II.E.2.c. Women/Maternal Health: Plan for the Application Year
 

State Priority Need:

Infant Mortality

 
State Performance Measure #1 (2016-2021)

Prenatal Care in the first trimester

Indiana will address Perinatal & Infant Health factors contributing to Infant Mortality to increase the percent of women that receive prenatal care in the first trimester. MCH will impact the increase by supporting, enhancing and promoting the MOMs Helpline and Early Start programs.

Current Activities (FY18) and Plans for the Coming Year (FY19)

The Early Start program is an outreach effort that facilitates connecting newly diagnosed pregnant women with a prenatal provider. There are 7 Early Start sites located throughout Indiana, most of them in health departments providing prenatal care. While this program has historically, focused solely on early identification of high risk pregnancies, the new service standards will focus on all women of childbearing age. Outreach includes offering pregnancy tests at no cost to the patient, community engagement such as participating in community health fairs, and linking all women of childbearing age to a medical home and community resources for optimal reproductive care.

At the first visit, every woman enrolled in the Early Start program will receive:

• Pregnancy Testing
• Sexually Transmitted Disease (STD) / Sexually Transmitted Infection (STI) Testing
• Health and Pregnancy History
• Overall Women’s or Prenatal Risk Assessment
• Social Determinates of Health Assessment
• Nutrition Assessment
• Height/Weight/ BMI
• Prenatal Labs, if applicable
• Dispense Women’s Multi or Prenatal Vitamin
• Trimester Education, if pregnant
• Contraceptive Education, if not currently pregnant.
• Discussion of Non-Healthy Habits with referrals
• Medicaid Enrollment, if eligible
• WIC Referral, if applicable
• Social Services Referrals
•  

Prenatal Care Coordination Referral, if applicable. The visits following the first, are dependent on the needs of each woman. If a woman identifies as not pregnant, contraceptive counseling should be provided and a referral to a local family physician is required to assist her in finding a medical home.

Infant mortality rates in Indiana have been higher than the national and Midwest average for ears, and for the past several years Indiana has had the highest infant mortality in the Midwest. Related to infant mortality, Governor Holcomb has issued a challenge to state agencies that Indiana be the “best in the Midwest” by 2024. Based on 2017 data, this will require saving an additional 200 babies each year.

In 2019, Indiana House Bill 1007 will require that “The state department shall establish a perinatal navigator program for the purposes of engaging pregnant women in early prenatal care and providing referrals to pregnant women for wraparound services and home visiting programs in the local community.”

In order to begin implementation of this legislation, and as a key component of the overall strategy to reduce infant mortality, the cross-agency (Indiana State Department of Health-ISDH, Family and Social Services Administration-FSSA, and Department of Child Services-DCS) OB Navigator Project has been approved to plan, design, build and implement a process to identify as early as possible in their pregnancy women insured by Medicaid who live in high risk areas, and refer the women in home visiting/navigator services that meet established criteria.

Launched on March 1, 2016, the rebranded MCH MOMS Helpline (formerly known as the Family Helpline) connects mothers and pregnant women with a network of prenatal and child health care services within local communities, state agencies and health care organizations around the state. These services include: providing site locations for free pregnancy tests, facilitating Presumptive Eligibility for Medicaid, linking mothers to qualifying clinicians for themselves and their infants, social service resources and referrals, home visiting options, and aiding with transportation. The Helpline has regular hours (Monday – Friday from 7:30am – 5:00pm) with voicemail outside of regular hours.  Spanish-speaking specialists are available. MCH intends to integrate the data received from the Helpline to identify gaps in services throughout the state and will be instrumental in connecting services to high-need areas that might have otherwise gone underserved.

The Indiana Perinatal Improvement Collaborative (IPQIC) Education Subcommittee has focused on increasing prenatal care in the first trimester, specifically for women who have experienced a previous preterm birth or short cervix (≤ 20mm). The goal is identification of all women who have experienced a previous preterm birth delivered at less than 37 weeks gestation and not induced for a medical indication.  Once these patients are identified, the next step is to offer a progesterone prophylaxes and expedite the initiation of weekly 17 hydroxyprogesterone (17P) injections or treatment with vaginal progesterone.

