Healthy Babies/Healthy Moms Coalition 1986 Indianapolis ... · Parenting Issues-Public education campaigns-Reproductive Health plans-Mentoring programs ... •30% with infant blankets

Indianapolis’ PPOR Story

Enhancing Infant Survival and Maternal and Family Well-Being Through Partnerships and Collaboration

National Healthy Start Association ♦ 12th Annual Spring Conference

Yvonne Beasley, MN, RN

Healthy Babies/Healthy Moms Coalition 1986

• Dialogue regarding poor birth outcomes in Marion County


Marion County IMR 1984-1989

4.54.512.115.2--Other

------Hispanic

21.620.824.218.32425.2Black non-Hispanic

8.99.19.37.011.39.9White non-Hispanic

12.112.213.314.214.413.7Overall

198919881987198619851984

Source: Epidemiology

Department, DR1255

*Some rates unavailable

National Healthy Start Association ♦ 12th Annual Spring Conference National Healthy Start Association ♦ 12th Annual Spring Conference


Community Based Approach 1989

• Business, political, and community leaders unite to form a public and private partnership, develop a work plan, and mobilize the community’s resources to reduce the infant mortality rate.



Indianapolis Campaign for Healthy Babies

1989: Indianapolis Campaign for Healthy Babies (ICHB) formed, and was active through 1992

• New Health Centers

• Expansion of existing health centers

• Care Coordination Services initiated for pregnant women

• WIC services expanded


Sustaining IHBC Efforts

• 1993 Health and Hospital Corporation of Marion County assumed responsibility for the Campaign under “Healthy Babies Initiatives”

• New services initiated: Prenatal Outreach, Prenatal Substance Abuse, Male Responsibility, and community awareness


Incentive Program for Pregnant Women

1995

• MCHD initiated Bed, Britches, Etcetera B.A.B.E. in partnership with St. Vincent Hospital, and St. Francis Hospital

• Women were given coupons for entering prenatal care and attending follow-up prenatal visits, WIC appointments, well child visits,etc.


Fetal and Infant Mortality Review

•1995 – Marion County Health Department establishes the Indianapolis Healthy Babies Consortium to begin efforts to administer a Fetal and Infant Mortality Review (FIMR) Project

•1999 – Healthy Babies of the New Millennium, the final volume in a series of reports prepared by the FIMR project


MCHD Infrastructure

• Indianapolis Healthy Start 1997 – present

• 1999 Executive Report Healthy Babies in the New Millennium

• 2002 Indianapolis Healthy Babies Consortium reconvenes

• 2003 Epidemiology Department established

• 2003-Consumer Connection Consortium established

• 2004 FIMR Program reestablished


Rebuilding Community Infrastructure

2004

• PPOR Team identified-Technical Assistance provided through CityMatCH

• FIMR – PPOR Workshop

• FIMR Chart Review Team Launched

• Healthy Start Community Assessment of MCH high risk population and identification of catchment area.



PPOR Team Members

•Originally started with only three members: currently 13 members:

•Marion County Public Health Department – 7 members•Populations Health Bureau Director, Maternal & Child Health Director, Healthy Start, FIMR, and Epidemiology

•Indiana State Department of Health – 2 members•MCH Nurse Consultant, Epidemiology

•Indiana Perinatal Network – 2 Members•Indiana Access, SIDS Alliance

•Wishard Health Services – 1 member•OB / GYN Primary Care Clinic

•Healthy Families – 1 member


PPOR Team Activities•Attended three PPOR “How to Do” Workshops

•Phoenix, AZ – December 2003•Washington, DC – March 2004•Portland, OR – September 2004

•Participate in monthly PPOR seminar calls

•Presented to Indianapolis Healthy Babies Consortium – July 2004

•Presented preliminary PPOR data•Recruited team members•Collected community surveys and community readiness tents

•Held three team meetings•Met bi-monthly – November, February and April•Review data until July 2005•Develop logic model and interventions by December 2005

Indianapolis PPOR Map

PPOR Excess Deaths *

Compared to Internal and External Reference Groups**1999-2003 Birth Cohort Data***

Marion County, IN

*Excluded are infants who weighed <500 grams at birth and fetal deaths that occurred before the 24th week or were <500 grams.

