III.E.2.c. Perinatal/Infant Health: Application Year

 

 

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

 

Strategies:

 

In September 2019, the Department completed the promulgation of Indiana’s Perinatal Level of Care rules. Based on AGOG guidance, the rules dictate standards of care for four distinct levels of delivery hospitals’ neonatal and obstetric care. As of September 2020, all but two of the anticipated level III and IV’s have completed the survey process. Through a gap analysis, hospital preparation, and the actual survey, MCH staff have been providing continued technical assistance and training to hospital staff in order for them to meet their anticipated level of care. In all but one level III hospital, all identified gaps were eliminated before actual the actual survey took place. MCH survey staff continue to complete the certification until all delivery hospitals are surveyed and are embarking on certifying perinatal centers.

 

As part of the ongoing work of ensuring all babies who require transport to higher levels of care, MCH will monitor and track very low birthweight (VLBW) babies born at level I and II hospitals. Monitoring this data will allow MCH, IPQIC, and hospital staff to use this information and fuel continued quality improvement work. A special emphasis will be placed on monitoring babies of racial and ethnic minorities as their mortality rates are higher than white babies. The MCH Epidemiology team will report on these trends annually.

 

 

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: Reduce disparities in Infant Mortality

 

Strategies:

 

Indiana’s Governor is committed to reducing the infant mortality rate until we are the best in the Midwest by 2024. ISDH’s roadmap to get there includes valuable information shared through the statewide needs assessment. Since there is no silver bullet to reduce the high rates of infant mortality, ISDH and statewide partners must commit to comprehensive wrap around care and support is easily accessible not only the baby but for the mother, caretaker, family, and community.

 

To best support pregnant women, ISDH MCH will expand group prenatal care programming, so women are connected to others with similar experiences. Support both during and after delivery can increase more regular medical care while increasing social support.

 

Group prenatal care after delivery can also support breastfeeding in a safe space. There are clear disparities in breastfeeding in the state, and the Indiana Breastfeeding Alliance (IBA) is working to address implicit bias in these rates. The IBA is also formulating a new State Breastfeeding Plan and ISDH MCH will continue to host an annual breastfeeding conference that promotes breastfeeding as a way to reduce infant mortality.

 

Racial disparities also persist in unsafe sleep rates in the state. Black infants are three times more likely to die in an unsafe sleep situation than white infants. The Fatality Review and Prevention team continues to work with communities around the state to reduce unsafe sleep deaths and is committed to increasing healthcare provider engagement and education related to the current safe sleep recommendations.

 

The FRP division also works closely with Community Action Teams (CATs) to address infant mortality through collaborative efforts.  FRP will continue to grow CAT teams across the state to continue regional community action. The collective impact of these groups should help address infant mortality rates as the community is taking charge and driving the unique needs of each geographic region.

 

Lastly, the FRP division will continue to lead statewide Fetal Infant Mortality Review (FIMR) teams to collect and review deaths. In the event of an infant death, FRP works closely with first responders, investigators, pathologists, and death certifiers to collect robust data that informs the work of Title V. Collectively, better death reporting and more case reviews allow ISDH to make recommendations to prevent  infant deaths and allow Indiana to be the best in the Midwest by 2024.

 

 

 

2015 - 2020

 

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  

 

Evidence-Based/Informed Strategy Measure linked to NPM#3:

Number of hospitals designated with Obstetric and Neonatal Level of Care

* We have accomplished this ESM and are working on implementing a new one once the rules become effective.”

 

State Performance Measure #2 (2016-2021):

Infant Mortality Rate per 1,000 live births

 

Current Activities (FY20) and Plans for the Coming Year (FY21)

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 for 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).

ISDH began the promulgation of Article 39 Indiana Perinatal Hospital Services in 2018. The Perinatal levels of care designation process started in September 2019. Upon implementation, all delivering hospitals and birthing centers will complete an initial survey followed by a three year cycle of resurveying to ensure risk appropriate care is maintained throughout the state. The state goal is to complete all hospitals applying for Level of Care 3 and 4 designation surveys within 1 year of the effective date. The nurse consultant team continues to collaborate with birthing hospitals to the legislative perinatal rules that will apply as Level 1 and Level 2 prior to their designation surveys in the next 2 years.

