Priority: Strengthen the capacity of the health system to promote mental health and emotional well-being.
Objective 1. Increase to 92% from baseline (89.2%, PRAMS 2018) the percent of birthing people who have moderate or high social support following the birth of their baby.
PRAMS
In 2022, 88% of PRAMS respondents indicated having moderate or high social support, level with 2021 at 88% and a modest increase from 86% in 2020. Massachusetts began to include the Social Determinants of Health Supplement with PRAMS in February 2022. Data are being analyzed and will be shared with our clinical and community partners through our PRAMS reports and Fact Sheets. In 2022, White non-Hispanic post-partum people had the highest reported prevalence of receiving social and emotional support (84%) when compared to Black non-Hispanic (61%), Hispanic (65%) and Asian 73%) postpartum people. The PRAMS survey also includes questions on support by the new infant’s father. In 2022, 90.9% of PRAMS participants reported receiving financial support from their infant’s father, and 84.3% received emotional support, percentages that were level with those in 2021.
Perinatal Mental Health Training and Technical Assistance (TA)
MDPH provided training and TA on perinatal mental health (including maternal mental health and co-morbidities such as substance use and interpersonal violence) to state agencies (such as the Department of Children and Families (DCF) and providers (including Early Intervention, home visiting programs and community health centers). The training and TA will contribute to increasing awareness and reducing stigma about perinatal mental health issues and will support continued implementation of the MA Postpartum Depression regulations.
Early Intervention Parenting Partnerships Program (EIPP)
EIPP is a home visiting program that uses a team approach to engage with and support families during pregnancy, continuing through the child’s first birthday. Maternal mental health is a key topic of discussion, education, support, and referral. In FY23, (49%) participants reported a history of depression, including postpartum depression (PPD), at enrollment. At the initial visit, all participants were screened for PPD using the Edinburgh Postnatal Depression Scale (EPDS) with 17 (8%) screening positive for mild depressive symptoms and 17 (8%) screening positive for moderate or severe depressive symptoms. Of the 19 participants referred to individual counseling, 17 (89%) were enrolled in services, 6 (31.5%) declined the referral, and 2 (10%) were placed on a waiting list.
EIPP participants are assessed on a three-question social connectedness screening tool at key prenatal and postpartum stages. At the initial visit, 192 participants were screened, with 39(20%) reporting that they do not have the support they need from others to care for themselves and their infant. EIPP facilitate groups for families enrolled in the program on topics like maternal mental health, mother/infant attachment, self-care, and parenting skills. To reduce barriers to participating in groups, EIPP programs provide transportation, childcare, and food for attendees.
MA Maternal, Infant, and Early Childhood Home Visiting Initiative (MA MIECHV)
MA MIECHV, funded by HRSA/MCHB, provides evidence-based home visiting services to pregnant and parenting families in 18 communities. MA MIECHV promotes emotional wellness and social connectedness among program participants through 1) training; 2) group supports; 3) and 3) screening and referrals to services.
MA MIECHV home visitors and supervisors attend training on common mental health concerns, strategies for supporting parents who experience mental health challenges, and mindful self-regulation skills to support home visitors when working with parents experiencing mental health challenges. The training incorporates reflective conversations and engages participants in help-seeking in response to episodes of mental distress, illness, or crisis. A three-day Facilitating Attuned Interactions training further supports staff to engage in reflective practice.
All MA MIECHV programs hold parent support groups and group series to facilitate connections among families. MA MIECHV home visitors screen for depression and social connectedness according to evidence-based model requirements and make referrals to services as needed. Depression screens are conducted using the EPDS or Center for Epidemiologic Studies Depression Scale (CES-D) within three months of delivery (for those enrolled prenatally) or within three months of enrollment (for those not enrolled prenatally). In FY23, 89% of MA MIECHV participants were screened for depression within the required time frame, an increase from 75% in FY22. In FY23, 41% of caregivers referred to services for a positive screen for depression were documented to have received one or more service contacts, a slight decrease from 43% in FY22. MA MIECHV programs continue to report limited language and cultural capacity among mental health services in many communities as barriers to successful access to treatment. The long waitlists for mental health supports were exacerbated by the COVID-19 pandemic.
Welcome Family
Welcome Family, funded by MA MIECHV, is a universal nurse home visiting program for families with newborns in five communities. It offers a one-time nurse home visit and follow-up phone call to caregivers with newborns in Boston, Fall River, Lowell, Holyoke, Springfield and New Bedford. The goal of Welcome Family is to promote optimal maternal and infant physical and mental well-being and provide an entry point into a system of care for families with newborns. The visit is conducted up to eight weeks postpartum. Nurses identify and respond to family needs by providing brief intervention, education, support, and referrals to community services and resources. Welcome Family nurses screen for depression using the Patient Health Questionnaire-2 (PHQ-2) and social connectedness at the time of the visit. In FY23, 99% of Welcome Family participants were screened for depression and social connectedness. Of those screened, 21% screened positive for depression and, of those, 51% received a referral to services. A family may decline a referral, or the nurse may not offer a referral if the family is already receiving services. Families who did not receive a referral received brief interventions by the nurse.
