Women’s/Maternal Health Domain

FY18 Annual Report

 

 

The Office of Family Health Services administers a number of programs and initiatives serving women, children, and their families. Title V funds are braided with a variety of state and federal funding streams and allocated across teams.

 

The FY18 workplan for the Women’s/Maternal Health Domain included the following performance measures:

1. Unintended Pregnancy
2. Maternal Mental Health
3. Low-Risk Cesarean Delivery

 

Strategies within the FY18 Women’s/Maternal Health workplan were implemented by the Division of Child and Family Health’s Reproductive Health Unit and Maternal and Infant Health Coordinator. Summaries of activities completed during the reporting period are presented by performance measure below.

 

Complementary efforts were completed by Title V-funded local health districts, the Office of the Chief Medical Examiner, the Virginia Neonatal Perinatal Collaborative (VNPC), and the Division of Prevention and Health Promotion’s Dental Health Program and Injury and Violence Prevention Program. These entities and their efforts are detailed in the ‘Other Programmatic Activities’ section below.

 

 

 

Objective

 

For the FY18 application, the proposed objective was:

• Reduce the rate of unintended pregnancies for all women of child-bearing age by 10%.

 

The updated objective is:

• By June 30, 2020, reduce the rate of unintended pregnancies for all women of child-bearing age (ages 15-44) from 49.5% (PRAMS 2016) to 47%.

 

 

Related National Outcome Measures

 

The national outcome measure (NOM) most relevant to this SPM is:

 

• NOM 23: Teen birth rate, ages 15 through 19, per 1,000

 

Significance of NOM 23: Teen pregnancy and childbearing have substantial social and economic costs for both teens and their children. Teen mothers are less likely to complete high school and further education which may reduce earning potential and contribute to intergenerational poverty. Although teen pregnancy and birth rates have declined substantially over the past two decades, rates are still higher than in many other industrialized countries and large racial/ethnic disparities persist. Birth rates for non-Hispanic Black and Hispanic teens are more than double that of non-Hispanic White teens. https://www.cdc.gov/teenpregnancy/about/index.htm

 

Related Healthy People 2020 Objectives:

• Family Planning (FP) 8.1: Reduce pregnancies among adolescent females aged 15 to 17 years (Baseline 40.2 per 1,000 in 2005; Target 36.2 per 1,000)
• FP 8.2: Reduce pregnancies among adolescent females aged 17 to 19 years (Baseline 116.2 per 1,000 in 2005; Target 105.9 per 1,000)

 

 

Progress Updates

 

The Division of Child and Family Health’s Reproductive Health Unit leads this effort. Title V funds provide salary support for administration of the LARC Initiative.

 

The unit is led by Emily Yeatts, MSW, MPH (Reproductive Health Unit Supervisor) and includes the following programs:

• Title X Family Planning (Title X): Clinical family planning programs consistent with Title X requirements and Quality Family Planning Services as defined by the CDC;
• Adolescent Health Program (Sexual Risk Avoidance Education Grant, Title V): Positive youth development programs that build protective factors among participants that will make them less likely to initiate sexual activity; and
• Resource Mothers (TANF, Title V): Adolescent health program providing support services to pregnant and parenting teens and their families.

 

The Adolescent Health Program is led by Madeline Kapur, Adolescent Health Coordinator. The Resource Mothers Program is led by Consuelo Staton. Both programs are detailed in the FY20 application for the Adolescent Health Domain.

 

 

Strategy 1: Partner with local health districts, healthcare providers, and community partners to increase access to quality family planning services for all women of childbearing age.

 

This strategy was operationalized through the Virginia LARC Initiative, as detailed below.

 

 

Strategy 2: Collaborate community partners to expand safety net services.

 

During FFY18, the LARC Stakeholder Workgroup met quarterly and worked together to identify the need for family planning services across the Commonwealth. According to the All Payers Claims Database, LARC utilization across the state was well below the national average. Furthermore, the workgroup surveyed 120 private family planning practice providers throughout state, and found that only half offered LARCs. The main reasons given for not offering LARCs included time, training, and cost of devices. This data stood in sharp contrast to 2015 PRAMS data, which stated that 16% of women were using LARCs at 2-6 months postpartum, and VDH Title X family planning patient data, which stated that 19.3% of patients used LARCs in CY2017. This data suggested that although VDH’s Title X family planning program is providing the broad range of contraceptive methods to patients, LARCs are largely inaccessible to many Virginia women.

 

These findings led the workgroup to initiate a partnership with the Power to Decide to the “Whoops Proof Birth Control” campaign. This campaign was designed to increase public awareness and positive regard of LARCs, and was scheduled to roll out in FFY19.