**Internal Reference Group: White, non-Hispanic women, age >=20 yrs., married, non-smoking, who have an education >=13 years, received

prenatal care in the 1st trimester and reside in Marion County, IN.

External Reference Group: White non-Hispanic women, age >=20 yrs., who have an education >=13 years.

***Data compiled from birth certificate data from the Marion County Health Department, Indianapolis, IN

Maternal Overall

All Marion County Health Maternal Newborn Infant Excess

Prematurity Care Care Health Deaths

Marion County (273 deaths) (148 deaths) (100 deaths) (163 deaths) (684 deaths)

Excess compared to Internal Group 137 77 19 97 331

Excess compared to External Group 117 40 20 92 268


Infant Health

•1999, 2000, 2003 Indiana was #1 in the Nation for:

•Injury-related fatalities for infants

•Unintentional injury-related fatalities for infants

•Leading cause of injury related fatalities was suffocation

•Leading cause of intentional injury-related fatalities was physical abuse/beatings


Study Population

• All births and fetal deaths that occurred in Marion County to Marion County resident mothers from 2001-2005, and all deaths that occurred in Marion County among those infants before the infants turned 1 year of age.

• Infants <500gms or <24wks were included in a separate category called PPOR Ineligible.

• Reference population was infants born to non-Hispanic white mothers over 20 years of age with more than a high school education (12+ years)


Ineligible group

418 Deaths

Excess Deaths=174 (97, 250)

Deaths per 1000 pregnancies=5.92 (5.37, 6.52)

Excess Death Rate=2.46

Maternal Health Prematurity

270 Deaths




Maternal Care Newborn Care Infant Health

146 Deaths 97 Deaths 143 Deaths

Excess Deaths=38 (-12, 89) Excess Deaths=27 (-15, 68) Excess Deaths=97 (59, 136)

Deaths per 1000 pregnancies=2.07 (1.75, 2.44) Deaths per 1000 pregnancies=1.37 (1.12, 1.68) Deaths per 1000 pregnancies=2.02 (1.71, 2.39)

Excess Death Rate=0.55 Excess Death Rate=0.37 Excess Death Rate=1.38

PPOR Mapping ResultsReference Group

17,075 Pregnancies and 148 Deaths

Deaths per 1000 pregnancies = 8.67

Overall

70,662 Pregnancies and 1,074 Deaths




Risk Factors for VLBW

• In a multivariate analysis, the following were statistically significantly associated with delivering a VLBW infant in Marion County:

• Black race (OR=1.58, 95% CI: (1.37, 1.82)) versus white race

• Multiples versus singletons

• <12 years education (OR=1.15, 95% CI: (1.07, 1.24) versus 12+ years education


Risk Factors for VLBW

• In a multivariate analysis, the following were statistically significantly associated with delivering a VLBW infant in Marion County Continued:

• Adequate+ PNC (OR=2.19, 95% CI: (1.77, 2.70)) versus adequate PNC

• Smoking (OR=1.27, 95% CI: (1.18, 1.38)) versus non-smoking


Causes of Postneonatal

Death

• Top 3 Causes of Death for PPOR Infant Health Category in Marion County

1. Unspecified threats to breathing

2. Hanging, strangulation, and suffocation

3. SIDS


Investigation into SUID Deaths

• Diagnosis ICD codes (ICD-9/ICD-10)

• SIDS (798.0/R95)

• Accidental suffocation and strangulation (E913/W75-W77, W81-W84)

• Intent unknown suffocation (E983/Y20)

• Neglect, abandonment, and other maltreatment syndromes (E967, E968.4/Y06-Y07)

• Unknown cause (799.9/R99)

