III.E.2.c. Perinatal/Infant Health: Application Year (10/1/2022-9/30/2023)

State Priority Need:

Reduce Preventable Deaths in the MCH population with a focus on reduction and elimination of inequities in mortality rates

National Performance Measure (2020 - 2025):

NPM 3: Risk- Appropriate Perinatal Care

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

ESM 3.1: Percent of delivery hospitals surveyed to determine OB and neonatal level of care as detailed by Indiana Rules.

Perinatal Levels of Care

IDOH’s Maternal and Child Health clinical team is a group of five nurses that have a robust perinatal nursing background. Collectively, the team works closely with each and every one of the 84 delivering facilities to designate a level of obstetric and neonatal care. Each nurse surveyor has built a unique partnership with their assigned facilities and uses these strong relationships to carry out this important work.

Over the past five years, each delivering hospital had a gap analysis completed. Through these gap analyses, hospital preparation, and the actual survey, MCH staff have provided continued technical assistance and training to hospital staff to meet their anticipated level of care. MCH chief nurse consultants continue to conduct surveys and is almost complete with the initial round of hospital surveys. Currently and over the next year, the MCH clinical team will embark on planning the process they will use for re-certification as six facilities are due to be re-designated in the fall of 2022.  

The Indiana Perinatal Quality Improvement Collaborative (IPQIC) is transitioning its perinatal centers taskforce into a collaborative format. All ten perinatal centers are invited to attend these meetings and discuss topics such as how they are working with their affiliate hospitals, what challenges and successes they are experiencing, needs from the MCH team, etc. These meetings have been popular and the MCH clinical team plans to continue in the next reporting period.

MCH epidemiology is working with the IDOH data analysis team to develop a method to share key perinatal metrics transparently across all 84 delivery hospitals. It is the desire of the Health Commission and others that these key metrics are made available not only to each delivery hospital, but also their Perinatal Center, and eventually the general public. Key metrics will be mined from the birth record to begin with, however, other data sources such as hospital discharge information could be added as the reporting tool evolves. As affiliates have varying degrees of ability to pull and review metrics, the department providing some data on these key metrics will enable Centers and affiliates to start quality improvement projects. As the available data grows and become available to consumers, families across the state have the potential to make choices in their healthcare.

During the reporting period, the MCH clinical team will continue to enhance our partnerships with key stakeholders/providers to identify and/or develop initiatives that support best practices for our maternal and neonatal patients in Indiana. An additional plan for our team is the development of the Maternal Clinical Outreach Program. The purpose of the outreach program is to offer educational opportunities to free-standing emergency departments, non-delivering critical access hospitals, and assist the ten Perinatal Centers with educational offerings for their affiliates. 

The MCH clinical team will continue to host maternal and neonatal recognition and stabilization courses. In 2021, the MCH Clinical team partnered with rural delivering hospitals to offer educational training on obstetrical hemorrhage. The training focused on obstetrical hemorrhage and the implementation of quantitative blood loss (QBL) instead if estimated blood loss (EBL) in vaginal and cesarean deliveries. In addition to that course, eight perinatal registered nurses completed education on best practices in the perinatal setting.

In 2021, the clinical team partnered with Community Hospital to co-lead four (4) S.T.A.B.L.E courses. The S.T.A.B.L.E program is a course that focuses on the post-resuscitation and pre-transport stabilization care of sick infants. It offers practical and effective education to healthcare providers to help in reducing infant morbidity and mortality and improve neonatal outcomes. In June 2022, the MCH clinical team hosted a S.T.A.B.L.E course at a non-delivering birthing facility, which multidisciplinary clinicians attended. The MCH clinical team currently has three additional S.T.A.B.L.E. courses currently scheduled for 2022. In addition to teaching S.T.A.B.L.E courses, the clinical team assisted with teaching two Neonatal Resuscitation Program (NRP) and Intermediate Electronic Fetal Monitoring in Southern Indiana. The MCH Clinical team continues to collaborate with delivering and non-delivering hospitals to implement quality improvement projects to combat poor maternal and neonatal outcomes. Our goal throughout this funding period is to continue to offer educational training to assist birthing facilities with meeting the Perinatal Level of Care rules.  