 

Based on conversations among LARC workgroup members, the group determined that community stakeholders could also benefit from learning more about the public health benefit of LARCs. Group members worked together to create a one-page document designed for policy makers, decision makers, and other leaders potentially interested in supporting public health programs. Stakeholders used this document to help make the case for the Virginia LARC Initiative, a $6 million pilot program designed to increase access to LARCs among low-income women launched in FFY19.

 

 

Strategy 3: Partner with local health districts and community partners to deliver abstinence programs to adolescents.

 

During FFY18, the Reproductive Health Unit partnered with eight local health districts and one community agency to offer Abstinence Education Programs to Virginia youth. During FFY18, VDH’s AEP program served 6,906 youth. Beginning in FFY19, VDH ceased receiving federal Abstinence Education Program funds and instead used a different federal funding stream, Sexual Risk Avoidance Education, to support evidence-based positive youth development programs across the Commonwealth.

 

 

State Performance Measure Update

 

This SPM was initially listed under the Life Course/Cross--Cutting domain within the FY17 application, with a focus on teen pregnancy (females ages 15-19). The metric was revised for the FY18 application to capture unintended pregnancy among all women of reproductive age (ages 15-44); proposed FY19 and FY20 strategies are detailed within the Women’s/Maternal Health and Adolescent Health Domains.

 

 

 

Objective

 

For the FY18 application, the proposed objective was:

• Increase the percentage of postpartum women attending a postpartum visit within 6 weeks by 5% (2020).

 

As reported within the FY19 Application / FY17 Annual Report, this SPM has been removed from the state workplan.

 

Progress Updates

 

Strategies proposed in the FY18 workplan included:

• Strategy 1: Partner with ACOG, VHHA, AWOHNN, DBHDS, and VNPC to increase use of the SBIRT process to screen for maternal mental health, with special emphasis on education and counseling (e.g. outpatient OB clinics and inpatient facilities).
• Strategy 2: Explore SBIRT as an approach to the delivery of early intervention and treatment for pregnant women with substance use disorders and those at risk of developing these disorders within local health departments.
• Strategy 3: Collaborate with local health departments and community partners to educate women about signs and symptoms of postpartum depression through the use of social media.
• Strategy 4: Partner with DBHDS and other partners to provide training to local health department staff on SBIRT approaches, including referrals to treatment.

 

The Division of Child and Family Health’s Maternal and Infant Health (MIH) Coordinator is Shannon Pursell, MPH. She serves as a subject matter expert housed at VDH’s Central Office who partners closely with an array of state and local partners, including the Virginia Neonatal Perinatal Collaborative (VNPC), the Maternal Mortality Review team, and the recently-formed maternal mental health workgroup and Pathway to Coordinated Care for Infants and Families (PCC) workgroup.

 

The MIH Coordinator currently supports interagency efforts to address maternal mental health and recently established a maternal mental health workgroup.

 

When the workplan was discussed for FY18, little had been done related to Maternal Mental health screening in the local health districts or through partnerships with outside agencies, non-profits or stakeholders. Therefore, the decision was made to remove this SPM from the workplan moving forward. At that time, 10/35 local health districts reported some form of screening and/or education was provided either during a home visiting encounters or in the clinic during a prenatal or post-partum visit. There were no standard screening tools used within the LHDs, and upon further discussion with LHDs many didn’t feel confident that they had adequate resources to make appropriate referrals for women who screened positive.

 

The summer of 2018, HRSA released a funding opportunity related to increasing screening, referrals and treatment for pregnant, post-partum and parenting women.  Virginia was excited for this opportunity and engaged a multidisciplinary team to develop a plan for application, after multiple meetings and attempts to develop a coordinated workplan to meet the grant requirements, the team took a step back and realized that we weren’t ready to develop a competitive grant and be successful in the implementation. However, this was the catalyst to bring together a team all focused identifying the challenges to screening, referrals and treatment for pregnant, post-partum and parenting women in Virginia. The workgroup decided to stay together, meet monthly (via zoom, given us being geographically separated throughout the state), and develop a “packet” to include: (1) Screening tools, (2) Reimbursement, (3) Benchmark data, (4) Algorithms, (5) Resources, (6) Opioid Use/Screening/Resources, (7) Frequently Asked Questions.  This “packet” will also have a complimentary tool kit to explain each “tab” in greater detail.  The packet will be piloted in multiple different settings and focus groups (pediatrician office, OB offices, in-take nurse, etc.), then an education/awareness campaign will be done for healthcare professionals, that this tool exists and how to use, and to the community to increase mental health awareness and screening. 

