Women/Maternal

Perinatal Quality

Vermont MCH works in close partnership with the Vermont Child Health Improvement Program to assess, monitor, and improve perinatal quality, which includes measures of prenatal care. In partnership with MCH and VCHIP, the Perinatal Quality Collaborative/OB initiatives works to:

• To strengthen and expand a network of obstetric providers and nurses at hospitals throughout Vermont and New Hampshire that serve Vermont births and collaborate to improve the quality of care provided to pregnant people and infants.
• To improve access, coordination, and quality of care, including prenatal, perinatal, and preconception care, provided to pregnant people and infants.
• To establish prenatal care standards and recommendations by standardizing quality assessment, benchmarking, and reporting.
• To identify potential recommendations for changes in policy and payment for obstetrical care of women.

Additional information regarding the perinatal quality collaborative is provided in the perinatal/infant narrative sections.

Maternal Depression

Vermont’s MCH program was awarded a five-year HRSA cooperative agreement: Screening and Treatment for Maternal Depression and Related Behavioral Disorders Program. Vermont’s program, Screening, Treatment and Access for Mother and Perinatal Partners (STAMPP), aims to improve the mental health and wellbeing of pregnant and postpartum women and their families and children. Our objectives are to:

1. Assess resources, gaps and opportunities in our existing system of care
2. Increase the capacity of Vermont’s health care providers to educate, screen, diagnose, prevent, and treat maternal depression and other related behavioral disorders
3. Increase the capacity of Vermont’s mental health system to diagnose, and treat maternal depression and other related behavioral disorders, including the exploration and implementation of telemedicine and technology innovations
4. Increase the capacity of the human service workforce to screen and support women at-risk for maternal depression and other related behavioral disorders
5. Identify and support innovative financing options to support the screening, diagnosis, and treatment of maternal depression and other related behavioral disorders
6. Ensure access to comprehensive maternal depression and educational information and support and treatment options
7. Develop up-to-date, real-time referral resources at the community level; and
8. Conduct a comprehensive evaluation

STAMPP works collaboratively with the Department of Mental Health, Department of Vermont Health Access (Medicaid and Women’s Health Initiative), Department for Children and Families, VCHIP, UVM Medical Center, Vermont’s designated community mental health centers, Help Me Grow and MIECHV. Please see the Perinatal and Infant Health section for additional information.

Reproductive Health

Two years ago the preventive reproductive health program changed to adolescent and reproductive health as some staff focus areas had shifted. The Director of Adolescent and Reproductive Health (formerly preventive reproductive health) works closely with the Title V Director to leverage reproductive health programming in a collaborative and administratively efficient manner and determine common goals and activities between Title V and funding sources related to reproductive health, such as the Family Planning Program and the Personal Responsibility and Education Program (PREP). This collaborative approach under MCH leadership supports outcomes such as those reflected in the national and state performance measures addressing women’s preconception health, adolescent birth rates, interpregnancy spacing, intended pregnancy, and prenatal care access/utilization.

The Division of MCH has overseen Title X funded clinical services that are contracted from MCH to Planned Parenthood of Northern New England (PPNNE) and are offered at PPNNE sites statewide for more than four decades. In 2019, the Health Department made the decision to relinquish Title X funding due to the Final rule issued by HHS/OPA that would have prevented the health department and our longstanding subrecipient from providing the full range of family planning and reproductive health care services for Vermonters. In the absence of Title X funding the state replaced these funds as part of contingency planning for FY20 and FY21 to allow for the continuation of these essential services in the absence of federal funding.

VT recently applied and was awarded Title X funding for a 5-year funding period.  We are in the process of reestablishing our Title X program. There have been several changes that have and will continue to impact our efforts, including the closure of 4 Vermont based Planned Parenthood health centers and one in New Hampshire that also serves Vermont patients, as well as the broader shifting landscape related to the Supreme Court overturning Roe v. Wade. We are assessing impacts and gaps and working closely with partners, such as the Women’s Health Initiative, to make sure we are well coordinated, able to identify and respond to gaps in a timely manner, to ensure that comprehensive family planning services remain available. In our most recent Title X application we built in a new position to support several key areas of MCH work. We will hire a Program Specialist in the fall of 2022 who will support Title X work, as well as Title V, and some of our mental health and perinatal health efforts. 

