volume 13, issue 2 2009 (focus: substance use during pregnancy)

1Download this newsletter online at www.indianaperinatal.org/sections/pp_newsletter.php Vol. 13 • Issue 2 • 2009

Volume 13 • Issue 2 • 2009 • News from the Indiana Perinatal Network (IPN) • www.indianaperinatal.org

Do you need a speaker for a conference, grand rounds, or trainings? IPN sta� is available to present on topics including

• The Business Case for Breastfeeding: Workplace Lactation Support

• Breastfeeding and Safe Sleep: Building Bridges

• Excellence in Child Care for the Breastfed Baby

• Domestic Violence and Pregnancy

• Maternal Mortality in Indiana

• Safe Sleep • Bereavement • First Responders and Infant

Deaths • Advocacy 101 • The Value of the Learner’s

Stance: Lessons Learned from Pregnant and Parenting Women

IPN will work with you to customize sessions to meet the needs of your group or program. To fi nd out more about staff qualifi cations, scheduling, and fees, contact IPN at (866) 338-0825 or email [email protected].

Controversies and Innovations in Perinatal Health Highlights Emerging Issues, Interventions

FOCUS:Substance Use During

Pregnancy(pages 4-6)

Physicians, nurses, breastfeeding advocates, childbirth educators, and other perinatal care providers convened at the second annual IPN Forum, Controversies and Innovations in Perinatal Health, to examine racial disparities and birth outcomes, trends in physician distribution, new models of prenatal care, and other hot-topic issues in maternal and child health.

Keynote speaker Sandra Lane PhD., MPH, chair of the Department of Health and Wellness in the College of Human Ecology at Syracuse University, discussed her groundbreaking research on infant mortality. Lane situated infant death within the context of systemic patterns of racism, structural violence, and neighborhood-level risk factors such as per-capita lottery sales in non-supermarket census tracts. Forum participants received a copy of her new book, Why Are Our Babies Dying? Pregnancy, Birth, and Death in America.

Other plenary sessions included a lively panel discussion among David Wiesman of the Indiana Hospital Association, James Hogan, JD, MBA from Hall Render, and Dr. Lane about the business of healthcare, hospital fi nancing, and trends in hospital mergers and closings.

IPN Director of Special Projects and Public Policy Caitlin Priest, MPH presented preliminary research on distribution of delivering providers in Indiana, showing maps that displayed the location of OBs, Family Practice physicians, Maternal-Fetal Medicine specialists, and Certifi ed Nurse Midwives throughout the state. Participants had the opportunity to explore workforce issues in further detail during a question and answer session with perinatologist Joe Landwehr, MD, Family Practice physician and Bowen

Research Center Director Deborah Allen, MD, and University of Indianapolis Midwifery Director Barb Winningham, CNM.

Breakout sessions covered a host of current topics and promising interventions, including how to set up a perinatal mood disorders screening program, the benefi ts and safety of maternal

continued on page 3

What Participants Said…

Wonderfully put together conference—the best I have ever attended in the 9

years I have been a social worker.

Topics are innovative and interesting and from multiple perspectives—

there’s something here for everyone.

Read Sandra Lane’s book & found it scholarly and practical. She was a great speaker. I appreciate IPN’s ability to fi nd such quality persons to share what they have done. I think that you help impact the perinatal systems in Indiana in a

powerful way.

The presentation on where providers are located was great and very informa-tive. It really made me think and it has spurred many discussions back onsite after the conference with other nurses.

Excellent content, with lots of take-aways. Knowledgeable and innovative

speakers and breakout sessions.

The mission of the Indiana Perinatal Network is to lead Indiana to improve the health of all

mothers and babies.

Participants network during

IPN Speakers Available

2 Download this newsletter online at www.indianaperinatal.org/sections/pp_newsletter.php Vol. 13 • Issue 2 • 2009

Perinatal PerspectivesA Publication of the Indiana Perinatal Network (IPN)

IPN thanks these individuals for their contributions to Perinatal Perspectives and its editorial standards.

EDITORIAL REVIEW BOARD Tina Babbitt, RN, BSN, IBCLC Perinatal Education Coordinator, IPN

Julia Tipton Hogan, MPA Community Outreach Coordinator, IPN

Larry Humbert, MSSW, PG Dip Executive Director, IPN

Sarah Hundagen Program Services Coordinator, IPN

Beth Johnson, RN, MSN State Perinatal Liaison, ISDH

Lauri McCoy, RN, MSN

CLINICAL CONSULTANTS Lauren Dungy-Poythress, MD Community Health Network

Howard Harris, MD Retired Neonatologist

Mureena Turnquest Wells, MD Maternal Fetal Medicine St. Mary’s Hospital, Evansville

Views and opinions expressed herein are those of contributing authors and do not necessarily refl ect those of the Indiana Perinatal Network (IPN).