Source: Rahmanifar, A (2008).Trends in sudden and unexpected deaths in Indiana 1990-2006: Evidence of recent

change in classification and reporting. http://www.in.gov\isdh\

Patterns of SUID DeathsComparison of Indiana and Marion County by SIDS vs. Other SUID

Rates, 1990-2007

Calculated as SIDS and Other SUID deaths/live births*100,000

0

50

100

150

200

250

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Year

SID

S/S

UID

Morta

lity

Rate

per 1

00,0

00

Indiana SIDS Rate Marion County SIDS Rate

Indiana Other SUID Rate Marion County Other SUID Rate

Source: Rahmanifar, A (2008).Trends in sudden and unexpected deaths in Indiana 1990-2006: Evidence of recent

change in classification and reporting. http://www.in.gov\isdh\,

Maternal

Health/

Prematurity

1. Pre & Inter-

Conception Care

2. Health Behaviors

3. Prenatal Care

Infant

Health

1. Safety Issues

2. Breast -Feeding3. Family &

Parenting Issues

-Public education campaigns-Reproductive Health plans-Mentoring programs-Better control ofChronic Diseases& Obesity-Expand Medicaid for FP & IC Care, Mental health and Substance Abuse Programs-PNC Coordination

-Safe Sleep & Home Safety education

-Breastfeeding

-Long term CC services

-Substance Abuse

Screening & Treatment

Focus Areas Action Areas

Actions

Strategic Actions to Improve Birth

Outcomes in Marion County

FP-Family Planning, IC-Interconception Care, PNC Prenatal Care Coordination, CC-Care Coordination

Based on Perinatal Periods of Risk (PPOR) data for Marion County 2001-2005

Marion County FIMR

• Investigated all SIDS and Other SUID deaths from cases reviewed from 2004-2009

• Cases SIDS/SUID statistics

• A total of 54 cases reviewed

• 33 maternal interviews conducted

• 89% of deaths were postneonatal

• 87% of deaths were accidental suffocation and strangulation

• 13% of deaths were classified as SIDS


Marion County FIMR

• Of the SIDS and Other SUID Deaths

• 85% of the mothers were single

• 48% of the infants were bed-sharing

• 41% were sleeping on an adult bed/pillow

• 19% were found on a couch or chair

• 39% of infants were found on their abdomen

• 72% of deaths occurred to families on Medicaid

• 55% of the mothers used tobacco


Addressing the Need for Safe Sleep Education

• 48% of the case histories did not include documented safe sleep education

• 2% claim they did not receive education at all

• In a majority of cases infants were found with items in their sleeping area

• 30% with infant blankets

• 20% with adult pillows

• 30% with adult blankets

• Almost 30% no documented information in death scene investigation


Why is sleeping on the back safer for baby?

SAFE: Back Sleeping PositionWindpipe lies on top of the stomach tube in this position. Anything vomited must work against gravity to go into the lungs.

UNSAFE: Stomach Sleeping PositionStomach tube lies on top of the windpipe so that anything vomited will pool at the opening of the windpipe and make it easier to go into the lungs.

Windpipe

Stomach Tube

Stomach Tube

Windpipe

Used with written permission from the National Institutes of Health. Adapted from Continuing Education Program on SIDS Risk Reduction: Curriculum for Nurses. National Institutes of Health. 2006. p.26. Revised for parent education.

Who Needs the Message?

• African American families living in poverty

• 96% of deaths occurred in families that lived in communities where more than 15% of the population lived under the Federal Poverty Line

• For a family of 4 = annual income of $22,050

• Specialized messages and education opportunities for women receiving Medicaid

• Reinforce education among single parent households

• Education for parents who use tobacco


How PPOR Became Part of Indianapolis Healthy Start (IHS)

• Focused Core Service Interventions

• Case Management, Outreach and Health Education

• Key Messages: Preconception care, Health behaviors, Safe sleep & injury prevention, Breastfeeding, Access to prenatal care

• Data Collection

• Local Health Systems Action Plan (LHSAP)

