Logic Model Development For

Road Map for Preventing Infant Mortality in Kansas

State-Level Logic Model...... 2 State Systems Logic Model...... 3 Safe Sleep Logic Model...... 4 Access to Health Care and Social Supports Logic Model...... 5 Glossary and Acronyms List...... 6 References...... 7

Updated February 23, 2011 OVERALL LOGIC MODEL: Preventing Infant Mortality in Kansas (Kansas Blue Ribbon Panel on Infant Mortality) Vision/Mission: Assuring healthy babies for all Kansans through collaborative action for enhanced services, community support, and policy advocacy. Context/Conditions: Risk/ Protective Factors: Recommended Intervention Components and Activities: Outcomes: - Kansas ranks 40th among Behavioral: Providing Information and Enhancing Skills: Behavioral Outcomes: states in infant mortality st - Early (1 trimester) prenatal care Patient/Mother/Family Behavior: rate - Multi-year Infant mortality public awareness campaign - Folic acid use - Promote safe sleep practices via professionals, CBOs, and statewide - Increased proportion of women - Kansas ranks worst in Black - Infant sleep position & sleep environment education & receiving prenatal care in 1st trimester IMR (BIMR is 2.7 times networks. increased awareness among parents, child care providers, and - Increased proportion of women of child higher than WIMR) - Promote healthy lifestyles among women of childbearing age health care providers bearing age consuming folic acid - Highest IMR rates in high- - Promote healthy behaviors among teens - Increase the proportion of mothers - Interconception care (including 1+ years between birth) risk places (especially in SG, Enhancing Services and Support: initiating breastfeeding for infants up to 6 - Exposure to tobacco smoke WY, GE counties) - Implement state-wide PRAMS (Prenatal Risk Assessment of the months - Alcohol, tobacco, caffeine, & other drug use - Increased proportion of infants in safe Mother) to determine trends/disparities in birth outcomes of overall Barriers: - Appropriate prenatal weight gain sleep position and environment Kansas births - Lack of urgency for - Preconception education (Life Course perspective to improve - Decreased maternal use of alcohol, - Establish and maintain the FIMR projects in Wyandotte and Sedgwick reducing IMR maternal health) tobacco, caffeine, & other drug use Counties to help identify social and medical factors that contribute to - Limited resources for Biological/History/Experience: - Increased maternal healthy eating, infant death physical activity, healthy weight assuring access to needed - Maternal birth weight (“Life Course Perspective”) health services and - Promote breastfeeding through existing coalitions and partners. - Reduced levels of teenage pregnancy - Elective delivery before 39 weeks community-based programs - KDHE & State Child Death Review Board (CDRB) partnership (and related behaviors of unprotected - Previous LBW or preterm delivery sex) - Cultural and language - State Perinatal Periods of Risk (PPOR) (every 5 years) - Previous fetal demise/infant death-Prior 1st trimester induced - Increase the interval between gestations barriers (low levels of health - Identify and implement best practice models literacy) abortion - Increase proportion of infants - Improve care coordination of high-risk pregnant women adequately immunized - Low levels of overall - History of infertility - Support perinatal collaboratives and surveillance systems Provider/Health Care System Behavior: Literacy - Nulliparity & high parity - Create neonatal-perinatal quality improvement collaborative - Increased number of health care & child - Gaps in government-to- - Placental, cervical, & uterine