F.O.R. Families (Follow-Up Outreach Referral)
The F.O.R Families program serves families experiencing homelessness with complex medical needs, substance use disorder, safety concerns, and high levels of depressive symptoms. The program is a joint initiative between BFHN and the MA Executive Office of Housing and Livable Communities (HLC). During the intake assessment, and as needed in subsequent visits, home visitors assess participants for symptoms of depression, identify any potential risks to the parent and baby, and make referrals to mental health services. Mental health is a key topic of discussion, education, and support with families. In FY23, 128 families were assessed. 22% of participants reported that someone in the household had been diagnosed with depression and 16% reported that a household member had been hospitalized for a mental health crisis. Home visitors provide support through reflective listening during their visits and refer clients to mental health treatment in their community. Families are encouraged to maintain connections with their natural supports as a source of assistance when facing housing instability.
Priority: Prevent the use of substances, including alcohol, tobacco, marijuana and opioids, among youth and pregnant people.
Objective 1 (NPM 14). By 2025, reduce the percentage of people who report smoking during pregnancy from the baseline of 4.3% in 2018 (RVRS) to 3.0%.
Title V plays an important role in preventing substance use during pregnancy. NPM 14 tracks progress on reducing tobacco use during pregnancy to mitigate the high mortality, morbidity, and economic costs attributed to tobacco use. The percentage of people who reported smoking during pregnancy decreased to 2.8% in 2021, meeting the previous 2025 objective of 3.0%. MDPH therefore revised the 2025 objective to 2.0%.
The ESM for this NPM is the percentage of people using the statewide smoking quitline who are pregnant, with a goal of increasing to 6.2% by 2025. 1-800-QUIT-NOW provides free and confidential services in English and Spanish, and translation for other languages, by a trained quit coach to stop smoking. Quit coaches connect callers with quit-smoking resources through the caller’s community programs, and callers may be able to receive free nicotine replacement therapy. While smoking during pregnancy has been declining, the number of women, both pregnant and not pregnant, using the Quitline annually has increased slightly from 1,933 in FY19 to 2,007 in FY23. Overall use of the Quitline among pregnant people has also decreased from 24 pregnant people in FY19 to 12 in FY23 with the percentage at 0.6% use among pregnant people for FY23. The ESM objective of increasing the percentage of people using the quitline who are pregnant has been changed to 1.2% by 2025 to reflect recent years’ experience and a more realistic target.
PRAMS
Continuing a years-long trend, smoking in the third trimester continues to decline as reported on both PRAMS and the birth certificate, although the prevalence remains higher on PRAMS. In 2022, 2.0% of PRAMS respondents reported smoking in the third trimester, compared to 1.5% of all births using data from the birth certificate. In 2021, these prevalences were 3.7% and 1.9% respectively. The decline in prevalence of smoking during pregnancy occurred across all varied by race/ethnicity groups, with smoking prevalence on the birth certificate highest among American Indian / Alaska Native non-Hispanic birthing people, at 5.28% during the third trimester (down from 9.7% in 2021), followed by 1.98% and 1.08% among White non-Hispanic, 1.08% and among Black non-Hispanic birthing people, and 0.9% among Hispanic birthing people, compared to 2.4%, 1.2%, and 1.2% in 2021 respectively. MA PRAMS presented these findings to the Title V Substance Use Priority Workgroup and the Registry of Vital Records and Statistics to support quality improvement (QI) efforts around data collection on the BC Parent Worksheet.
MA Tobacco Cessation and Prevention Program (MTCP)
In FY23, The Massachusetts Tobacco Cessation and Prevention Program (MTCP) contracted Market Decisions Research (MDR) to: Learn about the ways people who are pregnant and/or parenting access and experience existing tobacco quitting services and how these services might be adapted; and identify incentives, behavioral supports, mapping of networks (i.e., who influences decision-making), and messaging are needed to move people along the continuum of readiness to change. Market Decisions Research conducted a literature review to help inform the Identification of provider perspectives to test with people who are pregnant and parenting people by using findings from previously conducted family support provider and substance use treatment facilities research. MDR also conducted formative focus groups with people who are pregnant and/or parenting people impacted by substance use disorders and/or mental health challenges and began developing harm reduction and trauma-informed messaging through focus group findings. MTCP collaborated with Title V programs: BSAS Mom Do Care Programs, WIC programs, Home Visiting programs, and PNQIN to promote the focus groups among their clients, patients, and members.
MA MIECHV
MA MIECHV provides training on substance use and trauma-informed practice, and all home visitors routinely screen participants for substance use. During federal FY23, 11% of the households enrolled in evidence-based home visiting services reported a history of substance use or need for substance use treatment, a slight increase from 8% in FY22. However, this result is likely an under-report of the true number of households with a history of substance use given the community-level substance use data for MA MIECHV communities. During the same time, 12% of households reported that someone in the household used tobacco products in the home, up from 10% in federal FY22.