The Liv pregnancy mobile app was created to be a warm, friendly mobile environment that promotes early prenatal care and education from planning to pregnancy and parenting. The name Liv, represents the character who navigates users through the app and reflects the core mission of ensuring babies live beyond their first birthday. The goal of this app is to decrease the infant mortality rate in Indiana by connecting new or expecting mothers with education about resources and healthy behaviors. The app includes a searchable library filled with dozens of articles, calculators for due date and baby weight, an interactive calendar, a journal feature, checklists, and an “Ask Liv” feature for getting answers not addressed in the app. Liv grants the user access to other resources including contacts for doctors, hospitals, food banks, WIC clinics, drug treatment centers, and safe sleep education/crib distribution sites, all based on the location of the user. Users can also sign up to receive messages and alerts appropriate to their stage of pregnancy.  The Liv app was launched at the Indiana Labor of Love Infant Mortality Summit in November 2017 and is available for free in the Apple Store and Google Play in both English and Spanish. It may also be used on a computer and may be found here: www.askliv.com.

The information in this app has been a cross-collaboration effort across  ISDH, FSSA, the Indiana Office of Technology,  and the Indiana Management Performance Hub. There are plans to include more resources and features from the Indiana Department of Education and the Indiana Department of Child Services.

State Priority Need:

Alcohol and Drug Use

State Performance Measure #5 (2016-2021): 

Rate of infants born with Neonatal Abstinence Syndrome per 1,000 delivery hospitalizations.

MCH will demonstrate progress in addressing alcohol and drug use throughout the Lifecourse domain by identifying the rate of infants born with NAS in Indiana. Indiana Senate Enrolled Act 408 states that the ISDH may establish one or more pilot programs in hospitals that consent to implement appropriate and effective models for NAS identification, data collection, and reporting. In 2018, the pilot was expanded to a total of 30 hospitals. There were 39,278 births in the hospitals and 185 were tested for substance exposure. Of the cords tested, 36.7% were positive and 7.1% of the positive cords resulted in an NAS diagnosis. The rate of NAS diagnosis per 1,000 live births was 12.1, considerably higher than the reported US rate in 2012 of 5.8.

Current Activities (FY18) and Plans for the Coming Year (FY19)

The use of opioids during pregnancy has grown rapidly in the past decade. As opioid use during pregnancy increased, so did complications from their use, including neonatal abstinence syndrome. Several state governments responded to this increase by prosecuting and incarcerating pregnant women with substance use disorders; however, this approach has no proven benefits for maternal or infant health and may lead to avoidance of prenatal care and a decreased willingness to engage in substance use disorder treatment programs. A public health response, rather than a punitive approach to the opioid epidemic and substance use during pregnancy, is critical, including the following: a focus on preventing unintended pregnancies and improving access to contraception; universal screening for alcohol and other drug use in women of childbearing age; knowledge and informed consent of maternal drug testing and reporting practices; improved access to comprehensive obstetric care, including opioid replacement therapy; gender-specific substance use treatment programs; and improved funding for social services and child welfare systems.

ISDH facilitated this work through the IPQIC Perinatal Substance Use Task Force and the 30 participating hospitals. In 2018 a Perinatal Substance Use Toolkit was developed to support hospitals addressing perinatal substance use. The goal of the toolkit is non-criminally standardize protocols and reduce variability across hospitals. The toolkit has five modules:

• Pharmacologic Care;
• Non-pharmacologic Care;
• Transfer;
• Postnatal Discharge Planning; and
• Infant Discharge Planning.

The link to the full toolkit can be found at https://www.in.gov/laboroflove/files/perinatal-substance-use-protocol-bundle.pdf.

Other modules can be found on the ISDH website at https://www.in.gov/laboroflove/208.htm.

In 2019, ISDH plans to expand the project to the remaining 56 delivery hospitals.

In addition to the toolkit, ISDH has partnered with the Vermont Oxford Network (VON) to provide access to 19 educational modules developed by national and international experts. The two year membership provides access to the modules and provides CME and CNE hours for participants. Access to the modules will be expanded to include home visitors, child welfare caseworkers, early intervention providers and other relevant stakeholders.

Practice guidelines are currently being developed to support breastfeeding, when appropriate, for mothers who are using substances. The guidelines document will be available Fall of 2019.

In the recently completed legislative session, a bill was passed that requires a health care provider to:

1. use a validated and evidence based verbal screening tool to assess a substance use disorder in pregnancy for all pregnant women who are seen by the health care provider; and
2. if the health care provider identifies a pregnant woman who has a substance use disorder and is not currently receiving treatment, provide treatment or refer the patient to treatment.

The legislation also requires ISDH to establish guidelines for health care providers treating substance use disorder in pregnancy.

Indiana will also be participating in the Association of State and Territorial Health Officials (ASHTO)’s Opioid Use Disorder, Maternal Outcomes and Neonatal Abstinence Syndrome Initiative (OMNI) Learning Community in fall 2019 to improve management and care for pregnant and postpartum women with opioid use disorder and infants prenatally exposed to opioids. The OMNI project goal is to support implementation within states to address identifying and treating pregnant and postpartum women with opioid use disorders and strengthening systems of care for infants prenatally exposed to opioids, including infants born with neonatal abstinence syndrome, through a systems-level approach.

