III.E.2.c. Perinatal/Infant Health: Annual Report (10/1/2020-9/30/2021)

 

State Priority Need:

Reduce Preventable Deaths in the MCH population with a focus on reduction and elimination of inequities in mortality rates

 

National Performance Measure (2020 - 2025):

NPM 3: Risk- Appropriate Perinatal Care

 

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

ESM 3.1: Percent of delivery hospitals surveyed to determine OB and neonatal level of care as detailed by Indiana Rules.

 

General Information:

In October 2010, the Division of Maternal and Child Health (MCH) initiated the Hospital Levels of Care Task Force. Its goal was to ensure that all pregnant patients deliver at a hospital that could provide a risk-appropriate level of care. Because Indiana did not have a formal process for designating levels of care for the state’s 90 birthing hospitals, the Task Force was asked to 1) assess the current level of care definitions; 2) create standard definitions and guidelines for each hospital level of obstetric and newborn care, and 3) make recommendations to the health department and professional organizations on policy needed to improve quality perinatal care and what the next steps should be. The Task Force adopted principles to guide its work:

• Achieve the best outcomes for mothers and babies
• Comply but not exceed the American Academy of Pediatrics (AAP) and American Congress of Obstetricians and Gynecologists (ACOG) national standards
• All standards must be grounded in solid evidence
• Produce a visionary document.

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

In this reporting period, 19 Level I/I facilities and 18 Level II/II facilities were surveyed and designated. In partnership with the Indiana Perinatal Quality Improvement Collaborative, MCH’s Clinical Team worked through considerable challenges and problem solving to help facilities navigate through the designation process. Not only were hospitals dealing with considerable barriers due to COVID pandemic, staffing shortages on the units as well as on transport teams made it difficult for many facilities. Clinical team worked with each facility individually to understand their unique challenges and strengths. The team used tools such as remote chart reviews, flexible scheduling, and the increasing use of tele-health to evolve MCH’s survey process. 

Our MCH clinical team continues to seek ways in which we can partner with key stakeholders and providers to identify and/or develop initiatives that support best practices for our maternal and neonatal patients in Indiana. An additional plan for our team is the development of the Maternal Clinical Outreach Program. The purpose of the outreach program is to offer educational opportunities to free-standing emergency departments, non-delivering critical access hospitals, and assist our Perinatal Centers with educational offerings for our rural hospitals. MCH clinical team were able to teach S.T.A.B.L.E Program (Sugar, Temperature, Airway, Blood Pressure, Lab Work, Emotional Support) is a widely distributed and implemented neonatal education program. It focuses on the post-resuscitation and pre-transport stabilization care of sick infants. It offers practical and effective education to healthcare providers to help in reducing infant morbidity and mortality and improve neonatal outcomes. The team also identified and plan on building the team’s capacity to teach Fetal Monitoring courses.

Perinatal Centers

During this reporting period, IPQIC and MCH prepared for designating Perinatal Centers and the following affiliation of all delivering hospitals in the PLoC process. Centers will assist all affiliates in providing high-quality service throughout the system and promoting risk-appropriate obstetrical and neonatal care through the improved use of resources.   Perinatal centers and affiliates are required to establish a Memorandum of Understanding by November 2, 2021.  Unlike other states, Indiana chose not to focus on regional center due to the reliance on health systems with the state. Each center must affiliate with at least one facility not in their hospital system.

AIM

MCH has developed relationships with external partners at the Indiana Hospital Association and with our internal epidemiology team to study inpatient data, outcomes data sourced from the birth worksheet, and process measures through the Alliance Innovation for Maternal Health (AIM) to better understand what each facility can do to improve its clinical practices.

Transport Programs:

Maternal-Fetal and Neonatal Transport programs are essential requirements of perinatal centers and bring higher levels of care to outlying delivering hospitals by supporting safe and timely transfer of patients to tertiary centers. Article 39 Perinatal Hospital Services includes the Indiana Perinatal Transport Guidelines, which were written in accordance with evidence-based Certified Air and Medical Transport Systems (CAMTS) and Air and Ground Transportation guidelines from the American Academy of Pediatrics (AAP). Transport guidelines center on safety culture routines, quality assurance measures, education, competencies, and certifications of the transport team members and leadership. Evaluation of transport programs includes these essential standards for inter-facility transfers and management of maternal/fetal and neonatal transport teams.

