Adopted in December 2017, the Texas Department of State Health Services (DSHS) Healthy Texas Mothers and Babies (HTMB) Strategic Framework is modeled after the Prevention Institute’s Spectrum of Prevention and provides strategic direction for alignment, improvement, and development of existing and new interventions to support the healthy women, healthy mothers, and healthy babies' triple aim.

 

The HTMB Framework integrates Maternal and Child Health (MCH) women’s, maternal, perinatal, and infant health programs and expands upon MCH’s commitment and investments toward improved infant health outcomes. As shown below, the HTMB framework identifies 5 pillars and includes various interrelated and complementary initiatives that provide public health knowledge, partner mobilization, and implementation resources to drive system changes to support adoption and diffusion maternal and infant health and safety quality improvements.

NPM 14.1: Percent of women who smoke during pregnancy

 

According to the Pregnancy Risk Assessment Monitoring System (PRAMS), cigarette smoking rates have continued to decrease among Texas women in the months before, during, and after pregnancy. The percentage of women who reported they smoked cigarettes in the 3 months before pregnancy, last 3 months of pregnancy, and at the time of the survey (typically within the first year after giving birth) decreased respectively from 15%, 5.1%, and 9% in 2015 to 13.1%, 4.6%, and 6.3% in 2019. NOTE: These survey questions do not explicitly assess vaping or e-cigarette use.

 

State Action Plan Activities and Successes 

 

MCH administers and facilitates the multidisciplinary Texas Maternal Mortality and Morbidity Review Committee (MMMRC) to comprehensively review deaths of women that occur during pregnancy or within a year of the end of pregnancy and study state maternal mortality trends to understand causes, contributors, risk factors, and racial and ethnic disparities. Based on findings, the MMMRC develops targeted, actionable recommendations to help prevent future deaths. The MMMRC routinely assesses and documents tobacco use as part of the case review process to determine whether it contributed to death. The MMMRC also uses its Discrimination Assessment and Social Determinants of Health Facilitated Discussion Tool (DASH Tool) to evaluate whether tobacco use was a life course factor potentially impacted family wellbeing. In Fiscal Year 2022 (FY22), the MMMRC assessed 51 cases to determine whether tobacco contributed to maternal mortality.

 

In FY22, MCH encouraged HTMB Community Coalitions (CCs) and Peer Dad programs to disseminate Texas Department of State Health Services (DSHS) Tobacco Prevention and Control program social media posts about the state Tobacco Quit Line including on and around Father’s Day. Additionally, the City of Brownsville CC included topics such as mental health awareness and substance use (smoking, alcohol, and drug) during pregnancy as part of virtual community baby showers.

 

MCH provided subject matter expertise for developing and updating the Health and Human Services Commission (HHSC) Texas Health Steps Online Provider Education (THSteps) continuing education modules. THSteps preconception, prenatal, and postpartum health modules include tobacco cessation, health screening, brief smoking intervention, referral, and treatment. The THSteps portal also includes smoking and e-cigarette cessation tools and referral resources.  

 

In FY22, providers completed 1,819 modules on:

• Preconception Health: Screening and Intervention;
• Prenatal Health: Screening and Intervention; and
• Postpartum Health: Screening and Intervention.

 

Refer to NPM 7.1 for more information about THSteps.

 

Texas Health and Safety Code, Section 161.501 requires health care providers to give a resource pamphlet to the parents or adult caregivers of an infant during pregnancy and at delivery. Providers may distribute DSHS’ Information for Parents of Newborn Children pamphlet or use any similar material that contains the required information. The DSHS pamphlet is available in English and Spanish and covers a variety of maternal and infant health topics including information about the importance of maternal smoking cessation and smoke-free environments for infant health and safety and prevention of sudden infant death syndrome. In FY22, DSHS distributed over 70,000 printed pamphlets to health care providers to share with expectant and postpartum parents. Additionally, 538 pamphlets were downloaded from the MCH website.

 

In FY22, MCH worked to identify a site, procure contracts, and begin needs assessment and strategic planning with partners on High-Risk Maternal Care Coordination Services Pilot (HRMCCSP) program implementation. For this program, community health workers (CHWs) screen and counsel participants for tobacco and electronic cigarette dependence using the Ask, Advise, Refer (AAR) model. See SPM 5 for more information about the HRMCCSP program.