In FY23, 35% of primary caregivers enrolled in home visiting who reported using tobacco or cigarettes at enrollment were referred to tobacco cessation counseling or services within three months of enrollment. This represented a decrease from 40% in FY22. MA MIECHV continues to use a Tobacco Cessation Toolkit to support home visitors with resources on tobacco cessation and strategies for having conversations with participants about tobacco use.
Objective 2. By 2022, improve measurement of marijuana use/consumption among pregnant people by adding specific questions to the PRAMS survey.
PRAMS
In 2022, 3.6% of people reported any use of marijuana during pregnancy (4.1% for White non-Hispanic, 4.8% for Black non-Hispanic, 3.0% for Hispanic and 1.0% for Asian non-Hispanic). This is consistent with 2021, during which 3.8% of respondent reported marijuana use. Among those with Medicaid insurance, 6.9% used marijuana during pregnancy, compared to 1.6% with private insurance, and among people with some college education vs. college graduates, rates were 7.5% and 1.3%, These data were presented at PNQIN’s Perinatal Opioid Project described above, under Objective 1. MA PRAMS continues to analyze data to understand marijuana use during pregnancy and included the Marijuana supplement in PRAMS Phase 9, launched in July 2023 with January 2023 births.
Center for Birth Defects Research and Prevention (CBDRP)
The CBDRP collects data on marijuana use during pregnancy through the Birth Defects Study To Evaluate Pregnancy ExposureS (BD-STEPS) telephone interview, a population-based case-control study to understand the causes of birth defects and identify potential risks for having a baby with a birth defect. As part of the study, individuals participate in an hour-long telephone interview on a range of topics, including medications used during pregnancy, and smoking and alcohol use in pregnancy. Participants include birthing people who had a liveborn infant with no birth defect (controls) and birthing people who had an infant with one of the 23 eligible birth defects (cases). Control participants are randomly selected from the birth population and their responses represent marijuana exposures in the MA birth population.
The Stillbirth Study was incorporated into BD-STEPS to leverage the existing study design to understand risk factors and interventions to reduce the occurrence of stillbirths. As part of this study, people whose pregnancies ended in a stillbirth and were not affected by a birth defect are recruited into the study and participate in the main interview, as well as a follow-up interview focused on risk factors for stillbirth. People who participate in this study include 1) control participants who had a liveborn infant with no birth defect and 2) case participants who had a pregnancy that ended in a stillbirth (includes stillbirths with and without a birth defect). Given this is a population-based study, responses represent those in the general population. The questions related to marijuana use and consumption were added in 2019 and the data are expected to become available with the next data release in mid-2024.
Objective 3. By 2023, improve measurement of alcohol consumption among pregnant people by adding specific questions to the PRAMS survey.
PRAMS
MA-PRAMS Phase 8 does not include questions on alcohol consumption during pregnancy but includes questions on alcohol consumption in the past two years and during the three months before pregnancy. MDPH launched the MA PRAMS Phase 9 in July 2023, with January 2023 births and has included alcohol consumption during all trimesters of pregnancy questions on the Phase 9. Data from the 2022 MA birth certificate show alcohol consumption in the first trimester at 1.3% of all birthing parents, 0.95% in the second trimester, and 1.20% in the third trimester. Use of alcohol in pregnancy varied by race/ethnicity, with the prevalence highest among American Indian/Alaska Native non-Hispanic (AI/AN) birthing people at 3.63% in the first trimester, followed by 1.64% among White non-Hispanic (WnH) birthing people. By the third trimester, prevalence decreased among AI/AN birthing people at 1.65% compared to 1.84% among WnH birthing people. PRAMS and birth certificate data on alcohol consumption were presented at PNQIN’s Perinatal Opioid Project described above, under Objective 1.
Center for Birth Defects Research and Prevention
Interim findings from BD-STEPS show that 58% of respondents giving birth during 2014-2019 (n=224) reported consuming any alcohol from the month before their pregnancy began to the third month of pregnancy. This proportion was similar among those who reported trying to become pregnant (58%) and those who did not (57%). Among respondents reporting any alcohol consumption during this period, 41% reported alcohol consumption during the first month of pregnancy, 6% during the second month of pregnancy, and 5% during the third month of pregnancy. These figures represent alcohol use among respondents who gave birth to liveborn infants without a birth defect whose patterns of substance use are meant to reflect those in the general population.
Fetal Alcohol Spectrum Disorders (FASD) Task Force
The goal of the state FASD Task Force is to highlight this developmental disability and strategies to prevent FASD, support families with children diagnosed with an FASD and support children, youth, and young adults living with FASD. In response to the 2020 Title V needs assessment, the FASD Task Force was reframed to explicitly focus on prevention efforts. The Task Force convenes families, state agencies, academic institutions, and community agencies to address FASD at the policy, state, and community levels.
