Overview

The Indiana Title V program prioritizes reducing maternal mortality, supporting mothers, and improving health outcomes for women. This commitment extends beyond the Maternal and Child Health (MCH) Division to include essential internal partners such as the Family Health Data and Fatality Prevention Division (DFP), and the Commission for Women, Children, and Families (WCF) Clinical Team, the Indiana Perinatal Quality Improvement Collaborative (IPQIC), and various local partners throughout Indiana. To achieve Title V objectives, Indiana has strategically aligned work by engaging numerous external partners and braiding together complementary projects and funding sources.

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.
Objectives by 2025	To meet the CDC guidelines for weighted data by 2025.
	To obtain information not available from current data sources about maternal behaviors and experiences in pregnancy and early infancy
	Increase the percent of women receiving postpartum follow-up healthcare services.
	To increase the percent of mothers who receive a postpartum visit with a healthcare provider within 8 weeks of delivery
	To increase referrals of pregnant women to care.
	To reduce the incidence of poor maternal and infant health outcomes, related to chronic conditions.
	To increase the number of women receiving timely and appropriate preventive healthcare.
ESMs	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.
	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.

 

ESM 1.1: Number of Women who responded to PRAMS.

PRAMS Response Rate -Title V Supported

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 and continuously declining over time. Reaching the minimum response rate ensures that findings from Indiana’s PRAMS data represent the state and enable the data to create additional programs for mothers and infants. During this reporting period, strategies used to increase response rates included establishing a strong surveillance system within the Indiana Department of Health. To accomplish this, the PRAMS team began with updating the look of all PRAMS documents with our Office of Public Affairs (OPA) to reflect as official documents of the Indiana Department of Health. Through the support of Title V funding the printed documents now have a uniform look with the department's colors, logos, and resources. This helped to make the materials more recognizable and relatable to mothers throughout the state. The PRAMS team also experimented with the organizational aspect of the mailing materials, improving the streamline of materials in their package and highlighting the reward in hopes of more surveys being returned. To reduce mailing costs, IN PRAMS developed a mailing code to be used for returned mail. This ensures that the team doesn’t waste funding on undeliverable mail and finds an alternative method of reaching the mom. This is usually done by releasing the mom from the mail phase to the phone phase where she can either provide a new address for a re-mail, receive an email for the web version of the survey, or take the survey on the phone with an interviewer if she chooses to participate.

Further steps the team took were the use of the Moms Helpline number when conducting phone interviews, which has helped to increase response rates by phone. Other direct efforts for calls includes the hiring of a second call specialist. The call volume was overbearing for just one phone interviewer and would cause the team to fall behind so in May 2024; PRAMS hired an additional interviewer who is bilingual and able to work later hours in the workday. This enabled the team to conduct interviews with mothers who speak Spanish and allowed flexibility for mothers to participate in the survey until 7 in the evening during the week.

IN PRAMS was chosen for a site visit with the CDC Program Manager. Throughout the site visit, operational strategies were discussed for opportunities for improvement such as reconvening the steering committee, promotion and outreach, and data use and analysis. This encouraged the team to take the initiative of creating new promotional materials that could be shared with various partnering sites like WIC and community baby showers. With all efforts aimed at increasing response rates, Indiana has seen notable changes. Unweighted response rates for 2022 were 27%. At this point, PRAMS was still contracted out to Kent State. A year after bringing operations to IDOH, the PRAMS survey unweighted response rate rose to approximately 33% and is currently at 37% for the year 2024.

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 Surveillance Epidemiologist (funded through Title V) to analyze and review PRAMS data to understand the landscape of postpartum follow-up healthcare services. Keeping in mind the data caveats from not achieving the response rate threshold, PRAMS saw that around 92% of women received postpartum follow-up care within 4-6 weeks after delivery.

