III.E.2.c. Perinatal/Infant: Annual Report    (FY19 10/1/2018 - 09/30/2019)

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 

The Obstetric and Neonatal Level of Care gap analysis centered on the Indiana Perinatal Hospital Standards, which define risk appropriate care. These definitions establish that all very low birth weight (VLBW) infants shall be born in a hospital with a level III plus NICU. During the gap analysis, nurse surveyors conducted a thorough review of VLBW infants born in Level I or II facilities. Surveyors continue to assist delivering facilities with the development of policies, protocols, and guidelines to improve recognition of mothers requiring delivery at a higher level of care. During the levels of care survey process, there will be a strong focus on timely consultation and transfer of such patients to birthing hospitals able to support the level of care required by the condition of the mother and infant.

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

Throughout 2018 the nurse surveyor team edited the Indiana Perinatal Levels of Care Rules in preparation for final adoption into legislation. These rules define risk appropriate care with a goal of very low birth weight infants being born in a hospital with a Level III+ NICU. There is a strong focus on timely consultation and transfer to birthing hospitals able to support the level of care required by the condition of the mother and infant. To improve recognition of mothers and their infants requiring delivery at a higher level of care, surveyors assisted facilities with the development of policies, protocols, and guidelines.

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 are working on implementing a new one once the rules become effective.”

Article 39: Indiana Perinatal Hospital Services rules, (levels of care) was designed to ensure all women of child bearing 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, ISDH 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 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 continue to actively collaborate and partner with each of our delivering facilities in offering assistance with compliance to each rule. The central goal of this process remains providing support and guidance to all delivering hospitals in the evaluation of the level of care that most appropriately defines their practice. The surveyor team is committed to fostering relationships among our delivering facilities and will continue to work with external partners and delivering hospitals to provide additional resources, to address identified needs.

S.T.A.B.L.E Program

The S.T.A.B.L.E. program offers practical and effective education to healthcare providers in an effort to reduce infant morbidity and mortality as well as improve neonatal outcomes.

In 2019, a total of five (5) S.T.A.B.L.E. courses were offered at two (2) independent, non-network affiliated delivering hospitals. A total of fifty-two (52) registered nurses and six (6) respiratory therapists received the course.

Electronic Fetal Monitoring:

Plans for a “train the trainer” course, in 2021, are actively being discussed. 

 Perinatal Centers: Article 39 Perinatal Hospital Services, define the qualifications and responsibilities of Perinatal Centers in Indiana. Perinatal Centers will assist all affiliates to provide high quality service throughout the system and promote risk appropriate obstetrical and neonatal care through improved use of resources. Our goal is to award Perinatal Center Certifications for those hospitals meeting the required qualifications, by September 30, 2020.

 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.

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 FY 2019.  The IBA was formed with internal ISDH and external community partnerships, including the Division of Nutrition and Physical Activity, State Office of Rural Health, WIC, Primary Care, the Milk Bank, Indiana Breastfeeding Coalition, Indiana Black Breastfeeding Coalition, IN-AAP, and local hospital affiliates.  Strategic planning addressed lack of lactation education provided to OB and Pediatric providers, Registered and Advanced Practice Nurses, and other health related professions, and medical and nursing profession students.  Planning in FY19 for these strategies included 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. 

The 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.  Plans to implement a learning collaborative and research project for these pilots will also help evaluate the effectiveness of this model and grow the project in Indiana. The 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. Planning includes an implicit bias workshop offered through Peace Learning Center in Indianapolis, and this training will be offered in FY20 at the annual State Breastfeeding Conference. By addressing implicit bias in breastfeeding, the IBA seeks to reduce and eliminate health disparities in both breastfeeding initiation and duration.

The breastfeeding coordinator has been able 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.  In February 2019, the Division of Primary Care and Rural Health focused on breastfeeding for a one-hour learning collaborative for staff, and the topic of breastfeeding was included in state meetings of IN-ACOG and is included routinely in the calls of the IN-AAP. 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. 

In February 2019, around 500 professionals attended the fourth annual Indiana Breastfeeding Conference.  Topics addressed focused on strengthening the community connections to best support breastfeeding in a culturally competent way.  The keynote speaker, Dr. Brooke Scelza from UCLA, spoke about breastfeeding culture globally from her work in Africa, followed by a plenary speaker from Ohio, Christin Farmer, on how doulas can address systemic barriers to care in a racially equitable practice.  Kelli Brien, an Indiana Safety Pin grantee, also spoke about her work as the Program Director for Speak Life’s doula program and how addressing unconscious bias can help provide better care.  Afternoon speakers included local partners – employers providing best breastfeeding support, the Indiana Black Breastfeeding Coalition, Johnson Memorial Hospital and Johnson County WIC partnerships, a father engagement speaker, and IN-AAP’s expert on breastfeeding and safe sleep promotion, Dr. Emily Scott.  The 2020 Breastfeeding Conference will build on this work of strengthening Indiana’s breastfeeding network to best support families, and planning was started in August of 2019 for this conference.

The partnership between the MCH breastfeeding coordinator and the WIC breastfeeding coordinator is encouraging and 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 trained staff are crucial to increasing breastfeeding duration. In FY2019 and FY2020, this partnership will continue to build and provide more care coordination between both entities.  At the 2019 Breastfeeding conference, a partnership between Johnson Memorial Hospital and Johnson County WIC was highlighted to showcase how hospitals and WIC clinics are doing this work.