The FASD Task Force, staffed by two parents of children with FASD and funded by MDPH through a contract with the Institute for Health and Recovery met multiple times in FY23 with leadership support from BFHN and BSAS. FY23 was a building year, recruiting Task Force members and determining the scope and direction of the Task Force. The paid staffers on the Task Force advocated for a stronger focus on diagnostic and service capacity than on prevention. Prevention education materials about FASD were not updated in FY23 as anticipated.
PNQIN
The Perinatal-Neonatal Quality Improvement Network (PNQIN), the state PQC (Perinatal Quality Collaborative), is dedicated to improving health outcomes of birthing people, newborns, and families through a QI collaborative of providers and partners. PNQIN aims to achieve collaborative learning through sharing of data and best practices and use of real-time data to drive improvement, while targeting health inequities. PNQIN receives financial and leadership support from MDPH. Since 2017, PNQIN has focused on addressing perinatal opioid use during three time periods: during pregnancy, focusing on increasing medication assisted treatment for mothers with opioid use disorder during pregnancy; at delivery, focusing on improving breastfeeding rates among birthing parents of infants with NAS; and during the first year of life, focusing on increasing the enrollment of infants with NAS in Early Intervention (EI) services.
In FY23, PNQIN continued to support a core database of process and outcome measures related to the hospital-based care of mothers with OUD and newborns at risk for NAS, including maternal medication treatment, non-pharmacologic care of the newborn, and discharge coordination. The database is used to generate a monthly statewide progress report and quarterly hospital progress reports. “Eat-sleep-console” (ESC) has become increasingly popular as an approach to care of infants at risk for NOWS centered on family involvement and non-pharmacologic management. One of PNQIN’s Perinatal Opioid Project leaders, Dr. Elisha Wachman at Boston Medical Center, previously developed a robust ESC toolkit, including resources for teaching and training. As more PNQIN hospitals began to explore in ESC, PNQIN has continued offer support for interested teams through workshops, webinars, and training. Importantly, teams joining the PNQIN ESC effort are also asked to participate in the core database as well as a supplemental ESC database, which allowed for the collection of important data on this innovation. Many other hospitals and numerous other state collaboratives have asked to use the materials and toolkit developed by Dr. Wachman and our team, and many have joined in PNQIN ESC workshops and webinars. Dr. Wachman continues to support PNQIN teams that have or are seeking to implement ESC, and this will be one of the elements of the project
The critical importance of family engagement in improvement efforts has been made clear by numerous project activities. In 2022, with support from the state opioid-response funds administered by the Bureau of Substance Addiction Services at the Massachusetts Department of Public Health and provided to the Health Policy Commission, we launched a small pilot project to support hospitals to engage families with lived experience in their local quality improvement efforts related to perinatal opioid use. In addition to involving families in their improvement teams, hospitals were asked to explore collection of family-reported quality measures. In FY23, four hospitals continue to participate in this pilot with the plan to continue through FY24.
Plans of Safe Care (POSC)
The Child Abuse and Prevention Treatment Act mandates a POSC for every substance affected newborn. The purpose of the POSC is to support the prevention of ongoing substance use among pregnant people and new parents. POSC can also serve as a primary prevention strategy for a future generation of children by connecting children with developmental services and helping parents access recovery, parenting, and concrete supports. In FY23, Massachusetts participated in the National Center on Substance Abuse and Child Welfare’s (NCSACW) “2023 Policy Academy: Advancing Collaborative Practice and Policy: Promoting Healthy Development and Family Recovery for Infants, Children, Parents, and Caregivers Affected by Prenatal Substance Exposure” to assist with the POSC process. Massachusetts’ goals for the Academy were as follows:
- Establish a statewide leadership team that shares a common and public vision for the purpose and need for the Family Care Plan and improved collaborative practice across systems for families with infants born affected by prenatal substance exposure
- Review state agency data with a racial equity lens for the purpose of creating upstream and early screening and engagement strategies for pregnant people with substance use disorder and develop culturally appropriate models that connect health care with community and recovery supports.
- Develop a coordinated public health process for how MA will initiate a Family Care Plan with families impacted by substance use during pregnancy, birth and ensuring infants and caregivers are supported by the Family care plan process
The state then applied for, and was awarded, in-depth technical assistance from the NCSACW to reach the goals of the state-specific Action Plan, which details the steps, work assignments, and timelines developed during the 2023 Policy Academy.