Home Visiting Support Services- State Match

MCH and Title V funding continued to support women receiving postpartum follow-up health care services through home visiting support services. MCH tracks 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 by sharing 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 – Title V Led

The Liv Pregnancy Mobile Application is an app powered by the Indiana Department of Health (IDOH) and is monitored and curated by Moms Helpline staff in Maternal and Child Health (MCH). For 7 years, the Liv App has provided accessible information and resources to Indiana families that are planning pregnancies, currently pregnant, or seeking post-natal information and resources. Liv has successfully served Indiana families according to the agenda it was implemented on. The division of Maternal and Child Health for Indiana consistently seeks innovative methods of community engagement and how to provide valuable support. To that end, MCH has decided to decommission the Liv App at the end of 2024. Decommissioning this app provides an opportunity to apply funding and new innovative approaches for greater connections to MCH’s family support systems. The Liv App was a pioneering opportunity for MCH, that has and will continue to guide future approaches to Indiana family resource connections.

 

Addressing Gaps in Maternal Health—Title V Supported

MCH received the Maternal Health Innovation and Data Capacity Grant to expand efforts to reduce maternal mortality and improve access to care. Title V supports this program through staff time. Maternal Health Advocates will be hired at pilot sites to serve as first-line care for patients, focusing on perinatal/postpartum mental health and community health factors.

These advocates will screen patients before and after appointments, establishing SDOH baselines in domains including education, healthcare access, environment, social context, interpersonal violence, and economic stability. This information will be provided to healthcare providers and de-identified data will be submitted to MCH for analysis.

Training pathways for advocates include:

• Community Health Worker (CHW)
• Birth or postpartum doula
• Peer support specialist
• Stepped Care model with mental health lens
• Medicaid redetermination navigation training

The program aims to provide comprehensive support, education, and resources while identifying and addressing service gaps for pregnant and postpartum women. MCH will employ this approach through the pilot sites using community-level providers. This approach will provide an opportunity to test the effectiveness of the intervention before it is rolled out more widely. MCH will also provide support to community-level providers to help them implement the new approach.

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 – State Match

During FY24, Nurse-Family Partnership (NFP) expanded to all 92 Indiana counties, allowing local implementing agencies (LIAs) to build teams and extend services in surrounding counties. Title V continued to fund a portion of the home visiting programs within the state.

The IDOH Home Visiting team plans to expand with additional coordinator positions in late 2024 to provide cohesive direction for Indiana's NFP programs. The team implemented several initiatives including:

1. Quarterly NFP leadership meetings to share updates and increase collaboration between LIAs and the state
2. An IDOH NFP policy manual with standards required by the state (current policies include Virtual Home Visits, Joint Visits, Chart Audits, and Confidentiality)
3. A quarterly Indiana NFP Newsletter featuring agency spotlights, health topics, and achievements
4. A data committee with representatives from each agency to improve data quality
5. Training videos for home visitors on data entry

 

This new team has been working to build a more unified and strategic approach across Title V and home visiting programs throughout the state. Some of the approaches the team has accomplished during this period are: NFP leadership meetings, a quarterly newsletter, a data committee, and the development of a policy manual to help support the LIAs.

Additional activities included a Quality Improvement Workshop led by Michigan Public Health Institute and hosting the Labor of Love event focused on bridging health gaps. Future policy manual updates in FY25 will address budget changes, incident reporting, and referrals for mental health and intimate partner violence.

Goodwill Industries of Michiana, Inc – Title V Subrecipient

Goodwill Industries of Michiana (GIM) receives home visiting funds to implement Nurse-Family Partnership programming, from multiple funding sources, including Title V, Maternal, Infant, and Early Childhood Home Visiting (MIECHV), Temporary Assistance for Needy Families (TANF), and state funds. In early 2023, GIM began expanding its service area from serving 4 counties to 15 counties in the northwestern region of Indiana.  Goodwill was dedicated to expanding the program and hiring quality nurses to conduct these visits. This expansion impacted their existing team structures as staff moved to other positions. The Lake County team was not fully staffed throughout this timeframe, impacting the number of families able to be served. Goodwill has demonstrated strengths in outreach events, partnerships, and referral linkages. In FY24 Goodwill saw 209 total referrals in Lake County. In total, 97 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.