Ongoing challenges for Indiana’s transport system persists. Transport teams across the state continue to be overburdened and understaffed, which has been exacerbated by COVID-19. Additionally, while Indiana has clear guidelines as to when and where mothers and babies should be transferred in instances where higher levels of care are warranted, policies and procedures for how to get infants back to their ‘home’ hospitals are lacking. Namely, reimbursement for ‘back transport’ is unclear. This means many families are traveling long distances to see their sick babies and the care established in one facility may not be communicated clearly to the ‘home hospital.’

The IPQIC transport committee continues to examine the issue of ‘back transport’ as well as other important policy issues. In 2021, the transport committee updated the transfer algorithm to ensure mother-baby dyads are moved appropriately. These guidelines are authored by experts in the field, vetted by members of transport teams, and shared with facilities state-wide.

In 2021, transport teams were enrolled in the GAMUT (Ground Air Medical qUality Transport) program. The MCH Division anticipates collecting GAMUT data from each of the ten perinatal centers in the fall of 2022. 

Substance exposure/NAS:

IPQIC continued work with the substance use collaborative collecting data from cord blood tissue at participating hospitals.

The following data is only representative of the births occurring in the hospitals that participate in the Perinatal Substance Use Hospital Collaborative and the data are subject to each hospital’s practice, coding, and definition of NAS. It's also important to emphasize that any changes from 2020 to 2021 should be explained within the context of hospitals diagnosing and reporting NAS individually, often using different criteria to determine if a cord should be tested and possibly using a different panel to discern positivity. Hospitals operate using different algorithms to determine when to test a cord and that process is heavily dependent on the care provider’s experience. Also, with the addition of new hospitals to the collaborative in 2021, there is substantial change in the number of infants eligible to be tested and diagnosed. All of this makes it very difficult to compare data year to year. Instead, the data should be used as a one-time snapshot of participating hospitals and their current practices

The statistics provided below come from the 2021 Perinatal Substance Use Hospital Collaborative and the data reported by participating hospitals.

On average, there are over 80,000 births occurring in Indiana annually. 

In 2021, over 65,000 births occurred at hospitals participating in the Perinatal Substance Use Collaborative. In 2021, 69 out of 84 birthing hospitals were participating through data submission. Of the newborns delivered at participating hospitals, 20.3% of births had cords tested have been tested for drug exposure.

Of the tested umbilical cords, 38.2% of tested cords were positive for drug exposure.

Of the positive umbilical cords, 19.6% of positive cords received an NAS diagnosis (997 NAS cases) in 2021.

Over the past few years, MCH has noted increasing exposure to cannabinoids and in the future, the collaborative hopes to include fentanyl exposure as we see increased overdose deaths associated with fentanyl exposture.

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 3: Reduce disparities in Infant Mortality

 

General Information:

Indiana Perinatal Quality Improvement Committee

Indiana’s Perinatal Quality Improvement Collaborative (IPQIC) was established in 2010 in response to the state’s desire to develop rules and guidance around Hospital Levels of Care. The group has evolved to examine and respond to many issues related to the clinical interventions of maternal and infant health such as substance use disorder, AIM bundles, safe sleep promotion, breastfeeding, and others. Co-Chaired by the State Health Commissioner and the Executive Director of the Indiana Hospital Association, IPQIC is made up of well over 400 clinical volunteers representing the spectrum of provider types. Volunteers serve on workgroups and committees related to their interests and areas of expertise. Each workgroup, along with representatives from state level professional organizations make up a Governing Council. The Governing Council is responsible for passing recommendations and publishing toolkits and guidance for providers.

