II.E.2.c. Women/Maternal Health: Application Year (10/1/2022-9/30/2023)
 

State Priority Need:

Access to high-quality, family-centered, trusted care is available to all Hoosiers.

National Performance Measure (2020 - 2025):

NPM 1: Well-Woman Visit: Percent of women, ages 18 through 44, with a preventive medical visit in the past year

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

ESM 1.1: Number of Women who responded to PRAMS

Several strategies will be implemented to increase the number of women who respond to PRAMS, including continued monitoring of extra mailers to remind women to complete their PRAMS survey. This is set up as an experiment in the PRAMS data collection system and response rates are calculated among women who receive the extra mail reminder and among women who do not in order to determine if this is an effective strategy to increase PRAMS response rates.

Another strategy is to enhance the Indiana PRAMS website to attract more users and provide more information to both the women who are sampled and the general public. The intention is that if a woman is sampled, she will be able to go the PRAMS website and find a compelling message to motivate her to complete the survey and share her story so that her pregnancy experiences can help shape the public health landscape for other women. Also, a more appealing and streamlined website will allow the public and external partners to better understand the PRAMS project and data and perhaps request and utilize the data in their work, thus creating more awareness and buy-in of PRAMS.

Indiana is also hoping to complete a targeted social media campaign, Support PRAMS Moms, utilizing targeted ads via Facebook or other social media domains to enhance PRAMS awareness and branding among women of childbearing age. The intention is that if women see PRAMS advertising or branding when they’re online they will be more likely to complete a PRAMS survey if they’re sampled because the women are aware of PRAMS and trust that it is a legitimate project that will allow them to safely share their experiences.

The PRAMS Team also hopes to work more collaboratively with WIC to increase PRAMS awareness. While some collaboration already exists by utilizing WIC phone numbers to outreach and call sampled women, a more strategic partnership with WIC has shown to be successful in other PRAMS states. Utilizing maps that show PRAMS response rates by ZIP Code, specific WIC clinics will be used to target outreach and PRAMS advertisements. By utilizing response rate data to focus on specific ZIP Codes, the hope is to increase PRAMS awareness and response rates in areas that have been historically low.

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 8 weeks (56 days) of delivery

MCH plans to continue to improve the percentage of women receiving a postpartum visiting with a healthcare provider within eight weeks of delivery. MCH will ensure that home visitors have access to training and education about postpartum care. Home visitors benefit from being knowledgeable about the benefits of postpartum care to share that information with mothers served. The home visiting programs ensure that staff are receiving training and education about postpartum care and how to define a postpartum visit. MCH is committed to increasing the home visiting program data through a Maternal, Infant, Early, and Childhood Home Visiting (MIECHV) Program and My Healthy Baby (MHB). In partnership with MHB, MCH is working to strengthen and expand the data collected through home visiting programs. Data sharing agreements are in process with all agencies (including updating client consent forms) to ensure that all partners are onboard and supportive of how the data will be used. With more local implementing agencies reporting this metric, it may be possible to identify if some agencies have stronger connections with hospital systems and OBGYNs that could result in better access to postpartum care for their clients. This comparative data will allow MCH to provide local implementing agencies quality improvement tools so they may in turn implement strategies to improve process measures. MCH will also complement home visiting programs with more CenteringPregnancy programs, and more details on this expansion can be found below.

During FY22, some internal staffing changes took place that provided the opportunity to reevaluate and restructure the home visiting team. In an effort to create a more cohesive approach across Title V and home visiting programs, two positions have been restructured: the Federal Programs Manager and the Home Visiting Coordinator. The Federal Programs Manager will provide oversight of the operations for both Title V Block grant and the home visiting program (encompassing all funding streams used to support Nurse Family Partnership programming). This position will support the MCH division to oversee all grant-related responsibilities and strategies associated these programs, including direct leadership and supervision of the Home Visiting Coordinator and the Title V Coordinator. The Home Visiting Coordinator role has been expanded to administer Nurse Family Partnership (NFP) programming across the various funding sources, no longer limited to only oversight of MIECHV-funded programs. This expansion will help provide cohesive direction and strategic planning for the NFP programs in Indiana. This new team is working to build a more unified and strategic approach across Title V and home visiting programs. In the coming year, this team will continue to grow and develop as staff are onboarded and familiarized with these programs.

State Priority Need:

Reduce preventable deaths in the MCH population with a focus on reduction and elimination of inequities in mortality rates.

State Performance Measure (2020 - 2025):

SPM 1: Reduce maternal mortality rates and disparities by promoting best practices in clinical care.