abnormalities & infections - Support community-based programs including home visitation for care providers who deliver culturally government relationships for - Gestational bleeding competent education about safe sleep as high-risk families services - Intrauterine Growth Restriction (IUGR) well as integrate cultural assets for - Promote smoking cessation programs for families and caregivers - Multiple gestations healthy pregnancies Resources: - Promote WIC Program for all eligible women - Birth spacing - Collaboration via MOU or other process - Existing collaborative - Seek opportunities to work with IHS and tribal health clinics in KS. - Low pre-pregnancy weight & short stature for tribes in KS partnership for preventing - Elimination of elective deliveries prior to - Preeclampsia Modifying Access, Barriers, and Opportunities: IM, including among: 39 weeks . State health department - Diabetes - Ensure early, comprehensive prenatal care for all women - Race/ ethnicity (African American, Native American, Puerto - Create a more efficient and expedited process for access to Medicaid Environmental Outcomes: (including Center for - Reduced exposure to impoverished living Rican) services Health Disparities) conditions, occupational hazards, chronic . Health organizations (e.g., - Single marital status - Improve access to genetics counseling stress, tobacco smoke, and child abuse neonatal care) - Low SES & Low education - Provide Family Planning Service Option within Medicaid and neglect . March of Dimes - Maternal age (Teens & Older Age/ 35+) - Provide culturally tailored education and information - Reduced vulnerability through increased . SIDS/Safe Sleep Coalition - Family/Domestic Violence/Child Abuse/Neglect - Build collaborative relationships with organizations that are already social support, education, occupational . Professional associations - Depression addressing disparate populations and status (e.g., Kansas Academy of - Under-immunized status of infant Changing Consequences: Population-level Health/ Equity Pediatrics) Environmental: - Adequate insurance reimbursement for group visits and centering care Outcomes: . Academic and research - Impoverished living conditions - Payment of infant autopsies to coroners contingent on properly - Reduced incidence of infant mortality partners - Feelings of helplessness conducting those autopsies on infants - Reduced incidence of low birth weight . Promising Community - Unstable social support Modifying Policies & Systems: - Reduced disparities in rates of infant Initiatives (e.g., MCH mortality among different groups - Employment-related physical activity & occupation exposures - Apply for Medicaid—Family Planning Service & obtain funding Coalition of KC; Healthy (especially African Americans; currently, Babies/SG Co.) - Environmental exposures - Implement state genetics plan 3:1 ratio) . Sovereign nations & - Chronic stress (including DV, poor living conditions, - Develop hospital/provider collaborative to eliminate elective deliveries - Reduced premature birth rate (< 37 urban Indian populations unemployment, stressful living conditions) before 39 weeks weeks) in KS - Availability, access, & quality of health care (obstetric, - Support implementation of safe sleep policies in child care settings - Reduced intentional and unintentional perinatal, & neonatal) - Support tobacco legislation to reduce use and exposure injuries during first year of life Sub-Logic Model: Strengthening State Systems Preventing Infant Mortality in Kansas Vision/Mission: Assuring healthy babies for all Kansans by enhancing state-level supports for community efforts to prevent infant mortality.