The context in Vermont is one that is highly supportive of ensuring continued access to the highest quality comprehensive reproductive health care services. The Agency of Human Services recognizes that universal access to quality, culturally sensitive healthcare, including reproductive health care, is essential for the health and wellbeing of Vermonters. Ensuring health and wellbeing of Vermonters is core to the Agency’s mission. Vermont law codifies that it is a fundamental right that reproductive health care decisions remain between a person and their health care provider. While there is serious concern about the challenging national landscape, Vermont leaders are stepping up. Our Legislature and our Governor support access to important reproductive health care and are taking action to ensure care is safe and available here in Vermont. Governor Scott provided public notice on Proposition 5, an additional step in ensuring the right for reproductive care here in our state.

Proposal 5, a proposed amendment to the Vermont Constitution passed by the General Assembly, will appear on the November 2022 general election ballot. Section 72 of Chapter II of the Vermont Constitution and Chapter 32 of Title 17 of the Vermont Statutes Annotated require the Governor to give public notice of the proposed amendment by proclamation.

“Vermont has a long tradition of supporting a woman’s right to choose. These decisions are deeply personal and belong between a woman and her health care provider, free from government interference,” said Governor Scott. “In Vermont, we solidified the right to choose in law, and now Vermonters have the opportunity to further protect that right in our constitution. It is more important than ever to make sure the women in our state have the right to make their own decisions about their health, bodies, and their futures. In light of the recent decision by the Supreme Court of the United States, I thank members of the General Assembly and other advocates for their foresight and work to bring this question to the November ballot.”

MCH also provides oversight for the Medicaid grant funding to PPNNE via ACA provisions allowing PPNNE to be reimbursed for clinical services to patients with incomes under 200% FPL. This program allows PPNNE to serve uninsured and underinsured low-income clients at the time of the appointment and use the clinic visit to enroll the client in Vermont’s public health care insurance system. MCH is working with our partners in Medicaid eligibility to ensure that patients with incomes under 200% FPL are covered in all health care settings. We are presently engaged with Medicaid in discussions related to our waiver to explore opportunities to integrate the family planning option more fully into our state Medicaid program in 2023.

The MCH reproductive health workgroup had several successes over the past several years, including addressing some of the recommendations outlined in our most recent three-year Title X Needs Assessment. This workgroup was essential in informing our strategies related to promoting women’s and maternal health and to collaborating across the system to reduce redundancies and ensure coordination of services. It has also helped to enhance partnerships. Membership has included: primary care and family practices, Ob/Gyn, Title X (Planned Parenthood), FQHCs, MCH Coordinators from the Office of Local Health, an adolescent medicine specialist, Vermont’s Child Health Improvement Program (VCHIP) and other state agencies addressing reproductive health (Medicaid, Agency of Education).

Some of the outcomes of the workgroup have included creating a contraceptive referral form (read more below); collaborating with Medicaid to improve rates of post-partum insertion of LARC by establishing an add-on payment, which was further advanced by Medicaid in the current reporting period to include an add on payment that covers the full cost of the device; and collaborating with the Blueprint for Health, Vermont’s health reform initiative, on the Women’s Health Initiative (WHI), to enhance psychosocial screening for women and to improve access to LARC in women’s specialty practices (OB/Gyn and PPNNE). The Reproductive Health Workgroup was paused several years ago as many members also served on the Blueprint Women’s Health Initiative’s Steering Committee and wanted to avoid redundancy.  This work continued to be paused during the COVID response as well.  Now that VT has reentered the Title X program a reproductive health advisory will be reconvened in the fall of 2022.

The Vermont Department of Health has been a key partner throughout the process of planning the Women’s Health Initiative, and Planned Parenthood, the Title X service provider, has been engaged in the initiative since its inception. Through the Women’s Health Initiative, women’s health specialty providers (including Title X), are providing enhanced health and psychosocial screening in clinical settings. New staff, training, and payments support effective follow-up to provider screenings through brief, in-office intervention and referral to services for mental health, substance use disorder, trauma, intimate partner violence, food and housing. The Women’s Health Initiative helps ensure that women’s health providers, Patient Centered Medical Homes, and community partners have the resources they need to help women be well, avoid unintended pregnancies, and build thriving families. The Women's Health Initiative supports practices in building enhanced screenings into regular health care visits. Women identified as at-risk in the areas of mental health, substance use disorder, intimate partner violence, or access to food and housing are immediately connected to an initiative-funded social worker for brief intervention and counseling and referral to more intensive treatment as needed. Each social worker is a member of the Community Health Team and available to connect women with the local network of health, social, economic and community service providers. Women also receive comprehensive family planning counseling and services. Those who tell their providers they do not want to have a baby in the coming year will have immediate and affordable access to a broad range of contraceptive options, including LARC. Women who wish to become pregnant receive preconception counseling and services. While some of these efforts were paused or stalled during COVID, there is a renewed commitment to working in an integrated, well-coordinated, collaborative way to ensure the highest quality reproductive health services for Vermonters.