 

 

 

Objective

 

For the FY18 application, the proposed objective for NPM 2 was:

• Reduce primary cesarean births by 5% (2020).

 

As reported within the FY19 Application / FY17 Annual Report, this NPM has been removed from the state workplan.

 

Related National Outcome Measures

 

The national outcome measures (NOMs) relevant to this NPM include:

 

• NOM 2 - Rate of severe maternal morbidity per 10,000 delivery hospitalizations
• NOM 3 - Maternal mortality rate per 100,000 live births

 

Significance of NOM 2: Severe maternal morbidity is more than 100 times as common as pregnancy-related mortality—affecting about 52,000 women annually—and it is estimated to have increased by 75 percent over the past decade. Rises in chronic conditions, including obesity, diabetes, hypertension, and cardiovascular disease, are likely to have contributed to this increase. Minority women and particularly non-Hispanic black women have higher rates of severe maternal morbidity. [In 2014, a multistate analysis of racial and ethnic disparities in severe maternal morbidity found that] Non-Hispanic Black, Hispanic, Asian/Pacific Islander, and American Indian/Alaska Native women had 2.1, 1.3, 1.2, and 1.7 times, respectively, higher rates of severe morbidity compared with non-Hispanic white women.

 

Related Healthy People 2020 Objectives:

• Maternal, Infant, and Child Health (MICH) 5. Reduce the rate of maternal mortality. (Baseline:12.7 maternal deaths per 100,000 live births in 2007, Target: 11.4 maternal deaths per 100,000 live births)
• Maternal, Infant, and Child Health (MICH) 6. Reduce maternal illness and complications due to pregnancy (complications during hospitalized labor and delivery). (Baseline: 31.1%, Target: 28%)

 

Significance of NOM 3: Maternal mortality is a sentinal indicator of health and health care quality worldwide. After a century of general improvement, the U.S. maternal mortality rate more than doubled over the past decade. Although most of this increase was likely due to changes in the ascertainment and identification of maternal deaths, at least part of the increase appears to be real and may be attributable to increases in chronic health conditions, such as cardiovascular disease and diabetes. There are also significant racial disparities with Black women having rates of maternal mortality at least 3 times that of White women. Maternal deaths can be prevented or reduced both by improving underlying maternal health as well as health care quality for leading causes of maternal death, such as hemmorhage and preeclampsia.

 

Related Healthy People 2020 Objectives:

• Maternal, Infant, and Child Health (MICH) 5. Reduce the rate of maternal mortality. (Baseline:12.7 maternal deaths per 100,000 live births in 2007, Target: 11.4 maternal deaths per 100,000 live births)

 

 

Progress Updates

 

In FY18, the Division of Child and Family Health’s MIH Coordinator led this effort.

 

Strategy 1: Partner with the Virginia Hospital and Healthcare Association (VHHA) to adopt best practices and provide education to labor and delivery hospitals and OB providers.

 

VDH has a great working partnership with VHHA across several different programs and initiatives. VHHA is a member on the Virginia Neonatal Perinatal Collaborative (VNPC) Steering Committee, attending weekly meeting and is involved intimately with the quality improvement projects both currently and upcoming.  At the time of the FY18 workplan was written, Virginia was nationally recognized for reducing early elective deliveries (EED) to less than 2% and a plan was put in place to ensure sustainability of this effort and low rate. That plan included continued reporting by hospitals to VHHA with their EED rates for the accountability. 

 

With the EED rate reduced, Virginia still had a significant number of primary cesarean deliveries. In partnership with ACOG, VNPC, VDH and DMAS we provided awareness and education about reducing primary cesarean deliveries and the impact it has on improving maternal health outcomes.  While the work is just beginning with reducing primary cesarean deliveries in Virginia, an assessment of greatest impact to improve maternal health, resources needed to implement successful initiatives and not over extend/commit hospitals, this performance measure has been discontinued for now.

 

 

Strategy 2: Partner with the Virginia Neonatal Perinatal Collaborative (VNPC) to develop a quality improvement program through safe reduction of primary cesarean births.

 

Currently, the VNPC is working on implementing two Alliance on Innovation for Maternal Health (AIM) patient safety bundles: Obstetric Hemorrhage and Maternal Opioid Use Disorder (OUD). Once these quality improvement projects are completed (approximately 12-18 months from initiation), the VNPC Improving Pregnancy Outcomes advisory committee will identify the next patient safety bundle to be implemented.  Reducing Primary Cesarean Deliveries is a patient safety bundle available for implementation if that is the direction the VNPC in partnership with recommendation from the Maternal Mortality Review Committee decides to move.