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 3: Reduce disparities in Infant Mortality

Safety PIN (Protecting Indiana’s Newborns)

From 2005 until 2015, Indiana had some of the worst Infant Mortality Rates not only in the Midwest, but in the entire United States. To combat the trend and to help stop the preventable deaths of infants, Indiana passed legislation for the Safety PIN (Protecting Indiana’s Newborns) Grant Program, IC Section 16-46-14. This legislation allowed non-reverting appropriated state funds to be granted to organizations to reduce infant mortality. This state funding and support from the Indiana legislators is essential to further reducing infant mortality. 

Since 2020, the Maternal and Child Health division (MCH) has been working towards putting some structure in place for these state funds that enable the team to identify the various scope of work being done and to monitor and evaluate the impact of this investment. Changes were made to create a more formalized quarterly report template and the requirements for those awarded. This includes asking for information such as number served, demographics, and specific program information following goals and outcomes. This evaluation plan looks at four major outcomes from starting from 2021 until 2023. The outcomes are:

• Outcome 1: By March 2023, MCH will determine if the grantees are reaching the proposed number of infants, mothers, partners, and families that are provided with education and care from Safety PIN funding annually.
• Outcome 2: By March 2023, MCH will determine the demographics of those served to provide a clear picture of Safety PIN.
• Outcome 3: By March 2023, MCH will determine infants birth weight and gestagion age at birth in the program
• Outcome 4: By March 2023, MCH will determine if there is an improvement of the infant mortality rate in selected regions.

During 2021, all grantee cohorts were collecting data utilizing the new quarterly reports. These reports helped to paint a picture of the work being done by grantees around the state. Based on the initial analysis of the 2021 annual data, 6,931 participants were served across 16 programs in 43 counties. Pregnant and postpartum participants made up 5,229 of those served, with 735 infants and 967 other caregivers served. Of these participants, 59% were on Medicaid and 5% were uninsured. Multiparous clients, those having birthed more than one child, made up 59% of those served. The programs and services offered by grantees have filled an essential role – serving those who do not qualify for other evidence-based home visiting programs due to certain entry qualifications. MCH will continue with the evaluation of Safety PIN and utilize the information to guide the efforts of reducing infant mortality through this state funded program.

MCH has also recently submitted updates to the implementation guidelines for Safety PIN recipients. These updates, made in December 2021, will be used for all new and amended contracts starting in March 2023. These changes include:

• Updated language for components of the application that will be required by IDOH.
• A list of other considerations to be applied to applications beyond those listed in IC Section 16-46-14 including:
  • The infant mortality ration (IMR) burden in a targeted area.
  • The disparity ratio in the IMR in targeted area.
  • Level of evidence of the proposed intervention.
  • Cultural appropriateness of the intervention.
  • Size of the catchment area.
  • Putting an emphasis on reaching populations experiencing disproportionately worse birth outcomes.
  • Evidence of partnerships within the community.
  • The amount and array of existing services in the area.
  • The degree to which an applicant will improve identified birth outcomes/ measurable behavioral & secondary outcomes. 
• A change in the bonus award allotment
• Utilizing 5-year aggregated county level infant mortality rates to compare for the bonus award instead of annual regional rates.

MCH will also be looking at non-evidence-based home visiting programs and determine how to better support those programs in becoming a promising practice. This refocus and shift will also allow for other service standards to be developed for programs outside of home visiting such as Fetal Infant Mortality Review, substance use services, mental health services, and more. It is important to empower communities implement programming that will work for them, while also ensuring practices are evidence-based and standard data collection is completed to ensure programmatic success.

Sudden Unexpected Infant Death/Sudden Death in the Young

To create more consistent investigations and protocols, Title V Block Grant funds will continue to be leveraged to augment the injury prevention work of FRP. CDC–trained facilitators assist staff in providing Sudden Unexpected Infant Death Investigation (SUIDI) training across the state, upon request. The trainings will be provided in multiple locations, to increase accessibility by all death investigators and their respective jurisdictions. Training sessions will teach the appropriate responses and protocols at the scene of an infant death and emphasize the importance of standardization, community collaboration, and services to surviving family members. SUIDI trainees are also encouraged to become active members of their local FIMR and CFR efforts, if appropriate. Training sessions, supported in part by Title V funding, also provide opportunities for FRP to supply safe sleep educational resources to communities as well as the tools necessary to conduct standardized SUIDI, including a scene re-enactment doll. The training sessions will be offered in various locations across the state to improve accessibility for death investigators and their respective jurisdictions.