 

MCH Public Health Regions (PHRs) coordinated tobacco-related activities with their Regional Tobacco Coordinator (RTC). Many PHR staff are trained in Ask, Advise, and Refer and regularly assessed clients’ smoking status in field offices and regional clinics including pregnant women. Clinics displayed and distributed Quit Line business cards and DSHS material, such as Yes! I’m Ready to Quit, Smoking and My Baby, and You’re Never Too Young to Get Addicted. From July 25, 2022, to July 30, 2022, one major South Texas tobacco-related activity occurred where staff collaborated with the Tobacco Prevention Coordinator during Operation Border Health Preparedness (OBHP) to encourage tobacco users to quit smoking. During OBHP, participants received: QUIT Line program information, education on quitting benefits, encouragement to quit, and referred to the QUIT Line to receive the program services. Throughout the event, providers faxed 34 referrals to the QUIT Line.

 

Performance Analysis

Tobacco prevention among women of childbearing age continues to be an MCH priority. MCH partners with the DSHS Tobacco Prevention program and integrates tobacco prevention information, education, screening, brief intervention, and referral throughout maternal health efforts. The percentage of Texas women who smoke before, during, and after pregnancy appears to be declining.

 

Challenges

 

COVID-19 continues to affect program capacity in health care and other settings. In response to the continued impact of the pandemic, MCH adjusted some program timelines for initiatives that integrate tobacco prevention strategies. MCH is using feedback from health care organizations to responsively adapt program plans to current needs.

 

Opportunities

 

While current maternal health surveillance systems do not assess for prevalence of vaping among pregnant women, MCH is working to identify opportunities for assessing the extent of vaping and e-cigarette use in this population to inform future program efforts.

 

SPM 5: Percent of women of childbearing age who self-rate their health status as excellent, very good, or good

 

The 2020 Title V Needs Assessment identified addressing care coordination and health disparities among maternal and child health populations as priority needs. MCH programmatic efforts in the women’s and maternal health domains included policy, environmental, and systems level approaches to improve systems of care, prevent and control acute morbidity and chronic disease, and promote wellness throughout a woman’s reproductive years. Women in Texas experienced high rates of obesity, diabetes, hypertension, substance abuse disorder, and other morbidities as well as marked racial, ethnic, and geographic disparities. 

 

Self-reported health status is a helpful measure to account for multiple factors that impact a woman’s preconception and interpregnancy health beyond the primary care visit. As described by Broussard et al (2011), DSHS epidemiology and program subject matter experts contributed along with other state experts, to a multi-state consensus-based selection process to develop a set of Core State Preconception Health and Health Care Indicators. SPM 5 is a core preconception health indicator and is the only indicator of general health status included by the Council of State and Territorial Epidemiologists in this core measure set.

 

State Action Plan Activities and Successes 

 

MCH supports the MMMRC to evaluate causes, contributors, risk factors, and disparities in pregnancy-related deaths and make prevention recommendations to reduce Texas maternal mortality and severe morbidity.

In December 2022, DSHS released its MMMRC and DSHS Joint Report. The report included statewide rates, ratios, trends, and case review findings and MMMRC recommendations for reducing preventable maternal mortality and morbidity in Texas. The findings and recommendations directly inform MCH maternal health activities.

 

In FY22, the MMMRC met quarterly and fully reviewed and closed 51 cases from the 2019 and 2020 case cohort. Contemporary case review includes case identification, preparation, committee review, committee determinations, committee recommendations, and case finding entry into the Maternal Mortality Review Information Application (MMRIA) system within two years of each pregnancy-related death. MCH participates in the Centers for Disease Control and Prevention (CDC)’s Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM) Program, which sets targets for contemporary case review. Consistent with the MMMRC recommendation to support strategies to continuously improve the maternal mortality investigation and case review. During FY22, MCH and MMMRC members participated in educational opportunities including the MMRIA User Meeting, and monthly abstractor, coordinator, and analyst office hours.

 

In FY21, MCH competitively applied for and was awarded the five-year State, Local, Territorial, and Tribal Partnership Program to Reduce Maternal Deaths due to Violence grant from the U.S. Department of Health and Human Services’ Office of the Assistant Secretary for Health. The TSAP-RVPD program involves convening partners to study patterns and context of maternal mortality caused by homicide, suicide, and overdose; developing a strategic action plan; and implementing evidence-based, sustainable prevention interventions. The program is informed by the MMMRC’s recommendations to address violence and intimate partner violence and to improve access to integrated behavioral health services for women with mental and substance use disorders. In FY22, MCH:

• Began TSAP-RVPD staffing structure development;
• Successfully established an evaluation planning services contract with the University of Texas Medical Branch (UTMB) Center for Violence Prevention (CVP);
• Outreached to Texas violence prevention subject matter experts from HHSC’s and Texas Council on Family Violence (TCFV) through a series of key informant “meet and greet” interviews to learn more about Texas violent pregnancy-associated deaths (VPDs) services and stakeholders’ expertise;
• Studied and conducted VPD review processes by conducting intimate partner violence and maternal death demographic and geographic disparities, rates, and trend analyses  through reviewing and analyzing 2019 Texas PRAMS Data and 2019 MMMRC case review findings; and
• Leveraged existing maternal safety initiatives (such as Hear Her Texas and the TexasAIM Program) to begin promoting VPD prevention messaging and education to support improved maternal health outcomes.