 

 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

 

	Indiana (2015 births)	United States  (CDC data)	HP 2020 Goal
Ever breastfed	76.1	81.1	81.9
Breastfeeding at 6 months	37.7	51.8	60.6
Breastfeeding at 12 months	20.7	30.7	34.1
Exclusive breastfeeding at 3 months	39.3	44.4	46.2
Exclusive breastfeeding at 6 months	16.5	22.3	25.5

 

 Evidence-Based/Informed Strategy Measure(s) linked to NPM #4 A & B)

 

Increase the number of Obstetric and Pediatric providers who have completed breastfeeding education.

Indiana currently has 21 hospitals designated as Baby-Friendly.

A task force between ISDH and IHA has been formed with the goal of developing a program to recognize hospitals and infant care providers who demonstrate best practices for infant safety including feeding, safe sleep, reduced exposure to cigarette smoke, and best maternal and infant care practices.  This will reinforce the maternity practices measured in the mPINC survey and spread support for families with infants beyond hospital campuses. The hospitals who are unable or choose to not seek Baby-Friendly designation will find this state program emphasizes the same goals of breastfeeding support and infant safety.  But it will be more affordable and less restrictive than the Baby-Friendly program.  Provider education is included in the plan. Representatives of Indiana chapters of ACOG and AAP are working together to provide speakers at conferences targeting these providers so that consistent messages and expectations can be shared, broadly.  Recognition for breastfeeding-friendly clinics, workplaces, and businesses is included in the multi-year plan. 

 Indiana will improve Perinatal & Infant Health by increasing the number/percent of obstetric and pediatric providers who have completed education on better support of breastfeeding women.  The goal of this expanded education is an increase in the percentage of infants ever breastfed and breastfed exclusively through the first six months of life. MCH will impact these increases by aligning efforts within ISDH to support the Breastfeeding Strategic Plan, supporting efforts to provide training to obstetric and pediatric providers, and support pregnant women’s and new mom’s efforts to breastfeed through the Centering Pregnancy and Nurse-Family Partnership programs.

ISDH continues to support a breastfeeding coordinator, based in MCH, to facilitate these efforts and be the communication link between ISDH divisions, including Women’s Health, DNPA, Chronic Disease and Rural Health, Minority Health and WIC, to assure efficiency as well as collective impact.  The breastfeeding coordinator also interfaces with external partners, such as Indiana chapters of March of Dimes, AAP, AWHONN, Indiana Hospital Association, Indiana Breastfeeding Coalition and Nurse Family Partnership, to work on opportunities for collaboration.  

 

Current Activities (FY20) and Plans for the Coming Year (FY21)

 

Formed in June 2018, the Indiana Breastfeeding Alliance (IBA) is a partnership with internal ISDH and external community stakeholders, 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.  The MCH Perinatal Breastfeeding Coordinator has strengthened collegiate partnerships at IU School of Medicine, IU School of Nursing, Marian School of Nursing, Butler Pharmacy and Physician Education programs, and Ivy Tech’s nursing program in Evansville, IN.  Current plans in FY20 include continued implementation of lactation curriculum within collegiate courses and offer learning collaborative projects with lactation education to practicing providers.  Course instructors for Physician Assistant and Pharmacy students at Butler University provided the IBA opportunities to guest lecture about the benefits and process of lactation and support for their patients.  Ivy Tech has also partnered with ISDH as they begin the process of offering International Board Certified Lactation Consultant (IBCLC) programming at their Evansville campus.  Plans for FY21 include offering scholarships or funding to assist students interested in working in the hospital with completing this program, particularly people of color interested in becoming lactation consultants.  This is part of the IBA’s strategy to address racial equity in breastfeeding by developing a workforce of lactation providers reflective of the communities they serve.

 

In FY20, 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.  At the February 2020 annual breastfeeding conference, ISDH partnered with Peace Learning Center in Indianapolis to offer their first pre-conference entitled “What’s Hidden Inside?”, a workshop that explores personal biases and how they impact care given in breastfeeding.  By addressing implicit bias in breastfeeding, the IBA seeks to reduce and eliminate health disparities in both breastfeeding initiation and duration.  Plans for FY21 include doing more racial equity training for the IBA, including training on systemic racism and dismantling it.  This training will provide IBA members the perspective needed to promote equity in breastfeeding, and tailor training specific to breastfeeding and perinatal health.

