology teams. By moving operations into the hands of IDOH staff, MCH hopes to increase the response rate of women completing the survey. The PRAMS team has worked to redesign all products to ensure cohesive and correct materials for the program. Following final approval, the PRAMS team initiated large-scale printing of questionnaires, letters, calendars, and reminders, sending them to potential respondents. Instead of a monthly upload, the team shifted to an accelerated schedule, releasing a batch every two weeks due to delayed distribution compared to other states. The doubling of the number of batches allowed MCH to collect as much data on 2023 births as possible with plans to move to single batches starting in December 2023.

To continue to try to increase the response rate MCH now utilizes current state resources such as mailers and logos from IDOH and the MCH call center number in hopes of being a more recognizable program. The intentional use of having a call specialist sit within the MCH Mom’s Helpline was to have a trusted number appear when calls were made with the hopes that more would answer the phone and partake in the survey. The PRAMS team was able to work alongside the MCH Epidemiologists, Women Infant, and Children (WIC), and Vital Records to obtain sampled respondents’ information.

Another strategy to increase the response rate was introducing and utilizing the PRAMS online survey responses for the Indiana program. Included with every mailing, MCH provided a QR code and login information, allowing mothers to conveniently complete the survey online without mailing back the questionnaire or waiting for a phone interview. The integration of web surveys has contributed to seeing preliminary higher response rates.

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

Postpartum Follow-up Care 

MCH also utilized the PRAMS data to assist in reviewing the landscape of postpartum follow-up healthcare services within the first four to six weeks. Keeping in mind the data caveats from not achieving the threshold to have weighted data, MCH continued to see 90.0%.

 

Home Visiting Support Services 

MCH and Title V funding continued to support women receiving postpartum follow-up health care services through home visiting support services. MCH 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 and the home visiting programs ensured that staff received training and education about postpartum care and how to define a postpartum visit. Home visitors benefit from being knowledgeable about the advantages of receiving postpartum care to share that information with their clients. With more local implementing agencies reporting this metric it may be possible to identify if some agencies have stronger connections with hospital systems and OBGYN's that could result in better access to postpartum care for their clients. This comparative data gives MCH the ability to provide local implementing agencies with quality improvement tools so they may in turn implement strategies to improve process measures. The Home Visiting Team has been working on expanding the statewide data analysis (while the team is not looking at this measure currently, there are plans to expand data analysis in the future with the opportunity to include this measure).  

 

LIV Mobile Pregnancy App

The Liv Pregnancy App is a mobile app provided by MCH that includes all the fun features of a typical pregnancy app but also provides education and access to local Indiana resources.  Liv is a great tool that can help not only promote postpartum care but also fight against infant mortality within Indiana. All the content within the app is from trusted sources such as the National Institutes of Health (NIH) and the Centers for Disease Control and Prevention (CDC). Content is reviewed and updated yearly, making the latest information available to users. Features and content target users (and their support team) in Indiana who are planning for pregnancy, experiencing pregnancy, and parenting an infant after pregnancy. Digital marketing is used to reach MCH’s target audience in all corners of Indiana bringing Liv to them right on their phones.

In 2023, Liv had over 10,000 downloads, bringing the total lifetime downloads to over 32k. An annual focus group was held in quarter one of 2023 and kickstarted a makeover of the Liv app. When Liv first launched at the Labor of Love Summit in 2017, the design fit the amount of content, however, it has expanded to include over 160 articles and over twenty features.  A redesign is currently underway and will model other apps in the industry that have recently been refreshed to concisely display content in a way that is easily consumable to the user, all while allowing users to search the database of articles when they are trying to find something specific. Liv also implemented more detailed app analytics in 2023 to better understand user patterns to help answer the questions: what features are used the most, how long are users spending on each feature, and what features need to be refreshed to grab users’ attention more?