During this period, Indiana MIECHV saw an increase in the 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 of delivery, as compared to the last reporting period. In FY24, this performance measure was 47.2%, an increase from 44.6% in FY23. The IDOH HV program is planning to analyze this performance measure for statewide NFP teams in the future and anticipates having more data that represents NFP programs beyond MIECHV-funded teams. Indiana will continue to support all NFP teams through data technical assistance, data committee meetings, quality improvement support, and other strategies to improve programming and access to care for postpartum NFP clients.

My Healthy Baby –Title V Supported

The Women, Children, and Families Commission is committed to strengthening home visiting program data through the state’s Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program as well as the My Healthy Baby (MHB) program. 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 and the Division of Family Health Data and Fatality Prevention (DFP), My Healthy Baby continues 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. In the last year, My Healthy Baby has made around 6700 referrals to home-visiting partners throughout the state. My Healthy Baby has also collected, linked, and shared data back with partnering home-visiting programs that receive the largest percentage of My Healthy Baby referrals throughout the state.

Although My Healthy Baby was initially designed as a home visiting sitting referral system, it has since grown into a much broader initiative. Over the years it has become a central hub that promotes collaboration among home visiting programs across the state. A group of state agency stakeholders including Title V representation created a strategic framework this past year to be utilized for the upcoming Home Visiting Need Assessment. There is also an advisory committee that hosts a monthly community of practice and recently has piloted a regional collaboration meeting in Marion County, where home visiting programs came together to learn more about one another. Additionally, in the past year, a workforce workgroup was launched where a jobs board and an outreach toolkit were developed to support home visiting programs in recruiting new staff. Another new initiative is the creation of a translation workgroup, focused on translating resources into multiple languages to help home visitors better serve families in their preferred language.

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.
Other Initiatives, Programs, and Policies

Other Initiatives, Programs, and Policies: Increase Well Women Visits

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 meant 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 – State Match

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 Indiana 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 subrecipients 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 the Title X program.

• The Indiana Pharmacy Association (IPA) aims to promote and support the implementation of contraception prescribing by pharmacists through the development of training focused on fair healthcare access 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 women, including those with substance use disorders and those experiencing homelessness.

Women’s Health – Title V Connected/Supported

In early 2023, The Office of Women’s Health merged with the Maternal and Child Health Division at the Indiana Department of Health. 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. MCH has currently been in the process of a re-organization that will build up the women’s health team with a new director of women’s health and a women’s health coordinator. These positions will help be subject matter experts to the Title V team to further women’s health programming in the division.

 

Title V Subrecipients – Title V Led

Harrison County Health Department

The Harrison County Health Department (HCHD) 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 at-risk populations and individuals who had abnormal mammogram screening result. This expansion includes establishing and providing translation services to the influx of Haitian Creole speakers.

Over the past year, HCHD has

• Increased partnership in the community including the school systems
• Participated in the local Back2School for the first time where they provided education and resources to families about services
• Hosted the 2nd annual community baby shower
  • Safe Sleep Classes had 37 participants
  • Participants met with 15 local organizations about resources offered.

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. This past year, they offered:

• Pregnancy testing
• Prenatal care
• Prenatal and parenting classes
• A community baby shower

Hoosier Uplands

Hoosier Uplands, located in Lawrence County, Indiana, 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.

 

State Priority Need	Reduce preventable deaths in the MCH population with a focus on reduction and elimination of gaps in mortality rates.
State Performance Measure (2020 - 2025)	SPM 1: Prevent the use of substances, including alcohol, tobacco, and other drugs among youth and pregnant women.
Objectives by 2025	To increase the number of delivering Hospitals who participate in the perinatal substance use collaborative with the Indiana Perinatal Quality Improvement Collaborative
ESMs	N/A

 

Background

The 2020 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-Title V Supported

The MCH and DFP divisions continue to work closely with the Indiana Perinatal Quality Improvement Collaborative’s (IPQIC) Perinatal Substance Use (PSU) taskforce and hospital collaborative. Through this taskforce, the team has been able to work 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 centered around the DFP Epidemiology team’s analysis of monthly data received directly from hospitals on number of births, number of cord tests, number of positive cords, and number of NAS diagnoses as well as testing information directly from the United States Drug Testing Laboratories (USDTL) for participating hospitals.