 

Moving MMMRC recommendations into action, the Texas legislature directed DSHS to develop or adapt a high-risk pregnancy screening tool, create CHW training modules and education materials related to high-risk pregnancy, and develop a pilot in one or more Texas areas. To satisfy this requirement, MCH established the HRMCCSP pilot project.

 

In FY22, MCH completed procurement processes with 2 university partners, the University of Texas at Austin-Community Health Worker Institute (UT-CHWI) and University of Texas Health Science Center at Houston (UTHSCH) and 1 Texas health region, Northeast Texas Public Health District (NETHealth) in Tyler to implement the program. In June 2022, MCH hosted 3 monthly partner coordination meetings to: discuss pilot goals and objectives, review each partner’s role, identify collaboration opportunities, establish a collaborative approach to the pilot planning, implementation, and evaluation, and provide workplan development guidance. The program’s objectives include:

• Create a CHW maternal health and safety specialty course based on best practices for high-risk maternal care, risk assessment, and use of screening techniques (UT-CHWI);
• Carry out a pilot High Risk Maternal Care Coordination Services demonstration project in one Texas area (NETHealth);
• Evaluate high-risk maternal care coordination best practices (UTHSCH); and
• Provide HRMCCSP program technical assistance (UTHSCH).

 

MCH, in collaboration with UT-CHWI, began developing CHW training courses on self-efficacy, knowledge, and core competency skills for providing services to maternal patients identified as high risk for poor pregnancy and postpartum outcomes. UT-CHWI developed a key informant guide and plans to hold informational gathering sessions in FY23 with pilot site stakeholders and staff to identify training needs and gaps, obtain input on course topics, and involve stakeholders in the course development process.

 

MCH worked with UTHSCH to provide technical assistance (TA) and support for HRMCCSP pilot development, implementation, and evaluation. In August 2022, MCH held a two-day Meet the Experts workshop to provide NETHealth with information and resources to build pilot program implementation capacity. Workshop topics included:

• CHWs as Leaders in Reducing Health Disparities;
• Working with CHWs, and Multidisciplinary Teams to Improve Maternal and Health Outcomes; and
• Engaging Those with Lived Experiences.

 

NETHealth is the lead agency for the care coordination pilot site and will test, assess, and refine the implementation of the HRMCCSP Program. In FY22, NETHealth began a work plan and recruited CHWs based on workshop lessons learned.

 

MCH is the lead coordinating entity for TexasAIM, Texas’ program to support hospitals implementing the Alliance for Innovation on Maternal Health’s (AIM) endorsed maternal patient safety bundles (bundles) to address leading causes of Texas maternal mortality. While planning TexasAIM activities, MCH considered MMMRC’s findings, best practices, and recommendations to:

• Implement statewide maternal health and safety initiatives to reduce maternal mortality and morbidity;
• Engage Black communities and apply health disparity principles in maternal and women’s health program development ;
• Improve postpartum care management and discharge education for patients and families;
• Improve integrated behavioral health care access for women with mental and substance use disorders;
• Support coordination between emergency and maternal health services; and
• Implement evidence-based, standardized protocols to identify and manage obstetric and postpartum emergencies.

 

Participation is voluntary and hospitals may choose to join one of two levels:

• TexasAIM Basic or TexasAIM Plus as part of the bundle enrollment process.
• TexasAIM Plus hospitals receive support and tools for bundle implementation and quality improvement activities through learning collaboratives.

 

In FY 22, through the TexasAIM program, MCH provided COVID-19 support to hospitals, facilitated the Severe Hypertension in Pregnancy bundle, started developing the Substance Use Disorder Innovation and Improvement Learning Collaborative, and implemented a birthing center workshop series.

 

Obstetric Care and COVID-19 Support

 

In FY22, MCH hosted obstetric (OB) Care and COVID-19 support calls to provide guidance, support, and resources to hospital teams. The OB Care and COVID-19 support calls’ content and timing were based on hospital needs, case trends, hospitalizations, and new treatment developments. Starting in September 2021, MCH held weekly webinars and bi-weekly webinars throughout October 2021.  TexasAIM also hosted 6 OB Care and COVID-19 support calls from September 2021 through November 2021. The OB Care and COVID-19 support calls focused on topics such as COVID-19 clinical management including COVID-19 research updates and treatment disparity; a multi-perspective surge planning approach; simulation; patient and family support with a focus on patient COVID-19 experiences and breastfeeding resources; and staff support with an emphasis on leader wellbeing and mental health. The final OB Care and COVID-19 support call, held in December 2021, was an interactive state debrief that allowed hospital teams to reflect on what went well during the COVID-19 pandemic, what did not go well, and what they can improve for the future.