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 eight 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 and Title V. During FY23, there was a significant increase in state investment in home visiting that allowed for Nurse-Family Partnership (NFP) to expand services across all 92 counties in Indiana. This major investment allowed teams to expand their services to surrounding counties in their area. This expansion led to the creation of new teams and shifts in leadership to accommodate the growing teams.

Additionally, due to this increase in investment for home visiting, the internal staff on the MCH Home Visting Team restructured and expanded their team. The team now consists of a Home Visiting Program Manager, a Home Visiting Coordinator, and a Home Visiting Data Coordinator. The Home Visiting Coordinator and Home Visiting Data Coordinator role administers NFP programming across various funding sources.

My Healthy Baby Initiative

My Healthy Baby is a statewide initiative that seeks to identify and connect women as early as possible in pregnancy to home visiting programs within their local communities. In partnership with MCH, My Healthy Baby is working to expand home visiting data by collecting and analyzing identifiable, client-level data for My Healthy Baby clients who are referred and then go on to enroll and participate in partnering home visiting programs throughout the state. Data-sharing agreements and updated client consent forms have also been implemented to ensure that all home visiting partners and clients are informed of how their data will be utilized.

Title V Subrecipient

Goodwill Industries of Michiana, Inc

Goodwill Industries of Michiana receives home visiting funds from two funding sources, Title V and Maternal, Infant, and Early Childhood Home Visiting (MIECHV). Goodwill has demonstrated strengths in outreach events, partnerships, and referral linkages. In 2022 Goodwill saw 194 total referrals, which have spiked this reporting year with an increase to 307 referrals for 2023. This spike in referrals shows evidence that Goodwill has strived to keep the community informed about Nurse Family Partnership and supported as many families as possible. Goodwill was dedicated to expanding the program and hiring quality nurses to conduct these visits. In total, there were 220 clients served with Title V funds. Goodwill attended multiple community events, shared resources, and reached out to local organizations in Lake County to spread awareness of the benefits that home visiting offers. Though Goodwill has faced many staffing barriers they continued to keep up with competitive wages and use best practices to reduce staff burnout.

Increased Medicaid Coverage

Throughout the pandemic, pregnant women needed to have 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. IDOH and state legislatures worked throughout the pandemic to expand postpartum Medicaid coverage and beginning April 2022 Hoosier mothers can stay on Medicaid for up to 12 months after giving birth and has continued during the reporting period.

Reproductive Health and Contraceptive Care Services

Indiana passed Safety PIN – Protecting Indiana’s Newborns Grant Program, IC 16-46-14 (2015) - legislation to help stop the preventable deaths of infants in Indiana. This legislation allows the Indiana Department of Health, Maternal and Child Health Division (MCH), to receive non-reverting appropriated funds that can be granted to organizations to reduce infant mortality and aid the priorities set by Title V. An amendment to the legislation during the special session in 2022 expanded the use of funding to include increased access to reproductive health and contraceptive services and access to fertility awareness-based family planning methods.  

MCH was able to initially award one grantee from a non-competitive application after MCH and partners recognized a critical need within a specific population.  

• Health Care Education and Training, Inc. (HCET) will partner with IDOH and PATH4YOU, to complete activities that improve reproductive health in women’s prisons, with a focus on the Indianapolis Women’s Prison. These activities include education, health fairs, town halls, and staff support.

MCH also was able to work on updating the internal rules and procedures to create a request for applications (RFA) to grant funds to sub-recipients across the state. MCH was able to strategically assess existing coverage and other expansions to determine where this funding will make the most impact. Subrecipients must implement programs to increase access to reproductive health services and contraceptive care. Applicants were able to apply for one or both of the following components: Component A: Education, Training, and Awareness or Component B: Building Innovation.   

Of the applications three grantees were awarded for start dates in the next year and four applications were funded through partnerships and conversations with our Title X program.

