Indiana’s Plan to Reduce Infant Mortality Jerome Adams, MD, MPH State Health Commissioner November 13, 2014

Factors Contributing to Infant Mortality in Indiana Smoking (ISDH #3 priority) 16.5% pregnant mothers smoke 30% Medicaid Moms smoke!!! Indiana has 12th highest smoking rate in US Obesity (ISDH #2 priority) Obese=25% chance prematurity Morbidly Obese= 33% prematurity Indiana is 9th most obese state in US

Factors Contributing to Infant Mortality in Indiana Limited Prenatal Care Only 68.1% pregnant mothers in Indiana receive PNC in 1st trimester Unsafe Sleep (15.8% of deaths 2012) Elective deliveries before 39 weeks gestation

Indiana’s Plan to Reduce Infant Mortality Address the associated risk factors, which include: Promote good health in women and infants Appropriate diet, combat obesity, prenatal care Promote smoking cessation among pregnant women Prevent SIDS/SUIDS by promoting safe sleep Reduce elective delivery at less than 39 weeks Improve the overall rate of breastfeeding; and Ensure babies are delivered at risk appropriate facilities

Indiana’s Plan: Promote Good Health in Women and Infants Statewide Infant Mortality Campaign Statewide Public Health Home Visiting Program Collaboration with Nurse-Family Partnership and Goodwill

Immunizations = healthy moms, babies, and communities CDC recommends every pregnant woman receive an influenza vaccination Flu vaccines are safe; can be administered at any time during the pregnancy Flu vaccines during pregnancy may also protect the infant for up to 6 months after birth CDC recommends—Pregnant women should receive a dose of Tdap during each pregnancy, ideally between 27 and 36 weeks gestation

Source: Indiana State Department of Health, Maternal & Child Health Epidemiology Division [June 6, 2014] United States Original: Centers for Disease Control and Prevention National Center for Health Statistics Indiana Original Source: Indiana State Department of Health, PHPC, ERC, Data Analysis Team

Indiana’s Plan: Smoking Cessation Promote smoking cessation among pregnant women and their families Smoking during pregnancy accounts for 40% of preterm deliveries Implementing evidence-based Baby and Me-Tobacco Free program, which has proven to reduce smoking in pregnant women by 60% after 6 months in the program Collecting data from grantees to determine Indiana quit rate Home visiting programs refer clients to smoking cessation programs and educate families on the dangers of prenatal smoking and environmental smoke for infants

Indiana’s Plan: 39 Week Initiative Collaborative effort with March of Dimes, FSSA, and Hospital Association Target hospitals for IHA visit and March of Dimes Quality Improvement Service Package Toolkit IPQIC developed EED guidelines (approved January 2014) Medicaid 39 week elective early delivery (July 1, 2014)

Indiana’s Plan: 39 Week Initiative Case Studies on Early Elective Deliveries Linked to neonatal morbidities with no benefit to the mother or infant Neonatal morbidities include: increased adverse outcomes and death NICU admissions adverse respiratory outcome transient tachypnea of the newborn, newborn sepsis, treated hypoglycemia, CPR or ventilation extended length of stay College of Obstetricians and Gynecologists (ACOG) has promoted a clinical guideline discouraging elective deliveries prior to 39 weeks gestation without medical or obstetrical need

Indiana’s Plan: 39 Week Initiative Indiana Early Elective Delivery Percentage much higher than all other states in Region V* 2012 Birth Certificate Data includes 37 & 38 weeks * Indiana, Ohio, Michigan, Illinois, Wisconsin and Minnesota Data collection part of the HRSA COIIN Initiative to lower infant mortality

Indiana’s Plan: Safe Sleep Safe Sleep Program Since summer of 2013, ISDH has worked collaboratively with Department of Child Services’ Permanency Program regarding safe sleep. Safe sleep strategic plan Increase parent and caregiver awareness of SIDS as a problem. Cribs for Kids – distribution of Infant Survival Kits. Increase parent and caregiver knowledge of risk reduction methods. Reinforce the importance of safe sleep messaging within the community.

Indiana’s Plan: Safe Sleep Indiana Safe Sleep Distribution Sites, 2014 Infant Survival Kit: Portable crib, fitted sheet, wearable blanket, pacifier, and education