FIRST (Families in Recovery SupporT) Steps Together
FIRST Steps Together, administered by the Bureau of Family Health and Nutrition (BFHN) and funded by the State Opioid Response grant and the Bureau of Substance Addiction’s (BSAS) Block Grant, is a home visiting initiative for substance affected families that provides parenting and recovery support by peer family recovery support specialists to prevent ongoing substance use and subsequent substance exposed newborns. Program services include integrated home-based peer recovery support, evidence-based individual and group parenting interventions, care coordination, POSC, mental health services, dyadic therapy, and systems advocacy. In FY23, FIRST Steps Together continued its work and 250 new adult participants were enrolled in the program, in addition to the families continuing to be served from previous years. At the end of this year, one agency closed their site, and an emergency contract was issued to another agency to take over services, and a 7th site opened in a new geographic area and was fully enrolled within a few months.
FIRST Steps Together contributed to building the capacity of the peer recovery perinatal/parenting workforce through extensive curriculum development of trainings and facilitation of monthly learning collaboratives. All webinars were open and attended by providers across the state, including recovery coaches, clinicians, hospital staff and home visitors. Ten new Family Recovery Support Specialists attended Key Program Practices, a twelve-week intensive training on the foundations of home visiting and using lived experience to support parents impacted by substance use. In the spring, FIRST Steps Together staff from across the state attended a day long, in-person training around building workforce wellness.
FIRST Steps Together implemented data collection for an evaluation. 199 participants endorsed very high levels of satisfaction with the program. In FY23, FIRST Steps Together continued to build capacity in the state to implement Mothering from the Inside Out, an evidence-based intervention developed by the late Dr. Nancy Suchman to increase reflective capacity among parents with substance use disorders, through the training of two new cohorts of clinicians, and the implementation of a learning collaborative for peer staff. In FY23, 13 staff from FIRST Steps Together, and 3 staff from treatment programs participated in the 20 hr didactic component of the training because they are not clinicians. 8 FIRST Steps Together clinicians and 4 clinicians from other agencies (Early Intervention and substance use treatment) participated in the clinical supervision component of the training in addition to the didactic component. Two of these were unable to complete the full training but the other 10 did. In FY23, FIRST Steps Together continued to partner with the Executive Office of the Trial Courts to develop the first Family Treatment Courts in the state.
Moms Do Care (MDC)
MDC is a substance use disorder program in 11 project sites that offers pregnant, postpartum, and parenting people recovery and wrap around multidisciplinary support. In FY23, MDC continued the work of implementing peer led, seamlessly integrated, trauma informed continuums of wrap around care for pregnant, postpartum and parenting women with opioid use disorders. The MDC TA team provided extensive TA and training in building the program model and assisted the MDC health care systems to plan for ways to sustain the regional, integrated systems of support established by the program. MDC advanced the perinatal peer mentor workforce by assisting the health care systems to hire, develop and sustain this workforce through: identification and training of peer mentor candidates and supervisors; consulting on HR policies and procedures; assisting health care systems to understand and value the roles and competencies of peer mentors; implementation of statewide learning collaborative calls; and continued collaboration with BSAS to assist peer mentors through the recovery coach credentialing process. The MDC training and TA team' trainings included the staff and leaders of multiple hospital and health care center departments and community partners. Trainings focused on ways to develop trauma informed, family-focused and recovery-oriented systems of care. MDPH continued to work with MassHealth and public health stakeholders to bring this direct service and system change model to a statewide reimbursable scale. In FY23, 184 new participants were enrolled, in addition to existing participants continuing from the previous fiscal year(s).
MA MIECHV
MA MIECHV continued implementation of cross-training and enhanced supervision for a Parents as Teachers (PAT) home visitor with lived experience with substance use and recovery through the PAT Recovery Coach Overlay. The goals of the PAT Recovery Coach Overlay are to: 1) fill a gap in cohesive parenting support for families in recovery, 2) build capacity of home visitor/recovery coaches to support pregnant and parenting families with substance use disorder and supervisors’ capacity to support home visitor/recovery coaches; and 3) engage in cross-systems collaboration to support reunification and promote family stability. In FY23, 56 families participated in the PAT Recovery Coach Overlay.
MA MIECHV supports collaboration between home visiting and DCF offices at the state and local level to support services for families affected by substance use who are DCF-involved. Given racial inequities in the country’s child welfare system, policies that facilitate access to home visiting through transitions in custody arrangements promote more equitable access to home visiting. During custody disruptions, home visiting has the potential to support participants in their identities as parents, understand their children’s ongoing development, and allow for continuity of voluntary services through different stages of involvement with DCF. MA MIECHV programs identify strategies to enhance continuity of services for families who are working to regain custody of their children, including support and education for parents working toward reunification and support for families in which grandparents may have custody. To support families with varying custody arrangements, home visitors participate in supervised visitation at DCF offices and coordinate with DCF workers to support participants with their service plans. MA MIECHV also addressed model-specific barriers to supporting families through custody disruptions. Historically, PAT has specified that a parent and child be present during visits, disincentivizing programs from working with families experiencing custody disruptions despite a gap in parenting support services for this population. PAT home visitors offer visits with parents and children during supervised visitation at DCF offices supplemented by visits with only the parent and report that these visits without children, although not historically counted, are central to reinforcing parenting topics and building parents’ confidence. In FY23, TIER, in partnership with MA MIECHV, continued the mixed methods implementation study to understand these strategies and inform potential PAT policy changes and implementation guidance.