• The Indiana Pharmacy Association (IPA) seeks to promote and support the implementation of contraception prescribing by pharmacists through the development of health-equity focused training and provision of financial support until Medicaid reimbursement is enacted for services.
• The Family Health Center will provide access to reproductive health services and contraceptive care to clients, with a focus on migrant workers, Haitian and Creole populations, university students, and recovery homes through training, education, and awareness.
• Lifespring Health System aims to enhance the accessibility of dependable contraceptive options for vulnerable women, including those with substance use disorders and those experiencing homelessness.

Women’s Health

In early 2023, The Office of Women’s Health merged with the Maternal and Child Health Division at the Indiana Department of Health. The MCH Maternal Health Program’s Team has now become the Women & Maternal Health Team with the Maternal Health Administrator becoming the Director of Women’s Health. The Office of Women’s Health was restructured into three areas within MCH. With this restructuring, MCH has been working to incorporate more programming for women who fall outside the maternal health programs. These programs include Sexual Assault Nurse Examiner (SANE) Programming, Preventative Health and Health Services-funded sexual assault prevention, Rape Prevention and Education Preventing Violence Against Women, and Substance Use Initiatives.

 

Title V Subrecipients

Harrison County Health Department

The Harrison County Health Department (HCHD), Harrison County IN, offered annual well-women visits, pre-conceptual counseling, prenatal/postpartum care, and family planning services to all women in Harrison, Crawford, and Washington Counties. This past year, HCHD saw many successes including the expansion of services to reach underserved populations and individuals who had abnormal mammogram screening results. This includes establishing and providing translation services to the influx of Haitian Creole speakers. HCHD also expanded its services to include IUD placement, dispensing oral contraceptives, and in-house lab drawings. The registered nurse became a Certified Passenger Safety Technician; thus, Harrison County added a Car Seat Program to distribute car seats to those in need. The first community baby shower had the pleasure of hosting over 70 women from seven different counties. The amount of positive feedback from that event was overwhelming. While HCHD is breaking down barriers in many different areas, transportation continues to be a barrier for their clients to make it to preventative appointments. 

Healthy Communities of Clinton County

Healthy Communities of Clinton County (HCCC), Clinton County IN, implemented their Early Start, Better Finish model that will direct women through prenatal programming and care, specifically reaching rural, low-income, and Hispanic women, and indirectly serve women via awareness campaigns, traditional and social media, and events. They have offered pregnancy testing, prenatal care, prenatal classes, and parenting classes. One major success this year was the community baby shower. By expanding their presence and engagement within the community, they were able to deliver more comprehensive safe sleep education and Count the Kick information than ever before. They also assisted White County in hosting a baby shower and developed a similar program to implement. This has been a successful county-to-county partnership to share resources. HCCC proudly recounted a success story to MCH about a Latina client who, at 26 weeks pregnant, had no previous prenatal care, was residing with unfamiliar individuals, facing language barriers with English, and finding it challenging to navigate her community. They were able to connect her to all the resources, essential needs, and more. Resources and care resulted in the mother delivering a healthy baby at 36 weeks, spending only a little time in the NICU.

 

Hoosier Uplands

Hoosier Uplands, Lawrence County IN, has been implementing their Bright Futures for Families program. This program provides case manager services for any pregnant and postpartum woman needing help, advice, or services. The assigned case manager helps navigate needs to ensure a holistic approach to both pregnancy and the first year of the child's life. This reporting year, the program coordinator position at Hoosier Uplands went through a personnel change. They did experience some push-back and trust issues within the community about there being a new program coordinator since these new parents had a very trusting relationship with the old coordinator. The new coordinator was able to connect and establish trust within the community. They were able to order new supplies for diaper bags that were given to moms during their last prenatal appointment. These diaper bags include clothing, burp cloths, bath supplies, and now also include Infant Tylenol, gas drops, diaper rash spray, and health kits that include thermometers, combs, nail clippers and files, nasal aspirators, and a toothbrush. Expectant mothers who have received the updated bags have been very excited, as these are items they often do not have. The program coordinator has also begun sharing new curriculum including Help at Home, Partners for a Healthy Baby: Before Baby Arrives, as well as Baby's First Year to share with participants. These curriculums help to provide families with information about the baby's development every month, as well as activities for parents/caregivers to complete, including budget forms and questions regarding the baby's changes from month to month. They also continued to see transportation and housing as barriers in their rural setting and are continuing to seek support and opportunities to remove these barriers.