 

In February 2020, around 525 professionals attended the fifth annual Indiana Breastfeeding Conference, and saw an increase in physician and advanced practice providers in attendance.  Topics focused on strengthening community networks to best support breastfeeding in a culturally competent way and be accountable to outcomes for all communities.  The keynote speaker, Dr. Ruth Petersen from the CDC, spoke about breastfeeding trends nationally and efforts in Indiana in the last decade to improve breastfeeding.  The first plenary speaker, Ms. Kiddada Green, from Black Mothers Breastfeeding Association in Michigan, followed to address systemic barriers to care and a racially equitable and accountable practice in African American communities.  Breakout presenters focused on establishing breastfeeding-friendly clinic practices, reducing formula supplementation during the hospital stay, addressing equity in the WIC population, collective support for Black-led initiatives to improve equity, and breastfeeding in a home visiting setting.  ISDH also hosted two listening sessions to hear the community attendees discuss feeding and sleeping practices and how to improve both to reduce infant mortality and promote infant and maternal health.  Those sessions were well attended by nearly a third of the conference attendees!  Afternoon plenary speakers included Kimarie Bugg, founder of Reaching Our Sisters Everywhere, to discuss her community transformers programs that support local advocates in breastfeeding.  The United States Breastfeeding Committee Executive Director, Nikia Sankofa, wrapped up the day by discussing the establishment of a coalition network to collectively impact breastfeeding throughout the state.  The Indiana Breastfeeding Coalition closed out the conference with a brief Call to Action for all employees.  The conference was given Continuing education recognition points (CERPs) which helps lactation professionals maintain and/or achieve lactation certifications.  The 2021 Breastfeeding Conference will build on this work of strengthening Indiana’s breastfeeding network to best support families and build community with all of Indiana’s families.

Physician and hospital lactation support continues to bea prevalent gap across all levels of care and across the state.  The significant barriers to hospitals are training and adequate amounts of specialized support.  In FY19, 32 hospital and clinical staff had been trained to provide CLC services.  In FY20, ISDH supported initiatives by the Indiana Breastfeeding Coalition to provide education scholarships for providers of color to improve lactation training.  This is a strategy to increase representation in communities of color to improve breastfeeding inequities. Trainings included IABLE Breastfeeding Champion, ROSE and USBC Summit attendance, CLC/CLS 5-day courses, and online lactation education offerings, to name a few. At the start of FY20, the goal is to provide an IABLE training (formerly Milk Mob) for 35-40 providers, fully online, which includes both didactic and live case discussion components.  IABLE designed 8-hours of course training for providers and MCH will be supporting this for Indiana breastfeeding champions. The program will be piloted with medical students at IU School of Medicine and with a cohort of providers through partnerships with the AAP and hospitals throughout FY20, culminating in a researched evaluation plan and study by IABLE for efficacy.  Plans for FY21 will include expanding this education and building the learning collaborative for practicing physicians to gain Maintenance of Certification (MOC) quality improvement points. 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 continues working specifically in Marion County with HealthNet clinics and their Breastfeeding Champion, Dr. Lindsey Moore-Ostby, to research and implement a best breastfeeding model of care, in conjunction with IABLE, for their network.  FY21 will bring plans implement that further into other clinic settings in Marion County, and around the state, and grow the network of Provider Breastfeeding Champions.

 

In 2019 and into 2020, Indiana continues participating in the ASPHN CoIIN with the breastfeeding work stream at a technical assistance level.   This 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. Additionally, Indiana is participating in the Intensive Level Nutrition CoIIN work to implement more nutrition focused initiatives in the Title V Block Grant work.  Partnerships with DNPA’s nutrition and physical activity team is part of this work, and will continue throughout FY20 and into FY21.  Nutrition education in FY21 will focus on improved nutrition prenatally and while breastfeeding, and improve the promotion of breastfeeding as optimal nutrition for all babies.

 

The partnership between the MCH breastfeeding coordinator and the WIC breastfeeding coordinator is encouraging and improving partnerships at the local level through FY20.  Hospitals are encouraged to partner with local WIC offices and community agencies for ongoing support to mothers, and WIC peer counselors and trained staff are crucial to increasing breastfeeding duration. In FY20 and FY21, this partnership will continue to build and provide more care coordination between both entities in the form of a jointly supported project to build a breastfeeding network infrastructure in Indiana.. Through a partnership with the Indiana Breastfeeding Coalition and Indiana’s chapter of AAP, ISDH is helping to recognize breastfeeding-friendly clinics and providers in FY2020. 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 of these strategies will further the work of Indiana’s Breastfeeding Strategic plan into FY2021, and this plan will be revised at that time.