For each quarter of the reporting period, this data was analyzed and presented by the DFP Epidemiology team. For 2023, over 67,000 births in Indiana took place at participating hospitals. Almost 13,000 umbilical cords were tested (19% of births), and almost 5,000 cords (about 39% of cords tested) were positive for at least one substance. These teams also utilize the number of birthing hospitals who report this cord data (69 hospitals in 2023) in measuring the extent of prevention efforts for substance use in pregnant women.   

 

State Priority Need	Reduce preventable deaths in the MCH population with a focus on reduction and elimination of gaps in mortality rates.
State Performance Measure (2020 - 2025)	SPM 2: Reduce Maternal Mortality Rates by promoting best practices in clinical care.
Objectives by 2025	To reduce the number of maternal deaths by increasing the proportion of birthing hospitals that implement the AIM Patient Safety Bundles.
ESMs	N/A

 

SPM 2: Reduce maternal mortality rates 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 partner division, Family Health Data and Fatality Prevention (DFP), to reduce violent deaths, increase access to mental health services, and utilize the Indiana Perinatal Quality Improvement Collaborative (IPQIC).

Alliance for Innovation on Maternal Health Bundles (AIM) - Title V Supported

MCH has been focused and dedicated this past year to improving the rate of timely and accurate data entry with participating AIM birthing hospitals, heavily utilizing quality improvement metrics. This effort goes hand in hand with the work that has been done by building those valuable partnerships, including the Indiana Hospital Association, Title V, and Indiana birthing hospitals. Through these partnerships, more time has been dedicated to analyzing patient data, and birth worksheet outcomes, moving towards sustainability in the Alliance Innovation for Maternal Health (AIM) bundle implementation, and analysis of process measures through the AIM program.

Throughout the past reporting year, the MCH team has prioritized hosting monthly webinars with the AIM birthing hospitals to educate, discuss data findings, bridge gaps in care access, and focus on sustainability-related AIM: Obstetric Hemorrhage and Severe Hypertension in Pregnancy bundles, in addition to monthly office hours. In the past, the facilitator of these monthly meetings was IDOH’s AIM Data & Quality Manager, however, in March 2024 that position became vacant. IDOH’s Clinical Coordinator has taken this role over, emphasizing a sustainability plan and quality improvement e-learning courses.

The MCH team is working on piloting new AIM bundles into hospitals. One of the new bundles is the Postpartum Discharge Bundle, which is being implemented in nine birthing facilities. The focus of this implementation is to provide each pregnant and postpartum woman with a Maternal Health Advocate (MHA), who will be the first line of contact during every appointment and is in charge of screenings for mental health and SDOH. The MHA will provide appropriate support and resources depending on the severity and duration of the crisis. The second bundle is the Care for a Pregnant and Postpartum Patient with Substance Use Disorder, which is being piloted in 22 birthing facilities to standardize the process for managing and treating patients with substance use disorders in all facilities.

Maternal Mental Health & Severe Maternal Morbidity – Title V Connected

 

IDOH was re-awarded the Maternal Health Innovation and Data Capacity (MHI) grant through the Health Resources and Service Administration (HRSA). The focus of this funding opportunity is to enhance maternal mental health services, by preventing mental health provider burnout, creating more educational opportunities around maternal mental health, and mobilizing the workforce. MCH has partnered with the vendor, StoryCollab, to create a digital storytelling series that highlights experiences of labor, delivery, and postpartum mood disorders. This project is in Round 2 and will have a collection of 13 stories. 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.

To combat burnout for mental health providers while increasing the knowledge of postpartum mood disorders, MCH hosted two state-wide Postpartum Support International (PSI) Perinatal Mental Health (PMH) trainings. MCH had a total of 300 scholarships for the three-day training, along with fully paying to sit for the perinatal mood disorders certification exam.

Another main component of this grant has been to pilot, in three 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 care. IDOH 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, IDOH has implemented the Stepped Care Model to be a part of the Postpartum Discharge Transition Bundle implementation.