ISDH established a scholarship program in 2017 with Healthy Children to train at least 30 nurses or physicians to become Certified Lactation Counselors (CLC’s).  These CLCs are then encouraged to return to their community to educate families, nurses, and providers.  By November 2018, 32 hospital and clinical staff had been trained to provide CLC services.  In 2019, ISDH set a goal be to provide an IABLE training (formerly Milk Mob) for 35-40 providers online.  IABLE designed a one-day training for providers, that includes didactic and live case discussions of breastfeeding topics, and in FY19, 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 FY19 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.

According to Indiana vital records from birth certificate data, Indiana was above the HP2020 goal for breastfeeding initiation in 2018 and 2019.  Duration of breastfeeding continues to be the opportunity for the most improvement, though CDC report card from 2018 showed Indiana is moving in a positive direction.  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.  Goals for FY20 will include increasing support for 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 and/or pump after going back to work.

The Indiana Safe Sleep Coordinator and Perinatal Breastfeeding Coordinator work collaboratively around the state by holding key conversations with breastfeeding and safe sleep advocates from coalitions, communities, and hospital systems. The goal of these conversations is to determine what efforts are already underway for safe sleep and breastfeeding as well as to engage in key conversations about connecting the two messages together and engagement in this work. When presenting about breastfeeding in the community, the Perinatal Breastfeeding coordinator consistently presents safe sleep data and education compliant with the ABCs, as a method to feed and sleep Indiana babies safely.  Future collaborations for this work will continue as ISDH develops a core message so families can make informed decisions on infant feeding and sleep without sacrificing one infant mortality reduction strategy for another.  ISDH believes both can be done to save Indiana babies and promote optimal nutrition and strives to lead these conversations in the communities.

In January 2019, Indiana continued participating in the ASPHN CoIIN conversations with the breastfeeding work stream at a technical assistance level, and additionally began collaborations with DNPA for the Intensive Level Nutrition CoIIN to implement more nutrition-focused initiatives in the Title V Block Grant. The breastfeeding TA track has provided training and a platform to further engage hospital and WIC partnerships in the communities to eliminate barriers to referrals and improve communication between organizations. In the past three years, WIC has established partnerships at 15 hospitals around the state. Partnerships with DNPA’s and WIC’s teams have been an integral part of this work and have continued throughout FY 2019.

Through a community-level partnership with the Indiana Breastfeeding Coalition, ISDH has helped to recognize breastfeeding-friendly clinics and providers, piloting this project in Northern Indiana. This charter initiative will be an ongoing project to both recognize and monitor the providers who are completing continuing education in the realm of breastfeeding practice. All these strategies will further the work of Indiana’s Breastfeeding Strategic plan, which will be revised after FY 2020.

The Perinatal Breastfeeding Coordinator also led initiatives in FY19 to develop guidance documents for best evidence-based practices in breastfeeding for Indiana Providers.  In conjunction with a network of physicians, nurses, and lactation consultants from around the state, ISDH and the Indiana Perinatal Quality Improvement Collaborative created a guidance document for breastfeeding and perinatal substance use best practices, which included strongly encouraging breastfeeding when appropriate for parents with a perinatal substance use disorder.  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, and the benefits to a baby with neonatal abstinence syndrome and for their mother.  The document was approved by the IPQIC Governing Council and dissemination is in progress through the Perinatal Substance Use work group at the birthing hospitals.  The Perinatal Breastfeeding Coordinator has also presented on this topic in several venues throughout the state of Indiana.  Additionally, Indiana has a guidance document for Safe sleep and breastfeeding which will be updated in the most current recommendations, and plans are being made for a document that addresses family planning and feeding choices.  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.

State Performance Measure:

Infant Mortality Rate per 1,000 live births.

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 adopt 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.

FRP provides technical assistance and training to the local child fatality review (CFR) and Fetal-Infant Mortality Review (FIMR) teams across the state.  FRP traveled to 27 local CFR team meetings to guide them in the review process, offer resources, and assist with data collection. 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, but FRP has worked with local partners and stakeholders to increase the number of counties with FIMR teams to 36, with 18 more counties working toward team formation. Birthing hospitals and local health departments were targeted for presentations on FIMR, and 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 CFR and FIMR 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.

In addition, ISDH provided mortality and morbidity data to local CFR team members and stakeholders across the state. This information can be used by local injury prevention experts to implement evidence-based, data-driven prevention programming in their communities.

The Title V SUID Prevention Program, historically focused on providing cribs and safe infant sleep resources to partner organizations for distribution, has expanded. Program goals 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 death (SUID) 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 tasked with 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, 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. An additional 11 community action teams are in formation, including Marion, Lake, St Joe, Clark/Floyd, Vigo regional, Allen, Elkhart, Vanderburgh, Daviess, Dubois, Martin, Greene, Owen counties. Clark and Lake are the two pilots that we have focused on and funded.

These are counties actively engaged and have formed or are taking steps to form.

To better understand how to create a health marketing program aimed at reducing SUID 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. 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.

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.

FRP has also increased education and resources provided statewide to include print material and access to online safe sleep training. To ensure the continuity and 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, however, as there are gaps in procuring resources, due to contract and vendor supply issues.

During this reporting period, FRP staff also expanded their collaborative partnership with the Indiana Department of Child Services (DCS) to increase ISDH capacity to identify real-time SUID data.  In March 2018, DCS began sharing, on a daily basis, all child fatalities reported to the DCS hotline.  Because DCS investigates all SUIDs, this has allowed the FRP division to track these deaths as they occur, and over time will allow for more targeted prevention.