The Indiana Safe Sleep Coordinator and Perinatal Breastfeeding Coordinator work collaboratively around the state by holding key conversations with breastfeeding advocates around the state from coalitions and hospital systems.  Building on this work with physician advocates, our safe sleep coordinator and Perinatal breastfeeding coordinator are collaborating in FY20 with the Indiana Hospital Association through their Safety Pin grant to create a hospital recognition program that includes improving breastfeeding and safe sleep best practices. Continued conversations with key stakeholders in WIC and many hospitals around the state is part of developing culturally relevant tools and education for this safety pin project and for the state initiatives with breastfeeding and safe sleep. 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 our babies safely.

 

Additionally, our Perinatal Breastfeeding Coordinator has listened to members of the Indiana Black Breastfeeding Coalition on safe sleep and breastfeeding initiatives and impact on African American communities, as well as both safe sleep and breastfeeding dialogues taking places within African American faith communities to build partnerships with the community in this work. Additionally, the 2020 Breastfeeding Conference featured two breakout listening sessions related to feeding and sleeping practices, which will inform the support ISDH needs to give communities on how to message both equally.  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. This work will continue into FY2021, as Indiana continues infant mortality reduction by promoting breastfeeding and the ABCs of safe sleep as optimal practices for all infants.

 

By the end of FY2020, ISDH and the Indiana Perinatal Quality Improvement Collaborative will have created three companion guidance documents related to breastfeeding and other topics included to reduce infant mortality in Indiana.  These other topics are perinatal substance use, safe sleep, and family planning/contraceptive use, and each document offers the most current evidence for combining breastfeeding into their work.  The Breastfeeding and Safe Sleep document, created in 2017, will be updated in FY 2020 with new AAP recommendations on how to safely feed and sleep a baby in the most optimal circumstances.  Created in 2019, the Breastfeeding and Perinatal Substance Use strongly encourages 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.  Currently, the final document has been submitted for review of the IPQIC Governing Council, and that is the Breastfeeding and Family Planning document.  It discusses the evidence related to contraceptive choices and their effect on breastfeeding and milk production.  The document also heavily focuses on racial disparities and the history of these disparities in marginalized communities, for providers to gain a deeper understanding of why disparities exist and how to address them.  ISDH strives to convey the importance of breastfeeding in all of these conversations, to help support and empower communities in their decisions to feed their children and also plan their families according to their wishes.  Plans for FY2021 include use of these three documents within hospital quality improvement projects, and promoting their use throughout the state by presenting at conferences and partnering for information sessions across multisector stakeholders.

 

State Priority Need:

Infant Mortality 

 

 State Performance Measure #2 (2016-2021):

Infant Mortality Rate per 1,000 live births

 

 

Current Activities (FY20) and Plans for the Coming Year (FY21)

 

Fatality Review and Prevention division (FRP) continues to partner with professional trainers to provide Sudden Unexpected Infant Death Investigation (SUIDI) training at the Indiana Law Enforcement Training Academy and multiple locations across the state, upon request. The trainings are provided in multiple locations, in order to facilitate access to all death investigators and their respective jurisdictions.  Training sessions 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 child fatality review 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. As FRP has begun to recognize the need for a more sustainable training program, able to target smaller jurisdictions with limited training resources, a modified SUIDI training session is actively being developed and piloted, per request of death investigators in these areas.  “SUIDI Lite” removes the challenges associated with engaging the highly specified professional trainers needed for a full-day event, and instead focuses on the critical skills needed for SUIDI, including interviewing and interacting with families, scene documentation and doll re-enactment protocol.  . FRP recognized the need for a more sustainable training program, able to target smaller jurisdictions with limited training resources, and, as such, created a modified “SUIDI-Lite" training session. “SUIDI Lite” removes challenges associated with engaging the highly specified professional trainers needed for a full-day event, and instead focuses on the critical skills needed for SUIDI, including interviewing and interacting with families, scene documentation, and doll re-enactment protocol. Scheduling SUIDI Lite events will be by request, intentionally hosted in underserved part of Indiana, and aligned with the training required for work funded through the CDC’s SUID Case Registry grant, which FRP was awarded in 2018.Adopting this format allows for easier training of smaller jurisdictions, which may lack resources to travel to and attend a full-day event. During this reporting period, five events have been held, training a total of 230 professionals from 39 counties. These include 10 counties actively engaged in SUID/SDY project activities. In addition to SUIDI and scene re-enactment doll use, the mobile app has information on serious infant and child injury topics—such as abusive head trauma, abdominal injuries, bruising, burns, and fractures—suicide, drowning and ATV safety.  The app also provides information about state statutes pertaining to child abuse and neglect, pediatric developmental milestones, and investigator self-care. 