Maternal and Community Care Coordinator- Title V Supported

The Maternal and Community Care Coordinator, fully funded through Title V, helped lead healthcare access innovations for the Maternal Health Innovation Grant, overseeing the Health Transformation Subcommittee, AIM sites, and selecting training for the Maternal Health Advocates. Additionally, they developed a Stepped Care Model with a mental health focus being piloted at select hospitals. This model provides appropriate care based on mental health needs through tiered levels of intervention. Maternal Health Advocates serve as the first line for screening and support, with patients moved to more specialized care only as needed based on severity, duration, and impact. This approach reduces strain on specialized practitioners while ensuring preventive screening for all patients.

Another project that this position took the lead on was the Community Care Health Council to reduce gaps in maternal and child healthcare access and outcomes. An initial survey in 2024 was sent throughout the MCH division. It identified needs and informed strategy development for furthering this work. Due to MCH restructuring, the council was paused until 2025, when it will resume with revised goals aligned to the division's new objectives.

Centering Pregnancy

Title V Subrecipient - Reid Health

Title V funded Reid Health back in 2021 to start a Centering Pregnancy group in their community. 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.

 

This past year Reid Health was able to:

• Secure a meeting space that met the requirements
• Officially launched their Centering Pregnancy groups
• Increased partnerships and engaged local resources and referral systems
• Increased participation through implementing OB intake sessions for potential participants
  • One quarter had 5 patients enrolled, which increased to 14 the following quarter after implementation.
• Began the process of becoming a nationally accredited Centering Pregnancy site

 

Preventing Violence Against Women and Substance Use Initiative (Maternal Deaths Due to Violence Prevention) - Title V Connected

In 2021, IDOH 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 DFP collaborate to reduce maternal deaths due to homicides and suicides. In 2018-2021, almost half (47%) of all maternal deaths in Indiana were due to suicides, homicides, and overdoses.

Working towards greater access to prenatal care, MCH partnered with the Centering Healthcare Institute (CHI) to pilot the CenteringPregnancy and CenteringParenting models into practices and clinics in Indiana with a specific focus on intimate partner violence (IPV). 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 healthcare system. In Centering, groups of six to 12 women with pregnancies of similar gestational age attend monthly 90- to 120-minute sessions. During each session, there is a health assessment with a medical provider, an interactive learning opportunity for the group, and a community-building experience. Participating organizations or clinics implement the Centering model to address IPV through a supportive, group care environment.

The Indiana Perinatal Quality Improvement Collaborative (IPQIC)- Title V Led

The Indiana Perinatal Quality Improvement Collaborative Women’s Health Taskforce focused on four areas this past year to help improve areas in the clinical space. Please see perinatal/health for more information. 

• Mental Health Screening and Treatment: IPQIC sponsored the Mammha initiative as a pilot with a delivery hospital. Mammha was created by women experienced a mental health complication while pregnant and during their postpartum period for women experiencing the same kind of complications. The pilot hospital worked to embed the data from the app into the electronic medical record. The project was set to launch and then the hospital was sold and new management decided to go in a different direction. A second hospital is now in the process of working with Mammha. 

• Trauma-Informed Perinatal Care: Distributed guidance documents and created educational videos demonstrating adapted clinical practices. An additional video series on motivational interviewing was developed that builds on trauma-informed care and will be used in all IPQIC efforts. 

• Emergency Room Treatment of Pregnant and Postpartum Patients: Addressing care gaps in rural hospitals (42% of Indiana's 53 rural hospitals lack maternity services). As a result, many emergency room physicians and nursing staff are treating patients without the necessary recognition of perinatal risks and/or skills to address them. The subgroup is focused on the appropriate identification of women who are pregnant or postpartum immediately upon presentation in the ER and on risk-appropriate treatment and/or stabilization for transport to an appropriate facility. 

• Access to Care: Addressing workforce issues using Maternity Care Target Areas (MCTA). Fourteen Indiana counties have sufficient maternity care providers. The Access to Care subgroup is focusing on workforce issues including the expansion of birth centers, advanced practice nursing support, and the use of doulas in target areas. 