Priority: Reduce rates of and eliminate inequities in maternal morbidity and mortality
Objective 1 (SPM 1). By 2025, the MMMRC will increase the percent of pregnancy-associated deaths that are reviewed within two years of occurrence from 0% to 50%.
Objective 2. By 2025, develop a structure for community input to the review process that is authentic and addresses the power dynamics between medical providers and community stakeholders.
Maternal Mortality and Morbidity Review Committee
Since 1997, MDPH has convened the Maternal Mortality and Morbidity Review Committee (MMMRC) to review maternal deaths, study the incidence of pregnancy complications, and make recommendations to improve maternal outcomes and eliminate preventable maternal death. During the FY23 reporting period, review of pregnancy-associated deaths by the MMMRC were authorized by the MDPH Commissioner. This statute allowed MDPH to request birth and death records but did not require relevant entities to provide access to requested records nor did it authorize the MMMRC to access other sources of relevant data. As a result, there were critical records not consistently available, including autopsy reports from the Office of the Chief Medical Examiner, prenatal care records, toxicology reports, outpatient and emergency department records, and Emergency Medical Services records. This led to delays in the timeliness of review of pregnancy-associated deaths. Competing demands associated with the COVID-19 pandemic also caused delays in progress on these objectives. In FY23, 22% of pregnancy-associated deaths were reviewed within two years (an increase from 14% in FY22). The DPH Maternal Mortality and Morbidity Review Team (MMMRT) continued to use quality improvement methods to identify ways to streamline and increase the efficiency of processes to identify pregnancy-associated deaths, gather and abstract relevant information, and prepare the cases for review by the MMMRC. The MMMRT used Title V funding to support a Maternal Child Health Clinical Coordinator to ensure timely abstraction of pregnancy-associated deaths into the Maternal Mortality Review Information Application (MMRIA) to support a review within two years of the death.
In FY23, The MMMRT began participating in a pilot program with CDC in which the Registry of Vital Records and Statistics sends daily feeds of death, birth and fetal death files to CDC via the State and Territorial Exchange of Vital Events (STEVE) system. CDC links birth and fetal death data to data on deaths of reproductive-aged people who were able to give birth and generates a list of people who died within one year of being pregnant or giving birth. CDC also uses information on the death certificate to identify potential pregnancy-associated deaths that did not link with a birth or fetal death record by searching all cause of death fields for pregnancy-related ICD-10 codes and identifying checkbox values indicating pregnancy at the time of death, within 42 days of death, or within 1 year of death. The identified pregnancy-associated deaths are imported directly into MMRIA, thereby increasing the timeliness of identifying cases for MMMRC review.
With funding from the CDC “Preventing Maternal Mortality: Supporting Maternal Mortality Review Committees” grant, the MMMRT focused on efforts to improve data quality and to identify and characterize pregnancy-related deaths and address health inequities by supporting the capacity to develop and implement data informed strategies to prevent pregnancy-related deaths and reduce disparities. With this funding, The MMMRT hired two contracted abstractors to increase abstraction capacity and facilitate timely reviews.
CDC grant funding also supported efforts to develop a structure for community input to the review process to ensure representation of populations disproportionately affected by maternal morbidity and mortality. The MMMRT began developing plans to recruit community members to join the MMMRC, including representation from doulas, birth justice organizations, and those who lost a family member or who themselves have experienced SMM. This included the development of a structure for supporting MMMRC members that is authentic and addresses the power dynamics between medical providers and community members.
Objective 3. By 2025, leverage collaborative partnerships to inform practice and policy changes and disseminate findings including MMMRC recommendations.
Maternal Mortality and Morbidity Review Committee
With funding from the HRSA Maternal Health Innovation and Data Capacity grant, DPH convened the Maternal Health Task Force (MHTF) to create a strategic plan to improve maternal health in the Commonwealth, building on the Title V Needs Assessment results, the 2022 Racial Inequities in Maternal Health Legislative Commission Report, and recommendations from the MMMRC[1],[2]. The MHTF serves as the community and policy action arms of the MMMRC, mirroring and complementing the role of PNQIN, which serves as the clinical action arm (see PNQIN below). The MHTF will complement the work of the MMMRC and strengthen efforts to translate committee findings into prevention initiatives. The strategic plan will include strategies to strengthen maternal mortality and SMM data collection and support the adoption and implementation of community, state, and regional innovations and best practices that respond to identified state-specific gaps and improve maternal health more broadly. Representatives on the MHTF include representative from organizations including MDPH, MassHealth, Title V, MA Chapter of ACOG, MA Chapter of ACNM, MA Association of Health Plans, Boston Public Health Commission, Boston Healthy Start, the North American Indian Center of Boston, the Black Doula Coalition, Massachusetts Childhood Psychiatry Access programs (MCPAP) for Moms, perinatal social work, fatherhood groups, residents with lived experience, and other partners as appropriate.