 

IQPIC achieved its initial goal of Perinatal Levels of Care after state rules were promulgated in September 2019 and facilities’ surveys started quickly after. Although IPQIC remained in active in helping the MCH clinical team develop the next steps with Perinatal Centers, the Collaborative recognized the need to strategize on ‘what’s next’ for IPQIC. Members spent the reporting period examining data from the latest Title V Needs Assessment, PRAMS, MMRC, and other sources to prioritize needs for the future. Through extensive meetings and debate, IPQIC published its latest strategic plan for 2022 to 2024 which resulted in new goals, new committees, and new sub-committees. The plan aligns well Indiana’s State Action Plan and complements the public health inventions with the appropriate clinical framework. The new goals for IPQIC include:

1. Ensure all women of childbearing age in Indiana have access to comprehensive, trusted and risk appropriate health care before, during and after pregnancy.
2. Ensure that all Indiana parents and caregivers have access to the resources and supports they need to ensure their infants thrive and celebrate their first birthday.
3. All pregnant persons with substance use and/or mental health challenges have access to and receive risk appropriate treatment and support services
4. All pregnant persons receive timely, high quality, equitable and trusted prenatal care that results in an uncomplicated delivery and a healthy term baby.
5. All parents receive the support and resources needed post discharge to meet their individual needs and improves their opportunity to see their child’s first birthday

Work will be done in the following period on specific and measurable ways the committee would like to see improvements related to these goals.

FIMR

To address the disparate infant mortality rates in Indiana, Fatality Review and Prevention (FRP) coordinates the Fetal and Infant Mortality Review (FIMR) program and network. FIMR is an action-oriented community process that continually assesses, monitors, and works to improve service systems and community resources for women, infants, and families. 

Comprised of health, social service, medical, nursing, and other professionals, FIMR case review teams examine case summaries, which include information from medical data abstractions and maternal interviews. Data sources include birth and death certificates, records from hospitals and physicians, WIC, and Healthy Start. Cases are discussed based on all information gathered, and gaps in systems of care are identified.

By reviewing the circumstances surrounding the lives and deaths of these mothers and infants, as well as those who are never born (fetal deaths) and providing these findings to Community Action Teams (CATs), FIMR teams can develop recommendations that include innovative ideas to help improve birth outcomes and reduce infant mortality rates in Indiana.

The Indiana FIMR Network will continue to expand into the next reporting cycle. To date, there are 17 regional or county-based FIMR teams that cover more than 49 of 92 counties. These teams are in varying states of functionality, ranging from currently developing team membership to actively reviewing and reporting on fetal and infant deaths. In 2019, Indiana passed legislation requiring a Statewide FIMR Coordinator whose role is dedicated to training, supporting, and ensuring the success of the Indiana FIMR network. The coordinator has worked with other FRP Child Fatality Review (CFR) staff and community coordinators to expand into more counties, as well as collaborate with existing fatality review and child injury prevention efforts already underway. Monthly virtual networking meetings have been facilitated between local FIMR coordinators. Training events on best-practices and data entry has been offered along with continuous support for the development and execution of recommendations.

In February 2021, the Indiana FIMR Network partnered with the National Center for Child Fatality Review and Prevention (NCFRP) to host a virtual day-long training of the Indiana FIMR Network. Approximately 30 professionals joined the event and learned about best practices in FIMR, turning recommendations into action, and embedding health equity into the FIMR process. Participants also shared successes and challenges with each other in a round table format.  

The Indiana FIMR network utilizes the National Center for Fatality Review and Prevention (NCFRP) Case Reporting System to maintain data and findings resulting from the FIMR reviews. The coordinator prioritized improving local teams' data entry by providing virtual training and direct assistance with the data entry process. Data quality checks are regularly conducted by the FRP epidemiologist and feedback is provided to the local FIMR team coordinators. Particularly for those FIMR teams directly funded by Title V grants, data entry and timely reporting are a program requirement. The coordinator has continued to attend local FIMR team meetings and provide guidance and training as needed. 

During the reporting period, the coordinator attended, observed, and assisted more than 40 local FIMR team meetings, including CAT meetings. The St. Joseph County FIMR team hosted multiple meetings of their Birth Equity and Justice Workgroup, which was attended by FIMR teams around the state and extremely impactful. By partnering with local professionals of color and minority-serving agencies, the St. Joseph County FIMR team improved its outreach to and for marginalized populations and advised local policymakers in ways to improve outcomes for the most vulnerable mothers and infants. The team executed a weeklong virtual education series on Black infant and maternal health in April 2021.

The Southwest Regional FIMR Team, supported in part by a Title V grant, formed a subcommittee to address its high number of unsafe sleep-related infant deaths. To date, the team has conducted a SWOT analysis among all family-serving organizations in the four-county region. Ultimately, the subcommittee hopes to create a uniform safe infant sleep message for all professionals (clinical, social, first responders, etc.). 