 

Over the 6 calls, there was an average of 114 attendees per webinar. Additional participants accessed online webinar recordings.  Throughout the OB Care and COVID-19 support calls, MCH used a variety of approaches to engage participants, gather feedback, assess needs, and respond to questions.

 

In addition to OB Care and COVID-19 support calls, MCH provided an online collaboration space for hospital teams to communicate with one another and share information and resources. All OB Care and COVID-19 support call recordings, slides, handouts, and other resources were made available online and all hospitals with OB service lines were invited to use these resources. More than 1,800 health professionals from approximately 220 Texas hospitals and other organizations in and outside of Texas accessed information from the subscription-based TexasAIM OB Care and COVID-19 portal. Additionally, MCH developed free posters and social media content in both English and Spanish to encourage pregnant women, women who are breastfeeding, and women trying to get pregnant now or in the future to receive the COVID-19 vaccine. MCH made these free resources available to hospitals, clinics, and places where families gather.

 

Severe Hypertension in Pregnancy (HTN) Bundle

 

As of August 2022, 94% of Texas birthing hospitals (211 of 224 hospitals with obstetric services) were enrolled in the HTN Bundle. These hospitals serve more than 354,000 women every year and account for 95% of Texas’ births. Among the 210 fully enrolled hospitals, 180 hospitals (86%) were enrolled to participate in the TexasAIM HTN Plus Learning Collaborative while 30 (14%) enrolled for TexasAIM Basic participation. Hospitals enrolled as TexasAIM Basic participants committed to form TexasAIM improvement teams, participate in quarterly quality improvement metric reporting, and work in their units to independently implement the bundle, but do not participate in collaborative learning activities.

 

Although the TexasAIM HTN Learning Collaborative launched in December 2020 and activities were held in early 2021, HTN Learning Collaborative events were paused in August 2021 due to the COVID-19 Delta variant. At the hospitals’ request, TexasAIM HTN Learning Collaborative events remained paused throughout FY22. However, MCH continued to engage TexasAIM hospital teams through monthly qualitative data collection, one-on-one virtual hospital teams support meetings, and a bi-weekly newsletter accessed by more than 1,800 subscribers. During this pause, MCH focused on understanding the hospital team challenges due to COVID-19 and assessing their readiness to re-engage in quality improvement work. MCH also engaged in strategic planning meetings where MCH and the HTN Faculty Leadership Team developed a TexasAIM approach to the HTN Learning Collaborative Relaunch framework prototype.

 

During April and May 2022, as part of the strategic planning process the MCH and HTN Faculty Leadership Team met several times to develop goals, discuss challenges and opportunities, identify key players, and outline key processes to make the HTN Learning Collaborative relaunch successful. During this strategic planning, MCH held hospital team focus groups to gather feedback to inform this framework. In June and July 2022, MCH continued to meet to develop a workplan to incorporate key strategic planning takeaways and operationalize hospital team feedback gathered during interviews. As result of the strategic planning process, the MCH and HTN Faculty Leadership team identified the following HTN Learning Collaborative relaunch priorities:

• Create hospital team peer networking opportunities;
• Provide faculty coaching as part of the HTN Learning Collaborative;
• Improve data usability; and
• Create a “one stop shop” website to house TexasAIM resources.

 

In conjunction with strategic planning, MCH also worked on laying the groundwork for a functional customer management system to automate workflows and communications, track data, and optimize customer relations with Texas hospitals.

 

Throughout FY22, MCH collected monthly and quarterly data from the TexasAIM HTN Learning Collaborative Plus Teams. Hospital teams submitted monthly qualitative data through the TexasAIM+ HTN Monthly Report surveys. In these surveys, teams provided information about what they were learning from: tests of change; their aim statement, breakthroughs, challenges, and barriers; COVID-19 feedback; and any other questions or concerns.

 

In July 2022, MCH sent personalized emails to each hospital team summarizing their bright spots, barriers, aim statement, and questions. Noteworthy bright spots included:

• Time to treatment improvement;
• Patient, family, and staff education increases;
• Data to drive improvement use;
• Emergency department (ED) engagement and collaboration progress;
• Policy, protocol, and algorithm development; and
• Protocol adherence increases.

 

In addition to their bright spots, hospitals discussed their primary barriers in quality improvement work including physician and staff buy-in and consistent compliance with protocols, ED collaboration, and most importantly, COVID-19 hospital impacts specifically staffing shortages and turnover, new staff education, staff burnout, and quality improvement initiative setbacks.