PNQIN
PNQIN implements the Alliance for Innovation on Maternal Health (AIM) patient safety bundles, the goal of which is to reduce maternal mortality and SMM and reduce racial disparities by working with hospital teams to align hospital-level QI efforts. In FY’23, PNQIN adapted the Maternal Equity Bundle from the Alliance for Innovation on Maternal Health (AIM) Reduction of Peripartum Racial/Ethnic Disparities Bundle. This work was part of the overall MA AIM Initiative and a continuation of QI efforts to address Obstetric Hemorrhage, Severe Hypertension in Pregnancy, and Equity between 2012 and 2022. Between September 2022 and September 2023 (the first 12 months of an 18-month implementation period), PNQIN hosted a virtual Kickoff event and 12 monthly webinars featuring expert guest speakers. This project increased hospital engagement, governance, provider education, community engagement, and utilization of best practice for maternal equity among MA birth facilities. Among 40 birth facilities, 22 participated with 60 participants on average attending monthly webinars (range 37-71) and 17 regularly submitted monthly structure and process measure data. Among these 17 facilities, notable achievements are (1) the proportion of sites with a formal equity committee based in the obstetrics/reproductive health increased from 53% in September 2022 to 92% in September 2023 and (2) the proportion of sites stratifying maternal outcomes by demographic factors (race, ethnicity) increased from 4 to 10 sites (17% to 61%) over the 12 months – a 250% increase. PNQIN will continue to collect structure and process measures from participating teams through June 2024. In 2024, we will assess the association between implementing the Maternal Equity Bundle and SMM rates and racial differences among SMM rates.
PNQIN also helps lead MA’s efforts around Levels of Maternal Care (LoMC). In May 2023, the Betsy Lehman Center, in collaboration with DPH and PNQIN, with funding support through HRSA convened a LoMC Implementation Steering Committee. Members included a diverse array of stakeholders including, but not limited to payers, community organizations, community health centers, transport, people with lived experience, etc. The charge of this committee was to recommend a framework for implementing levels of maternal care to. In September, the Betsy Lehman Center, MDPH, and PNQIN brought the Implementation Steering Committee together for a two day in-person meeting facilitated by ASTHO with the overall goal to deliberate on a framework for implementing LoMC in MA. Following the September site visit, the Betsy Lehman Center drafted a report with the Implementation Steering Committees recommendations to the MDPH Commissioner. The Implementation Steering Committee’s recommendation included recognition that, for LoMC to achieve its purpose and avoid unintended consequences, several significant challenges would need to be addressed during the regulatory and implementation process. In FY24, the perinatal regulations will be updated to include the maternal levels of care.
Objective 4. By 2025, reduce inequities in rates of COVID-19 infection among birthing and lactating people of color by improving their vaccination coverage during pregnancy from 21.6% for Hispanic individuals, 21.5% for non-Hispanic Black individuals and 14.0% for non-Hispanic American Indian/Alaska Native/Other individuals to above 50.0% for these groups.
Surveillance for Emerging Threats to Pregnant People and Infants Network (SET-NET)
In FY23, the MA Center for Birth Defects Research and Prevention (CBDRP) continued surveillance for SARS-CoV-2 infection in pregnancy through their participation in CDC’s Surveillance for Emerging Threats to Pregnant People and Infants Network (SET-NET). The goals of MA SET-NET are to monitor the effects of COVID-19 on pregnant people and their infants, inform clinical guidance and practice, and ensure that MDPH is prepared to meet the needs of pregnant people and infants during public health emergencies.
MA SET-NET identified people with SARS-CoV-2 infection during pregnancy through deterministic linkages between infectious diseases laboratory data and birth and fetal death records and submitted data to CDC quarterly. in FY23, MA SET-NET completed onboarding two medical records abstractors to support infant follow-up, monitoring outcomes of infants born to people with SARS-CoV-2 infection during pregnancy by collecting data from the 2 week, 2-month, and 6-month well child visit records. In addition, in FY23 a CSTE fellow in CBDRP began a formal evaluation of the COVID-19 Pregnancy Surveillance system and administered surveys to users, contributors, and funders to understand the strengths of the system and areas for growth.
PRAMS
MA PRAMS administered a COVID-19 supplement to collect data on how COVID-19 has affected pregnant and postpartum people and their infants for births from June 2020 through December 2021. PRAMS also administered a COVID-19 vaccine supplement, including questions about receipt of COVID-19 vaccination before, during and shortly after pregnancy, and reasons for not obtaining COVID-19 vaccination, for births January-December 2021. Data analysis has been completed and findings will be included in the upcoming PRAMS report with data through 2022.