FRP will continue participating with the Centers for Disease Control and Prevention (CDC) in the SUID and Sudden Death in the Young (SDY) Case Registry grant, which was awarded to FRP in 2018. The five-year grant aims to enhance IDOH’s coordination with the CDC’s SUID/SDY Case Registry. The grant supports efforts to improve investigation techniques, promote safe sleep education, and obtain more accurate and complete data for the registry. This will be accomplished with state and local child fatality review teams, coroners, law enforcement and the Indiana Department of Child Services (DCS) having complete and comprehensive records after investigations. Using the 67 CFR teams the program will ensure all necessary records are collected and entered into the CRS in a timely manner and checked for accuracy by the end of 2022. FRP staff will continue to on-board coroners to the project to ensure tissue and blood samples can be saved at autopsy and that all child deaths that are eligible for the project are captured and analyzed. This project will continue to grow through 2023.

For any of the SUIDs whose cause of death remained unexplained after a review by the local FIMR or Child Fatality Review (CFR) team, escalation to an Advanced Review Team (ART) occurs. Developed as a subcommittee to the Indiana Statewide Child Fatality Review Committee to support the SUID/SDY Case Registry project in Indiana, ART is made up of an esteemed panel of specialists and doctors including forensic pathologists, epileptologists, pulmonologists, cardiologists, geneticists, genetics' counselors, and others. ART does a deeper review of medical records, care levels, lifestyle patterns, autopsies, and possible genetic testing of children that die suddenly and unexpectedly. ART examines the medical aspects and triggers that may have caused an underlying condition such as cardiomyopathy or a seizure disorder to cause the death when no other factors were found at autopsy. The team can also make suggestions for genetic testing if postmortem blood is available and there is concern for other family members. While the program is still growing, coroners can take blood and tissue samples at the time of autopsy for any child that dies suddenly and unexpectedly to send to the MPHI biorepository for DNA banking and/or research, upon family consent. This portion of the SUID/SDY Case Registry offers families the unique choice to save their child’s DNA if they ever decide to have future testing done and allows the family to consent for their child’s DNA to be used in genetic research.

FRP will finalize and analyze 2020 SUID data, the outcomes and findings will be disseminated to CFR and Community Action Teams (CAT) to ensure the correct education surrounding safe sleep is being received by the public. Communities will be able to use this trend information to guide the focus of their prevention work, as well as address any disparities revealed by the data. Analysis will include opportunities for improvements in SUID investigations and community response. By identifying gaps, FRP can highlight to coroners and death investigators how they might improve their processes. It will also aid in determining which, if any, resources must be procured to meet this need (i.e., SUIDI reporting forms, training sessions, re-enactment dolls, etc.). As some of the funding is earmarked to support the improvement of infant death investigation protocols, FRP will also determine if any jurisdictions require support for the necessary toxicology or autopsy equipment and begin a process to support them appropriately.

Fetal-Infant Mortality Review

FRP coordinates the Fetal and Infant Mortality Review (FIMR) program in an effort to reduce the fetal and infant mortality rate in Indiana. FIMR is an action-oriented community process that continually assesses, monitors, and works to improve service systems and community resources for women, infants, and families. Comprised of health, social service, medical, nursing, and other professionals, the FIMR case review team examines the case summary, which is information from medical data abstractions and a maternal interview. Data sources include birth and death certificates, records from hospitals and physicians, home visiting agencies, and autopsy reports. The case is discussed based on all information gathered and gaps in the systems of care are identified.

By reviewing the circumstances surrounding the lives and deaths of these mothers and infants, as well as those who are never born (fetal deaths), and then providing these findings to community action teams, FIMR teams produce creative ideas to help improve birth outcomes and reduce fetal and infant mortality rates. FIMR teams turn the recommendations for system gap and policy improvements into actionable prevention measures.

The Indiana FIMR Network will continue to expand across the state. To date, there are 18 regional or county-based FIMR teams, which cover 44 of Indiana’s 92 counties. These teams are in varying states of functionality, ranging from developing team membership through actively reviewing and reporting on fetal and infant deaths in their jurisdictions. In 2019, Indiana passed legislation requiring a Statewide FIMR Coordinator, whose role is dedicated to training, supporting, and ensuring the success of the Indiana FIMR Network. The FIMR Coordinator will continue to work with CFR staff and Community Action staff to expand into other counties, as well as collaborate with existing fatality review and child injury prevention efforts already underway. Monthly virtual networking meetings will be facilitated between local FIMR coordinators, training events on best-practices and data entry will be offered, and support for the development and execution of recommendations will be offered.