Context/Conditions: Types of System-level Activities/In Priority System Changes: Effects: Outcomes/Results - Kansas ranks 40th among terventions: - Enhance surveillance systems to assess and states in infant mortality rate - Monitor IM rates related report IMR and disparities at state, local, and By 2012 By 2015 By 2020 - Kansas ranks worst in Black risk/protective factors for tribal levels - Develop a comprehensi Behavioral Outcomes: Environmental IMR (BIMR is 2.7 times higher state/disparities groups to identify, - Promote community assessment tools, risk ve strategic plan for prev - Increased proportion of Outcomes: than WIMR) diagnose and investigate problems and monitoring tools ention of infant mortality women receiving prenatal - Reduced exposure to - Highest IMR rates in high-risk goals - Establish a website about infant mortality, it in Kansas and document i care in 1st trimester impoverished living places (especially in SG, WY, - Inform, educate and empower people s risk/protective factors, strategies & resourc ts implementation and pr - Increased time interval conditions, GE counties) about IM issues es for intervention, contacts ogress between births occupational hazards, - Mobilize and support community - Develop asset map of services and supports Barriers: - Implement and evaluat - Increased assessment and and chronic stress partnerships to prevent IM, including (MADIN toll-free line) - Lack of urgency for reducing e statewide public aware screening for depression, - Reduced vulnerability among those with IM disparities - Facilitate action planning, technical support, IMR ness campaign on infant family violence/domestic through increased - Develop policies and plans to support implementation, and evaluation of comprehe - Limited resources for mortality violence social support, individual & community health efforts nsive interventions using evidence-based stra assuring access to needed - Resources secured and - Increased proportion of education, and - Enforce laws & regulations that tegies health services and comprehensive, women who report occupational status protect health and ensure safety of - Build capacity of workforce and partnership community-based programs community-based consuming adequate amounts infants and mothers s for preventing IM in local communities programs (e.g. FIMR) of folic acid Population-level Resources: - Assure access and link people to - Enhance reimbursement mechanism for pre established and - Increased proportion of Health/ Equity - Existing collaborative needed prenatal services ventive services enhanced in high-risk zip infants in safe sleep position Outcomes: partnership for preventing IM, - Strengthen system (training) for - Address gap between existing laws and iden codes and environment - Reduced incidence of including: collecting accurate data on tified IM goals - KS Perinatal Quality - Decreased levels of maternal preterm births  State health department risk/protective factors for those - Expand health insurance coverage to assure Improvement smoking - Reduced incidence of (including Center for Health completing birth and death certificates needed services Collaborative garners - Decreased maternal use of infant mortality Disparities) - Payment of infant autopsies to - Prepare local and regional staff in public technical assistance from alcohol, tobacco, caffeine, & - Reduced disparities in  Health organizations (e.g., coroners contingent on properly health departments California and/or Ohio other drug use rates of infant neonatal care) conducting those autopsies on infants -Assess KS Perinatal Quality Improvement Coll Quality Improvement - Increased maternal healthy mortality among  March of Dimes - Assure a competent workforce in aborative Collaboratives eating, physical activity, different groups  SIDS/Safe Sleep Coalition preventing IM - Establish monitoring and evaluation systems healthy weight (especially African  Professional associations - Evaluate effectiveness, accessibility, to see progress and assure accountability By 2015 - Reduced levels of teenage Americans; currently, (e.g., Kansas Academy of and quality of personal and population- - KS Perinatal Quality Imp pregnancy (and related 3:1 ratio) Pediatrics) based health services rovement Collaborative is behaviors of unprotected sex)  Academic and research - Educating workforce around the risks functioning: funding acq - Improved preterm birth partners related to infant mortality uired, partner participati outcomes  Promising Community on, data collected, analyz -Decreased level of preterm Initiatives (e.g., MCH ed and reported births Coalition of KC; Healthy -Decreased C-section rate Babies/SG Co.)  Sovereign nations & urban Indian populations in KS