Fatherhood/Second Parenthood Survey
MDPH launched a pilot of the Fatherhood/Second parent experiences survey in September 2023. This survey collects data about fathers’ experiences during pregnancy and the birth of their child, and their experiences with COVID-19 including testing, vaccination, health status, social determinants of health, mental health, and racism during the pandemic. Data will be collected through December 2024 and an analytic plan is being drafted. See more about the Fatherhood survey in the Crosscutting domain under the family engagement priority.
PNQIN
Previously, PNQIN developed a curriculum designed to provide information to clinicians about discussing COVID-19 vaccination with pregnant and postpartum people, parents and caregivers of young children, and families. The training focused on addressing vaccine hesitancy and eliminating racial disparities in vaccination rates. These trainings remain available on PNQIN’s website. In FY23, MA birthing hospitals were re-surveyed to understand what they still in place from prior COVID efforts. Of the reported providers who 1.) completed this year’s survey and 2.) did attend the training either for the live virtual session or asynchronous viewing (N=6), 75% of these attendees reported increased levels of confidence in their abilities to discuss COVID-19 vaccination. Additionally, we surveyed 7 of 31 hospital teams participating in bundle activities during quarterly coaching calls aimed at supporting teams across the year with COVID-19 and POP activities. Of the 7 teams interviewed during September 2023, 50% reported that their team engaged in provider education with PNQIN. Among hospitals surveyed, 82% reported having a protocol for screening and administration of COVID-19 vaccination among pregnant/postpartum people, 50% reported having a protocol to provide other vaccination counseling and 43% reported having a protocol for respectfully addressing vaccine hesitancy.
Vaccine Equity Initiative (VEI)
The VEI launched in February 2021 and aimed to 1) increase trust in the COVID-19 vaccine’s safety and efficacy, acknowledging that in many communities of color, mistrust and hesitancy can stem from a history of medical mistreatment, 2) identify and reduce barriers for accessing the vaccine, and 3) increase vaccine access for priority populations. VEI focused on the 20 cities and towns hardest hit by COVID-19 and priority populations disproportionately impacted by COVID-19, including but not limited to: Black, Indigenous, and People of Color; individuals with disabilities; individuals with mental illness and/or substance use disorder; and individuals who identify as LGBTQ+. To ensure an equity and community-driven approach VEI engaged and funded community- and faith-based organizations, Tribal and Indigenous People Serving Organizations, Community Health Centers (CHCs), rural health programs, local boards of health, and other community-based healthcare organizations to implement outreach, engagement, education, and access efforts.
MDPH Title V staff continued to play a critical role in various components of VEI during FY23. As part of the Vaccine Operations and Engagement team three BFHN staff continued served as liaisons to VEI communities identified as most disproportionately impacted by COVID. The BFHN staff provided critical support both as MDPH staff people with knowledge of state supports and systems and also as members of those identified communities. Their work continued to support community-based strategies to increase knowledge of and access to the vaccine. Their efforts included exploring specific outreach and education opportunities and increasing availability and ease of accessing vaccine through community-based or mobile clinics in trusted spaces. In addition, BFHN staff continued to chair and participate on the Pediatric and Family Vaccine Workgroup. Specific Workgroup activities included:
- Partnering with VEI teams to continue to promote and implement family-friendly clinic ideas and locations (after work hours or on the weekends, trusted locations like libraries or schools, and kid-friendly activities while waiting).
- Leveraging partnerships with community-based partners such as Early Intervention (EI), libraries, Boys and Girls Clubs, and YMCAs to engage them in a variety of activities including supporting outreach and awareness, partnering to host vaccine clinics, organizing community conversations, and/or distributing educational materials.
- Leveraging relationships with other statewide systems and partners such as the MA Board of Library Commissioners, who provided outreach and education support, enabled VEI Communications staff to table at the annual MA Library Conference in May 2023, and provided key feedback on outreach and marketing materials.
- Partnering with the MA Chapter of the American Academy of Pediatrics (AAP) to host a series of trainings titled How to Become a Vaccine Champion: Strategies to Improve Confidence in COVID-19 Vaccines to share evidence-based strategies, including motivational interviewing, to help improve COVID-19 vaccine conversations and address hesitancy with families with young children. Three trainings were held in the late summer/fall of 2022. All trainings provided simultaneous interpretation in Spanish and Portuguese.
- Continued to partner with Boston University/Wheelock Child Life and Family-Centered Care program to hone the development and implement a system for Child Life Specialists to volunteer at family COVID clinics. Child Life Specialists can help with managing cognitive fears, provide comfort goals and distractions, and promote coping among children and families to ensure a trauma-informed approach. Incorporated feedback from family and partner listening sessions and surveys into family-centered COVID information materials and campaigns to addressed family questions and concerns.
- Sought and incorporated feedback from the LGBTQIA+ community into COVID campaigns and marketing materials to ensure visual representation and inclusivity.
During the winter/spring of the reporting period, due to the shift in the nature of the pandemic, VEI began to transition to a new phase focusing on integration and sustainability of the work within existing DPH bureaus and programs as there was no longer a need for a standalone initiative.
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