 

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.

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 a partner division, Fatality Review, and Prevention, to reduce violent deaths, increase access to mental health, and 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, MCH has successfully implemented the Obstetric Hemorrhage bundle and the Severe Hypertension in Pregnancy bundles. MCH has been dedicated to building valuable partnerships with internal and external teams, including participating birth hospitals, the Indiana Hospital Association, and the MCH Epidemiology team. These partnerships have allowed us to analyze patient data, birth worksheet outcomes, and process measures through the AIM program. The MCH AIM Data & Quality Manager hosted monthly office hours to enhance clinical practice throughout Indiana. These office hours are aimed at finding areas where birth facilities could discuss clinical practice.

Throughout the 2023 reporting year, the MCH team organized monthly webinars to educate attendees on data findings, health equity, and sustainability related to our AIM: Obstetric Hemorrhage and Severe Hypertension in Pregnancy bundles. The team also arranged a multidisciplinary panel discussion that attracted over 150 attendees, including obstetrics, maternal-fetal medicine, emergency medicine specialists, informatics nurse specialists, clinical nurse educators, managers, and directors.

Also in 2023, the MCH team introduced new AIM bundles to pilot in hospitals. These bundles include the Postpartum Discharge Bundle, which is being tested with five birthing facilities to assess how it improves the patient discharge process. Another bundle is the Care for a Pregnant and Postpartum Patient with Substance Use Disorder, which is being piloted with thirteen birthing facilities to standardize the process for managing and treating patients with substance use disorders in all facilities.

Maternal Mortality Review Committee

The Indiana Maternal Mortality Review Committee (MMRC) was formalized in July 2018 following the 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 considered these and made the necessary changes required. MCH and FRP have partnered to use Title V funds for reviews and recommendations to influence policy changes and improve mortality outcomes. 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, and 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.

 

The MMRC continued to review maternal deaths from October 2022 to September 2023. During this time, the committee reviewed pregnancy-associated deaths of Indiana residents regardless of cause. As the goal of MMRC is to identify systems-level changes and not assign individual blame, the names of patients, medical providers, and involved institutions are not disclosed during the review process. FRP has been concurrently identifying and gathering records for deaths that occurred in 2023 to facilitate the beginning of that cohort's review immediately following the completion of 2022 in early 2024.

 

The fourth annual MMRC report was completed with data on 2021 deaths during this time. The fourth annual report aligns with previous reports and identifies continued disparities in rates of maternal mortality among different races and ethnicities, ages, and insurance statuses. The Indiana MMRC hopes to break down the disparities more as it gains more data. The continued use of DCS data, familial interviews, EMS, law enforcement, and medical records will benefit our ability to see a fuller picture of the lives of Indiana mothers.

The fourth annual MMRC report identified 80 pregnancy-associated deaths among women in 2021 and convened 10 times between May 2022 and April 2023 to review each death. Of these 80 deaths, the MMRC was able to determine 14 deaths to be pregnancy-related and 64 deaths to be pregnancy-associated but not related. For the remaining 2 deaths, the MMRC could not conclusively determine the relatedness from available records. The pregnancy-associated mortality ratio in 2021 was 100.1 deaths per 100,000 live births. The pregnancy-related morality ratio was 17.5 deaths per 100,000 live births.