Preventing Violence Against Women and Substance Use Initiative

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 the Fatality Review and Prevention division (FRP) are collaborating to reduce the number of maternal deaths due to homicides and suicides in Indiana. As almost half (47%) of all maternal deaths in Indiana are due to suicides, homicides, and overdoses, MCH and FRP focused on 1) developing new processes for data collection of maternal deaths due to both suicide and homicide, 2) designing and implementing interventions that are evidence-based to reduce these maternal deaths due to violence upstream, and 3) evaluating these interventions for efficacy and sustainability.

In alignment with the first goal, by September 30, 2023, FRP will improve the quality of the review process for maternal deaths due to violence by increasing completeness of available records for review to 65% of cases being reviewed having “complete” or “mostly complete” records, with a 10% increase per year for the following project years. FRP is on track for this goal and has onboarded new staff, identified and collected more non-traditional and supporting records, and increased availability of data through collaboration. They will identify a smaller subset of volunteers from the MMRC in the upcoming year to take a closer look and a second review of deaths due to violence.

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

For the education component, MCH has collaborated with the IU School of Medicine (IUSM) to develop and deploy an Extension for Community Healthcare Outcomes (ECHO) model of physician and social service provider education. ECHO is a virtual learning approach used to deliver continuing education around clinical concerns with the overall goal of increasing accessibly to best practices and evidence-based care. Following the emerging data trends that were released in the Annual MMRC report for 2022, MCH’s ECHO is focused on preventing deaths due to intimate partner violence (IPV) through seven, one-hour courses. Each course includes a brief didactic presentation and a de-identified case discussion. The goal of the ECHO course is to increase knowledge of healthcare and social service providers who offer screenings, intervene, and refer pregnant people to services if vulnerable to violent situations. The ECHO model will help address several recommendations published in the 2022 MMRC Annual Report including: disseminating a standard and validated screening tool for providers to help identify women in domestic violence situations, as well as standardization of tools to screen women for depression. These tools will also be disseminated through our partnership with IHA, the IPQIC website, as well as through IDOH’s annual Labor of Love conference. The first round of this ECHO series launched in mid-July 2022 and had 115 attendees for the first session, far exceeding our anticipated participation in this course. IDOH will continue the same ECHO for a second round over the next year if there is enough interest.

For expanded access to prenatal care, MCH has 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 which encourages group-centered prenatal and postnatal care and has benefits including improved health outcomes, better health care experiences, improved job satisfaction, and reduced costs to the system. In Centering, groups are comprised of six to 12 patients of similar gestational age for 90 – 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 will receive full funding for the first two years from MCH to assist in the process of becoming certified in Centering and will be supported throughout implementation. These awards will aid in reducing morbidity and mortality by funding sites to implement the Centering model to address intimate partner violence (IPV) and intervene through a supportive, group care environment. MCH is providing full funding to five pilot sites to implement the Centering model of care in their practice to include training, technical assistance, resources and materials, and certification and licensing. This process is underway, and sites should be launching this model within the next year.

The evaluation component of this grant is still being planned as the first year of the grant was planning and getting things into place. IDOH anticipates starting a process or implementation evaluation for all three components of this grant.

Indiana Maternal Mortality Review

The Indiana Maternal Mortality Review Committee (MMRC) was formalized in July 2018 following passage of IC 16-50, which required the multi-disciplinary review of pregnancy-associated deaths in Indiana and secured protections for the confidentiality of the process. Coordination for the MMRC and related activities is under the purview of IDOH’s Divisions of Fatality Review and Prevention (FRP). In 2019, FRP was awarded funding through the CDC project entitled Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM).

The Indiana MMRC includes representation from a broad range of physicians and nurses from multiple specialties (obstetrics and gynecology, cardiology, pulmonary medicine, anesthesiology, pathology, maternal-fetal medicine, public health), along with social workers, coroners, health advocates, and other allied health professionals. These volunteers extensively review pregnancy-associated deaths to identify opportunities for prevention. As the goal of the review is to identify systems-level changes and not assign individual blame, the names of patients, medical providers, and involved institutions are not disclosed during the review process.

The Indiana MMRC is continuing its work to identify and review all deaths of women within one year of pregnancy and childbirth. Deaths occurring in 2021 will be completely identified and reviewed by late spring 2023. FRP has been concurrently identifying and gathering records for deaths which occurred in 2022 to facilitate the beginning of that cohort's review immediately following the completion of 2021. The fourth annual MMRC report will be completed and released by fall of 2022.

The second annual MMRC report identified continued disparities in rates in maternal deaths among different races and ethnicities, ages, and geographies in Indiana. Food service and the healthcare industries were the most listed occupations on death certificates among pregnancy-associated deaths. The MMRC also found the 67.7 percent of pregnancy-associated deaths had DCS history. The MMRC hopes to be able to perform more in-depth analysis of disparities and contributing factors to maternal deaths with the third annual report and even more in-depth analysis with the next cohort of cases. The continued use of DCS data, familial interviews, EMS, and potential WIC data will benefit our ability to see a fuller picture of the lives of Indiana mothers. 