The Director of Adolescent and Reproductive Health supervises the MCH Adolescent Health Program Manager (formerly the PREP Coordinator), as well as the MCH Injury Prevention Coordinator, which supports increased alignment of efforts across these interconnected areas of work. In addition, the Director now supervises a Public Health Nurse Administrator who oversees the state’s EPSDT program, and a broad body of work related to children and adolescents in health care settings.  

Adolescent Sexual Health:

PREP awards are granted to community organizations to educate young people on both abstinence and contraception to prevent pregnancy and STIs, and covers three adult preparation topics: healthy relationships, healthy life skills, and adolescent development. The program targets youth ages 10 to 19 who are homeless, in foster care, live in rural areas or in geographic areas with high teen births, or come from racial or ethnic minority groups. The program also supports pregnant and parenting youth under 21. Making Proud Choices continues to be the primary curriculum used by PREP sites. More generally in VT, PREP programs use a combination of resources to teach a consent lesson and an LGBTQ+ Inclusivity lesson before they begin the PREP curriculum. Facilitators use the Vermont Network Against Domestic and Sexual Violence’s recently revised Consent Campaign, ETR’s Affirmative Consent and LGBTQ Inclusivity Handbooks, and other resources.

We had our first PREP site visit, which was virtual.  This provided a rich opportunity for us to showcase several our implementing program sites, highlight our partnerships and receive TA.  We are in the process of reassessing the structure of our program, consulting with other states about their models, and moving towards leveraging our partnership with VT Afterschool to serve as an umbrella organization for our PREP program.  This approach would reduce some of the administrative tasks and enable the MCH Program Manager to engage in more training, TA, monitoring, and partnership building.

The PREP Program Manager/Adolescent Health Program Manager was fully deployed to our Health Operations Center as part of the COVID-19 response in late May of 2020. During this time, the Director of Adolescent and Reproductive Health covered many aspects of our MCH work, including PREP. The Adolescent Health Program Manager role as a health equity technical advisor was critical to our state’s COVID-19 response, and in this role, she has managed a team of six. This experience has further enhanced future PREP activities. While PREP implementation has been very challenging due to COVID-19, some other work related to sexual health education in our state has been ongoing, with some important successes happening over the past several months. 

For the fifth year we have a Title V funded contract with Dr. Erica Gibson, Adolescent Medicine Specialist at the University of Vermont Children’s Hospital. Dr. Gibson has provided a wide variety of trainings to PREP staff over the past years and this work has expanded to include pediatricians, family practice physicians, afterschool staff, and school-based health educators. Trainings have been in person and via webinars on several different topics; Adolescents and LARC, Adolescents and STIs, and Adolescents and Emergency Contraception.

Dr. Gibson has also supported some new work related to eating disorders. Dr. Gibson is the medical director of an adolescent eating disorders clinic at UVMMC and played a key role in help to planning and lead a one-day training on multidisciplinary approaches to eating disorders.  The MCH Director of Adolescent and Reproductive Health also served on this planning committee.

MCH continues to collaborate with the Agency of Education, and several community partners through the Sexual Health Education Stakeholders Group on workforce development activities related to improving sexual health education in schools and community-based settings, as well as to support the implementation of the Condom Availability Law and share resources, guidance, and sample templates for procedures that were created to support schools with the implementation of the law. Efforts have included offering a webinar through the Vermont School Nurses Association on the new law and collaborating with community partners to offer educational sessions to Vermont health educators through the VT Higher Education Collaborative on Essential Topics in Sexual Health Education. We also continue to collaborate with Elevatus to support attendance in their 3-day Sexuality Educator training for people who work with people with Intellectual and Development Disabilities. By the end of January 2022 over 50 people had been trained in the Elevatus curriculum through support from MCH.