The Indiana MMRC was also able to assess and analyze the timing of pregnancy-related and pregnancy-associated- deaths for 2021 and aggregated four-year data. While most of the pregnancy-associated deaths (60%) occurred 43 days or more postpartum, 86% of the deaths determined to be pregnancy-related occurred either during pregnancy or within the first 42 days postpartum. These findings suggest women are most at risk of dying from a pregnancy complication or other condition aggravated by pregnancy either during pregnancy or in the first six weeks following childbirth. However, their risk of dying from other causes, including injury or other medical conditions, is highest more than six weeks after childbirth. Through these findings the MMRC was able to report that prevention and maternal health initiatives for pregnancy-related deaths should be targeted towards specific risks experienced by women.

After reviewing all case-relevant obstetric, medical, and social histories of pregnancy-associated death the MMRC was able to collectively discuss whether or not the death was preventable. A death is considered preventable “if the committee determines there was at least some chance of the death being averted by one or more reasonable changes to patient, family, provider, facility, and/or community factors,” according to the MMRIA Committee Decisions Form. The Indiana MMRC found the majority (71%) of all 2021 pregnancy-associated deaths and 77% of pregnancy-related reviews were preventable.  

 

After reviewing all pregnancy-associated deaths the Indiana MMRC was able to make 271 recommendations for the 2021 cohort. Repeated case characteristics and themes gave the MMRC the ability to tailor recommendations toward systems of care, communities, facilities, providers, and the patient and their families. Among pregnancy-associated deaths, the MMRC was able to determine that many deaths could have been avoided with the increase in publicly funded improvements to maternal health. Some of these include publicly funded childcare, universal access to long-acting reversible contraception, increased Medicaid coverage for medical procedures, and access to public transportation. In addition, the Indiana MMRC created recommendations for communities. Some recommendations included all obstetric cases should be referred to OB case management and the My Healthy Baby Program through Medicaid, increased doula intervention, vaccine education, state-funded expansion of housing programs, and increased availability of harm reduction strategies.

FRP continues to evaluate the membership of the MMRC and the types of records and information that can be accessed to understand each woman’s history and each touchpoint or type of services/care she received. With continued review and data gathering, we will make more specific, evidence-based recommendations to reduce maternal mortality in Indiana.

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. As of September 2023, Indiana had 31 Suicide and Overdose Fatality Review (SOFR) teams covering 32 counties. Of cases reviewed by teams between January and September 2023, 94 were among women who lived and died in Indiana. 72 of the women whose cases were reviewed died by accidental drug poisoning; 19 women whose cases were reviewed died by suicide. In addition, three cases were reviewed in which the manner of death could not be determined or was natural with substance use listed as a contributing factor. SOFR team's primary recommendations included strategies related to improving care-coordination, referral, and follow-up, improved access to treatment, and prevention education to address suicide and overdose in 2023.

SOFR staff worked with local teams throughout the year to improve the case review processes, analyze data, and implement their recommendations. Some of the successes local SOFR teams had in 2023 include training law enforcement officers in Mental Health First Aid, changing follow-up procedures at a community mental health center to try to engage patients for a longer amount of time before closing their case, beginning the process to establish a recovery housing facility, installing naloxone boxes, and establishing a grief response team for survivors of suicide and overdose.

Preventing Violence Against Women and Substance Use Initiative (Maternal Deaths Due to Violence Prevention)

In 2021, MCH was awarded the State, Local, Territorial, and Tribal (SLTT) Partnership Programs to Reduce Maternal Deaths due to Violence Grant, through the Office on Women’s Health (OWH). Through this opportunity, MCH and FRP collaborated to reduce the number of maternal deaths due to homicides and suicides in Indiana. Almost half (47%) of all maternal deaths in Indiana are due to suicides, homicides, and overdoses. This past year, MCH and FRP focused on developing new processes for data collection of maternal deaths due to both suicide and homicide, designing and implementing evidence-based interventions to reduce these maternal deaths due to violence upstream, and evaluating these interventions for efficacy and sustainability.