IPN welcomes stories and photo contributions. Send submissions to IPN, 1991 East 56th St., Indianapolis, IN 46220, Attn: Perinatal Perspectives Editor, or e-mail: [email protected]. For information on advertising, e-mail: [email protected]

1991 East 56th StreetIndianapolis, IN 46220

P: 317.924.0825 • F: 317.924.0831E: [email protected]

2009 Educational Partners ($5,000)Indiana Perinatal Network Staff

Larry Humbert, MSSW, PG DipExecutive [email protected]

Leah Sumners YorkDirector of [email protected]

Tina Babbitt, RN, MSN, IBCLCPerinatal Education [email protected]

Tina Cardarelli, IBCLC, RLC, CLEState Breastfeeding [email protected]

Gayla Hutsell Guignard, MA CCC-A/SLP, CERT AVTState EHDI [email protected]

Barbara Himes, CLCSIDS and Infant Loss Program [email protected]

Julia Tipton Hogan, MPACommunity Outreach [email protected]

Sarah HundagenProgram Services [email protected]

Amy KorbeOffi ce [email protected]

Sherry MatemachaniSpecial Projects [email protected]

Caitlin Finnegan Priest, MPHDirector of Special Projects & Public [email protected]

Mark YourC A L E N D A R S

State Perinatal Advisory BoardJuly 15, 2009

10 am - noon (*special time)Indiana State Department of Health, Rice Auditorium

All are invited to hear Sarah Brown, CEO of the National Campaign to Prevent Teen and Unplanned Pregnancies, speak about the recent national increase in teen pregnancies and the Campaign’s new focus on unplanned pregnancies in young adults as well as teens. Regional and IPN updates will follow

the presentation.

Please RSVP to [email protected] by

Donor Spotlight: The Women’s Hospital

IPN salutes The Women’s Hospital, part of Deaconess Health System, for its long-standing commitment to improving the health of Indiana’s mothers and babies. An IPN Education Partner since 2006—and renewed through 2010—The Women’s Hospital will showcase its facility and hospitality when it welcomes IPN’s regional trainings on breastfeeding and perinatal mood disorders in July.

CEO Chris Ryan, RN, MHA brings the hospital’s wealth of expertise in clinical innovation and community outreach to IPN’s Board of Directors, which she joined this spring.

“We value and appreciate our longstanding partnership with The Women’s Hospital,” says IPN Executive Director Larry Humbert. “We welcome Chris to our Board and look forward to working together to improve perinatal care and outcomes in Indiana.”


IPN Presents Annual Spirit of Service Awards

Going the Extra Mile

The 2009 Spirit of Service awards, designed to honor outstanding eff orts in the perinatal healthcare fi eld, were presented at IPN’s annual Forum on March 26. The selection committee received a record number of nominations from around the state in the categories of Advocacy, Community Service, and Communication.

The Advocacy award was presented to Ruthann Mishler, CNM, of Union Hospital Maternal Health Clinic in Terre Haute. A tireless advocate for women in the Wabash Valley area, Ruthann educates physicians and patients alike about the high-touch and low-tech care a midwife can provide, and is well known for her personal commitment to each family she serves.

Connie Kerrigan, RN, BSN, of Parkview Hospital in Ft. Wayne was awarded the Marilyn Graham Community Service Award for her dedication to improving the health and safety of children and families in her community. She helps develop, implement and promote numerous programs, such

as a Safe Slumber program, Cribs for Kids, WE CAN!, and a school-based fl u vaccine program.

The Julie A. Foster Communication Award was presented to the Dubois County Breastfeeding Advocacy Group for their strong history of using creative, innovative methods to share their breastfeeding message. The group developed a successful ad campaign that encouraged local physicians and organizations to voice their support for breastfeeding. The ad campaign has been used as a model for other coalitions across the state.

IPN also honored Dr. James E. Sumners for his long service to the organization. A founding member of IPN’s Board of Directors, Dr. Sumners has shared his vision and expertise with the organization for the past ten years. He will remain an Emeritus member of the Board.

IPN congratulates the winners, as well as all of our nominees, for their outstanding work

to improve the health of mothers and babies in Indiana.

Patricia Scherle accepts the Julie A. Foster Communication Award on behalf of the Dubois County Breastfeeding Advocacy Group.

IPN honored outgoing Board member Dr. James Sumners, of St.Vincent Women’s Hospital Center for Prenatal Diagnosis.

Patricia Scherle accepts the Julie A. Foster Communication

“She has a passion for supporting women in their choices for birth...

her patients are truly blessed.”

- nomination letter for Ruthann Mishler

“The Advocacy Group is constantly looking for new ways to promote, support and advocate for breastfeeding

in their community.”

- nomination letter for Dubois County

continued from cover

air medical transport, and creating standards of care for relinquishing mothers.Over 140 participants from throughout Indiana attended the Forum, representing community-based programs, large and small hospitals, and human service agencies.___________________________________________________Visit www.indianaperinatal.org to download speakers’ presentations.

Save the Date! The 3rd annual IPN Forum will be held March 18 – 19, 2010, at the Sheraton

Indianapolis City Centre Hotel.

Controversies and Innovations in Perinatal Health Highlights Emerging

James Hogan, David Wiesman, and Sandra Lane discuss the business of healthcare.


FOCUSSpotlight on . . .

What’s the Problem?• Alcohol, tobacco and other drug (ATOD) use

during pregnancy is a major public health and social problem in Indiana. It is estimated that at least 20 percent of women in Indiana use tobacco, 10 percent use alcohol, and 5 percent use other drugs during pregnancy.

• ATOD use during pregnancy is linked to increased risk of miscarriage, preterm delivery, low birth weight, and stillbirth.

• Only 5-10% of pregnant women who need ATOD treatment receive professional help.

• The estimated lifetime costs of caring for a baby exposed to alcohol, tobacco and other drugs range from $750,000 to $1.4 million.

IPN’s ResponseAs part of our mission to lead Indiana to improve the health of all mothers and babies, IPN…

Develops and disseminates timely information and innovative solutions.