2 Sub-Logic Model: Increasing Safe Sleep to Reduce Infant Mortality in Kansas Vision/ Mission: Assuring healthy babies for all Kansans through collaborative action safe sleep

Context/Conditions: Risk Factors: Recommended Intervention Components & Activities: Outcomes: - Kansas ranks 40th among states Behavioral: Providing information/enhancing skills: Behavioral Outcomes: in infant mortality rate - Cultural norms and practices - Educate parents, grandparents and caregivers of all infants on the AAP’s safe sleep - Increased number of - Kansas ranks worst in Black - Co-sleeping and/or Bed-sharing recommendations parents, caregivers, and IMR (BIMR is 2.7 times higher - Improper sleep surface - Distribute safe sleep DVD to parents, grandparents, and caregivers of all infants child care providers than WIMR) - Use of loose bedding and soft objects in - Advocate for the use of stickers on cribs demonstrating the safe sleep position consistently adhering to the - Highest IMR rates in high-risk sleep space AAP’s safe sleep places (especially in SG, WY, GE - Improper sleep position - Train health care providers, child care providers, and home visitors to provide AAP counties) - Alcohol, tobacco, cocaine, & other drug safe sleep recommendations recommendations - Encourage pediatricians, primary care physicians, and staff to educate - Increased number of Barriers: use parents/caregivers about safe sleep practices during all well-baby checks properly conducted infant - Lack of urgency for reducing - Educate child welfare workers (e.g. SRS, family preservation, and foster care) to autopsies IMR Biological/History/Experience: - Limited understanding and - Race (African American and Native provide AAP safe sleep recommendations support/ resources for Safe American) - Promote state-wide awareness of safe sleep practices through media Environmental Sleep messages - Male infant - Participate in statewide education campaign on infant mortality Outcomes: - Living in poverty - Transient population - Create and promote infant death scene investigation training via DVD and/or - Ensure parents have full - Being between one and six months old -Lack of proper scene webinar access to safe sleep tools for investigation or autopsy of - Sibling loss to SIDS - Maternal age < 20 during first pregnancy - Promote use of CDC’s Sudden Unexplained Infant Death Investigation (SUIDI) form newborns at hospital/birth unexpected infant deaths settings -Inadequate documentation - Obstetric History, Medical Illnesses & - Emphasize the relative frequency of SIDS where positional asphyxia cannot be - Increased public during infant death scene Conditions ruled out  Premature birth awareness of the risk factors investigations Enhancing services/support:  Low birth weight contributing to infant deaths - Require the Safe Sleep DVD be watched when a child care provider has a violation Resources:  Inadequate prenatal care - Ensure parents have full of safe sleep - Existing collaborative  Low maternal weight gain access to safe sleep tools partnership for preventing IM,  Placental Abnormalities - Encourage addition of a safe sleep consultation prompt to the Parents as Teachers before leaving hospital including among:  Anemia data form(s)  State health department - Develop culturally-tailored safe sleep awareness campaigns (including Center for Health Population-level Psychosocial & Environment: - Support and encourage more frequent home health visitation for infants Disparities) Health/Equity - Environmental exposures Modifying access, opportunities, and barriers:  Health organizations (e.g., Outcomes: neonatal care) - Exposure to smoke - Supply a wearable blanket to newborns - Inconsistent safe sleep messages  March of Dimes - Supply a crib (portable or other) for newborns as needed - Decreased racial disparity - Highly transient populations  SIDS/Safe Sleep Coalition - Collaborate with lactation consultants to promote consistent safe sleep messages of infant deaths - Grandparent influence on young parents  Professional associations - Child safety agencies will - Poor access to safe sleep resources (i.e. Changing Consequences: (e.g., Kansas Academy of have an increased proper cribs, wearable blankets, etc.) and - Build an incentive program for child care providers who implement a safe sleep Pediatrics) knowledge of safe sleep education materials policy based on the AAP’s recommendations  Academic and research - At-risk Families and communities with practices and risk factors partners Modifying Policies: concentrated poverty associated with infant sleep-  Promising Community - Support implementation of a safe sleep policy based on the AAP’s - Child care providers without proper safe related deaths Initiatives (e.g., MCH recommendations for hospitals and health care centers sleep education - Decreased number of Coalition of KC; Healthy - Endorse a policy for all coroners to follow the National Association of Medical - Child care providers not adhering to safe infant deaths of babies born Babies/SG Co.) sleep protocols Examiners (NAME) and Forensic Autopsy Performance standards manual for all  Sovereign nations & urban into poverty infant autopsies Indian populations in KS - Support safe sleep training regulation for new and current childcare providers - Add a safe sleep checkbox to child care surveyor’s inspection form. 3 Sub-Logic Model: Enhancing Access to Health Care and Social Supports to Reduce Infant Mortality in Kansas. Vision/ Mission: Assuring healthy babies for all Kansans through collaborative action for enhanced services, community support, & policy advocacy Context/Conditions: Risk/ Protective Factors: Recommended Intervention Components & Activities: Outcomes: -Kansas ranks 40th among Behavioral: Providing Information and Enhancing Skills: A. No elective induced labor < 39wk B. Increased folic acid intake for