III.E.2.c. Perinatal/Infant: Annual Report  (FY20 10/1/2019 - 09/30/2020)

State Priority Need:

Infant Mortality 

National Performance Measure #3 (2016-2021):

Percent of very low birth weight infants born in a hospital with a Level III + Neonatal Intensive Care Unit 

Evidence-Based/Informed Strategy Measure linked to NPM#3:

Number of hospitals provisional surveyed to determine Obstetric and Neonatal Level of Care

* We have accomplished this ESM and have new ESMs for the 2020 – 2025 State Action Plan.

Indiana Perinatal Hospital Services rules (levels of care) were designed to ensure all women of childbearing age receive risk-appropriate care before, during, and after pregnancy, with a long-term goal of reducing infant mortality rates in Indiana. During the 2018 Indiana legislative session, IDOH was given the authority to establish a program to certify perinatal levels of care designations for every delivering hospital and birthing center in the state. The related rules were revised in 2018 to ensure continued compliance with evidence-based practice guidelines and recommendations from national organizations such as the American Congress of Obstetricians and Gynecologists (ACOG), the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), and American Academy of Pediatrics (AAP). Indiana’s team of hospital surveyors continues to collaborate actively and partner with each of our delivering facilities in offering assistance with compliance to each rule. The central goal of this process remains to provide support and guidance to all delivering hospitals in the evaluation of the level of care that most appropriately defines their practice.

Throughout 2018 and 2019, the nurse surveyor team edited the Indiana Perinatal Levels of Care Rules in preparation for final adoption into legislation. These rules defined risk-appropriate care and outlined criteria for designation. There is a strong focus on timely consultation and appropriate transfer to birthing hospitals able to support the level of care required by the condition of the mother and infant.

In September 2019, legislation titled Perinatal Hospital Services went into effect. It requires all hospitals that offer obstetric and neonatal care to be certified as Level I, Level II, Level III or Level IV, based on the services they offer.

The Level of Care certification will give pregnant women and their doctors information to help them choose the facility that is best for them. This will be especially critical for women in high-risk pregnancies. A study by the American Academy of Pediatrics shows that states with levels of care certifications have lower numbers of infant and maternal deaths and illnesses. A description of Indiana levels of care is shown in the chart below.

ISDH surveyor team has begun certification surveys as facilities apply according to their desired level of care. The ISDH expects it may take through 2022 to certify all delivering facilities. After initial certification, facilities will be placed on a 3-year certification cycle.

State Priority Need:

Breastfeeding

National Performance Measure #4A (2016-2021)

Percent of infants who are ever breastfed

National Performance Measure #4B (2016-2021)

Percent of infants who are breastfed exclusively through 6 months

After its formation in June 2018, the Indiana Breastfeeding Alliance (IBA) continued its strategic work into 2019 and early 2020. The IBA was formed with internal ISDH and external community partners, including the Division of Nutrition and Physical Activity, State Office of Rural Health, WIC, Primary Care, the Milk Bank, the Indiana Breastfeeding Coalition, the Indiana Black Breastfeeding Coalition, IN-AAP, and local hospital affiliates. A needs assessment revealed the biggest gap: a lack of lactation education provided to OB and Pediatric providers, Registered and Advanced Practice Nurses, and other health-related professionals including medical and nursing school students. Strategies for 2019 included creating a lactation curriculum within collegiate courses and beginning coordination of a learning collaborative project with practicing providers for improved lactation education and services. Course instructors for Physician Assistant and Pharmacy programs at Butler University provided the IBA opportunities to guest lecture about the benefits and process of lactation and support for their patients. 

IBA began work with the Institute for the Advancement of Breastfeeding and Lactation Education (IABLE) to implement breastfeeding curriculum using the model developed by Dr. Anne Eglash, MD, IBCLC, FABM. This curriculum model to grow breastfeeding champions among providers will be used in the IBA’s future plans for both medical school and practicing provider curriculums. IABLE designed a one-day training for providers, that includes didactic and live case discussions of breastfeeding topics, and in 2019, Indiana supported a partnership with IABLE to train Indiana breastfeeding champions. The goals of this training include learning to troubleshoot, assess, support and triage breastfeeding issues so that better information is shared, and mothers get support during and beyond the hospitalization at delivery. The breastfeeding coordinator has also worked specifically in Marion County with Healthnet clinics in to research and implement a best breastfeeding model of care, in conjunction with IABLE, for their network. The long-term plan would be to implement that further into other clinic settings in Marion County.

IBA also prioritized addressing implicit bias in breastfeeding care by partnering with the Indiana Black Breastfeeding Coalition and the Indiana Minority Health Coalition to offer training to the IBA and partners around the state. We were able to offer an implicit bias workshop through Peace Learning Center in Indianapolis to begin to address the need. This training was offered in 2020 at the annual State Breastfeeding Conference hosted by IDOH. By addressing implicit bias in breastfeeding, IBA seeks to reduce and eliminate health disparities in both breastfeeding initiation and duration.

