II.E.2.c. Women/Maternal Health: Plan for the Application Year
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
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
Current Activities and Plans for Coming Year:
To increase the percentage of women who have an annual well-visit, MCH must better understand how many women are getting into well-woman care and their reason for either continuing regular medical visits or not obtaining consistent care and eliminate barriers to care. A top need from the five-year needs assessment demonstrated the urgency to have an easier transition from labor and birth to postpartum care. Survey participants noted that postpartum care is either insufficient or too long after delivery for many women which makes the transition back to well-woman care after delivery challenging, especially when much of the attention is focused on babies. ISDH will aim to assist women to navigate their health and care with supportive programming and policies to ensure women have regular, trust care before, during, and after pregnancy.
To better understand women’s experiences before, during, and after pregnancy, ISDH will depend on data from the Pregnancy Risk Assessment Monitoring System (PRAMS). Indiana PRAMS began collecting data in 2017 and has achieved one year (2018) of weighted data since the CDC retroactively reduced the response rate threshold for weighting. Indiana PRAMS continues to use data to inform quality improvement (QI) projects aimed at increasing PRAMS response rates.
Past data showed very low survey completion among the final weeks of phone outreach, so a tickler postcard was created to send to non-respondents during the phone phase. The postcard is colorful, eye catching, and only includes a small amount of text while highlighting the incentive – a $25 gift card upon survey completion. The postcard also contains the direct phone number that the mother can call to complete the interview. This QI project was set up as an experiment within the PRAMS data collection database and women are randomly assigned to a postcard or non-postcard receiving group. Data collection began in March 2021 and will be used to inform future QI projects and efforts. Other work around increasing PRAMS response rates has included testing and implementing caller scripts to convert refusal statements, using data to increase peak call times and implement new call schedules, creating enhanced website content for Indiana PRAMS to grow awareness of the survey, more colorful and eye-catching PRAMS envelopes, and dissemination of program specific PRAMS data to stakeholders to increase utilization and demand for PRAMS data. Another need for Indiana PRAMS is more stable PRAMS staff who are well versed in both data surveillance and analysis and also in program coordination and grant maintenance. In an effort to remedy this, Indiana PRAMS has been actively pursuing two full-time employees to support PRAMS moving forward.
IDOH recognizes that PRAMS data is only a snapshot into postpartum care, and we are actively working to better collect information and data on these visits. Over the next year, we will explore the possibility of collecting data around postpartum visit frequency and insurance coverage in a partnership with the Indiana Hospital Association through outpatient data. This could also lead to more conversation around best practices for physicians, better postpartum visit coverage, and policy change that can be led by IPQIC, Indiana’s PQC.
We will also continue working to promote postpartum care among women and encourage them to make the transition from postpartum care back to well-woman care when ready. ISDH MCH will promote both self-care and transition to annual care through marketing campaigns on our Liv Mobile Pregnancy App and through patient empowerment advertisements from Hear Her®. To ensure IDOH is able to meet women where they are, MCH will implement more group prenatal care options (serving women before and after delivery while providing a sense of community) and more community paramedicine home-based programs so that emergency medical technicians (EMTs) can operate in an expanded capacity to reach underserved populations in the community. Furthermore, MCH will analyze the impact of implicit bias experienced by women in accessing care in order to ensure that care – if and when provided – is part of a trusted relationship between women and their healthcare provider that will help promote regular checkups.
Lastly, we will increase the percentage of women who have an annual visit is by tracking the percentage of mothers enrolled in home visiting who receive a postpartum visit 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 Program and My Healthy Baby. The 10/1/2019 - 9/30/2020 data is representative of two local implementing agencies receiving MIECHV funding. 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. Lastly, MCH is committed to maintaining or increasing the current home visiting service capacity to ensure that more clients have access to home visiting.
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: Reduce maternal mortality rates and disparities by promoting best practices in clinical care.
Current Activities and Plans for Coming Year:
The Indiana 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. The MMRC was developed with guidance from the Centers for Disease Control and Prevention (CDC) Division of Reproductive Health’s Building US Capacity to Review and Prevent Maternal Deaths program and is modeled after other well-established MMRCs in the United States. Coordination for the MMRC and related activities is under the purview of IDOH’s Division of Fatality Review and Prevention (FRP).
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 identifying systems level changes and not assigning individual blame, the names of patients, medical providers, and involved institutions are not disclosed during the process.
In 2019, FRP was awarded funding through the CDC project entitled Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM). This grant and the associated technical assistance have allowed for the expansion of efforts already underway to systematically identify and collect relevant information pertaining to pregnancy-associated deaths, review the findings, and make data-driven recommendations.
The Indiana MMRC is currently continuing its work to identify and review all deaths of women within one year of pregnancy and childbirth. Deaths occurring in 2019 will be completely identified and reviewed by late spring 2021. FRP has been concurrently identifying and gathering records for deaths which occurred in 2020 to facilitate the beginning of that cohort’s review immediately following the completion of 2019 deaths. The second annual MMR report will be completed and released in August 2021.