State Priority Need:

Smoking

National Performance Measure #14 (2016-2021):

A. Percent of women who smoke during pregnancy.

B. Percent of children who live in households where someone smokes.

Evidence-based/Informed Strategy Measure linked to NPM #14:

Number of adults enrolled in Baby and Me Tobacco Free that remain nicotine free at six months post-partum.

MCH will demonstrate improvements in smoking within the Lifecourse domain by increasing the number of adults that remain nicotine free at 6 months postpartum, after participating in the Baby and Me Tobacco Free program.  This promotion of smoking cessation among women of child-bearing age and families in the Children and Adolescent Health Programs will lead to a decrease in the percent of women who smoke when pregnant and children living in households where someone smokes.

Current Activities (FY18) and Plans for the Coming Year (FY19)

Indiana continues to struggle with women who smoke while pregnant.  In 2017, 13.5% of Hoosier women smoked. For women on Medicaid, that number increases to 23.4%.  County rates range from a low of 2.4%, to 31.4%. Integration of the Baby and Me program into community Health Centers and Federally Qualified Health Centers is a priority, as the ISDH continues to target the Medicaid population in areas of highest need.

ISDH funded 22 sites to implement the Baby and Me Tobacco Free program. Nineteen sites are funded through Title V, while three are funded through funds through our sister agency the Division of Mental Health and Addiction within the Family and Social Services Administration. The remaining site is funded through the Safety PIN grant state funds.  ISDH Baby and Me Tobacco Free sponsored programs enrolled a total of 1,037 participants.

Of the 22 ISDH sites, 8 locations are supported with Title V funding and 11 are supported in partnership with the Division of Mental Health and Addiction using SAMHSA Prevention funding.  This close collaboration has strengthened both agencies work on primary prevention, in that the Baby and Me Tobacco Free Program emphasizes keeping new mothers and their families smoke free after baby is born so that children can be raised in a healthy, smoke-free environment. In an effort to better serve rural communities, some site facilitators have partnered with Nurse Family Partnership home visitors and paramedicine professionals. MCH also collaborates with the ISDH Tobacco Prevention and Cessation Division’s quit line to ensure families are referred to the program that best meets their needs and to maximize the efforts of the agency. ISDH is in the process of evaluating program outcomes to determine if funding should remain invested in this program or if alternative national programming options should be pursued.

On July 15th, The Indiana State Department of Health and Indiana Family and Social Services Administration acted on direction from Governor Eric J. Holcomb to improve access to and the affordability of tobacco cessation products for Hoosiers wanting to quit smoking or using tobacco.

The State Health Commissioner issued a standing order effective Aug. 1 allowing Hoosiers to purchase tobacco cessation products at Indiana pharmacies without having to obtain an individual prescription. Indiana became the 12th state with a policy or standing order allowing pharmacists to prescribe tobacco cessation products, eliminating financial and time barriers for individuals considering quitting smoking.

The Secretary of Indiana Family and Social Services Administration, also announced Indiana Medicaid will follow Gov. Holcomb’s directive to reimburse health care providers offering tobacco cessation counseling for expectant mothers. She also announced that Indiana Medicaid will remove copayments for tobacco cessation products for pregnant women or members up to one year postpartum.

“One of our main priorities is reducing the smoking rate of our expectant moms, and we know they will respond positively,” said the State Health Commissioner. “Studies show that women are more likely to quit smoking during pregnancy because they want to give their baby the best possible start in life. Quitting tobacco will improve maternal health and send us farther down the path to achieving Governor Holcomb’s goal of being best in the Midwest in infant mortality by 2024.”

Women who smoke are at least twice as likely to have a preterm birth, which is the leading cause of infant mortality in Indiana. Indiana has the 7th highest infant mortality rate in the nation and is 3rd in the U.S. for maternal mortality. Gov. Holcomb has made reducing Indiana’s infant and maternal mortality a top health priority of the state, and smoking is one of the most important modifiable causes of poor pregnancy outcomes. Studies show that smoking during pregnancy increases the risk of stillbirth by almost 50 percent and neonatal death by over 20 percent.

Nearly 25 percent of expectant Indiana mothers on Medicaid smoke during pregnancy compared to approximately 8 percent of all expectant mothers nationwide. Increasing access to smoking cessation products and further reducing barriers to success will help improve both maternal and infant health.

Training will continue for health care professionals, such as medical assistants and community health workers, to connect them with pregnant women seeking tobacco cessation counseling.