A particular challenge to the Indiana FIMR Program is standardizing an annual report of activities of the network. Because the teams vary in functionality, review criteria, reporting protocols, funding streams, and data entry practices, amassing the entirety of the state’s efforts within FIMR has been difficult and yet to be formalized. Legislation mandates that local FIMR teams must produce an annual FIMR report to the state. Across the nation, no state has yet to produce a state-level FIMR report, however, Indiana plans to produce the first annual Indiana FIMR Report in 2022 that will highlight the findings of local FIMR teams, as well as their community-based prevention and intervention work.

Critical issues identified by Indiana FIMR teams include those associated with infant safe sleep education among parents, clinicians, and childcare providers; improvement of education on kick counts for pregnant persons; improvement of bereavement support; and identifying access to care barriers that affect Indiana families.

As the issues affecting Indiana women and infants are further identified by local teams. One focus will be on health equity by identifying the access to care barriers that prevent pregnant persons and families from obtaining the care that they need. The state FIMR Coordinator will collaborate with local FIMR Coordinators and stakeholders to produce a universal Access to Care Barrier Survey in which clinicians can utilize to provide resources or referrals for families that may need additional help in getting to their prenatal, postpartum, and well child visit appointments. The FIMR program will also continue to support and participate in birth equity events held by local teams throughout the state.

FRP has recently identified connections of grief and trauma to pregnancy loss and/or the death of a child upon reviewing maternal mortality, suicide, and overdose cases. The impact that grief has on Indiana families after the loss of a pregnancy or child death can often have a ripple effect on those left behind. An often-overlooked piece of prevention is proper bereavement support. The FIMR Coordinator will educate and help implement bereavement support in Indiana hospitals as well as work with agencies, including DCS, home visiting, and local first responders, to provide bereavement support for grieving families. The FIMR Coordinator will begin working with hospitals in recruiting bereaved parent volunteers to provide peer support during the loss of a pregnancy or infant death. By focusing on bereavement support in Indiana, the Indiana FIMR Network hopes to improve maternal mental health, reduce fatalities and substance use in those family members left behind, and provide opportunities for communities to actively help remember the lives lost while also bringing awareness to pregnancy and infant loss in Indiana.

Finally, the Indiana FIMR Network will increase education on the importance of fetal movement and encourage earlier reporting of decreased fetal movement from pregnant persons to their clinicians through the means of a mobile app. The state and local FIMR Coordinators will provide education to local clinicians and providers across the state about the app and its features which provide daily kick count reminders and education for pregnant persons on recognizing their own baby’s movements, so they feel empowered to tell their provider when baby’s movements are not normal.

Infant Safe Sleep and Community Action

The Infant Safe Sleep and Community Action (ISS/CA) program within the Division of Fatality Review and Prevention (FRP) works to prevent Sudden Unexpected Infant Deaths (SUIDs). There are currently 14 Community Action Teams (CATs) in Indiana, and efforts will continue to support existing teams and create new teams in high-risk counties.

During the reporting period, FRP will continue a project evaluating a new safe sleep simulation kit that was developed by a local county hospital. The Simulation to Promote Safe Sleep Project, developed by the Mirro Advanced Medical Simulation Lab, Parkview Health System, Inc, is an innovative approach to infant safe sleep education. It focuses on local primary prevention education using advanced medical simulation technology and hands-on interactive scenarios to promote experiential learning. All education provided along with the Simulation to Promote Safe Sleep education kit will be consistent with current recommendations from the American Academy of Pediatrics. The Mirro Advanced Medical Simulation Lab will partner with five Community Action Teams that currently provide safe sleep education to caregivers in Elkhart, Clark, Lake, Vigo, and Howard Counties.

The Mirro Advanced Medical Simulation Lab will produce and supply the educators with a Safe Sleep Airway Infant. The production process involves the 3D printing of a custom model of an infant trachea and esophagus and the silicone casting of an infant. The airway model is transparent and contains a high-contrast colored fluid. This will be placed inside of the 2-piece (left-right halves) silicone infant body and used to demonstrate anatomic and physiologic responses to different infant sleep positions. Simulations of safe and unsafe sleep practices will be used in the learning experience. The 3D model will also be used to simulate vomiting in prone and supine positions. The propensity for vomit to enter the trachea in the prone sleeping position will be demonstrated to address the common misconception that it is safer to place infants on their bellies for sleep. During 2015-2019, 45% of infants in Indiana who died during sleep were found on their sides or stomachs (n=240). Results of the evaluation of the kits will be available in Fall 2023.