 

In Fall 2022, to prepare for HTN activities relaunch, MCH sent hospital teams packages that included quality improvement, educational, and patient education resources. MCH also launched a Learning Management System to provide educational resources to hospitals, including continuing education modules featuring HTN Faculty experts and other national experts, access to the Institute for Healthcare Improvement (IHI) Open School trainings, and the Society for Maternal Fetal Medicine (SMFM) webinars.

 

Substance Use Disorder Innovation and Improvement Learning Collaborative (OB-OSUD IILC)

 

While TexasAIM collaborative activities paused due to the COVID-19 Delta variant surge, National AIM launched the Care for Pregnant and Postpartum People with Substance Use Disorders (CPPSUD) Bundle in October 2021. This bundle revised and updated the previous Obstetric Care for Women with Opioid Use Disorder (OUD) Bundle to encompass broader areas of substance use which is a contributor to pregnancy-associated and pregnancy-related deaths. MCH reviewed and adapted the bundle to establish the Obstetric Care for Women with Opioid and other Substance Use Disorder Innovation and Improvement Learning Collaborative (OB-OSUD IILC) and engaged 10 “early adopter” hospitals to participate.

 

In FY22, MCH held biweekly planning meetings with the OB-OSUD Faculty and Improvement Advisor to plan for the OB-OSUD IILC launch. The faculty and MCH identified the learning collaborative aims, developed a key driver diagram, and identified change package elements that were feasible and realistic for the current landscape. The team reviewed the current measurement strategy to align with the updated CPPSUD Bundle, data implementation guidance, and identified process, outcome, structural, and state-specific measures to adopt. MCH prepared prework and collaborative packets and identified the need for additional members to join the Wave 1 Faculty team. These experts included physicians and nurses in and outside Texas who bring years of experience implementing OSUD care programs for women. The OB-OSUD IILC will launch in August 2023.

 

Birthing Center Workshop Series

In FY22, MCH held the TexasAIM Birthing Center Workshop Series (BCWS), a collaborative virtual workshop series focused on adapting and implementing National AIM Safety Bundles in Texas licensed free-standing birthing centers. MCH developed the BCWS specifically for the birthing center environment in response to interest expressed by several Texas birthing centers. The 6 workshops, held from January 2022 through May 2022, focused on obstetric hemorrhage best practices review, hypertension in pregnancy and opioid and other substance use disorder in pregnancy. Leveraging quality improvement methodology and peer-to-peer collaboration, participants identified opportunities for improved maternal care processes and outcomes while strengthening relationships and communication with referral hospitals and community-based partners.

 

MCH was able to provide continuing education credits for two workshops. A total of 90 unique attendees from 44 of the 86 Texas licensed birthing centers (51%) participated in the workshop series and 13 other individuals attended including steering group members, doulas, and midwives. Evaluation results indicated participants appreciated the opportunity to engage with other birthing centers, learn more about TexasAIM, and hear how to adapt AIM bundles to their settings.

 

Consistent with the MMMRC recommendation to continue and strengthen activities to increase public awareness and prevention, MCH worked to increase awareness and education about maternal health and safety throughout FY22. MCH renewed the maternal health and safety awareness, education, and communication campaign contract. MCH aligned the Texas campaign with national efforts including the CDC’s and the Council on Patient Safety’s Maternal Urgent Warning Signs. DSHS signed licensing and co-branding agreements with the CDC to integrate elements of their national Hear Her Campaign into the Texas campaign. The Hear Her Texas campaign focuses on Texas women affected by maternal mortality and expands maternal health messaging beyond the national Hear Her campaign.

 

In October 2021, MCH launched the DSHS Hear Her Texas Campaign to prevent maternal morbidity and mortality by increasing awareness of serious pregnancy-related complications and their warning signs among Texas women, their partners, and other advocates. The campaign also aims to empower women to know their health risks and warning signs and speak up when they have concerns. FY22 efforts included:

• Ongoing campaign media and creative strategies;
• Market research engaging pregnant or postpartum women and providers statewide;
• Campaign website development with Texas-specific educational and social media resources;
• Educational resource development to create awareness of urgent maternal warning signs during pregnancy and for a year after; and
• Survivor interviews, campaign videos, and Public Service Announcement development highlighting 5 Texas survivor pregnancy and postpartum stories.

 

The campaign reaches Texas pregnant and postpartum women and their support networks with a focus on non-Hispanic Black women, lower income families, and people who are underserved by the health care system. Secondary target audiences included health care and social service providers who serve pregnant and postpartum women, local public health partners, and community-based organizations. During FY22, the media campaign had almost 18 million impressions.