Data from Review Committees

Title V partners with the Division of Family Health Data and Fatality Prevention (DFP) to utilize data and recommendations from their review committees and prevention strategies. This important partnership allows for further collaboration in preventing maternal deaths not just for clinical support, but other prevention opportunities.

Maternal Mortality Review Committee – Title V Connected

The Indiana Maternal Mortality Review Committee (MMRC) continued to review maternal deaths from October 2023 through September 2024. In this period, the committee reviewed pregnancy-associated deaths of Indiana residents irrespective of cause. The review process is completed through an internal abstraction team and a multidisciplinary committee with representation from clinical and non-clinical specialties. The goal of MMRC is to identify opportunities for systems-level changes and make recommendations for the prevention of future deaths.

DFP uses multiple methods to ensure all pregnancy-associated deaths are accurately identified and counted each year. Cases are identified via a pregnancy checkbox on death certificates, causes of death listed on death certificates, assistance from the Indiana Hospital Association, matching of death certificates to birth certificates and fetal death certificates, and facility notifications. After individuals are identified, abstraction staff obtain any records necessary to confirm or negate pregnancy status. These may include hospital records from death, birth, or prenatal care, autopsy reports, and direct communication with coroners. This process is critical to eliminate false positives and locate false negatives. DFP uses multiple methods to ensure that every maternal mortality case is identified, and no deaths are missed.

The fourth annual MMRC report was released in March 2024 and included data from 2018 through 2021. Eighty pregnancy-associated deaths were reviewed in the 2021 cohort, with 60% occurring 43 days to one year postpartum. The non-Hispanic White maternal mortality rate was 90.7 deaths per 100,000 live births, and the non-Hispanic Black maternal mortality rate was 156.3 deaths per 100,000 live births. Because the rate was based on a count of fewer than 20, the non-Hispanic Black rate is unstable and should be interpreted with caution. The rate among Hispanic women, also unstable, was 79.4 deaths per 100,000 live births. The MMRC determined that 71% of 2021 deaths were preventable. The top cause of death for 2021, as with previous years, was overdose, accidental or undetermined intent.

Pregnancy-associated deaths that occurred in 2022 were reviewed from July 2023 to May 2024. Those deaths will be included in the fifth annual report which will be released after the submission of this report. Maternal deaths that occurred among Indiana residents during 2023 are in the process of being reviewed (cases are reviewed based on the calendar year of death, so the timing does not align with Title V reporting dates). The 2023 cohort will be completed in the spring of 2025. While reviewing 2023 deaths, DFP has identified and started to collect records for deaths that occurred in 2024. The fifth annual MMRC report with data on 2018-2022 deaths will be released in early 2025. That report will include five full years of data with a sample size large enough to allow for additional geographic analyses.

Through the Maternal Deaths Due to Violence Prevention Grant and MMRC, DFP improved the quality of the review process for maternal deaths due to violence by increasing the completeness of available records for review. By March 2024 when the fourth annual Indiana Maternal Mortality Review Committee report was released, 75% of cases being reviewed had “complete” or “mostly complete” records. On average, there has been a 10% increase in completeness for each project year. DFP is on track to achieve the goal of 85% “complete” or “mostly complete” for the 2022 case cohort.

Suicide and Overdose Fatality Review – Title V Connected

As of September 2024, Indiana had 33 Suicide and Overdose Fatality Review (SOFR) teams covering 34 counties. Of cases reviewed by teams between October 2023 and September 2024, 147 were among women who lived and died in Indiana. Of these women, 96 died by accidental drug poisoning, and 31 died by suicide. In addition, 18 cases were reviewed in which the manner of death could not be determined or was natural with substance use listed as a contributing factor.

As with all other forms of fatality review, the purpose of SOFR is to develop and implement strategies to prevent future deaths from occurring. Local SOFR teams’ primary recommendations included strategies related to improving care coordination, referral, and follow-up, improved access to treatment, increased bereavement support, and prevention education to address suicide and overdose. 

The DFP worked with local teams throughout the reporting period to improve case review processes, analyze data, and implement recommendations. Some of the successes local SOFR teams had during the reporting period included training first responders in Mental Health First Aid, beginning the process to establish substance use disorder treatment facilities, installing naloxone boxes, creating resource packets with bereavement resources, and establishing grief response teams for survivors of suicide and overdose.