 

Indiana first responders and the Indiana Department of Child Services continue to request training on  safe infant sleep, how to identify potential hazards in the sleeping environment, and effective  strategies for educating clients and patients. FRP is actively encouraging community-led networking and resource allocation to improve outcomes for infants in Indiana. FRP is working on moving most safe infant sleep trainings to a more accessible online platform. This free resource allows for greater reach for consistent, standard education. Ensuring all clinicians, home-visitors, and caregivers receive the same training module, thereby reducing instances when families receive conflicting information. These training modules were generated in partnership with FSSA, and include a general sessions, as well as one targeting child care providers. FSSA has mandated the childcare module as required education for providers receiving any level of government funding.

 

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 within FRP and supported by Title V funding, and additional Title V funding has been made available to teams requiring financial support for the work. FRP has actively worked to expand our FIMR network during this reporting period. Title V funding helped support FIMR implementation in four counties, and 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 local Child Fatality Review (CFR) and FIMR teams collaborate or share membership. Not only does this reduce duplication of review in smaller jurisdictions, but it also to exponentially increases the weight of their recommendations and the ability to share resources toward collective impact.

 

In 2017, FRP began the process of establishing a formal process that will help reduce the alarming maternal death rate in the state. Efforts included the creation of a dedicated a Maternal Mortality Review (MMR) coordinator and a statewide multidisciplinary MMR committee (MMRC) that represents both professional and geographic diversity. The MMR coordinator oversees the medical records abstraction done by FRP Chief Nurse Consultants in each county; organizes data collection tools and summarizes case-level data; oversees the community data collection process; manages the Maternal Mortality Review Information Application (MMRIA) database; and aggregates the data through a systematic review of important contributing factors.

 

In 2018, during implementation of the MMR program, IC 16-50 was passed.  This legislation provided the statutory authority critical for ISDH to sustain the multi-disciplinary MMRC, whose goal is to determine risk and protective factors contributing to pregnancy-related or -associated deaths, and use the resulting data to identify interventions aimed at improving systems of care and preventing future maternal morbidity and mortality in Indiana. Through an intensive vetting process led by ISDH staff and Indiana ACOG, a multi-disciplinary MMRC team was identified.  Team members were selected based on required specialties from diverse areas, including obstetrics and gynecology, perinatal nursing, critical care, maternal-fetal medicine, psychiatry, family medicine, pediatrics, social work, substance use disorder, public health nursing, midwifery, anesthesiology, mental health, epidemiology, cardiology, and pathology. Once identified, each team member was personally invited to participate, and joined with the common goal of building Indiana’s capacity to care for women of childbearing age. The passage of IC 16-50 also allowed for access to relevant records and confidentiality protections for MMRC members.

 

In order to capture input from all parts of Indiana, the MMRC membership is intentionally robust (approximately 70 active members) and originates from jurisdictions all over the state. Team member expectations include attendance and participation in comprehensive reviews of pregnancy-related and associated deaths, generating recommendations for prevention, and supporting MMR program staff in acquiring medical records and other necessary documents not readily provided. Further, should a maternal death necessitate the need for an ad hoc member from a specific discipline not already in attendance at the MMRC, the MMRC chair or the MMR coordinator may invite that individual to attend and participate in the review session.

 

The MMRC assembled for the first team meeting in August 2018. At this meeting, MMR program staff, along with additional FRP and MCH staff, were trained by the CDC in maternal death case abstraction and data collection into the web-based MMRIA database. MMRIA is a CDC resource, housed within ISDH secure server. Building of this database was supported by Title V block grant. The MMRC currently convenes on a quarterly basis to conduct reviews of the de-identified summaries prepared by MMR program records abstraction staff. To date, the team have reviewed a total of 11 maternal death cases.

 

For the 2019 fiscal year, in order to review all maternal deaths in a timely manner, the MMRC anticipates scheduling additional review sessions. To further strengthen ISDH ability to review all identified maternal deaths, FRP acquired additional Chief Nurse Consultants to abstract all available medical records and/or coroner reports for all verified maternal deaths, and also create a well-structured case summary that will enable the MMRC understand the circumstances surrounding the event that led to the maternal mortality.