The Allen County FIMR team also maintains its staffing infrastructure through a Title V grant.  Through its monthly meetings, the multi-disciplinary group has identified several prevention and intervention activities for the local community. Allen County does not have a formal CAT structure, but the FIMR coordinator is intentional with providing data and recommendations to the multiple community partners already actively working to support pre-, ante-, and post-natal health in the area. Both delivering hospital systems have recently added bereavement staff to their labor and delivery floors, in direct response to recommendations from the FIMR team. Community health workers are improving their delivery of safe infant sleep messaging during home visits. Efforts to meet the needs of the large Burmese population included improved language services and the use of members of that community group to obtain the trust of young mothers and ensure culturally appropriate care.

Other local FIMR teams supported directly with Title V funding, and some of their resulting activities include:

• Bartholomew County – Began in 2017 in response to several fetal demises in their community hospital. The Bartholomew County FIMR team immediately recognized the need for the simultaneous development of a CAT to implement their prevention recommendations. While COVID-19 made in-person community events challenging, the FIMR coordinator was still able to improve safe infant sleep education across clinical and social service providers and develop a perinatal mental health support system within the delivering hospital. These activities have helped improve the well-being of and support offered to new parents, but also has reduced the number of infant deaths in their county.
• Lake County – Lake County is recognized as a high-risk region for infant mortality in Indiana. They began their CAT in response to the high number of unsafe infant sleep deaths, and the FIMR team’s formation followed. While this approach was non-traditional, FRP supported the development and work of the CAT with available injury and fatality data and safe infant sleep resource distribution. The FIMR team was challenged by COVID-19 and hesitancy from hospital systems to participate. As such, the FIMR coordinator and medical records abstractor spent much of the reporting period developing and enacting data sharing agreements with clinical service providers. They held a mock FIMR review and participated in all offered training events. FRP assisted with case identification through vital records and guided the team on best practice for case review, formations of recommendations, and data entry. The first FIMR review for Lake County was held in April 2021, and the team reviewed eight fetal and infant deaths.
• West Central Regional – The West Central Regional FIMR team is the largest in Indiana, consisting of 12 counties. The FIMR coordinator is housed within the Tippecanoe County Health Department, and the team has the support of the two large hospital networks in the region. They began reviewing fetal and infant deaths in fall 2019 and have continued to meet quarterly throughout the reporting period. They developed a CAT in late 2020 and have focused their prevention work on creating a network of resources for families in the region.
• Elkhart County FIMR – The Elkhart County FIMR team has struggled with capacity challenges during this reporting period. The current coordinator and medical records abstractor have been COVID-deployed, in addition to their other duties within the local health department, and their FIMR work could not be prioritized. FRP has refocused on helping the county formalize a CAT, in conjunction with their CFR team, so that prevention work can continue. The FIMR team attempted to conduct remote reviews of four fetal demises but found the process unsuccessful. Despite this, progress was made with infant death investigation practices in their county. Additionally, Elkhart County has a large Amish population and outreach to that community to address their pre-conception health challenges has improved.

Other critical issues identified by Indiana FIMR teams include those associated with infant safe sleep education among parents and clinicians; improvement of education on kick counts for pregnant persons; accessibility of folic acid and prenatal vitamins; and the impact of Adverse Childhood Experiences in the generational health outcomes. Not only do all these topics drive Indiana’s high infant mortality rate, but also lend to the disparities in those rates among race and geography across the state.

The Indiana FIMR Network identified gaps in the identification of fetal demises resulting from congenital anomalies. The Genomics and Newborn Screening (GNBS) program identifies and collects data on infants who are born with congenital anomalies through the Indiana Birth Defects and Problems Registry (IBDPR), but congenital anomaly information of fetal demises is often missed in the registry. As the FIMR teams identified and reviewed these as part of their processes, the coordinator captured the demographic information of fetal and infant deaths resulting from preventable congenital anomalies and share them with GNBS. This collaboration had the goal of improved accuracy of the data collected by both FRP and GNBS regarding these deaths. Particularly, for preventable congenital anomalies, health programs can be more accurately developed if the burden of these is better documented.