FRP worked diligently to improve the quality of the review process for maternal deaths due to violence by increasing the completeness of available records for review to 75% of cases being reviewed having “complete” or “mostly complete” records, with a 10% increase per year for the following project years. FRP is on track for the goal of 85% “complete” or “mostly complete” for the 2022 case cohort and has onboarded new staff, identified and collected more non-traditional and supporting records, and increased the availability of data through collaboration.

MCH has developed two evidence-based interventions targeting preventing maternal deaths due to violence. This includes further education for healthcare and social services providers and expanded access to prenatal care and social support for those at risk and currently surviving through violence. 

For the education component, MCH collaborated with the IU School of Medicine (IUSM) to develop and deploy an Extension for Community Healthcare Outcomes (ECHO) model of physician and social service provider education. ECHO is a virtual learning approach used to deliver continuing education around clinical concerns with the overall goal of increasing access to best practices and evidence-based care. MCH’s ECHO is focused on preventing deaths due to intimate partner violence (IPV) through seven, one-hour courses. The second and final session of ECHO started in November 2022 and saw success in those involved, but fewer participants than the previous session held. 

Working towards expansion and greater access to prenatal care, MCH partnered with the Centering Healthcare Institute (CHI) to pilot the Centering Pregnancy and Centering Parenting models into practices and clinics in Indiana with a specific focus on intimate partner violence. Centering is a healthcare model that encourages group-centered prenatal and postnatal care. This model has various benefits including improved health outcomes, better healthcare experiences, improved job satisfaction, and reduced costs to the system. MCH utilized Title V funding to assist in the start-up of CHI in five local implementing clinics. Clinics work directly with Centering to implement the program and become certified. Participating organizations or clinics received full funding for the first two years from MCH to assist in the process of becoming certified in Centering and will be supported throughout implementation.

Maternal Health Equity Specialist

The Maternal Health Equity Specialist position sits within the MCH’s programs team and was filled at the beginning of 2023. This position was created to challenge and integrate innovative ways of incorporating health equity, specifically maternal health equity, into all aspects of work and programming across MCH. The responsibilities of this position include engaging in new ways to improve outcomes for women and birthing persons outside of current public health initiatives, providing input on cross-divisional/agency work, and assisting with grant management programs and operations. In the past year, the Maternal Health Equity Specialist has begun the planning for the MCH Health Equity Council and connected with other IDOH divisions to partner in equity efforts.

Title V Subrecipients

Community Health and Wellness

Community Health and Wellness Center, Lawrence County, IN, served pregnant persons and infants up to one year of age. This center has created two programs with the support and funding from Title V. One begins in pregnancy and the other ends one year after delivery. These two programs aim to support positive birth outcomes, as well as promote optimal health and well-being for both mom and baby. The Mom’s Journey Together program focuses on centering pregnancy to foster a community for those around the same stage of pregnancy. These programs aimed to reduce maternal mortality, improve infant safe sleep outcomes, and provide prenatal care to 82% of people in their program. Community Health and Wellness Center surpassed the goal of 82% and provided prenatal care to 89% of its participants during this past grant cycle. In addition to interacting with the participants to provide resources and support, infant care was also provided. Prevent Child Abuse Indiana chose Lawrence County to pilot an Indiana Supportive They have built a huge network of partners across county lines to offer wraparound services to anyone in their care.

Reid Health

Reid Health started a Centering Pregnancy group. Centering Pregnancy delivers prenatal care in a different way that allows patients to have more time with providers and learn more about pregnancy, the birthing process, and caring for a newborn. Since this is a group setting, there is also the added benefit of connectedness with peers.

After a delayed start during the initial grant year cycle, this year was overall much more successful. Reid Health was able to secure a space that met the requirements and officially launched its Centering Pregnancy groups. They also worked to increase participation through partnership, outreach, and marketing. Community partnerships have strengthened as they have engaged local resources and referrals to spread the word about the Centering Pregnancy Program.