Although breastfeeding/chest feeding rates have increased over time in Indiana, duration of breastfeeding continues to be another opportunity for improvement. Work is being done to improve collaboration between hospitals and WIC peer counselors during the admission process in an effort to achieve more seamless support for mothers after hospital discharge. More hospitals are supporting outpatient breastfeeding follow-up visits. The biggest barrier to breastfeeding is separation from the infant when a mother goes back to work. MCH will continue to determine how to best support mothers in the workplace and childcare settings. A broader understanding for these professionals regarding their responsibility to support lactating mothers will help mothers continue to breastfeed, chest feed, and/or pump after going back to work.

The breastfeeding coordinator continued to grow partnerships with Indiana chapters of professional organizations who are in position to support improved breastfeeding rates in Indiana and strengthen awareness of breastfeeding as a public health initiative. The concept of weaving breastfeeding into more conversations instead of isolating it as a stand-alone part of perinatal care, has been very well-received. The partnership between the MCH breastfeeding coordinator and the WIC breastfeeding coordinator is improving partnerships at the local level as well. Hospitals are encouraged to partner with local WIC offices and community agencies for ongoing support to mothers. Peer Counselors and other trained staff are crucial to increasing breastfeeding duration.

On February 26 2020, over 500 professionals attended the fifth annual Indiana Breastfeeding Conference. The conference focused on breastfeeding successes in the last decade and looking forward to the next decade with to improve outcomes equitably across the state. It also focused on strategic planning in breastfeeding and the power of coalitions to implement the plan. The keynote speaker, Dr. Ruth Petersen from the Centers for Disease Control and Prevention, spoke about breastfeeding plans and the overall strategy at the CDC moving forward. Next, Nikia Sankofa from the US Breastfeeding Committee also shared the strategic framework of the USBC and how to leverage local coalitions as vehicles of change. Kimarie Bugg of Reaching Our Sisters Everywhere (ROSE) built on the coalition theme by challenging attendees to build diversity into their coalitions and address disparities head on. Lastly, Kiddada Green of the Black Mothers’ Breastfeeding Association spoke to community voice and community integration to increase breastfeeding rates and how to use those voices for policy change. Attendees also had a chance to engage in two breakout listening sessions related to feeding and sleeping practices, which will inform the messaging IDOH should use on how to message the importance of both breastfeeding/chestfeeding while also thinking about safe sleep practices.

The Perinatal Breastfeeding Coordinator worked closely with the Indiana Perinatal Quality Improvement Collaborative (IPQIC) to update guidance for breastfeeding/chestfeeding and substance use. The document discussed times when breastfeeding cannot be encouraged, addressed current practices for marijuana and breastfeeding, and provided evidence-informed data about the use of breastfeeding with methadone and other MAT medications. It also shares the benefits to a baby with neonatal abstinence syndrome and for their mother. The document was approved by the IPQIC Governing Council and was disseminated widely. Indiana also has a guidance document for safe sleep and breastfeeding which is also being updated. These collaborative guidance documents are important to improving breastfeeding rates through implementation of evidence-based policies and protocols related to other infant mortality reduction strategies. This was especially true during the pandemic, when the Perinatal Breastfeeding Coordinator also led initiatives in March 2020 to develop guidance documents for breastfeeding during COVID-19. This guidance document was vital to share with families in the beginning of the pandemic when there was not much public information.

State Performance Measure:

Infant Mortality Rate per 1,000 live births.

SUIDI Training

During this reporting period, the Fatality Review and Prevention (FRP) division staff, recognizing the need for improved consistency in investigation, classification, and coding of infant deaths to inform prevention efforts, provided Sudden Unexpected Infant Death Investigation (SUIDI) training. These are offered as a free training events to local CFR teams, law enforcement, DCS, prosecutors, first responders, and coroners. The full-day SUIDI sessions led by a forensic pathologist, a master’s level social worker, a forensic pediatrician, a master’s level public health professional, and a coroner teach death scene investigators how to conduct a comprehensive infant death scene investigation. During this reporting period, more than 270 professionals have received this training and accompanying program materials. To date, FRP has trained more than 920 death scene investigators, and this training class has now been recognized by the Indiana Law Enforcement Training Academy. A recent adoption of SUIDI-lite sessions allows FRP to increase availability and sustainability of SUIDI skills by reducing the SUIDI training to half-day events. FRP also support investigators and promote SUIDI outreach by improving evidence and data collection, and standardizing child death/injury investigations.  As a result of this collaboration, FRP provided 60 dolls to investigators to ensure resources were available for complete scene reenactments at the local level.

FIMR

FRP provides technical assistance and training to the local Fetal-Infant Mortality Review (FIMR) teams across the state. By supporting the local capacity for review processes, data collection, and the development of recommendations, FRP helps provide local community stakeholders with quantitative and qualitative data on which to base injury prevention programming. The aggregate data available also informs state and national level activities.