Indiana’s Plan: Improve Overall Rate of Breastfeeding Breastfeeding to reduce infant mortality:   Case-control study published in 2004 found children who were ever breastfeed had lower risk vs never breastfeed children for dying in the postneonatal period. Longer breastfeeding was associated with lower risk. Source: Chen, A., Rogan, W.J. Breastfeeding and the risk of postneonatal death in the united states. American Journal of the American Academy of Pediatrics. Volume 113, No. 5. May 1, 2004. Pp 435-439 Exclusive breastfeeding reduces infant mortality due to common childhood illnesses such as diarrhea or pneumonia, and helps for a quicker recovery during illness. Source: World Health Organization Breastfeeding to reduce the risk of SUIDs: Case-control study determined that breastfeeding reduced the risk of sudden infant death syndrome by 50% all ages of infancy. Source: Vennemann, M.M., Bajanowski, T., Brinkmann, B., Jorch, G., Yucesan, K., Sauerland, C., Mitchell, E.A. Does breastfeeding reduce the risk of sudden infant death syndrome? American Journal of the American Academy of Pediatrics. Volume 123, No. 3. March 1, 2009. Pp 406-410 Meta-analysis (288 studies included) found that breastfeeding is protective against SIDS, the effect is stronger when breastfeeding is exclusive. Source: Hauck, F.R., Thompson, J.M., Tanabe, K.O., Moon, R.Y., Vennemann, M.M. Breastfeeding and reduced risk of sudden infant death syndrome: a meta-analysis. American Journal of the American Academy of Pediatrics. Volume 128, No. 1. July, 2011. Pp 103-110

Indiana and National Breastfeeding, 2011 State Ever Breastfed Breastfeeding 6 Months Breastfeeding 12 Months Exclusive Breastfeeding at 3 Months Exclusive Breastfeeding at 6 Months U.S. National 79.2 49.4 26.7 40.7 18.8 Indiana 74.1 38.6 21.5 35.7 18.1 Source: Centers for Disease Control and Prevention National Immunization Survey (NIS), 2011 births.

Indiana’s Plan: Improve Overall Rate of Breastfeeding Breastfeeding-state strategic plan Being developed by National Institute for Children’s Health Quality (NICHQ) Collaboration between ISDH MCH, WIC, DNPA, Chronic Disease/Primary Care/Rural Health, Minority Health, and Women’s Health Conducted an expert panel meeting on November 5, 2014 to provide essential guidance towards creating the strategic plan and improving the overall rates of breastfeeding in Indiana Identify gaps, prioritization and funding allocation Identify policy barriers and considerations as we move from strategy to action

Indiana Perinatal Quality Improvement Collaborative Established by ISDH/MCH in fall of 2012 with a vision for Indiana that includes: All perinatal care providers and all hospitals have an important role to play in assuring all babies born in Indiana have the best start in life. All babies in Indiana will be born when the time is right for both the mother and the baby. Through a collaborative effort, all women of childbearing age will receive risk appropriate health care before, during and after pregnancy.

IPQIC Guiding Principles Produce a visionary document Achieve the best outcomes for mothers and babies Comply with but not exceed AAP and ACOG National Standards All standards must be grounded in solid evidence

Indiana Perinatal Quality Improvement Collaborative Indiana Perinatal Quality Improvement Collaborative (IPQIC) Levels of Care MCH Hospital Nurse Surveyors will survey at least 2 of the pilot hospitals by January 1, 2015 Once the pilot phase is complete with all 6 pilot hospitals, the voluntary phase will begin Certification is tentatively scheduled to start in 2016 Neonatal Abstinence Syndrome Committee Final report will be delivered to the legislature with recommendations ISDH will be piloting the recommendations with 2-3 pilot hospitals Quality Improvement Retreat Scheduled for February 28, 2015 at the IU School of Medicine Medical School Library Purpose: defining quality improvement collaborative in Indiana; identify data collection infrastructure; describe financing strategies for quality improvement structure; identify possible priority projects Included in IPQIC NAS report: 1) The appropriate standard clinical definition of "Neonatal Abstinence Syndrome"; (2) The development of a uniform process of identifying Neonatal Abstinence Syndrome; (3) The estimated time and resources needed to educate hospital personnel in implementing an appropriate and uniform process for identifying Neonatal Abstinence Syndrome; (4) The identification and review of appropriate data reporting options available for the reporting of Neonatal Abstinence Syndrome data to the state department, including recommendations for reporting of Neonatal Abstinence Syndrome using existing data reporting options or new data reporting options; and (5) The identification of whether payment methodologies for identifying Neonatal Abstinence Syndrome and the reporting of Neonatal Abstinence Syndrome data are currently available or needed.

Source: Indiana State Department of Health, ERC, Data Analysis Team, 2014

Disparities in Infant Mortality If Indiana lowered the black infant mortality rate in 2012 from 14.5 per 1,000 live births to the white infant mortality rate of 5.5 per 1,000 live births, we would save over 90 black infants…

Indiana Infant Mortality Rate by Race in Communities In Indiana 95 of the 146 black infant deaths (65%) in 2012 occurred in just three counties, Marion, Lake and Allen Nine grantees in these three counties, totaling $1.7 million/year, providing: Prenatal Care Coordination Family Planning Smoking Cessation School-based services

Final Thoughts Infant mortality is a multi-factorial health problem—improving our rate will require a multi-faceted approach Partnerships throughout the state are vital to our success! With support from the Administration, we have a great opportunity to change our current trajectory The work we do today will continue through tomorrow and the foreseeable future Our goal: to get our rate down to the Healthy People 2020 goal of 6.0 per 1,000 live births