FRP continues to evaluate the membership of the MMRC and the types of records and information that can be accessed to understand each women’s history and each touchpoint or type of services/care she received. The MMRC has been working to incorporate and broader knowledge of our Emergency Medical Services. We are beginning collaboration to include EMS at the MMRC meetings and working alongside EMS to gain better access to records. We are also hoping  to gain EMS cooperation to report maternal deaths in the field, hopefully making our reporting of maternal deaths more streamlined. As we work with EMS and continue to attempt to gather WIC information, we can make more targeted, evidence-based recommendations for preventing similar deaths and reducing maternal mortality in Indiana.

State Priority Need:

Reduce preventable deaths in the MCH population with a focus on reduction and elimination of inequities in mortality rates.

State Performance Measure (2020 - 2025):

SPM 2: Prevent the use of substances, including alcohol, tobacco, and other drugs among youth and pregnant women.

IDOH has continued to work with the American College of Obstetricians and Gynecologists (ACOG) to reduce maternal mortality and morbidity through evidence-based patient safety bundles under the Alliance for Innovation on Maternal Health (AIM). IDOH has successfully implemented the Obstetric Hemorrhage Bundle and the Reduction in Severe Hypertension Bundle. Both bundles continue to have high rates of enrollment, with now almost all of Indiana delivering facilities participating, as of July 2022. Indiana will next implement its third patient safety bundle: Care for Pregnant and Postpartum People with Substance Use Disorder. IPQIC is developing a toolkit to assist in the implementation of this bundle. The toolkit for this bundle is scheduled to be completed by late 2022, and IDOH will review the toolkit application and guidance to address the disparities and concerns raised in the Annual MMRC report. After this internal review, IDOH will schedule a rollout to all hospitals for enrollment into the bundle with toolkit availability and a webinar for guidance.  We anticipate this being a challenging bundle to implement, as substance use extends far beyond the scope of delivering hospitals and is extremely complex in nature. The IPQIC team is working on incorporating treatment centers, emergency room staff, and social service providers into the proposed toolkit.               

With almost 100% of delivering hospitals now enrolled in AIM, IDOH is prioritizing data quality and hospital support to increase the submission of timely data, increase the racial/ethnic data collected for process and outcome measures, and analyze and utilize the data for action and evidence-based interventions for meaningful and equitable changes. To further this priority, IDOH has participated in two community of learning (COL) opportunities: 1) QI COL (quality improvement) - offered by the National Institute for Children’s Health Quality (NICHQ), and 2) the AIM Data Support COL offered by the AIM Data Team. In the QI COL, IDOH has gained valuable insight to QI methodology including models for improvement, how to use data for improvement work, and spreading the work by encouraging sustainability of all changes made. As part of this learning opportunity, IDOH has plans to create an evaluation and communication plan to increase the quality of data submitted by hospitals by providing increased support through communication and learning opportunities relating to each bundle. In the AIM Data Support COL, IDOH gained valuable skills and resources in identifying, evaluating, and utilizing the data through the lens of severe maternal morbidity, racial and ethnic disparities, hospital and administrative data sources, and many others. Each of these COLs gave IDOH valuable tools, strategies, and resources to reach the next phase in creating meaningful change for the women birthing persons in Indiana. In the next year, Indiana AIM will continue to work alongside hospitals to demonstrate the impact AIM patient safety bundles can truly have on moms and babies, which has been difficult to maintain and sustain throughout the COVID-19 pandemic.

MCH will also continue to support evidence-based programs to help pregnant women quit smoking. The maternal health team working in close partnership with the Tobacco Prevention and Cessation (TPC) Division to explore how pregnant women can receive tobacco use treatment/cessation services through additional programming. By September 30, 2023, MCH plans to have adapted the American Academy of Pediatrics Clinical Effort Against Secondhand Smoke Exposure (CEASE model) into five OB/GYN offices. The AAP and Mass General have agreed to pilot this model among OB provider locations to assist patients and their families who are smoking before, during, and after pregnancy with an assessment, resources, and next steps. MCH is also working on adapting a tiered model that offer a menu of smoking cessation options that can be tailored to the needs of individual organizations throughout the state. The tiered model will consist of promoting a tobacco-free environment, including e-cigarettes; will give the option of adapting the intervention, Ask-Advise-Refer (AAR), into offices; will fund a clinical staff member to be trained as a Tobacco Treatment Specialist (TTS); and/or access to the new Quitline, which will launch the summer of 2022. MCH and TPC will join efforts to create tailored, targeted ads to pregnant and birthing persons that consist of addressing gaps in knowledge about tobacco use in pregnancy, shifting social norms, and promoting a smoke-free lifestyle if approved by the agency.