• IPN convened a group of experts from across the state to develop a comprehensive consensus statement that includes recommendations for providers, the public, and policy makers to address this complex issue. Visit www.indianaperinatal.org to download this resource.

• IPN hosted a statewide summit featuring national and state experts that showcased eff ective intervention programs throughout our state. Visit http://www.indianaperinatal.org/sections/substance_use.php to download copies of these presentations.

• IPN developed a unique provider training DVD, Integrating Screening and Treatment of Substance Use into Prenatal Care, which will be released this summer.

Advocates for responsive, e� ective public policy.

IPN has played a lead role getting bills passed by the Indiana General Assembly to impact ATOD use during pregnancy.

• Prenatal Substance Use Report – HEA 1314; P.L. 86-2006. Required the State Health Department to assess the incidence and factors associated with substance use during pregnancy in the State of Indiana. To download a copy of this comprehensive report go to: http://www.in.gov/legislative/igareports/agency/reports/ISDOH30.pdf

• Prenatal Substance Use Commission – HEA 1457; P.L. 193-2007. Established a statewide, multi-agency, bipartisan Commission to make recommendations on how to reduce substance use during pregnancy in the State of Indiana.

• Cigarette Tax Increase – HEA 1678; P.L. 218-2007. Increased the tax on cigarettes and

designated funds to support smoking cessation activities, covering uninsured individuals, and childhood immunizations.

• Tobacco Warning During Pregnancy – HEA 1118; P.L. 94-2008. Required all retail outlets that sell tobacco products to post a warning of the dangers of smoking during pregnancy and the toll-free Indiana Tobacco Quitline.

Collaborates in multidisciplinary, successful partnerships.

IPN brings its expertise and experience to groups including the Indiana Prenatal Substance Use Commission, the Coalition to Promote Smokefree Pregnancies, and the Indiana Campaign for Smokefree Air.____________________________________For more information about IPN’s e� orts to address substance use during pregnancy, contact us at [email protected] or (317) 924-0825.

At-risk drinking and illicit drug use: ethical issues in obstetric and gynecologic practice.

Alcohol, Tobacco, and Other Drug Use during Pregnancy

ACOG Committee Opinion Number 422, December 2008.

State Policies Regarding Substance Abuse during Pregnancy

Drug and alcohol abuse is a major problem for American women regardless of their socioeconomic status, race, ethnicity, and age. It is costly to individuals and society. Obstetrician-gynecologists have an ethical obligation to learn and use a protocol for universal screening questions, brief intervention, and referral to treatment in order to provide patients and their families with medical care that is state-of-the-art, comprehensive, and eff ective. In this committee opinion, the American College of Obstetricians and Gynecologists’ Committee on Ethics proposes an ethical rationale for this protocol in both obstetric and gynecologic practice, off ers a practical aid for incorporating such care, and provides guidelines for resolving common ethical dilemmas that arise in the clinical setting.

• 15 states, including Indiana, consider substance abuse during pregnancy to be child abuse under civil child-welfare statutes, and three consider it grounds for civil commitment.

• 14 states require health care professionals to report suspected prenatal drug abuse, and four states require them to test for prenatal drug exposure if they suspect abuse.

• 19 states have either created or funded drug treatment programs specifi cally targeted to pregnant women, and nine provide pregnant women with priority access to state-funded drug treatment programs.

• 4 states prohibit publicly funded drug treatment programs from discriminating against pregnant women.

_______________________________________________________Source: Guttmacher Institute State Policies in Brief: Substance Abuse During Pregnancy, June 1, 2009. Available online at http://www.guttmacher.org/statecenter/spibs/spib_SADP.pdf.


ISDH Update

New Data on Smoking during Pregnancy among Medicaid Recipients

New data from the Indiana State Department of Health indicate that in 68 of Indiana’s 92 counties, at least 30 percent of pregnant women on Medicaid smoke.

The following data are among the fi rst to emerge from a new data-sharing agreement between the Offi ce of Medicaid Policy and Planning and the Indiana State Department of Health. OMPP and ISDH plan to use this and other linked data to help improve health outcomes for Medicaid recipients in the state.

In counties with high numbers of Medicaid births (over 1,000) the percentage ranged from 15% (Lake County) to 33% (Vanderburgh County).

Source: ISDH/OMPP combined birth record data. Singleton births during CY07 only. Statewide average for smoking during pregnancy (ISDH Maternal and Child Epidemiology

From the Research—Tobacco and PregnancyEff ects of Maternal Smoking during Pregnancy on Neonatal Behavior

A new study investigates the impact of smoking during pregnancy on neonatal behavior. 62% of study participants reported smoking during pregnancy, with 24% smoking one pack per day or more. The authors found that exposure to maternal smoking was associated with increased irritability and hypertonicity (decreased muscle tone) in neonates as early as three days of age. Eff ects remained signifi cant after controlling for factors including maternal socioeconomic status, age, and race, and infant birth weight and age.

Stroud, L.R., et al. (2009). Maternal smoking during pregnancy and neonatal behavior: A large-scale community study. Pediatrics, 123(1), 3842-848.

