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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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)

10. 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

11. 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

12. 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.

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

14. 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, Pp
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, Pp
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, Pp

15. 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.

16. 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

17. 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.

18. 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

19. 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.

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

21. 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…

22. 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

23. 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