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

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
Percent Smoked During Pregnancy, 2007-2012
25.0
PERCENT
20.0
15.0
10.0
5.0
0.0
Indiana
United States
Healthy People 2020
Goal
2007
18.5
10.4
2008
18.5
9.7
2009
18.2
9.3
2010
17.1
9.2
2011
16.6
8.9
2012
16.5
8.7
1.4
1.4
1.4
1.4
1.4
1.4
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 MeTobacco 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
o
o
o
o
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 metaanalysis. 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
o
Identify gaps, prioritization and funding allocation
o
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)
o
o
o
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
o Final report will be delivered to the legislature with recommendations
o ISDH will be piloting the recommendations with 2-3 pilot hospitals
Quality Improvement Retreat
o Scheduled for February 28, 2015 at the IU School of Medicine Medical School Library
o Purpose: defining quality improvement collaborative in Indiana; identify data collection infrastructure;
describe financing strategies for quality improvement structure; identify possible priority projects
Infant Mortality Rates by Race, Indiana, 2002-2012
20.0
Total
White
Black
18.0
18.1
17.1
Rate per 1,000 Live Births
16.0
14.0
15.6
16.9
15.9
15.7
16.1
14.9
14.7
12.0
14.5
12.3
10.0
8.0
6.0
7.6
6.5
7.4
6.4
8.1
6.9
8.0
6.9
7.9
6.4
7.5
7.8
6.9
6.5
7.7
6.7
6.9
6.4
6.0
2009
2010
5.5
4.0
7.5
5.5
2.0
0.0
2002
2003
2004
2005
2006
Source: Indiana State Department of Health, ERC, Data Analysis Team, 2014
2007
2008
2011
2012
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