 

Maternal Mental Health & Severe Maternal Morbidity

In 2022, MCH was awarded the Maternal Health Innovation and Data Capacity (MHI) grant through the Health Resources and Service Administration (HRSA). Through this opportunity, MCH spearheaded combatting the maternal mental health crisis. MCH has partnered with the vendor, StoryCollab, to create a digital storytelling series that highlights lived experiences of labor, delivery, and postpartum mood disorders. Collecting this needed qualitative data set is a huge success for the state and will help determine where and what programs MCH will target in the future. MCH is also working with StoryCollab to create a maternal health podcast, which will have a big focus on mental health and the fourth trimester.

Another main component of this grant has been to pilot, in five different sites, the implementation of the AIM Postpartum Discharge Transition bundle with a unique purpose of promoting mental health. The Postpartum Discharge Transition Bundle calls for a dedicated and concerted effort towards mental health and the promotion of respectful and equitable care. MCH chose this bundle for this part of the pilot project because of this focus and how it relates to the needs echoed in the Title V Needs Assessment. Individuals, including mothers, and caretakers voiced their needs for mental health support, more education on postpartum care, and a better communication pathway between healthcare providers and patients. To alleviate the strain on the existing mental health system, MCH has implemented the Stepped Care Model to be a part of the Postpartum Discharge Transition Bundle implementation. In this model, community health workers or other providers are the first line of care for screening and providing mental health support, resources, and services, with treatment increasing depending on the severity, duration, or impact of the mental health crisis.

To combat burnout for mental health providers while increasing the knowledge of postpartum mood disorders, MCH hosted a state-wide Postpartum Support International (PSI) Perinatal Mental Health (PMH) training through the MHI grant. MCH had a total of 175 scholarships for the three-day training, along with fully paying to sit for the perinatal mood disorders certification exam and a total of 220 providers were trained.

Justice-Involved Mothers and Infants

In September 2020, MCH awarded funding to the IU Richard M. Fairbanks School of Public Health to support Grassroots Efforts to Improve Indiana’s MCH Outcomes. The Title V funding supported the 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, create a resume, think about job placement upon release, provide clothing, hygiene supplies, 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 project aims 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 with a community navigator who supports the mom and baby in attending well-child visits and securing social services like Section 8 housing.

In the previous year of the program, they had faced various challenges including, keeping up with their mother changing their contact information, transportation and housing barriers, and toxic relationships. Addressing these barriers this past year required MOTR to rely mostly on partnerships, forming new alliances in communities, and recruiting community navigators. For instance, MOTR has partnered with the IU McKinney School of Law to provide legal aid and services to women. Also, the women participating who were in the nursery unit of the prison were given education through a weekly Me as Mommy Curriculum which addressed trauma-informed care around parenting and recovery. This curriculum was developed by the lead community navigator who helps the women understand the intersection of trauma, addiction, and parenting, and provided strategies for women to use to rewrite their life narratives. Another great success MOTR displayed was their community navigator’s ability to assist and secure safe housing to prevent mother/baby pairs from homelessness, connect mothers to mental health services, and prevent these women from returning to the justice system.

Data has been shared with HRSA MCH Bureau, National Maternal Health Innovation Symposium, United Women of Faith in Indiana Annual Celebration Program, and Elevance Health Project Partnership. Since these presentations, MOTR has expanded statewide partnerships. A 6-month social network analysis of 23 participants shows distinct engagement patterns: maintenance vs. crisis management (housing insecurity or mental illness). Weekly engagement for maintenance periods involves three contacts, averaging 36 minutes, with 19% initiated by participants. Crisis engagement entails seven contacts per week, averaging 161 minutes, with 71% participant initiated. Mental health crisis engagement involves six weekly contacts, averaging 152 minutes, with 33% participant initiated. Community navigators from MOTR prevented homelessness for five mother/baby pairs, facilitated crisis mental health care for seven, and engaged with social welfare programs thirteen times. Mothers on the Rise has a 3.1% recidivism rate, contrasting with 20% for non-participants.