FRP strives to increase the number of counties with Fetal Infant Mortality Review (FIMR) teams with an emphasis on communities with disparate populations. Understanding the impact of clinical and non-clinical resources for women of childbearing age and their infants, FIMR teams aim to examine their local efforts and utilize sentinel events as a barometer for potential systems improvements. With the goal of all fetal and infant deaths reviewed by an active FIMR team, FRP has actively targeted birthing hospitals and health departments to identify potential coordinators for new FIMR teams in underserved areas. Support for the work of FIMR teams is facilitated by a dedicated FIMR Coordinator, housed in FRP, and Title V funding has been made available to teams requiring financial support for the work. Title V funding helped support FIMR implementation of four teams including eight counties. In addition, FRP has worked with local partners and stakeholders to increase the number of counties with FIMR teams to 36, with 18 more counties working towards forming a team. As the network expands, intentional capacity-building activities are conducted. In 2019, this included the development of an Indiana FIMR Workgroup, which convenes monthly and allows for peer-to-peer technical assistance of developing FIMR teams. Support from the National Center on Fatality Review and Prevention (NCFRP) has also been critical. A day-long training and networking event was led by FRP and NCFRP staff. More than 40 professionals from across the state attended to receive education on the processes and impact of FIMR in Indiana, as well as resources available to families and infants in the state. Intentional emphasis on health equity, as it pertains to the FIMR and CFR processes, was a main focus for the day.

FRP encourages collaboration among review processes, so many FIMR and Child Fatality Review (CFR) teams collaborate or share membership. Not only does this reduce duplication of review in smaller jurisdictions, but it also exponentially increases the weight of recommendations and the ability to share resources toward collective impact.

SUID Prevention

The Title V SUID Prevention Program has historically focused on providing cribs and safe infant sleep resources to partner organizations for distribution. This has recently expanded to now emphasize the facilitation and support of the formation of local Community Actions Teams (CATs). FRP examined five years of data on sudden unexplained infant deaths (SUIDs) to identify counties with the highest rates and/or number of deaths. These communities were then approached to pilot collaborative community action activities aimed SUID prevention, ideally in conjunction with their child fatality review and FIMR teams. Communities are encouraged to use a strengths-based approach to determine how they can effectively implement sustainable programming. To improve the technical assistance FRP provides to community-based prevention work, FRP expanded staff capacity to include three coordinators who are guiding and supporting communities as they develop their own goals and activities. Each coordinator partners with approximately 30 counties, in direct partnership with the fatality review program staff, allowing a more individualized and data-driven approach.

Concerted efforts began in two counties, Clark and Lake, as data revealed they had a combined number of 51 SUID deaths from 2013-2017. Development took several months, as nontraditional partnerships and comprehensive membership of the group was critical. Activities include regular meetings and evaluation of membership, examination of existing policies, and education of both member agencies and the local community. Prevention work has focused on educating caregivers, clinicians, first responders, and community members on recognizing the risk of unsafe infant sleep behaviors, as well as steps to reduce that risk. In addition, all hospitals systems in these two counties are providing updated, consistent safe infant sleep education to the families they serve. Based on the success of the first two CATs, FRP has supported the formation and growth of additional teams during the reporting period. These teams were formed in the following counties: Marion, Allen, St. Jospeh, Elkhart, Madison,Vanderburgh, with two regional teams in the Wabash Valley (Vigo, Vermillion, Park, Clay, and Sullivan counties) and Southwest Indiana (Daviess, Dubois, Martin, and Greene counties).

To better understand how to create a health marketing program aimed at reducing SUIDs in Indiana, FRP utilized Title V funding to commission ten focus groups (eight in person, two online). Six counties, each with disproportionately high numbers of SUID, provided information FRP will utilize to update safe sleep education and SUID prevention programming. A total of 101 respondents participated and all were parents who reside in Indiana.

Key Findings:

• Nearly all participants knew the ABCs of safe sleep.
• Despite this knowledge, almost all parents reported that they have co-slept with their babies at one point in time and/or will continue to do so.
• When asked about the ways that their co-sleeping behaviors could be influenced or changed, participants overwhelmingly reported that hearing first-hand accounts from caregivers who have experienced an infant death could potentially impact their beliefs and behavior.
• When asked who they see as voices of authority on safe sleep information, responses included doctors, nurses, family members, other moms with more experience raising children, ISDH, and WIC classes.
• Participants said that safe sleep education should take place before pregnancy or very early during pregnancy.
• Parents also suggested adherence to safe sleep behaviors would increase with increased access to free or low-cost cribs and easy-to-access education classes.

The SUID Prevention Program continues to provide field guides with graphics and helpful diagrams to facilitate comprehensive and consistent safe infant sleep education. In addition to providing 3,000 field guides to hospitals, first responders, home visitors, and other social services statewide, 2000 were also provided to Indiana Department of Child Services staff.

 To ensure the availability of resources for families, 3,252 portable cribs and 10,740 sleep sacks were supplied to partners across the state for distribution to at-risk families. Challenges exist with this process though as there continue to be gaps in procuring resources due to contract and vendor supply issues.

FRP has continued working closely with the Indiana Hospital Association (IHA) to standardize safe sleep policies, education, and training methods throughout Indiana’s hospitals. IHA recently executed a hospital recognition program, in coordination with and sponsored by ISDH. To be eligible for recognition, one required criterion is meeting all required education, training, and adherence to safe sleep policies. Work at each facility must be documented and shared with ISDH and IHA.