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 Accelerating Progress to Improve Birth Outcomes through the COIIN

By Lacy Fehrenbach
Director of Programs, AMCHP

After stalled progress at the start of this century, the U.S. infant mortality rate declined 12 percent between 2005 and 2011. This is certainly welcome news. Even more promising though, the data indicate that death rates for babies born to black mothers declined the most during this time, which narrowed slightly the disparities gap in birth outcomes. We certainly must celebrate this success and acknowledge that we still have much work do. Unfortunately, the U.S. infant mortality rate remains worse than most developed countries. It is imperative that we learn from states that succeeded in driving down their rates and disparities and use that knowledge to improve birth outcomes. Several recent national initiatives, including the HRSA CoIIN to Reduce Infant Mortality, refocused national attention on infant mortality and opened a window for MCH leaders to accelerate progress on our efforts to reduce infant mortality.

Earlier this month, more than 150 state and national health leaders gathered in Arlington, VA for the Region IV, V, VI Meeting of the CoIIN to Reduce Infant Mortality. The meeting provided a forum for these leaders to drive further implementation of regional CoIIN strategies and state infant mortality plans and learn from the successes and challenges of efforts to date. The meeting included sessions where the states and CoIIN strategy teams from Regions IV and VI, who started their formal CoIIN work in 2012 but have been working collaboratively to reduce infant mortality for the past few years, shared their successes and lessons learned with each other and the states in Region V. Three keys to success emerged.

Use data strategically: In every session and discussion, states underscored the importance of having strong, timely data and using it to drive decision making, address the drivers of preterm birth and infant mortality, improve quality, and target investments and interventions where they are most needed. For example, Georgia used GIS mapping of births to identify six clusters of high infant mortality where they focused their efforts. Georgia also mapped access to obstetric care and used this information to expand access to care in rural, underserved areas through their existing state telehealth program. These are two of many program and policy interventions Georgia has used to reduce infant mortality from a rate of 8.4 deaths per 1000 live births in 2006, to 6.4 in 2011.

Find opportunities to innovate: Most know that CoIINs apply a quality improvement approach to each region’s infant mortality reduction efforts, but innovation – the second I – also is a priority that the states in Regions IV and VI are using to develop policies that improve access to and use of interconception care through Medicaid. Innovation appeared in other CoIIN approaches. To promote safe sleep, Tennessee used Title V MCH Services Block Grant funds to purchase copies of Sleep Baby, Safe and Snug board books, which are given as free gifts to new parents in Tennessee Hospitals. The book contains safe sleep dos and don’ts for parents. Tennessee also prints safe sleep messages on 38,000 WIC vouchers each month.

Engage partners who will help you succeed: All CoIIN strategy teams and states noted the importance of engaging key partners to drive quality improvement and achieve aims. For example, state Medicaid program, hospital associations, and the March of Dimes Chapters have been instrumental in reducing early elective deliveries (EEDs) within the region. State health departments worked with the March of Dimes and their state hospital associations to increase voluntary ‘hard stop’ policies on non-medically indicated induction or cesarean prior to 39 weeks. As of August, more than 50 percent of hospitals in 9 of the 13 states, have these policies to stop EEDs. The Texas, South Carolina and Georgia Medicaid programs no longer pay for EEDs.

Hospitals and medical societies are essential partners in states improving perinatal regionalization. States also are working with provider groups and their home visiting programs to increase referrals to quitlines and evidence-based tobacco cessation interventions for pregnant women who smoke.

The composition of teams that states brought to Arlington reinforced the criticality of partnerships. Nearly every state brought a Medicaid representative. Several brought leaders from their hospital association, state medical society or state March of Dimes chapter.

Region V employed these keys to success as they began their regional CoIIN work. Addressing social determinants was the first collaborative strategy chosen by the region, which has the worst disparities in infant mortality in the nation. Addressing social determinants also is foundational in all other strategies. The region is exploring the following approaches to address social determinants collaboratively:

  • Use hot spotting within states to focus interventions where data indicate they are most needed
  • Develop a collaborative of urban areas, where disparities in birth outcomes are the greatest
  • Form a partnership with state health departments and the Committee on Institutional Cooperation, which is the academic arm of the Big 10 Conference schools
  • Implement a social determinants of health curriculum for key health leaders and staff across the region

These approaches start with strong data about the drivers of disparities, are innovative, and engage current partners and bring in new strategic ones.

AMCHP looks forward to continued learning from the improvement and innovation among the 19 states in regions IV, V and VI, which we hope to spread to all our members nationwide. The early progress and ongoing commitment and energy from Regions IV and V combined with the bold commitment of Region V to use social determinants as a framework for their work to improve birth outcomes give great hope that we can continue to improve birth outcomes and reduce disparities therein across the states, regions, and nationally.


Funding from the HRSA Maternal and Child Health Bureau (MCHB) made the CoIIN meeting possible. MCHB, the Centers for Medicare & Medicaid Services, the Center for Disease Control and Prevention (CDC) Division of Reproductive Health, AMCHP, Association of State and Territorial Health Officials (ASTHO), Abt Associates, the National Improvement Partnership Network at the University of Vermont, CityMatCH, the March of Dimes, the National Association of Medicaid Directors, and the National Governors Association provided support for the CoIIN in Regions IV/VI and V and contributed to the success of the meeting.

Presentations, recordings,and resources from the meeting will be available on the MCHB CoIIN resource page mchb. in the coming weeks, but are delayed due to the recent government shutdown.

About the CoIIN

The Collaborative Improvement and Innovation Network (CoIIN) to Reduce Infant Mortality is a public-private partnership to reduce infant mortality and improve birth outcomes. Participants learn from one another and national experts, share best practices and lessons learned, and track progress toward shared benchmarks.

Through the CoIIN, regions identify shared priorities, informed from their state infant mortality plans,  which they address together as a region using a quality improvement approach in a virtual environment.

Region IV & VI Priorities

  • Reduce elective delivery at less than 39 weeks of pregnancy
  • Expand access to interconception care through Medicaid
  • Promote smoking cessation among pregnant women
  • Promote infant safe sleep practices
  • Improve perinatal regionalization

Region V Priorities

  • Address social determinants of health
  • Reduce elective delivery at less than 39 weeks of pregnancy
  • Expand access to preconception and interconception care
  • Reduce sudden infant death syndrome (SIDS)/sudden unexpected infant deaths (SUID) and promote safe sleep

For more information about the CoIIN, visit

Resource: CDC Grand Rounds