Link Between Smoking and Low Birth Weight Explained

A mechanism linking smoking during pregnancy to low birth weight has been identifi ed. Researchers found that smoking during pregnancy lowers production of an enzyme called endothelial nitric oxide synthase (eNOS), which regulates blood vessel dilation. Reduced eNOS production causes narrowing of blood vessels and less blood fl ow to the fetus, resulting in lower birth weight, shorter length and smaller head circumference. Researchers also found that if women quit smoking early in pregnancy, eNOS levels return to normal, and infants are born at normal birth weight.

Andersen, M.R., et al. (2009). Smoking cessation early in pregnancy and birth weight, length, head circumference, and endothelial nitric oxide synthase activity in umbilical and chorionic vessels. Circulation,

119, 857-864.

Study Examines “Third-Hand Smoke”

Recent research describes how tobacco smoke contamination lingers even after a cigarette is extinguished – defi ned as “third-hand” smoke. Small children are especially susceptible to third-hand smoke exposure because they can play on, touch, and mouth contaminated surfaces. Third-hand smoke can remain indoors long after the smoking has stopped, and even low levels of tobacco particulates have been associated with cognitive defi cits among children. These fi ndings underscore the possibility that even extremely low levels of these compounds may be neurotoxic and, according to the researchers, justify restricting all smoking in indoor areas inhabited by children.

Winickoff , J.P., et al. (2009). Beliefs about the health eff ects of

CountyNumber of Births to

Women on Medicaid, 2007

% Smoking during Pregnancy

Vanderburgh 1,259 33%

Allen 2,603 24%

Tippecanoe 1,001 24%

Elkhart 1,724 23%

Marion 8,781 21%

St. Joesph 1,934 21%

Lake 3,652 15%

Smoking Rates among Pregnant Women in Counties with >1,000 Medicaid Births

Source: ISDH/OMPP combined birth record data. Singleton births during CY07 only. (ISDH Maternal and Child Epidemiology Reports)

A review of counties with the highest percentages of smoking during pregnancy among Medicaid recipients revealed rates as high as 48% in Lagrange and Washington Counties.

CountyNumber of Births

to Women on Medicaid, 2007

% Smoking During Pregnancy

Lagrange 126 48%Washington 162 48%

Perry 115 47%Dekalb 290 44%Fayette 203 44%Morgan 454 44%

Blackford 109 43%Ripley 164 43%

Montgomery 273 41%Scott 199 41%

Shelby 286 41%

Rate of Smoking during Pregnancy among Medicaid Recipients–Top Counties

Source: ISDH/OMPP combined birth record data. Singleton births during CY07 only. (ISDH Maternal and Child Epidemiology Reports).

6 Download this newsletter online at www.indianaperinatal.org/providers-perinatal-perspectives-newsletter.aspx Vol. 13 • Issue 2 • 2009

How should providers screen pregnant women for alcohol, tobacco, and other drug use?

By James J. Nocon, MD

Department of Obstetrics and Gynecology, Indiana University School of Medicine

Director, Prenatal Recovery Clinic, Wishard Memorial Hospital

Providers have an ethical duty to screen all pregnant women for substance use—however, many providers have not received adequate training on how to screen, or aren’t sure how to treat or refer a woman who screens positive.

We know that pregnancy enhances recovery, and therefore it’s a unique and important time to ask the question and encourage treatment. Often, the health impacts of alcohol, tobacco, and other drug use can be reduced or eliminated if the pregnant woman stops using early in the pregnancy. If smoking cessation is achieved by 16 weeks, for example, most or all adverse eff ects to the fetus can be avoided.

Screening Strategies

Common screening strategies include patient self-reporting (which usually results in signifi cant under-reporting), urine testing (which only captures recent use), and urine and meconium testing (which is most accurate but too expensive for screening). Two questionnaires have been found to work well, the two-item questionnaire and the 5 P’s.

Current alcohol or other drug problems can be detected in many patients with the following verbal screening questions:

“In the last year, have you ever drank alcohol or used drugs or smoked cigarettes more than you meant to?” and

“Have you felt that you wanted or needed to cut down on your drinking or drug use or cigarette smoking in the past year?”

These two questions can then be followed up with a modifi ed 5 P’s screening for pregnant patients:

1. Did any of your parents have a problem with alcohol or drugs?

2. Do any of your peers have a problem with alcohol or drugs?

3. Does your partner have a problem with alcohol or drugs?

4. Have you had a problem with alcohol or drugs in the past?

5. Have you smoked any cigarettes or used any alcohol or drugs in this pregnancy?

Interventions

The FRAMES intervention has shown success with pregnant patients.

F: Feedback about the adverse eff ects of drugs or alcohol.

R: Responsibility for a change in behavior. “Only you can decide that you want to stop using. If you do, how would your life be better?”

A: Advise to reduce or stop use. “For the next two weeks, stop using and let’s see how you feel.”

M: Menu of options. “If you � nd that not using for the next two weeks is impossible, then let’s consider other options.”

E: Empathy is critical. “This must be real hard to do.”

S: Self-e� cacy. “I am impressed that you are considering making this change. Your strong determination is going to help you succeed.”

Both cognitive-behavioral treatment and motivational empowerment can be successful, but the patient needs to be ready to take action and to change her behavior. If she has stopped using, tell her you are proud of her choice to stop. Be sure to compliment her on her courage and eff orts. Patients are most empowered by a supportive clinician.

In the Wishard Prenatal Recovery Program, we focus on motivating and empowering the patient to make choices and use the stages of change model endorsed by ACOG. The women in our program have better compliance with scheduled

visits, more frequent drug-free visits, signifi cant reductions in positive drug tests at delivery, higher birthweight babies, and continued abstinence postpartum.