 

HHSC is legislatively mandated to develop and implement a 5- year strategic plan to improve postpartum depression (PPD) screening, referral, treatment, and support service access. MCH collaborated in the Postpartum Depression Strategic Plan FY21 development, including exploration of current practices of DSHS-administered programs relevant to perinatal mood and anxiety disorders and identification of specific activities to initiate or continue in FY22. Featured FY22 MCH activities included:

• Promoting PPD awareness and screening with program partners including contractors and hospitals that participate in the TexasAIM initiative;
• Promoting public awareness of perinatal mood and anxiety disorders in the Maternal Health and Safety Public Awareness Campaign;
• Promoting awareness of perinatal mood and anxiety disorders in the Information for Parents of Newborn Children pamphlet distributed to all parents and other adult caregivers of infants;
• Including perinatal mood and anxiety disorders in the development of the High-Risk Maternal Care Coordination Services Pilot Program; and
• Planning and hosting DSHS Grand Rounds continuing education series on perinatal mood and anxiety disorders.

 

MCH administers community-based programs focused on improving maternal and infant health outcomes. Efforts are informed by MMMRC recommendations to foster supportive community environments and leverage programs and services to help women of childbearing age achieve their full health potential.

 

Along with lactation promotion and support services, the LSCS-SEP provides information, education, and referrals for key maternal, infant, and early childhood health topics that impact infant feeding outcomes, including perinatal mood and anxiety disorders. As part of this work, the Houston, San Antonio, Dallas, and Hidalgo LSCs continued to screen women for postpartum depression throughout FY22 using the Edinburg Postnatal Depression Scale and made referrals for community-based mental health services as indicated. LSC staff provided 1,413 depression screenings for women seeking services with 116 women who screened positive for signs of depression receiving mental health resource referrals. See the Perinatal and Infant Health annual report for more information about other LSCS-SEP services.

In collaboration with the Office of Women’s Health (OWH), the Houston LSC became a Self-Measured Blood Pressure Program (SMBP) Partner. In May 2022, the LF received blood pressure cuffs from the OWH and staff received implementation training.  MCH shared CDC’s Hear Her Campaign materials for maternal warning signs patient education.  MCH will share Texas-specific materials for the state-wide maternal health and safety campaign, Hear Her Texas, with the LF as they are developed. The LF also used a CDC Blood Pressure Log and an American Heart Association blood pressure infographic as patient education materials. On August 15, 2022, the LF began SMBP education and follow-up visit monitoring. All patients received SMBP education materials and SMBP monitoring education at their in-person, follow up visits. In FY22, 25 clients received SMBP education and monitoring and the LF plans to increase efforts to include all in-person, new patient visits in FY23.

The SMBP program has already made a reported impact on LF clients. On the first day of clinic program implementation, LF staff identified a client with possible postpartum preeclampsia. Through communication with the client’s OB/GYN, LF staff sent the client to the emergency department, and she was admitted for postpartum preeclampsia for several days. She continues to seek lactation care at the LF and is currently doing well.

HTMB CCs collaborate with community partners and stakeholders to strengthen local capacity to improve maternal and infant health outcomes. Local public health partner organizations in nine communities across the state receive MCH funding to coordinate and support community coalition efforts. HTMB CCs conduct activities related to community needs assessment, strategic planning, coalition capacity development, and education and awareness to engage community stakeholders and motivate audiences to address identified needs for maternal and infant health improvement. FY22 activities related to women’s and maternal health included:

• Local public awareness campaigns to communicate strategic messages and promote preventive health and social services;
• Partner coordination to develop referral systems among service providers for improved continuity of care; and
• Coordination with local colleges and universities to assess opportunities to sustainably develop preconception peer education programs within their student services structures.

 

The City of Amarillo HTMB CC collected Perinatal Periods of Risk (PPOR) companion data by surveying community members of reproductive age during educational classes, community events, and through community partner referrals. This data is a continuation of efforts started in late 2019 to create a companion data analysis that addresses state and regional PPOR analysis gaps.

 

The City of Brownsville (Breastfeeding for a Healthy Brownsville) HTMB CC included topics such as mental health awareness and substance use (smoking, alcohol, and drug) during pregnancy in virtual community baby showers and created online education curriculums focused on general nutrition, gestational diabetes, and domestic violence. These videos garnered nearly 450 YouTube views.

 

A woman’s partner can be an important advocate and source of support for her health and wellbeing before, during, and beyond pregnancy. Engaging and educating fathers about risk factors and healthy behaviors empowers them as partners in improving maternal and infant health outcomes. Peer Dads are men experienced in parenting and supporting their partners during pregnancy, breastfeeding, and postpartum and who have completed specialized training in peer counseling, breastfeeding, normal baby behavior, urgent maternal warning signs, and other relevant topics.