Maternal Fatality Prevention – Title V Connected

The Division of Family Health Data and Fatality Prevention (DFP) hired a Maternal-Fetal Fatality Prevention Coordinator in July 2024 to facilitate the implementation of recommendations from the Indiana Maternal Mortality Review Committee. Initial projects have focused on fetal fatality prevention and have included the development of a stillbirth awareness and prevention toolkit containing resources for pregnant women. To address maternal deaths due to overdose, the coordinator developed a prenatal kit that includes naloxone. Training on the administration of naloxone will be provided to organizations that distribute the kits. The coordinator will continue to develop maternal and fetal fatality prevention initiatives in 2025.

State Priority Need	Reduce preventable deaths in the MCH population with a focus on reduction and elimination of gaps in mortality rates.
State Performance Measure (2020 - 2025)	SPM 2: Reduce Maternal Mortality Rates by promoting best practices in clinical care.
Other Initiatives, Programs, and Policies

Other Initiatives, Programs, and Policies: Reduce Maternal Mortality Rates

Title V Subrecipients

Community Health and Wellness Center

Community Health and Wellness Center (CHWC), Lawrence County, IN, served pregnant women and infants up to one year of age. This center has created two programs with the support and funding from Title V. The Early Start program begins during pregnancy and the Baby and Mom’s Journey program starts after birth and at the child’s first birthday. These two programs aim to support positive birth outcomes, as well as promote optimal health and well-being for both mom and baby. The Baby and Mom’s Journey Together program focuses on addressing community risk factors to foster a community for those around the same stage of pregnancy.

This year, CHWC was able to

• Collaborate with the Prevent Child Abuse (PCAIN) pilot program to establish a transportation panel and create a local transportation resource guide
• Developed the Infant Nutrition Essentials class and worked closely with families on infant growth patterns
  • They saw an increase in successful infant growth after periodic weight checks, nutrition guidance, breastfeeding support, and medical referrals
• Provided each graduate with a ‘Parent Resource Binder’ to help support moms and fathers past the end of the program
  • Included information on CPR, Poison control, family planning, eating, mental health, discipline, oral health, and basics of cooking
• Enrollment numbers remain consistent, and the impact continues to be shown throughout enrolled families

 

Justice-Involved Mothers and Infants

In September 2020, MCH awarded funding to the IU Richard M. Fairbanks School of Public Health to develop Mothers on the Rise (MOTR), which serves mother/baby pairs transitioning from the Leath Nursery Unit at Indiana Women's Prison to their communities. MOTR provides education, resume creation, job placement assistance, clothing, hygiene supplies, infant care supplies, and connections to food banks, mental health services, prenatal care, and women's healthcare. They also help with BMV and legal matters. The project aims to provide fair services to formerly incarcerated women who have experienced socioeconomic factors. Each mother/baby pair is matched with a community navigator who supports them in attending well-child visits and securing social services like Section 8 housing.

This past year, they were able to:

• Expand data collection and evaluation measures to also collect cost benefit data
• Created the Me as Mommy curriculum to discuss the intersection of trauma and parenting
  • This course was taught with one 12-week cohort in the unit
• Navigated Indiana Department of Corrections turnover and leadership changes
• Increased professional development opportunities through partnership with Area Health Education Centers
  • Including two moms completing the peer-recovery training
• Lead Community Navigator worked on a storytelling project through her Turning Point Book to expand awareness and break down stereotypes of moms incarcerated
  • Highlighted stories of mothers transitioning from the prison nursery to the community including interviews with 15 women
• Implemented monthly legal session to expand understanding of rights
• Presented at multiple programs, partners, and conferences
  • Including AMCHP, United Women of Faith, and the Academic Consortium on Criminal Justice
• Program team members expanded their training by completing the peace education program and domestic violence prevention training

MCH staff was able to visit the mother/baby pairs while in the Leath Unit to gain insight into the health goals and barriers once they are released into the community. The themes of these conversations were included in the 2025 Title V Needs Assessment.