states in infant mortality - Alcohol, tobacco, & other drug use - Text for Baby messages rate - Maternal Nutrition: child bearing age women (100%) - PSA’s on risk of elective preterm deliveries -Kansas ranks worst in Black  Low pre-pregnancy weight (BMI < [consider link on prenatal vitamins IMR (BIMR is 2.7 times 19.8) - Public campaign on benefits of folic acid & harm of alcohol, tobacco, cocaine, & to message on safe sleep] higher than WIMR)  High pre-pregnancy weight (BMI > other drug use C. Increased access to care & -Highest IMR rates in high- 26.0) - Public campaign on spacing pregnancies utilization before, during and after risk places (especially in SG,  Inappropriate prenatal weight gain - Multi-year statewide infant mortality public awareness campaign pregnancy within a medical home, with optimal inter-pregnancy WY, GE counties)  Lack of folic acid use - Information on improving health literacy -Leading Causes of Infant - Employment: unemployed, long work hours, spacing Mortality: prematurity, low prolonged standing, low job satisfaction Enhancing Services and Support: a) Access and utilization of birth weight, birth defects, - Exercise in pregnancy - Implement state-wide PRAMS (Pregnancy Risk Assessment Monitoring System) preconception care SIDS/sleep-related deaths - Early prenatal care to determine trends/disparities in birth outcomes of overall Kansas births b) Access and utilization of care during and after the post- Barriers: Biological/History/Experience: - Establish and maintain the FIMR projects in Wyandotte and Sedgwick counties - Race/Ethnicity (African American, Native partum period -Lack of urgency for to help identify social and medical factors that contribute to infant death American, Puerto Rican) c) Access to care during minimal reducing IMR - Increased data collection, analysis, and dissemination of information on infant - Foreign born mother 18 month inter-pregnancy -Limited resources for - Early (1st trimester) prenatal care: lack of access mortality related to disparities period assuring access to needed to quality prenatal care - State Perinatal Periods of Risk (PPOR) (every 5 years) d) Access to preventive services for health services and - Multiple gestations, assisted reproductive - Identify and implement best practice models infant and mother community-based programs e) Access to genetics counseling technology - Support perinatal collaborative and surveillance systems Resources: D. Increased Social & Health Care - Maternal age (teens & older age/35+) - Create neonatal-perinatal quality improvement collaborative -Existing collaborative - Obstetric History Supports: - Support evidence-based community programs including home visitation for partnership for preventing  Previous LBW or preterm delivery a) Care coordination and high-risk families IM, including among:  Previous fetal demise/infant death family support services available st - Promote smoking cessation programs for families and caregivers for all women in high risk zip  State health department  Prior 1 trimester induced abortion codes (including Center for  Short inter-pregnancy interval - Train health care workers on screening and referral for DV/IPV, tobacco, alcohol, b) All prenatal women are Health Disparities) (<6mo) drugs, and anxiety/depression provided with education on  Health organizations  Inadequate interconception care - Improve availability of bilingual services benefits of breastfeeding, and (e.g., neonatal care)  Reproductive tract abnormalities - Support funding for state genetics plan all post-partum women have  March of Dimes & infections Modifying Access, Barriers, and Opportunities: access to breastfeeding  SIDS/Safe Sleep Coalition  Nulliparity & high parity  Professional associations - Expedite Medicaid application for prenatal care supports  Elective deliveries <39 weeks (e.g., Kansas American - Increase Medicaid access for genetic counseling pre and postnatal c) All pregnant women are - Medical Illnesses & Conditions screened for tobacco, substance Academy of Pediatrics) - Provide culturally tailored education and information  Chronic Hypertension & abuse, mental health, and DV  Academic and research Preeclampsia - Provide interconception care and get appropriate referrals partners  Systemic Lupus Erythematosus E. Attain Healthy Pregnancy for All  Promising Community (Lupus) Changing Consequences: Kansas Women Initiatives (e.g., MCH  - Provide adequate insurance reimbursement for group visits & centering care Restrictive lung disease & Asthma a) No tobacco, alcohol, drug use Coalition of KC; Healthy  Hyperthyroidism Modifying Policies & Systems: b) Appropriate physical activity Babies/FIMR/SG Co.)  Pregestational & gestational - Promote universal provision of prenatal care for uninsured women c) Appropriate prenatal weight diabetes - Apply for Medicaid Family Planning Service Option for expanded post-partum gain  Sovereign nations &  Pregestational renal disease coverage (or Medicaid 115 waiver in 2014) F. All maternal child health providers  Maternal birth weight (“Life Course urban Indian populations - Secure full funding to assure Medicaid coverage for pregnant women to 250% are culturally competent in KS Perspective”)  Prior STD history FPL. G. Inter-pregnancy period spacing:  Previous history of genetic risk - Increase in state tobacco tax >18mo - Increased spending on tobacco prevention for childbearing age women H. Data available that characterizes Psychosocial & Environment: 4 - Stress: - Change hospital/reimbursement policy for elective induced deliveries disparities and specific state and  Anxiety - Improved linkages and coordination among public, private, and tribal entities local risk factors related to infant  Depression focused on infant mortality and associated risk/protective factors mortality  Domestic Violence Glossary and Acronyms List