The St. Joseph County FIMR team, FRP, and GNBS partnered to create a health education program about the need for folic acid or folate before and during pregnancy. This module was piloted through the St. Joseph County Health Department in June 2021. Additional FIMR teams and local health departments were identified to expand the rollout of the education and began distributing it into their communities in August 2021. As part of this, GNBS and the FIMR coordinator were able to identify sources of free or low-cost prenatal vitamins to provide to Indiana women in need.

Beginning in 2015, NCFRP created an ongoing Data Quality Initiative (DQI) to improve the quality and consistency of data entered in the CRS, particularly through the FIMR module. To improve usefulness of infant and child fatality data at the state and national level, select variables were prioritized for data entry for each decedent case. These priority variables are helpful in identifying prevention strategies and monitoring the effectiveness of prevention measures that have been implemented. FIMR priority variables are currently under review at the national level. NCFRP appointed a taskforce to determine the most effective variables required to fully depict the life and death of infants/children in the entered in the CRS. FRP is being consulted on this project, and the FIMR coordinator provides input regarding the most valuable data points needed for prevention work.

FIMR coordinators from the state and local levels are actively engaged with IPQIC in a continued effort to find what is impacting the health of pregnant women and babies in Indiana. The coordinators serve on several different subcommittees within IPQIC and help make suggestions and improvements that will impact the lives of all Hoosier families. Working together with IPQIC allows coordinators to share FIMR processes, findings, data, recommendations, and prevention activities from across the state. Together, the Indiana FIMR network and IPQIC are a critical collaboration that support better outcomes for pregnant women and babies in Indiana.

New partnerships with the Indiana FIMR network continue to be developed, as the issues affecting Indiana women and infants are further identified by local teams. One focus has been on food deserts and addressing the nutritional needs of women and children in high-need areas. This will be a partnership with IDOH DNPA. The coordinator has continued to work with other FRP programs, including SUID Prevention, CFR, Community Action, and Maternal Mortality Review teams to create consistent messaging and data collection protocols. Adopting FIMR teams into the SUID/SDY Case Registry project will also be a target goal of the upcoming year. Most of the Indiana FIMR teams review SUIDs and requiring them to follow the protocols and guidelines outlined by the CDC will increase the standardization of these reviews and may improve the timeliness, as well.

 

Safe Sleep

The Fatality Review and Prevention (FRP) Division continued its work on the promotion of infant safe sleep and data driven Sudden Unexpected Infant Death (SUID) prevention. In January 2021, the Infant Safe Sleep and Community Action (ISS/CA) Program began working on an online safe sleep training module for the My Healthy Baby Program’s in-home care providers. The training will assist in-home care providers to educate caregivers and ensure their clients have safe places for their infants to sleep. In February 2021, the program began working with the Indianapolis Fire Department to restart its infant safe sleep program. The Indianapolis Fire Department responds to emergencies in zip codes with some of the highest Sudden Unexpected Infant Death (SUID) rates in the state, and firefighters and EMTs have opportunities to engage with families and conduct checks of infant sleep environments and provide education and resources.

In March, the Safe Sleep Program partnered with IDOH MCH, and the Bartholomew County Community Action Team in a collaboration with CityMatch. This is a national organization of urban maternal and child health leaders that works toward strengthening public health leaders and organizations to promote equity and improve the health of urban women, children, and communities. As part of this collaboration, the program began participating in the National Region V Infant Mortality webinar series for HHS Region V state and local MCH professionals. The goal of this series is to supplement the prevention work occurring in each state as they drive towards reducing infant mortality and eliminating racial disparities.

In May 2021, ISS/CA Program completed a project with the Indiana Chapter of the American Academy of Pediatrics to develop a webinar for statewide AAP-affiliated providers. This project was funded by a grant from NCFRP and provided education to pediatricians on the importance of having conversations about safe sleep (including both nighttime sleep and naps) with patients. The webinar also included information regarding consumer products that are not safe for use in infant sleeping environments.

During this reporting period, the ISS/CA Program began working on new safe sleep materials with an external marketing consultant. The content of these materials was based on the results of focus group data analysis that was completed in the summer of 2021 and included interviews with Indiana mothers who lost their infants in unsafe sleep environments. Additional materials will be developed throughout 2021 with plans to disseminate the final products in 2022.