 

 

Strategy 3: Partner with insurance companies and the Virginia Department of Medical Assistance Services (DMAS) to reduce primary cesarean deliveries by implementing policies supporting a culture that values, promotes, and supports spontaneous onset and progress of labor and vaginal birth and understands the risks for current and future pregnancies of cesarean birth without medical indication.

 

DMAS is a partner at the table with the VNPC and the VNPC selected to implement the Maternal Hemorrhage AIM bundle first and per the recommendation of AIM it isn’t recommended to implement multiple bundles at the same time. The VNPC has identified Primary Cesarean Deliveries as an important AIM bundle to implement but at this time, it is unknown when it will be implemented given the above mentioned explanation.

 

 

Strategy 4: Develop and promote (through organizations such as ACOG, VHHA, and the VNPC) provider education and training techniques that develop knowledge and skills on approaches which maximize the likelihood of vaginal birth, including assessment of labor, methods to promote labor progress, labor support, pain management, and shared decision making.

 

This is part of the implementation of AIM bundles, providing technical assistance to hospitals and providers on the steps of the patient safety bundles, to address challenges and barriers to implementation.  This is happening with the current patient safety bundles, as mentioned above Primary Cesarean wasn’t been selected as of yet for implementation.

 

 

Strategy 5: Continue collaboration with VHHA to maintain low rates of early elective delivery in Virginia.

 

VHHA continues to monitor annually the EED rates from delivering hospitals, through self reporting by hospitals to VHHA to ensure sustainability of their success.

 

 

Evidence-Based Strategy Measures

 

The strategies proposed in the FY18 workplan aligned with the following ESM(s):

• ESM 2.2 - Completion of a report identifying primary cesarean data/rates for all Virginia delivering hospitals to identify facilities for C/S reduction/QI interventions

 

As reported in the FY19 Application / FY17 Annual Report, the VNPC is working to implement a number of hospital quality improvement projects. More details on the VNPC can be found within the Other Programmatic Activities section below.

 

This report wasn’t completed because the VNPC selected to implement the Maternal Hemorrhage patient safety bundle across all the delivering hospitals. Given this focus, the bandwidth of resources and staff didn’t exist to create this report. Given the selection of the Maternal Hemorrhage patient safety bundle, this ESM was discontinued.

 

 

 

Other Programmatic Activities

 

Local Health Districts

Title V funds are allocated to 35 local health districts (LHDs) to address locally-identified priorities; each LHD must maintain a workplan and report annually on successes, challenges, and emerging needs. Title V-funded Central Office staff provide technical assistance to LHDs through site visits and bimonthly webinars.

 

LHD priorities for the current grant cycle are strongly linked with maternal and infant health topics. This is in part due to alignment with state-level work led by the Maternal and Infant Health Coordinator (Shannon Pursell), who currently serves as the LHD liaison.

 

Funded LHD priorities include: (1) access to maternal/prenatal care, (2) substance use, including tobacco and opioid use among pregnant women, and (3) safe sleep. To build capacity of LHDs to enhance community partnerships and community/family voice in program planning and delivery, a fourth funded priority has been included for the FY20 grant year: (4) increased coordination with community-based organizations. Each LHD must select at least one of these four priorities.

 

For the 2021-2025 grant cycle, the Title V program aims to broaden the range of topics to include child health, adolescent health, and family/community-based efforts.

 

Each LHD is charged with conducting a community health assessment (CHA) every 5 years. This process includes identifying local priorities for MCH populations. Local CHAs, combined with the results of the 2021-2025 Title V needs assessment, will drive identification of funded LHD priorities for the new grant cycle.

 

For the new grant cycle, a team-based approach is planned for technical assistance and workforce development for distract staff. A team of subject matter experts will be available to deliver technical assistance through cross-team technical assistance calls and site visits. Districts will receive assistance with developing workplans, selecting local performance measures, and building capacity for grant-writing and outcome reporting.

 

Title V LHD funding will continue to balance addressing local emerging issues within specific populations with sustained commitment to a core set of statewide MCH priorities and services.

 

 

Office of the Chief Medical Examiner

Maternal mortality review is co-led by VDH Office of the Chief Medical Examiner (OCME) and the Office of Family Health Services. Letters to members are co-signed by Dr. William Gormley and Dr. Vanessa Walker Harris.

 

OCME also leads the state’s child fatality review team.

 

Title V funds contribute to OCME staffing support for both maternal and child fatality review. In addition, Title V-funded and non-Title V-funded OFHS staff serve on both review teams.