AAP American Academy of Pediatrics MADIN Make a Difference Information Network

BIMR Black Infant Mortality Rate MCH Maternal and Child Health

BMI Body Mass Index MCHC Maternal and Child Health Council

BRP Blue Ribbon Panel NAME National Association of Medical Examiners

CBO Community Based Organizations Neonatal Pertaining to the period of time immediately following birth

CDC Center for Disease Control and Prevention Nulliparity A condition or state in which a woman has never given birth to a child, or has never carried a pregnancy. CDRB Child Death Review Board Perinatal Pertaining to the period immediately before and after birth. DV Domestic Violence Positional A form of asphyxia which occurs when someone's position FIMR Fetal and Infant Mortality Review asphyxia prevents them from breathing adequately

FPL Federal Poverty Level PPOR Perinatal Periods of Risk

IM Infant Mortality PRAMS Pregnancy Risk Assessment Monitoring System

IMR Infant Mortality Rate PSA Public Service Announcement

IHS Indian Health Service SES Socioeconomic Status

IPV Intimate Partner Violence SIDS Sudden Infant Death Syndrome

IUGR Intrauterine Growth Restriction SRS Social and Rehabilitation Services

KDHE Kansas Department of Health and Environment SUIDI Sudden Unexplained Infant Death Investigation

LBW Low Birth Weight WIMR White Infant Mortality Rate

5 References

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2. Xu JQ, Kochanek KD, Murphy SL, Tejada-Vera B. Deaths: Final Data for 2007. National vital statistics reports; vol 58 no 19. Hyattsville, MD: National Center for Health Statistics. May 2010. Available from: http://www.cdc.gov/nchs/data/nvsr/nvsr58/nvsr58_19.pdf. Accessed: 18 February 2011.

3. Kansas Department of Health and Environment. Annual Report: 2009 Annual Summary of Vital Statistics. Topeka: Division of Health, Bureau of Epidemiology and Public Health Informatics. November 2010. Available from: http://www.kdheks.gov/hci/as/2009/AS_2009.pdf. Accessed: 18 February 2011.

4. Shore R, Shore B. “KIDS COUNT Indicator Brief: Reducing Infant Mortality.” Annie E. Casey Foundation. July 2009. Available from: http://www.aecf.org/~/media/Pubs/Initiatives/KIDS%20COUNT/K/KIDSCOUNTIndicatorBriefReducingInfantMortalit/ReducingInfantMortality.pdf.

5. Task Force on Sudden Infant Death Syndrome. American Academy of Pediatrics. “The Changing Concept of Sudden Infant Death Syndrome: Diagnostic Coding Shifts, Controversies Regarding the Sleeping Environment, and New Variables to Consider in Reducing Risk.” PEDIATRICS; vol 116 no 5, pp. 1245- 1255. November 2005. Available from: http://aappolicy.aappublications.org/cgi/reprint/pediatrics;116/5/1245.pdf.

6. Wise Paul H., “The Anatomy of a Disparity in Infant Mortality.” The Annual Review of Public Health; vol 24, pp. 341-362. May 2003

7. Office of the Kansas Attorney General. Annual Report: 2010 Annual Report (2008 Data). Topeka: Kansas Child Death Review Board. October 2010. Available from: http://www.ksag.org/files/Final_2010_Annual_Report_with_2008_data.pdf.

8. Behrman, Richard and Butler, Adriene Stith. “Preterm Birth: Causes, Consequences, and Prevention.” The National Academies Press. 2007

9. Mandy, George T. “Incidence and Mortality of the Premature Infant.” UpToDate. September 2010. Available from: http://www.uptodate.com/contents/incidence-and-mortality-of-the-premature-infant?source=HISTORY. Accessed: December 2010.

10. Zacharias, Nikolaos. “Perinatal Mortality.” UpToDate. September 2010. Available from: http://www.uptodate.com/contents/perinatal-mortality? source=search_result&selectedTitle=1~146. Accessed: December 2010.

11. U.S. Department of Health and Human Services. “Evidence of Trends, Risk Factors, and Intervention Strategies.” Health Resources and Services Administration, Maternal and Child Health Bureau. 2006. Available from: ftp://ftp.hrsa.gov/mchb/OriginalFilesEvidence.pdf .

12. March of Dimes. “Toward Improving the Outcome of Pregnancy III.” December 2010. Available from: http://www.marchofdimes.com/TIOPIII_FinalManuscript.pdf. 6