_________________________

For more information, contact Dr. Nocon at [email protected]. Detailed information about Dr. Nocon’s approach and outcomes is available in the forthcoming DVD, Integrating Screening and Treatment of Substance Use into Prenatal Care.

Integrating Screening and Treatment of Substance Use into Prenatal Care

New DVD to Be Released This Summer The Indiana Perinatal Network will soon release a comprehensive, CME-approved provider training DVD addressing tobacco, alcohol and other drug use during preg-nancy. This fi rst of its kind educa-tional product was produced in cooperation with the IU School of Medicine, the Indiana Section of ACOG, the Indiana Chapter of AAP, the Indiana State Depart-ment of Health, the Indianapolis Healthy Start Project, and the In-diana March of Dimes. Entitled “Integrating Screening and Treat-ment of Substance Use into Pre-natal Care”, this unique training program incorporates practical role-play scenarios with clini-cal and research-based material

and interventions. The DVD also includes additional PowerPoint presentations on related clinical topics, referral resources, and in-formation on how to obtain re-imbursement for screening and intervention services. The DVD features the work of Dr. James Nocon, Clinical Associate Profes-sor, IU School of Medicine, and Director of the Prenatal Recovery Clinic at Wishard Memorial Hospi-tal. Developing tools to educate health care providers on how to screen all pregnant women for substance use fulfi lls a recom-mendation of the Indiana Prena-tal Substance Use Commission. ______________________________________________________The DVD will be available in summer 2009. For more information, go to www.indianaperina-tal.org or call 866-338-0825.


Ask The Expert

FOCUSAlcohol, Tobacco, and Other Drug Use during


Smoking and Breastfeeding: Does one cancel out the other?

Breastfeeding Update

By Tina Cardarelli, IBCLCState Breastfeeding Coordinator

If a woman doesn’t stop smoking, is there still a benefi t to breastfeeding? The answer to this question is yes. Women who breastfeed and continue smoking have infants with lower incidence of acute respiratory illness compared with bottle-fed infants of mothers who smoke. In addition, the very nature of breastfeeding reduces the opportunities to smoke, since breastfed babies eat more frequently and can only be fed by their mothers. Many mothers report that breastfeeding supports their eff orts to stop or greatly reduce their smoking.

A recent study in the journal Pediatrics looked at how women’s knowledge of the benefi ts of breastfeeding and the dangers of smoking aff ect their decisions to breastfeed and their desire to smoke. Overall, only 19% of the mothers knew that it was safe to breastfeed while smoking. Smoking had a notable impact on the breastfeeding practices of smokers, with 45% deciding to not breastfeed and 55% deciding to reduce or eliminate smoking in order to breastfeed.

This study indicates there is much work to be done by smoking cessation and breastfeeding educators to ensure that women who continue smoking are encouraged to stop or decrease smoking following birth, just as they were during the pregnancy. In fact, smokers often need increased breastfeeding support due to the eff ects that smoking has on the supply of breastmilk and on breastfeeding. Women need to hear a strong no smoking message before, during, and after pregnancy—as well as a strong message to breastfeed. We need to be clear in all of our education that one does not cancel out the other—and that the benefi ts of breastfeeding lessen many of the very same health problems increased by smoking. We can capitalize on a woman’s desire to breastfeed, and extend the time that she reduces or eliminates smoking during pregnancy and beyond, resulting in improved health for her and the baby.________________________________________________________For more information, contact Tina Cardarelli, IBCLC, at [email protected] or (317) 924-0825 ext. 4223.

Breastfeeding Day of Excellence Informs and Inspires

The Indiana Perinatal Network and La Leche League of Indiana partnered to sponsor the recent Breastfeeding Day of Excellence. Held at Methodist Hospital in Indianapolis, the program was attended by breastfeeding advocates from nearly 40 counties throughout the state.

Renowned author Linda Smith, BSE, FACCE, IBCLC explained the processes and practices that lead to Baby

Friendly certifi cation, and detailed the steps that hospitals can take to improve breastfeeding support and move closer to this signifi cant goal. Representatives from each of Indiana’s three Baby Friendly Hospitals—Methodist Hospital, Anderson Community Hospital and Ball Memorial Hospital—provided their perspective on the certifi cation process and how their facilities maintain these high standards, urging attendees to improve breastfeeding “customer service” in their programs.

The Indiana Perinatal Network also presented the inaugural Breastfeeding Awards of Excellence to recognize innovative and dedicated people throughout the state.

Sherry Franscoviak, RN, IBCLC from the Kathryn Weil Center in Lafayette won Rookie of the Year. A newly-certifi ed IBCLC, Sherry has focused her eff orts on increasing pump availability and outpatient breastfeeding counseling support, and on identifying methods to fi nance each.

The MVP (Most Valuable Player) Award was given to Terry Jo Curtis, CLC from The Indiana Mothers’ Milk Bank. Founder of the Indiana Black Breastfeeding Coalition, Terry works with African American mothers and families to improve the traditionally lower rates of breastfeeding.

Wayne County Breastfeeding Coalition was named Coalition of the Year, earning special recognition for its work to increase breastfeeding support and promotion in surrounding counties and to create a stronger regional breastfeeding presence. Their eff orts led to the formation of the White River Valley Coalition.

Ball Memorial Hospital was the winner of the Award of Excellence for Hospital of the Year. This has been an exciting year for Ball Memorial, which has recently been awarded Baby Friendly status.