The first annual MMRC report was able to identify some disparities in rates in maternal deaths among different races and ethnicities, ages, and geographies in Indiana. However, as the last report was based on just one year of data, there were limits to the conclusions that could be made based on groups with small numbers. The MMRC hopes to be able to perform more in-depth analysis of disparities and contributing factors to maternal death in the next annual report, as additional cases are added and data can be analyzed in aggregate. As the MMRC collects more data through continual review of all maternal deaths, they can also continue to make more targeted, evidence-based recommendations for preventing similar deaths and reducing maternal mortality in Indiana.
FRP continues to evaluate the membership of the MMRC and expand the types of records and information that can be accessed to understand each woman’s history and each touchpoint or type of service/care she received. This process has become more refined with experience over the first two years. The MMRC has been working to incorporate more records into the review process that provide a full picture of both medical and social events that could have impacted outcomes. FRP plans to engage state and local service providers in the future, including WIC, FSSA and Medicaid data, local jails, the Department of Correction, substance use treatment providers, mental health providers, and more. Recent changes were made to the legislation which now guarantees access to mental health records. This will allow the MMRC to evaluate the presence and management of mental health challenges among these women in the same way we would evaluate other chronic conditions. This is especially important as mental health conditions were found to be a major contributing factor to maternal deaths in 2018.
Another planned addition to the records reviewed by the MMRC are informant interviews, or interviews with the family or loved ones of the women who died. The goal of these interviews is to understand the women’s perceived experiences and well-being during pregnancy or in the time leading up to death. Sometimes the official records do not tell the whole story, and these interviews will provide valuable insight into how a woman was feeling and what she may have experienced during this time. To achieve this, Indiana MMRC has contracted with the Grassroots Maternal Child Health Leadership Training Project. Grassroots trains and mentors women to help their neighborhoods improve pregnancy and infant development outcomes. They work to make change at the community, organizational, and policy levels, while meeting the needs of women, infants, and families in their neighborhoods by linking them to services. These community leaders and the FRP nurse consultants are receiving appropriate training for conducting survivor interviews and will ultimately embed these qualitative data into the pregnancy-associated death case presentations. This critical addition to the case narratives will help the Indiana MMRC better understand the experiences of women who died, as well as their families, friends, and communities who endured the loss of a pregnant or recently pregnant woman. By hearing stories directly from those closest to the women who died, recommendations generated by the committee can be informed by the individual circumstances leading to pregnancy-associated deaths. The MMR team has begun sending notifications to families of the deceased and have already conducted two family interviews.
Under the purview of FRP, the Suicide and Overdose Fatality Review (SOFR) Program began in 2018 as a pilot program in three counties. Since then, the program has expanded to 20 functioning teams, with six more in the formation phase. The local expertise of the SOFR team membership has been a critical addition to the MMRC work because there is a high burden of suicide and overdose death among maternal mortality in Indiana. MMRC members have been identified through SOFR teams and coordinated case identification and records sharing processes have been established. As additional SOFR teams are created and prevention efforts are recommended through the MMRC, the joint efforts of both programs will be critical for information dissemination and guidance for evidence-based best practices.
IDOH also plans to continue working 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). To date, IDOH has successfully implemented the Obstetric Hemorrhage and rolled out the second bundle - Reduction in Severe Hypertension – in summer 2021. Both bundles have high rates of enrollment, with just over 92% of Indiana delivering facilities participating. Indiana will continue to implement new AIM bundles following the release of the Annual MMRC report in order to follow emerging data. Over the next 12 months, MCH plans to pay extra attention to hospitals that are currently not enrolled in order to increase enrollment to 100% and to better monitor goals and outcomes of each facility while encouraging continuous quality improvement.
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: Prevent the use of substances, including alcohol, tobacco, and other drugs among youth and pregnant women.
Current Activities and Plans for coming Year:
Substance use is on the rise in the Midwest and truly impacting Indiana. The statewide needs assessment survey showed substance as the second highest need (behind mental health) for communities across the state. Inevitably, women who use substances may become pregnant, and MCH is committed to ensuring they have optimal healthcare throughout and after their pregnancy. As MCH improves the ability to screen and identify women using substances during pregnancy, we hope to grow in our capacity to provide further treatment and care for all families.
MCH will increase the number of delivering hospitals who participate in the substance use collaborative with the Indiana Perinatal Quality Improvement Collaborative (IPQIC). Exact rates of substance exposure and Neonatal Abstinence Syndrome are not well understood in Indiana, and this goal aims to improve surveillance. Identification of women and their children who are exposed to substances will allow ISDH and partners to plan for and provide follow-up services for the mother-baby dyad and focus on prevention in high burden areas of the state. MCH collected cord blood screens from 41 delivery hospitals (2019 data) to collect positivity data for a wide array of substances. MCH and IPQIC’s goal is to collect this data from all hospitals willing to be enrolled in the system.