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, the hope is to grow in capacity to provide further treatment and care for all families.

Perinatal Substance Use Taskforce

MCH continues to work closely with the Indiana Perinatal Quality Improvement Collaborative’s (IPQIC’s) Perinatal Substance Use (PSU) taskforce and hospital collaborative. Through this task force, MCH has been able to work closely with participating birthing hospitals and establish best practice recommendations centered around PSU and Neonatal Abstinence Syndrome diagnosis and surveillance. A component of the work of IPQIC’s PSU hospital collaborative continues to be that MCH receives monthly data directly from hospitals on the number of births, number of cord tests, number of positive cords, and number of NAS diagnoses. For each quarter of the reporting period, this data was analyzed and presented by the MCH epidemiology team. MCH also utilizes the number of birthing hospitals that report this cord data in measuring the extent of prevention efforts for substance use in pregnant women.

Fetal Alcohol Spectrum Disorder

This past year, the umbilical cord tissue panel that includes testing for alcohol was supported by IPQIC’s Perinatal Substance Use Hospital Collaborative. Most hospitals have committed to utilizing the updated panel beginning October 1, 2023, which means there will be additional context on alcohol exposure during pregnancy shortly.

Tobacco Cessation

Tobacco usage during and after pregnancy has been a prolonged issue in Indiana. The MCH Women and Maternal Health team has partnered with the IDOH Tobacco Prevention and Cessation (TPC) Division to explore how pregnant women receive tobacco use treatment/cessation services through additional evidence-based programming. MCH is in the second year of adapting the American Academy of Pediatrics (AAP) Clinical Effort Against Secondhand Smoke Exposure (CEASE model) into five OB/GYN offices. This model was piloted among OB provider locations to assist patients and their families who are smoking before, during, and after pregnancy with an assessment, resources, and next steps. MCH completed the one-year trial on a new tobacco approach, that allowed hospitals and community partners to pick and choose out of three tobacco approaches. The greatest success of this pilot was funding for clinical staff members to be trained as a Tobacco Treatment Specialist (TTS). MCH and TPC have also created tailored, targeted ads for the smoking and vaping population that consist of addressing gaps in knowledge about tobacco use, shifting social norms, and promoting a smoke-free lifestyle.

Other Substance Prevention Collaboration

MCH has continued to work 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). MCH has successfully implemented the Obstetric Hemorrhage Bundle and the Reduction in Severe Hypertension Bundle. Both bundles continue to have high rates of enrollment, with now almost all of Indiana's delivery facilities participating. Indiana has implemented its third patient safety bundle: Care for Pregnant and Postpartum People with Substance Use Disorder. The toolkit, created in partnership with IPQIC, has been finalized and given to the first round of thirteen delivery hospitals. This bundle is being implemented in five hospitals and will screen for SUD, Social Determinates of Health, and Maternal Mental Health.

Rape Prevention and Education (RPE)

With the Office of Women’s Health merger, MCH has now absorbed the Rape Prevention and Education (RPE) Cooperative Agreement funding for sexual violence primary prevention through the Centers for Disease Control and Prevention (CDC). The RPE program tied to women’s health aims to prevent first-time occurrence of sexual violence victimization and perpetration by reducing the risks and increasing the protective factors to reduce the likelihood of perpetration/victimization. In the final year of the 5-year grant cycle, RPE funding supported Indiana Coalition Against Domestic Violence, Indiana University – Bloomington, LifeSmart Youth, Multicultural Efforts to End Sexual Assault – Purdue University, and YWCA Greater Lafayette in their work to prevent sexual violence. Since the merger, MCH has begun to utilize information, staff knowledge, and project knowledge to inform Title V work.