 

MCH funds Peer Dad programs in two communities to:

• Conduct outreach;
• Engage fathers in direct communication through texting, email, and 1-on-1 counseling;
• Provide group discussion, education, counseling; and
• Facilitate local resource connection including referrals related to workforce training, food insecurity, mental health counseling, and other identified need services.

 

In addition to their peer support work, Peer Dads served as subject matter experts on fatherhood engagement and networked and consult with community programs to increase fathers’ involvement in maternal and infant services. For example, the Northeast Texas Health WIC program made program changes to increase father inclusion throughout program services.

 

PHRs continued to emphasize the importance of coalition and stakeholder meetings. Meetings with community organizations help promote breastfeeding (BF) importance and establishment of Texas Mother-Friendly Worksites as well as the importance of access to prenatal and perinatal care for women.

 

PHRs continued to provide resources to various independent school districts (ISD) as designated TMFWs and connections with community organizations. PHRs helped connect ISDs and Texas Women, Infant, and Children (WIC) to facilitate collaboration and provide peer to peer counseling and staff and student BF presentations.  Additionally, PHRs began organizing 2 new local BF coalitions and each coalition covers 4 counties.

 

Since many PHRs work in clinic-based locations they use the Whole Person Project assessment to address women of childbearing age and continue to ask female clients the One Key Question (OKQ) assessment - “Would you like to become pregnant in the next year?” Based on client’s responses and individual needs, staff offered reproductive support or referred them to the Quit Line, food assistance programs, and other organizations.

 

Performance Analysis

 

Efforts to integrate women’s and maternal health promotion continued across assessment, strategic planning, educational, community-based, and health care quality improvement programs and activities. MCH uses the MMMRC’s findings and recommendations to prioritize maternal health and safety activities in preconception, prenatal, postpartum, and interpregnancy periods. 

 

Challenges

 

MCH and many contractors experienced staffing changes and vacancies, impacting program capacity. Additionally, COVID-19 continues to impact program capacity in community and health care settings. TexasAIM participating hospitals experienced full team turnover, so additional MCH staff time was spent retraining quality improvement basics. Contractors continued to develop approaches for virtual community engagement strategies.

 

Opportunities

 

MCH is collecting and using ongoing stakeholders and health care organizations feedback to responsively adapt program plans to current needs.

 

SPM 4: Maternal Morbidity Disparities: Ratio of Black to White severe maternal morbidity rate.

 

Analysis of the 2020 Title V Needs Assessment findings and stakeholder input identified implementing health disparity strategies across all maternal and child health populations as a State Priority Need. 

 

Breastfeeding is one of several healthy behaviors included in the 2020 Surgeon General’s Call to Action to Improve Maternal Health and improves health across the life course for both mothers and their infants. Breastfeeding reduces a mother’s risk for hypertension, type 2 diabetes, breast, and ovarian cancer, and decreases the risk for postpartum hemorrhage.

 

Return to work remains a top barrier to initiation and exclusive breastfeeding continuation in Texas with more than half of Texas WIC mothers reporting early weaning due to return to work or school (2018 WIC Infant Feeding Practices Survey). Non-Hispanic Black mothers are more likely to return to work in the first year after delivery and return to work earlier, on average, than mothers of other races or ethnicities. Non-Hispanic Black women are also disproportionately represented in low-wage jobs with less flexible work hours and less social breastfeeding support.  WIC Infant Feeding Practices Survey data analysis showed non-Hispanic Black mothers were less likely than mothers of other races or ethnicities to report their worksites were supportive of breastfeeding.

 

In FY22, breastfeeding support activities continued to target known breastfeeding disparities and barriers. The TMFW Program provided targeted technical assistance to employers on a 1-on-1 basis. Additionally, a direct outreach campaign specifically targeted employers in the service and low-wage industries in Texas that employ large numbers of low-wage earners.

 

State Action Plan Activities and Successes 

 

Throughout FY 22 MCH supported the MMMRC Subcommittee on Maternal Health Disparities (subcommittee) to study drivers and root causes of maternal mortality and morbidity racial disparities to guide MMMRC case review continuous improvement.

 

In FY21, the subcommittee developed the DASH Tool to provide a standardized process to guide targeted discussion, evaluate relevant information for each case, and assess whether community and environmental level drivers contributed to the death. The MMMRC discusses tool elements  and complete the MMRIA Committee Decisions Form to identify what factors contributed to the death and whether inequity contributed to the death. In FY 22, the subcommittee continued to refine the DASH Tool based on MMMRC feedback through their tool testing experience.

 

In FY 22, MCH consulted with the subcommittee to develop a MMMRC Case Presentation Guide resource. This Presentation Guide streamlined and standardized the format for initiating MMMRC closed executive sessions used to recognize the loss of life reflected in cases. The Presentation Guide also provided a case presentation format to incorporate language to further humanize the case review process.