In early 2020 IPQIC added a subcommittee specifically tasked to explore how public health and clinical providers can work together to examine how to measure, prevent, and mitigate Fetal Alcohol Spectrum Disorder (FASD). During the year, the committee will examine strategies to measure the impact of FAS/D by screening for ETOH on the cord blood tests. Additionally, MCH seeks to understand how to work with providers to better report alcohol exposure to the Birth Defects and Problems Registry. The committee is also tasked with providing recommendations on appropriate interventions in the clinical setting at the prevention (maternal health) level, and screening for children during grade schools. MCH is also seeking population health interventions and prevention strategies that can be deployed within the structure of the Title V program.
In 2019, Indiana’s legislature passed HEA 1007. This bill required that all women receive a validated verbal screening for substance use as part of their prenatal care and is referred to treatment if the screen came back positive. MCH will work with IPQIC and relevant professional organizations to ensure these screens are happening, and if women happen to screen positive for substance use there is an available provider in her community to provider care. Continued technical assistance through direct communication as well as updated and relevant clinical bundles will be provided and disseminated. Additionally, MCH is partnered with the Office of Medicaid Policy and Planning (OMPP) to determine the feasibility expanding Medicaid coverage for 12 months after delivery for women enrolled in treatment for substance use disorder. Providers will also be provided opportunities for training on substance use during pregnancy through traditional conference-style training events as well as the availability of collaborative style training events through the ECHO model.
In partnership with the Family and Social Services Administration (FSSA) and the Department of Child Services (DCS), MCH and IPQIC will develop protocols for delivery hospitals to develop plans of safe care for all mother/baby dyads discharged from the hospital. Currently, plans of safe care are completed for some families involved in child services; however, it is the goal that all families are connected to needed resources, regardless of circumstance. MCH is committed to prevent the use of substances, including alcohol, tobacco, and other drugs among pregnant women. Babies born exposed to substances as a result of prenatal substance use will be treated appropriately and families will be referred to services as needed as a dyad and unit.
MCH will continue to support evidence-based programs to help pregnant women quit smoking. Currently, Title V supports many sites in implementing the Baby and Me Tobacco Free program. Maternal health staff are involved in internal workgroups to explore how pregnant women can receive tobacco use treatment through additional services or programming. IDOH will no longer fund BMTF programming beyond 9/30/2021 as the collected data is not showing intended outcomes.
In early 2022, IDOH plans to begin implementation of the AIM Obstetric Care for Women with Opioid Use Disorder bundle to address maternal substance use disorder. Based on data from the IPQIC Neonatal Abstinence Syndrome project, MCH recognizes that many other substances are being used by pregnant and postpartum women. To address substances other than opioids, Indiana AIM will create additional measures and data metrics to best capture all women with a substance use disorder.
Members of the Title V program, including MCH Director, Clinical Director, and members of FRP are participating with partners in DMHA on a PRISM project with ASTHO. The Promoting Innovation in State & Territorial MCH Policymaking (PRISM) Learning Community provides technical assistance and capacity building over a twelve month period to support and advance policy implementation within states and territories to equitably address substance misuse and addiction and mental health disorders in women, children, and families within the context of the COVID-19 pandemic. Indiana is seeking to better understand the current landscape of substance use prevention and intervention across the state and what gaps exist.
In 2019 Indiana was awarded a Centers for Medicare and Medicaid (CMS) grant to address opioid use disorder in pregnant patients. The Indiana Pregnancy Promise Program is a free, voluntary program for pregnant Medicaid members who use opioids or have used opioids in the past. The program ensures individuals’ privacy and confidentiality. The Pregnancy Promise Program connects individuals to prenatal and postpartum care, other physical and mental health care, and treatment for opioid use disorder. The Pregnancy Promise Program provides support during the prenatal period and for 12 months after the end of pregnancy. Through these supports and relationships, the Pregnancy Promise Program provides hope to parents and babies and sets a strong foundation for their future. The project director the program serves on IPQIC and MMRC. The MCH Director serves on the board for the promise program.
The MCH Director is also working with NACCHO and CityMatCH on the Alignment for Action Learning Collaborative with Bartholomew County. This partnership seeks to examine how state and local health departments can more collaboratively learn and work together to align strategies for population health improvement. Specifically, the state is learning from Bartholomew County how they implemented a FIMR program that essentially eliminated safe sleep related deaths in their community. The Title V program will take those learnings and spread and sustain to other counties with similar projects. Additionally, Bartholomew County is working to build prevention and intervention strategies related to substance use disorder in pregnant people. These learnings are especially important as Bartholomew County is considered ex-urban and rural. Its population is similar to many other counties within the state where these strategies may be replicated. The Title V program is grateful for the opportunity to forge new and strengthen existing partnerships as a result of this opportunity.
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