 

 

In the fall of 2019, the MMRC will submitted their first annual report containing comprehensive recommendations on best clinical and non-clinical practices and policies developed through case review finding, aimed at improving the health outcomes of Hoosier women of reproductive age and also eliminate preventable maternal deaths. MMRC findings will also be used to empower our communities with the education, training, resources needed to make necessary changes in maternal health, and the development of Alliance for Innovation on Maternal Health (AIM) safety bundles that will improve the health outcome of women and children. This report will be made available for public access.

 

Establishing a MMRC has been encouraged as a feasible strategy to reduce maternal deaths. Accurately capturing what is happening when women die while pregnant or within a year of the end of pregnancy will help us create prevention programs at the local, state and national levels.

In 2020, the Indiana MMR program seeks to develop and implement policies and protocols to improve timely recognition of early warning signs, ensure appropriate escalation of care, and provide effective discharge counseling and follow-up.

As one of 25 recipients of the award, the Indiana MMR Program will use this funding to better identify and characterize maternal deaths, leading to better focused prevention strategies to reduce maternal mortality and morbidity in Indiana.

 

Also in 2019, the MMR program applied for the funding opportunity, titled CDC-RFA-DP19-1908, Preventing Maternal Deaths: Supporting Maternal Mortality Review Committees. The MMR program and staff is currently supported by Title V funding. If awarded the grant, FRP will utilize the funding award to increase agency infrastructure and capacity, and allow the MMR program to provide information and education to the public and healthcare providers on the emerging issues contributing to maternal mortality and morbidity.  Establishing a MMRC has been encouraged as a feasible strategy to reduce maternal deaths. In the coming year, the Indiana MMR program seeks to establish a strong, reliable, and timely maternal mortality surveillance system in order to inform, guide, and evaluate mortality and morbidity prevention strategies.

 

The Safe Sleep program continues to partner with agencies across the State of Indiana to offer education and  related to infant sleep and tools to assist partners with reducing sudden unexpected infant death (SUID), the third leading cause of infant death in the state, and the first leading cause of death of infants over 28 days. FRP has traveled throughout Indiana and trained over 140 agencies representing community partners throughout the State of Indiana on current SUID data, as well as appropriate community and parent education delivery related to safe infant sleep. FRP also presented during the staff trainings of several home health care agencies and offered material and implementation information to assist the agencies in adopting safe sleep education protocol for families they serve. FRP continued to partner with over 160 community partners to serve all 92 counties by offering safe sleep education and resources. These resources include a portable crib, educational material, sleep sacks, and outreach to help connect caregivers with other support and resources, when needed.

 

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. 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 at SUID prevention, ideally in conjunction with their CFR 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 other FRP staff and program coordinators, allowing for 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 included 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. Joseph, Clark/Floyd, Vigo regional, Allen, Elkhart, Vanderburgh, Daviess, Dubois, Martin, Greene, and Owen counties.

 

FRP continues work funded by the Centers for Disease Control and Prevention (CDC) to participate in the SUID and Sudden Death in the Young (SDY) Case Registry program. This five-year grant supports resources to enhance coordination with the CDC’s SUID/SDY Case Registry, improve child death investigation techniques, obtain more accurate and complete data through collaboration with state and local CFR and FIMR teams, coroners, law enforcement, and DCS, and utilize resulting data to promote infant suffocation prevention and safe sleep promotion. Funds support dedicated staff, as well the work of Indiana coroners, as they strive to obtain full and complete autopsies and other investigative protocols on children who die suddenly and unexpectedly. Costs associated with this work have often been prohibitive and resulting investigations do not meet best-practice standards.

 

A required component of a funded partnership with SUID/SDY Case Registry is timely fatality review of each infant and child death. As such, targeted efforts by FRP to engage, train, and provide technical assistance to local CFR and FIMR teams across the state has been ongoing. In order to meet project timelines, a baseline training module is being created for local CFR teams. Topics will include effective review procedure, the necessity of complete data collection, and the implementation of evidence-based recommendations. FRP is examining training formats for sustainability and accessibility for the local CFR teams. Guidance is being provided by the NCFRP, as well as the CDC project officers. Local review teams are convened, trained on the appropriate case review algorithm, and are then able to respond appropriately upon notification that a child death has occurred in their jurisdiction. To date, ten local fatality review teams have been engaged, 12 coroners have agreed to participate, and two forensic pathologists have been trained on collecting the blood and tissue samples required for an advanced medical review and genetic testing. FRP continues to engage additional professionals and local review teams, and will strive to reach the goal of adding at least 20 in each subsequent year.