 

MCH leverages partnerships with HTMB CCs to promote and support women’s and maternal health and safety. Examples of HTMB CCs FY22 activities that targeted maternal health disparities included:

• The Dallas County HTMB CC supported Parkland Health’s Extending Maternity Care After Pregnancy (eMCAP) program which connects Dallas County women in zip codes with the highest rates of maternal morbidity and mortality with medical and case management services.
• The Dallas County HTMB CC also hosted an Infant Mortality Awareness Summit that featured Charles Johnson, founder of 4Kira4Moms and an advocate for reducing Black mothers’ mortality. The Summit also covered perinatal mental health, extending maternal care after pregnancy, and postpartum care. Six hundred individuals attended the Summit.
• The NET Health HTMB CC partnered with a local historically Black sorority chapter, Zeta Phi Beta, to increase hypertension awareness during and after pregnancy among Non-Hispanic Black women. The sorority funded the purchase of 100 blood pressure wrist cuffs and the NET Health HTMB CC developed several educational materials including wallet sized handouts outlining normal blood pressure ranges, blood pressure logs in English and Spanish, and blood pressure distribution forms. MCH reviewed the educational materials and made recommendations to add informative links on patient-facing educational materials. MCH also shared the educational resources that the LF (Houston LSC) used as part of the WomensHealth.gov blood pressure project, including the CDC Blood Pressure Log, American Heart Association blood pressure infographic, and information from the CDC Hear Her campaign on maternal warning signs.

 

In FY22, MCH continued HRMCCSP pilot development. The pilot’s purpose is to reduce poor outcomes for pregnant and postpartum women. Non-Hispanic Black women experience disproportionately higher maternal mortality rates compared to other racial and ethnic groups. Racial and ethnic maternal health disparities components are considered throughout program planning, including the risk assessment tool planning, the CHW curricula, CHW-led patient education, and pilot site(s) location(s) identification. In FY22, the pilot site recruited 3 CHWs including 2 non-Hispanic Black and 1 Hispanic CHW.

 

Refer to SPM 5 for more information about the HRMCCSP pilot.

 

In partnership with the University of Texas Health Science Center at Tyler and the University of Texas System, MCH continued to fund Texas Collaborative for Healthy Mothers and Babies (TCHMB) facilitation and activities which functions as Texas’ state perinatal quality collaborative.

 

TCHMB is a collaboration of over 150 health care providers, hospitals, state agencies, and other stakeholders with a shared goal of developing strategies, designing projects, and collecting data to improve Texas birth outcomes.

 

In February 2022, TCHMB hosted its 2022 annual summit virtually. The summit included presentations on Texas data on maternal and birth outcomes, lessons learned and future considerations of COVID-19 impacts on perinatal care, and other maternal and infant health topics.

 

TCHMB has a workgroup that aims to help reduce and eliminate health care disparities. Over 250 attendees participated in the summit and its pre-session workshops.

 

The DSHS Hear Her Texas campaign aims to increase awareness about:

• The impact of severe maternal morbidity and mortality on Texas women, families, communities, and the state overall;
• The disproportionate impact of severe maternal morbidity and mortality on non-Hispanic Black and Hispanic women particularly those with a low income;
• Activities that communities can do to lower the risk of severe maternal morbidity and mortality and improve maternal health outcomes;
• The importance of, and opportunities for, promotion of maternal health, safety, and wellbeing; and
• Evidence-based or promising prevention strategies and the role and responsibility of providers to implement these strategies.

 

To accomplish these aims, MCH conducted market research to understand maternal health disparities, particularly among non-Hispanic Black women, community level drivers influence, and how maternal health providers and stakeholders can work to reduce these disparities. MCH used these findings to inform the campaign strategy and materials.

 

Refer to SPM 5 for more information about Hear Her Texas.

Performance Analysis

Addressing maternal health disparities and closing disparity gaps remains an MCH priority. Maternal health outcome disparities persist and Non-Hispanic Black women are most disproportionately impacted by severe maternal morbidity and maternal mortality. MCH uses assessment findings to target opportunities for addressing maternal health disparities and works to prioritize and integrate disparity prevention strategies across all maternal health programs.

 

Challenges

Like with the other NPM’s, MCH and many contractors experienced staffing changes and vacancies directly impacting program capacity. Additionally, COVID-19 continues to impact program capacity in community and health care settings.

 

Opportunities

MCH continues to develop and support mobilization of a wide network of partners across the state focused on maternal health and safety improvement. MCH will continue to assess opportunities to specifically address and work to eliminate racial disparities in maternal health outcomes
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