Proceeds from the conference supported the work of the La Leche League of Indiana, which provides direct mother-to-mother breastfeeding support and education.

Terry Jo Curtis CLC (right), and her daughter celebrate the MVP Award.


Marcia Boring Comes “Full-Circle”

Profi le

To Marcia Boring, MSW, ACSW, LCSW, being named Social Worker of the Year for Indiana Region 7 by the National Association of Social Workers is humbling—but work-ing with new moms suff ering from perinatal mood disorders is “the most important thing I do.”

When Boring began working on PMD at the Community Health Network’s Gallahue Mental Health Services program fi ve years ago, she spent 10 hours a week with these clients. Now, she says, “it’s not ever enough hours per week. I’m cramming in people.”

Long passionate about women’s health issues, Boring’s early career included crisis service, participa-tion on domestic violence commit-tees, and crafting rape protocols. “Women’s issues are under-repre-sented,” Boring maintains, empha-sizing that “I’ve always wanted to do whatever I can for other wom-en.” She has a long-standing inter-est in the “mind-body-hormone” connection, and her current work with clients experiencing post-partum depression “feels like I’ve come full circle. It’s something I’ve always loved.”

Boring provides individual and group therapy, as well as pro-grams for partners of women with perinatal mood disorders. She attributes her increasing casel-oad to heightened recognition of the problem, and lauds women for “talking about it, asking ques-tions, and recognizing that this just isn’t right.” She fi nds working with these new mothers and fami-lies especially rewarding. “These women want to be well,” she says. “They have things they are look-ing forward to. They’re motivated. They want to enjoy their babies, and they have a real desire to get better. They tell me “‘I want it to be better than this.’”

Boring sees fi rsthand the signifi -cant challenges her clients face. Many of them are “moving heaven and earth to get here,” confronting childcare issues, increasing fees, and confl icting information from health care providers about what medications are safe to take while breastfeeding. “Providers tell me ‘I don’t know a lot about this,’” she says. “They need more education and information. It’s not some-thing that many of them routinely roll into their practice.” Improved

training on coding and reimburse-ment strategies, she believes, would boost screening and inter-vention eff orts.

An additional hurdle confronts her clients on Medicaid, who lose coverage after 60 days postpar-tum. “We barely get them in and they’re gone,” she says, noting that the economic climate has forced many programs to increase fees or abandon sliding scales—mak-ing it even harder for low-income women to get help.

Over the past fi ve years, Boring has seen a gradual shift in the types of issues her clients present. “I’m seeing more moms of special needs babies, whose issues are more distinct than the standard postpartum depression,” she says. Mothers of premature or NICU ba-bies are increasingly seeking help, a population she believes will con-tinue to increase. “We’re keeping babies alive we never used to, “she notes. “Moms are in the NICU for weeks or months; they see their babies covered with tubes. It’s a distorted reality for them, and they need support to deal with that.”

Boring’s empathetic and eff ective

approach is lauded by her col-leagues. “She is a wonderful asset to new moms and babies,” says Birdie Meyer, RN, MA, CLC, coordi-nator of Perinatal Mood Disorder Programs at Clarian Women’s Ser-vices and President of Postpartum Support International.

An avid gardener, Boring wel-comes the warm weather and the chance to unwind by “digging in the dirt.” She enjoys playing Mah Jongg, participating in her book club, and spending time with daughter Claire Voorhees, a recent IU graduate.

Minority Health

April was National Minority Health Month and the Minority Health Coalition of Marion County (MHCMC) celebrated in style, hosting a variety of events to spotlight the importance of minority health issues. To kick off the month, MHCMC hosted a town hall meeting entitled Accessing Health Care, which allowed participants to discuss their experiences with representatives from the three Medicaid managed care

companies and a representative from the Marion County Division of Family Resources.

On April 16, MHCMC hosted its fi rst Teen Summit. Over 125 teens and pre-teens attended the summit and discussed issues vital to teens today, including tobacco, teen pregnancy, adolescent obesity, teen mental health, and stress.

The celebration of Minority Health Month culminated with

the 12th Annual Membership Forum. At this event, the Coalition focused on men’s health, featuring prominent speakers addressing the mind, body and spirit.

Participants attend teen summit during Minority Health Month.

Minority Health Coalition of Marion County Celebrates Minority Health Month


Model Program

The FACES Program: Innovations in Treating Alcohol Use during Pregnancy

A pilot demonstration program in St. Joseph County is successfully identifying and treating pregnant alcohol users through universal screening, intervention, and support.

A project of Memorial Hospital of South Bend, the FACES program (Foundations for Alcohol Cessation, Education and Support) has screened over 1,000 pregnant women in its fi rst year and, according to program supervisor Jamie Reinebold, MSW, has ambitious plans to eff ect “system change” around alcohol use during pregnancy.

One of fi ve pilot sites in the country funded by SAMHSA (the federal Substance Abuse and Mental Health Service Administration) and Northrop Grumman, the FACES program focuses on pregnant women at two WIC clinics in St. Joseph County. Each pregnant WIC client is screened with T-ACE, a tool developed for

use with pregnant women. A woman who scores “positive” (higher than 2) on the T-ACE becomes a FACES participant, and receives an assessment and monthly phone interventions. “We include other resources, such as breastfeeding information and other referrals, in the monthly calls,” says Reinebold. “It’s a natural fi t to include this other information along with the alcohol intervention.”