The program provided ongoing support for existing Community Action Teams (CATs) and worked on developing new teams in high-risk counties. CATs work at the local level to prevent infant mortality by building on the existing strengths of a community. By September 30, 2021, there were 13 CATs covering 31 of 92 counties in Indiana. Community coordinators continued to provide CATs with safe sleep resources, training, and technical assistance.

 

SUIDI Training

To create more consistent investigations and protocols, Title V Block Grant funds will continue to be leveraged to augment the injury prevention work for FRP. CDC-trained trainers assisted staff in providing Sudden Unexpected Infant Death Investigation (SUIDI) training across the state, upon request. The trainings are provided in multiple locations, to facilitate accessibility by all death investigators and their respective jurisdictions. Training sessions teach the appropriate responses and protocols at the scene of an infant death and emphasize the importance of standardization, community collaboration, and services to surviving family members. SUIDI trainees are also encouraged to become active members of their local FIMR and CFR efforts, if appropriate. Training sessions, supported in part by Title V funding, also provide opportunities for FRP to supply safe sleep educational resources to communities as well as the tools necessary to conduct standardized SUIDI, including a scene re-enactment doll. The training sessions were offered both through virtual events and in various locations across the state to improve accessibility for death investigators and their respective jurisdictions.

FRP continued to work with the Centers for Disease Control and Prevention (CDC) to participate in the SUID and Sudden Death in the Young (SDY) Case Registry grant, which was awarded to FRP in 2018. The five-year grant aims to enhance IDOH’s coordination with the CDC’s SUID/SDY Case Registry. It also supports efforts to improve investigation techniques, promote safe sleep education, and obtain more accurate and complete data for the registry through work with state and local child fatality review teams, coroners, law enforcement and the Indiana Department of Child Services. Using the 54 already-functioning CFR teams and training any additional teams formed during the next reporting period, the program will ensure all necessary records are collected, entered into the CRS in a timely manner, and checked for accuracy by the end of 2021. FRP staff will continued to on-board coroners to the project to ensure tissue and blood samples can be saved at autopsy and that all child deaths that are eligible for the project are captured and analyzed. This project will continue to grow through 2023.

For any of the SUIDs whose cause of death remained unexplained after a review by the local FIMR or Child Fatality Review (CFR) team, escalation to an Advanced Review Team (ART) occurs. Developed as a subcommittee to the Indiana Statewide Child Fatality Review Committee to support the SUID/SDY Case Registry project in Indiana, ART is made up of an esteemed panel of specialists and doctors including a forensic pathologist, epileptologists, pulmonologists, cardiologists, geneticists, genetics' counselors, and others. ART does a deeper review of medical records, care levels, lifestyle patterns, the autopsies, and possible genetic testing of children that die suddenly and unexpectedly. ART examines the medical aspects and triggers that may have caused an underlying condition such as cardiomyopathy or a seizure disorder to cause the death when no other factors were found at autopsy. The team can also make suggestions for genetic testing if postmortem blood is available and there is concern for other family members. While the program is still growing, coroners can take blood and tissue samples at the time of autopsy for any child that dies suddenly and unexpectedly to send to the MPHI biorepository for DNA banking and/or research, upon family consent. This portion of the SUID/SDY Case Registry offers families the unique choice to save their child’s DNA if they ever decide to have future testing done and allows the family to consent for their child’s DNA be used in genetic research.

Once FRP has finalized and analyzed 2019 SUID data, outcomes and findings will be disseminated to CFR teams and CATs to ensure the correct education surrounding safe sleep is being received by the public. Communities use trend information to guide the focus of their prevention work, as well as address any disparities revealed by the data. Analysis has included opportunities for improvements in SUID investigations and community response. By identifying gaps, FRP can highlight to coroners and death investigators where and how they might improve their processes. It also aided in determining which, if any, resources must be procured to meet this need (i.e., SUIDI reporting forms, training sessions, re-enactment dolls, etc.). As some of the funding is earmarked to support the improvement of infant death investigation protocols, FRP determined if any jurisdictions required support for the necessary toxicology or autopsy equipment and began a process to support them appropriately.

 

Safety PIN

From 2005 until 2015 Indiana had some of the worst Infant Mortality Rates in not only the Midwest, but in the country. To combat the trend and to help stop the preventable deaths of infants, Indiana passed the Safety PIN (Protecting Indiana’s Newborns) Grant Program, IC Section 16-46-14. This legislation allowed non-reverting appropriated state funds to be granted to organizations in the efforts to reduce infant mortality. The funding and support from the state of Indiana is essential to further reduce infant mortality.