• Resources allocated for collaboration


LHSAP– Maternal Health/Prematurity

• Sponsor Indiana Perinatal Network provider education to increase screening of ATOD

• Public education campaigns – Baby R U Ready, folic acid


LHSAP– Maternal Health/Prematurity

Continued

• Increase access to care

• Group prenatal care

• Indiana Medicaid Presumptive Eligibility

� Indiana Perinatal Network

� Reversal of the decision to not adopt presumptive eligibility for Indiana Pregnant women

� Began July 1, 2009


Baby’s Early Development

Week of Pregnancy

Missed Period

1st Prenatal Care Appt

Adapted from: Damus, K. (2010). History, Highlights and Hope: Shattering the U.S. Infant Mortality Glass Ceiling, Emerging issues in Maternal Child Health Webinar. https://cc.readytalk.com/cc/schedule/display.do?udc=o7kewuje4j81

LHSAP–Infant Health

• Efforts to promote Sudden Unexpected Infant Death Investigation (SUIDI) training, reporting, and education

• State Child Fatality Review Teams lead by Dr. Toni Laskey

• Safe Sleep Education – collaboration between Indianapolis Healthy Start and hospitals provides $1500 stipends for staff and patient education

•DVD’s purchased to show safe sleep education

• Implementation of safe sleep sacks at discharge


SUID Death Investigation


LHSAP–Infant Health

Continued

• Bedtime Basics for Babies campaign – First Candle Collaboration

• Safe Sleep Media Campaign

• Participation in Breastfeeding Coalitions

• Conduct Child Safety Checklists –Safe Housing


Infant Mortality Media Campaign

Marion County InfantMortality

Infant Mortality Marion County 1993-2009

0

5

10

15

20

25

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

Cases/1

00,0

00

Over allWhite Non-LatinoBlack Non-LatinoLatino


Stakeholder Involvement Assisted By:

• Tailored Messages

• Front line staff

• Hospital Staff

• Community

• CRT and CAT Accomplishments (Action)

• Increase in Perceived Value of Data



What Helped to Keep Stakeholders involved

• 2004 – 2006 ISDH GAP Grant: FIMR Nurse Abstractor and Epidemiologist

• 2004 PPOR TA from City MatCH

• 2005 – 2007 ISDH GAP Grant: Preconception Health Nurse

• 2006 Purchase of BASINET

• September 1, 2007 – August 31, 2010 Bilingual Bicultural Healthy Start Demonstration Grant-Office of Minority Health


What Helped to Keep Stakeholders Involved?

• Repetition of Information

• Indianapolis Healthy Babies Consortium

• FIMR Case Review Team

• FIMR Community Action Team

• Local Conferences


Challenges

• Keeping Partners Informed and Focused

• New Partners/Staff Turnover

• New Data

• Data Interpretation

• Three Epidemiologists

• Develop a data-driven community


PPOR Directs Action

• Helps Determine Who Needs the Information

• Safe Sleep example (Dissemination of data to front line staff)

• Resource Allocation


Conclusion

• PPOR provides the Big Picture for community efforts

• Catalyst for the development of a more data-oriented community


ConclusionContinued

• The use of PPOR Investigations allows for a comprehensive look into fetal and infant mortality

• Looks deeper into the causes behind the problem and provides guidance to develop solutions

• Directly aids in systems change

• Allows for the targeting of specialized messages to those in the community that need them

• Aids in resource allocation


Final Thought

“The problem of infant mortality is one of the great social and economic problems of our day. A nation may waste its forest, its water power, its mines and to some degree even its land, but if it is to hold its own…its children must be conserved at any cost. On the physical, intellectual and moral strength of the children of today, the future depends.”

Julia Lathrop, MD, first Director,

Federal Children’s Bureau, 1913


Documents

Healthy Babies/Healthy Moms Coalition 1986 Indianapolis ... · Parenting Issues-Public education campaigns-Reproductive Health plans-Mentoring programs ... •30% with infant blankets