Referrals to the local Perinatal Exposure Prevention Project (PEPP) allow women using other substances or higher levels of alcohol more in-depth treatment and support. “If a woman expresses low confi dence in her ability to abstain from alcohol for the next 30 days, or if she drinks in the month between calls, PEPP is there for her,” explains PEPP Director Julie Sellers.

The FACES program follows women for up to 36 weeks, depending on when they entered the program; staff follows up after delivery to assess the baby’s birth weight and check on the mother’s progress. Participants sign releases allowing FACES staff to share information with their child’s pediatrician, who can then consider maternal alcohol history as

a potential diagnostic tool. “Often long-term outcomes of alcohol exposure aren’t evident until the child is 7 or 8,” notes Sellers, “so we may be years away from knowing the eff ects of the substance exposure”.

In its fi rst year of operation, the FACES project screened 1,061 pregnant women—each of whom received education about alcohol use and was encouraged to talk to friends and family about the importance of abstaining during pregnancy. Of these, 161 scored higher than 2 on the T-ACE or drank within the past 30 days, resulting in their participation in FACES. Six of the 161 were referred to the PEPP program for more in-depth treatment. “They’re so primed for treatment,” says Sellers. “They want the skills and guidance to have a healthy baby.” Medicaid covers treatment costs.

According to Reinebold

and Sellers, little data exists on alcohol use during pregnancy, especially during the early pregnancy period. Funders SAMHSA and Northrop Grumman plan to use the data from the fi ve pilot sites—also located in Ohio, Illinois, Arizona, and on reservations in North and South Dakota—to develop baseline information.

Reinebold points to the commitment of the WIC program, the hospital’s support, and a strong community task force as keys to the program’s early success. “We had some of the puzzle pieces already,” she says. Another strength, according to Reinebold, is the supportive and personalized nature of the phone interventions. “We try to speak their

language,” she asserts. “We tell them we know they can have a healthy pregnancy.”

The project is funded for two more years, and Reinebold’s primary goal is to bolster awareness about the problem and the program. Reinebold and Sellers point to physicians who tell patients they can drink in moderation as a barrier to success. “You say they can have one drink; they’ll have two,” Sellers observes. In the next year, they plan to work with physicians at the hospital’s two residency programs, as well as private physicians, to educate them on what Reinebold calls “the social medicine piece.” Other goals include addressing the binge drinking they hear about during community presentations, especially among teens and underage women.

Ultimately, Reinebold says, she’d like to see this program in every WIC clinic. “It’s a great partnership,” she says. “It’s a unique and eff ective way to help moms.”______________________________________For more information about the FACES program, contact Jamie Reinebold, MSW at (574) 647-1354 or [email protected].

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FACES Foundations for Alcohol Cessation, Education and Support


Celebrating 19 years of promoting childbirth education, the Indiana Perinatal Educators Committee held their annual conference on April 30th in Carmel. Many of the 130 attendees were fi rst-time IPEC participants and brought fresh ideas and perspectives. The keynote sessions, led by Margie Wallis, focused on the role of technology in decision-making for child-bearing couples. Wallis, a Lamaze certifi ed educator who also serves on the curriculum review committee and is the Specialty Workshop Chair for Lamaze International, challenged the audience to help “close the gap” between evidence-based information and what young women in our culture believe about childbirth. She shared exercises and activities educators can use to introduce the evidence-based Lamaze care practices. Participants reported they were inspired, and left the day with new tools to use in their classes.

Caitlin Priest, MPH from the Indiana Perinatal Network presented sobering statistics on the prevalence of homicide and suicide among

pregnant and postpartum women in Indiana. Since childbirth educators often have the most one-on-one contact with expectant moms, Priest encouraged the audience to pay attention to warning signs of depression or abuse among their clients.

The conference closed with the thought-provoking new documentary, Pregnant in America. The fi lm examines the journey of one young couple as they explore the current attitudes and practices surrounding childbirth in the U.S. Following the fi lm, a panel of local experts, plus fi lmmaker Steve Buonaugurio, had a spirited discussion about the issues raised by the fi lm and how educators can help improve the birth experiences of their clients. ________________________________________________________Copies of Pregnant in America are available for $25, and proceeds benefi t the conference. Contact Sharon Johns at [email protected] to order a copy. For more information about the fi lm, visit www.pregnantinamerica.com.

Indiana Perinatal Conference Explores Birth in A High-Tech World

Education

IPN Launches New WebsiteResources for Mothers & Families, Providers, Policy Makers, and Media Available

Patient resources, professional education opportunities, policy statements, and the latest clinical innovations are available on IPN’s newly-revised website, www.indianaperinatal.org. Log on to learn the

latest news about breastfeeding, Medicaid access for pregnant women, substance use screening strategies, and much more. Visit today to register for events, order materials and resources, and sign up for IPN e-alerts.

Regional Trainings Address Access to Care, Engaging Community Partners

IPN’s inaugural Regional Training program is underway, and is being met with great success. To date, trainings have been held in Fort Wayne and Bloomington, where participants—including health care providers, community agencies, and home visitors—have learned methods to impact patient access and retention, identifi ed new strategies to reach at-risk women, and networked with local colleagues.

___________________________________

View the back of the newsletter to learn where IPN will be next—or log on to www.indianaperinatal.org.