 

 

Virginia Neonatal Perinatal Collaborative

As detailed in the FY18 application, the Virginia Neonatal Perinatal Collaborative (VNPC) exists to ensure that every mother has the best possible perinatal care and every infant cared for in Virginia has the best possible start to life. The VNPC believes in an evidence-based, data-driven collaborative process that involves care providers for women, infants and families as well as state and local leaders. The VNPC believes that working together now will create a stronger, healthier Virginia in the future.

 

The goals of the VNPC are:

• To provide assistance to hospitals and obstetric providers in performing quality improvement initiatives designed to improve pregnancy outcomes, including decreasing the preterm birth rate to Healthy People 2030 Goals and to decrease maternal mortality by 50%;
• To enhance the quality of state-wide perinatal data and to provide hospital-specific data back to participating hospitals promptly so as to accomplish quality improvement goals;
• To provide assistance to hospitals and newborn care providers in performing quality improvement initiatives designed to improve neonatal outcomes, including decreasing morbidity and mortality as well as decreasing length of stay;
• To inform and involve the community, including health care providers, nurses, ancillary medical staff, payers, hospital administrators, and, most importantly, patients in efforts to make Virginia the safest and best place to deliver babies; and
• To narrow the racial and ethnic disparities with the achievement of health equity in pregnancy and neonatal outcomes.

 

The VNPC is led by:

• Chair: Donald Dudley, M.D., William T. Moore Professor and Director, Division of Maternal-Fetal Medicine at University of Virginia
• Co-Chair: Joseph El Khoury, M.D., Asst. Professor of Pediatrics, Medical Director, Neonatal Transport Team, Virginia Commonwealth University
• VHHA representative: Joan Williamson RN, MN, CPHQ, CPPS
• March of Dimes representative: Marie Pokraka MSN, RN, IBCLC
• Virginia Department of Health representative: Shannon Pursell, MPH
• National Association of Neonatal Nurse Practitioners representative: Barbara Snapp, DNP, NNP-BC

 

In addition, the VNPC’s Executive Leadership Committee includes a member/representative from each of these professional organizations: Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), American College of Nurse-Midwives (ACNM), American Congress of Obstetricians and Gynecologists (ACOG), American Academy of Pediatrics (AAP), American Academy of Family Physicians (AAFP), Managed Care Organization (MCO), Insurance Company, Department of Medical Assistance Services (DMAS), Office of Secretary of Health and Human Resources (OSHHR), and a Family Representative.

 

In FY17, the MIH Coordinator supported VNPC infrastructure development. The VNPC was formally launched in June 2017 to help improve pregnancy and birth outcomes by advancing evidence-based clinical best practices to enhance the quality of care provided to pregnant women and infants. This joint initiative is a result of cooperation from several leading health care organizations, clinicians, and stakeholders. In October 2017, the MIH Coordinator supported coordination of the first statewide meeting of the VNPC, which brought together obstetric, neonatal, and other practitioners as well as members of the health care community, state agencies and stakeholders with a focus on improving maternal and infant health outcomes. The meeting drew close to 250 attendees, including representation from eight local health departments.

 

Once formed, input from VNPC stakeholders was leveraged to prioritize five initial projects. The collaborative will employ evidence-based strategies and quality improvement bundles from the Vermont Oxford Network for NAS and Antibiotic Stewardship in the NICU and from AIM on Obstetric Hemorrhage and Maternal Opioid Use Disorder. In collaboration with MOD, the VNPC will also work to identify and reduce barriers related to administering 17P.

 

These five projects are not included in the FY19 or FY20 Title V state action plan, as ownership will remain with the VNPC and no Title V funds are directly allocated to these efforts. However, Virginia will continue to report annually on the VNPC as a key MCH initiative supported by and aligned with the efforts of the Title V-funded MIH Coordinator.

 

 

Injury and Violence Prevention Program

Prevention of opioid poisonings as a result of misuse, overuse, and abuse continues to be a growing focus throughout Virginia. There are several drivers to this public health issue, which continue to escalate this epidemic, including the problematic practice of opioid case management, prescribing, and dispensing among healthcare providers.

 

In FY17, the IVPP used Centers for Disease Control and Prevention (CDC) Prescription Drug Overdose Prevention for States grant funding to partner with the Virginia Department of Medical Assistance Services (DMAS) to host a series of 31 statewide healthcare provider trainings utilizing the Providers Clinical Support System for Medication Assisted Treatment (PCSS-MAT). Content also included Virginia specific education for current and potential Virginia Medicaid members. These trainings increased the number of physicians who are knowledgeable about and qualified to prescribe buprenorphine to their patients with opioid use disorder. After completing the trainings, eligible providers received continuing medical education units and were eligible for their DEA waiver. Over 1,000 broad-spectrum healthcare providers received education during the training sessions.