Throughout the life of the Safety PIN fund, IDOH MCH has seen different types of programs utilized including doulas, home visiting, tobacco cessation, statewide hospital requirements, safe sleep prevention, staff education, parent education, and more. Every organization has their own target population and programmatic layout which could span regionally, multi-county, or single county wide depending on the reach and needs of the community.

All projects and proposals for funding must have a defined target area where a reduction in the infant mortality rate can be measured. The legislation states that 60% of the total funds to an organization must be granted in the first two years of the program while the remaining 40% of the funds will be released for the following two years if and only if the infant mortality rate in the defined region decreases. If there is no decrease, the 40% award is not given, and any funds left on the contract would be reverted to the department to be granted out in the future. The regional infant mortality rate and state infant mortality rate are determined by the department’s epidemiology team.

In late 2020, a new RFA was released with that aligned possible programming ideas with the statewide Title V Needs Assessment. These options were catered towards issues communities are seeing such as substance abuse and mental health issues. A new cohort of eight organizations was awarded and began in April 2021. One additional organization was awarded in July 2021. Below is the reach of each cohort operating during this grant year. Cohorts overlap due to the nature of the two- and/or four-year grant award periods.

 

2017 Cohort: January 2017 – December 2020

Total Organizations: 4

Reach: 282 individuals and 86 birthing hospitals from October 2020 – December 2020

 

2018 Cohort:  January 2018 – December 2021

Total Organizations: 4

Reach: 3,804 individuals from October 2020 – September 2021

 

2019 Cohort: April 2019 – March 2021

Total Organizations: 4

Reach: 204 individuals from October 2020 – March 2021

 

2019 Cohort: April 2019 –March 2023

Total Organizations: 3

Reach: 2,176 individuals and 63 birthing hospitals from October 2020 – September 2020

 

2021 Cohort: April 2021 – March 2023

Total Organizations: 8

Reach: 1,189 individuals from April 2021 – September 2021

 

2021 Cohort: July 2021-June 2023

Total Organizations: 1

Reach: 38 individuals from July 2021 – September 2021

 

IDOH MCH completed the updates to the quarterly report templates in January 2021 after testing the format with the 2018 grantees from April 2020 – December 2020. These updates include asking for more data including demographics, population served, and questions regarding the specific programs being implemented. The reports are catered to each of the subrecipients while maintaining some data points applicable to all grantees. With the new reporting system, IDOH MCH be utilizing findings to assist in the evaluation of the grant program and to help inform the work done within the division and the state.

 

In fall 2021, IDOH MCH started work to update IDOH rules for implementing the Safety PIN program. This legislative change will continue past September 2021 and into 2022. 

 

Genomics and Newborn Screening Program

The GNBS program updated the critical congenital heart disease (CCHD) screening protocols. The updated protocols took effect July 1, 2021. The goals of the updated protocols were to mirror the new recommendations of the AAP, ensure valid screens were performed, ensure timely follow-up for infants that did not pass the screen, and reduce deaths due to CCHDs. Weekly webinars were held from February 2021 through June 2021 to ensure all hospitals, licensed birth centers, and midwives were able to review the new guidelines and ask questions before the implementation date of July 1. The updated protocols allow exceptions to screening such as a prenatal diagnosis of CCHD, an echocardiogram being performed prior to screening, administration of supplemental oxygen or respiratory support, or palliative care. For those infants on supplemental oxygen, the clinical recommendation includes screening after the infant is removed from supplemental oxygen at the discretion of the physician. This allows physicians to indicate whether an echocardiogram or a CCHD screen was performed. If an infant does not pass the CCHD screen, it is required to complete an echocardiogram, at a minimum, to ensure timely confirmatory testing and ultimately, reduce mortality associated with the most severe CCHDs. Additionally, it is required to report all exceptions to CCHD screening to the GNBS program monthly. The oxygen saturation levels from the pulse oximeter must be documented on the newborn screening card. These requirements allow for the GNBS program to complete follow-up if confirmatory testing was not performed, and to understand how and why infants are not being screened for CCHD.