Indiana Perinatal Network NEWS

11Download this newsletter online at www.indianaperinatal.org/sections/pp_newsletter.php Vol. 13 • Issue 2 • 2009 11Download this newsletter online at www.indianaperinatal.org/providers-perinatal-perspectives-newsletter.aspx Vol. 13 • Issue 2 • 2009

The Indiana General Assembly reviewed and passed new legislation, and now moves into a special session to develop a state budget. Some of the issues IPN monitored throughout the course of the legislative session include:

Smoking and Tobacco

IPN collaborated on the development of SB 317, Nonsmoking Tobacco Products Tax, designed to increase taxes on nonsmoking tobacco products and appropriate part of the revenue to support the recommendations of the Prenatal Substance Use Commission. The bill was not heard in committee. However, a provision was added to the House Ways and Means Committee budget bill requiring the state Department of Revenue to conduct a study of the costs and potential increased revenues associated with creating a “high-tech” tax stamp for cigarettes and other tobacco products. Some of the increased revenue on tobacco products could be used to fund the Commission, with additional portions dedicated for retail tobacco enforcement or tobacco prevention strategies. The fate of the study depends on whether it is included in the budget the legislature approves during the special session.

Signifi cant media attention was given to HB 1213, Smoking Ban in Public Places, which was passed with exemptions by the House but not heard in the Senate. The Indiana Campaign for Smokefree Air (ICSA) will continue its eff orts at the local level to protect all workers from exposure to secondhand smoke. More information about the ICSA and future legislative direction is available at http://www.worksmokefree.org.

On a federal level, S.982, the Family Smoking Prevention and Tobacco Control Act, which provides for FDA regulation of tobacco products, has been passed by the Senate. Indiana Senators Bayh and Lugar were among the bill’s sponsors.

Provider Workforce

SB 393, Primary care physician loan forgiveness program, was passed and is awaiting the Governor’s signature. Filed in an eff ort to attract and retain Indiana primary care physicians, the bill provides annual student loan forgiveness payments to qualifi ed primary care physicians (in family practice, pediatrics, obstetrics and gynecology, or internal medicine) who are residents of and practice medicine in Indiana.

Indiana Family and Social Services Administration: Medicaid and Division of Family Resources

Several bills addressed issues related to Medicaid and Indiana’s eligibility determination processes. Senate Enrolled Act (SEA) 344, Restoration of County Offi ces of Family Resources, has been passed and signed by the Governor, eliminating the authority of the Division of Family Resources to replace county offi ces with regional offi ces. House Enrolled Act (HEA) 1572, Medicaid Matters, establishes a health policy advisory committee to provide information and assistance to the Select Joint Commission on Medicaid Oversight. It also requires eligibility determination contractors to provide information on intake processes, call wait times, and other outcomes.

On July 1st, Presumptive Eligibility for pregnant women will begin in Indiana. For more information, or to become a Qualifi ed Provider, visit http://www.indianamedicaid.com/ihcp/MCE/content/peInfo.asp.

The Offi ce of Medicaid Policy and Planning has developed a new Notifi cation of Pregnancy (NOP) form, a comprehensive risk assessment used by all three Medicaid managed care organizations. The NOP includes questions about maternal medical, obstetrical, psych-neurological and substance use history, and social risk factors. Prenatal care providers that complete and electronically submit the NOP using Web interChange may be eligible for $60 for each form returned. For more information about the NOP, visit http://www.indianamedicaid.com/ihcp/MCE/content/nopInfo.asp. _____________________________________________________________For more information, contact Caitlin Priest, MPH Director of Special Projects and Public Policy, at 317.924.0825 ext. 4231 or [email protected], or visit the Indiana General Assembly webpage at http://www.in.gov/legislative/.

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The Indiana Perinatal Network is now offering ad space in the Perinatal Perspectives newsletter mailed to over 4,500 professionals statewide.

cost $100/issue or $250/year (3 issues)size Quarter page

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visit www.indianaperinatal.org phone 866.338.0825 e-mail [email protected]

Legislative Update


1991 East 56th StreetIndianapolis, IN 46220

2009 CALENDAR at-a-glance

July 15 State Perinatal Advisory Board

____________________________July 22 Regional Training Newburgh, IN____________________________September 18 Regional Training Monticello, IN____________________________October 13 Regional Training Indianapolis, IN____________________________November 4 State Perinatal Advisory

Board

IPN REGIONAL TRAININGS—WE’RE COMING TO YOU!IPN will be visiting Newburgh, Monticello, and Indianapolis during the second half of 2009 as part of our Regional Training Series. Customized to meet the needs of Indiana’s diverse communities, these trainings will include community mobilization strategies, up-to-date clinical innovations, and best practice models to improve care for mothers and babies.

UPCOMING SESSIONS:

Breastfeeding: Putting Expertise into Action

Something’s Not Right: Exploring Perinatal Mood Disorders

Change from Within: Improving Patient Access, Loyalty, and Retention

Improving Outcomes: Engaging Community Partners to Reach At-Risk Moms and Families

CEUS ARE AVAILABLE. VISIT WWW.INDIANAPERINATAL.ORG FOR A COMPLETE LISTING OF DATES AND LOCATIONS.

Volume 13, Issue 2 2009 • News from the Indiana Perinatal Network (IPN)

volume 13, issue 2 2009 (focus: substance use during pregnancy)

Documents

indiana perinatal network

ipn sta

perinatal care providers

child health

pregnancy maternal mortality

indiana hospital association

annual ipn forum

child care