The ISS/CA program will develop new safe sleep materials to address the current disparities in SUID rates. In Indiana, SUID is the third leading cause of death for all infants, but it is the second leading cause of death for Black infants. Black and Hispanic infants have higher rates of SUIDs compared with White infants in Indiana. FRP will continue working with Black and Hispanic communities to identify the barriers to safe sleep behaviors and develop strategies to increase healthy sleep practices in local populations of color. After completing videos with three Indiana mothers who lost their infants in unsafe sleep environments, FRP will develop additional videos featuring diverse families and their experiences with infant sleep.

FRP will continue to provide safe sleep resources to local partners, including portable cribs, sleep sacks, and printed materials. These resources are provided to families, along with education, who may not have access to safe sleep environments for their infants. Community Coordinators will continue to provide technical assistance to teams regarding safe sleep and conduct trainings for first responders and other providers who work with families.

Indiana Perinatal Quality Improvement Collaborative (IPQIC) updates:

As a result of data driven strategic planning in the previous reporting periods, IPQIC formulated five new goals:

The commitment of the planning group was to ground the priorities for 2022-2024 in existing data and evidence-based approaches. Their recommendations were presented to the IPQIC Governing Council and were ratified by the Council.

Five new goals were adopted:

• All women of childbearing age in Indiana have access to comprehensive, trusted and risk appropriate health care before, during and after pregnancy.
• All pregnant persons with substance use and/or mental health challenges have access to and receive risk appropriate treatment and support services
• All pregnant persons receive timely, high quality, equitable and trusted prenatal care that results in an uncomplicated delivery and a healthy term baby.
• All Indiana parents and caregivers have access to the resources and supports they need to ensure their infants thrive and celebrate their first birthday. (Focus on infant)
• All parents receive the support and resources needed post discharge to meet their individual needs and improves their opportunity to see their child’s first birthday. (Focus on parent) 

Specifically related to perinatal and infant health, four existing IPQIC task forces will continue to focus on the following topics: perinatal transport, perinatal centers and their affiliate hospitals, perinatal substance use and genetics and genomics. The Maternal and Child Health epidemiology team is seeking a way to provide perinatal health metrics to Perinatal Centers and their affiliates to help track infant health outcomes at the hospital level. 

The substance use taskforce will continue to monitor the pilot for universal plans for safe care. Ideally, all babies born in Indiana are discharged from the hospital with connections to appropriate resources specific to their families’ needs. Parkview Hospital in the Fort Wayne, Indiana has been the pilot site for the project and IPQIC will determine in the next year how to scale this project to other facilities.

The taskforce will also continue examining the data collected from hospitals on drug screens on cord blood tissue submitted to the MCH Epi section. The epidemiology team has added other analyses to the data to include information gleaned from the birth record, PRAMS, maternal mortality review committee, and suicide and overdose fatality review teams. These data will inform new interventions in clinical sites and through public health policies and practices.

The perinatal transport taskforce will continue to examine issues related to the transport of infants and pregnant people between hospitals. Specifically, the taskforce will examine the significant staffing shortage of appropriate teammates as well as the issue of ‘back-transport’ and reimbursement.

Perinatal centers taskforce has evolved into a collaborative space for Perinatal Centers to meet and discuss the challenges and successes of providing support for their affiliate hospitals. Centers will also be asked to weigh in on the process of Levels of Care redesignation as well as re-certification of existing centers and potential new Centers.

Genetics and Genomics taskforce will be responsible for implementation of Indiana’s new process for reviewing and approving new conditions on the newborn screening list. In 2021, Indiana passed legislation that requires an independent committee to review and recommend new conditions based on objective and science-based criteria.

Two new task forces were initiated in 2021 and will continue to refine their focus and goals: Infant Well-being and Perinatal Access to Care. In 2022, infant well-being will focus on developmental screening of infants and children and follow-up to care as appropriate, safe sleep and breastfeeding. . The group will begin by examining the data regarding safe sleep and breastfeeding which highlight the disparity in outcomes for black infants. In future years, priority areas include immunizations, medical home and family support. These task forces will provide clinically based expertise to complement the work of the Department. Staff from FRP, MCH, and the Division of Nutrition and Physical Activity provide support to each of these work groups. Access to care taskforce will spend the next year develop its goals and strategies to best connect people to appropriate care regardless their location in the state, identity, primary language, insurance status, or other considerations that could prevent them from accessing care.