Injury and Violence Prevention:

MCH oversees the CDC Rape Prevention and Education (RPE) grant, that supports the expansion of primary prevention efforts related to sexual violence within the statewide domestic and sexual violence coalition, with their member agencies, and community partners. Based on an extensive stakeholder engagement process in the previous year, a five-year state action plan and evaluation plan were developed.  The five-year plan aims to prevent sexual violence (SV) perpetration and victimization by using a public health approach to decrease SV risk factors and increase SV protective factors; selecting, implementing and evaluating prevention strategies based on the best available evidence across multiple levels of the Social Ecological Model (SEM), with an increasing emphasis on community-level strategies; and through partnerships and linkages that support using strategies to address shared risk and protective factors across multiple forms of violence. The plan also supports local level efforts in key focus areas:

1. Partnering with youth and support their leadership in implementing individual & relationship level programs and initiatives
2. Growing youth activism, leadership and voice, leveraging existing programs and resources.
3. Equipping adults to support and partner with youth to prevent sexual violence, utilizing the Youth Thrive and WholeSomeBodies frameworks
4. Implementing an Askable Adults social norms campaign to engage adults in sexual violence prevention

The focus populations outlined in the plan are: youth ages 12-18, with a focus on youth of color, LGBTQ youth, youth with disabilities and youth living in poverty, and adults engaged with youth.

Our long-time injury prevention coordinator retired in April 2021.  This position was reclassified to a non-nurse and includes violence prevention.  We hired a MCH Injury and Violence Prevention Program Manager in September 2021 who oversees all violence and injury relation topics including our RPE work. This has been a rich opportunity to further streamline and enhance coordination across our work in the realm of injury and violence prevention.

The Director of Adolescent and Reproductive Health, with support from Title V leadership and funding, works to increase services and systems for reproductive health and specifically for women who may be at risk of domestic and interpersonal violence. Over the years, Title V funding has enabled MCH to renew several long-planned ideas for key improvements in services and systems for women. MCH has chaired the Domestic Violence Advisory Group (DVAG) at VDH and participates on the Agency of Human Services’ Domestic Violence Steering Committee, allowing for both cross-departmental and agency-wide approach to addressing domestic violence. This group heightens awareness of domestic and sexual violence by such activities as community education, coordination across state child and adult service systems, monitoring violence related data, updating state policies and procedures to address violence against women, and providing training and resources for state employees. There have been changes to these groups due to staff turnover across the Agency and due to COVID-19 and staff deployments.  We will be working to identify the best next steps and optimal structure for the future of this work in the coming year.

The Director of Adolescent and Reproductive Health is also a member of Vermont’s Domestic Violence Fatality Review Commission. The purpose of the Commission is to collect data and conduct in-depth reviews of domestic violence-related fatalities in Vermont with the goal of making policy recommendations to prevent future fatalities. The Commission’s report includes data on children killed in a domestic-related-incident and refers these cases to Vermont’s Child Fatality Review Team (Division of MCH ensures representation on Child Fatality Review Team, see Child Health Domain). MCH has worked closely with injury prevention surveillance staff over the past several years to provide support to the Chair for the DV Fatality Review Commission to make recommendations for changes to the structure and format of the annual report, as well as with data reporting, preparation of tables and graphs, etc., to make the findings and recommendations more meaningful and impactful. This work is ongoing.

Another critical advancement has been a newly created position within the Agency of Human Services, the Director of Trauma Prevention and Resilience Development, which sat within VT’s health care reform initiative. Over the past year this position was transitioned into the Department of Mental Health. MCH leadership represent the health department on an agency-wide team that works closely with the new director to help set priorities and identify and plan activities related to workforce development needs across AHS related to trauma and resilience.

Substance Use in Pregnancy

To address Vermont’s high rate of tobacco-use in pregnancy, nurse home visitors, parent educators, and WIC staff regularly screen pregnant women for tobacco use and refer to the Quit Line resources and medical follow up. The IMR Collaborative Improvement and Innovation Network (CoIIN) supported a closer coordination and strategic direction of the prenatal tobacco use cessation activities between MCH and the Health Department Tobacco Control Team. Over the years, we have worked with the Tobacco Control Program to bring evidence-based training on prenatal tobacco use (SCRIPT) to health care providers. We have also developed a contingency management pilot study in Rutland County to provide cessation counseling and incentives (up to $1100) to pregnant women based on national research out of the University of Vermont, which launched in spring 2018 and is currently being evaluated.

Although Vermont has high rates of substance use in pregnancy, several efforts are underway to improve this. Vermont has engaged in several activities to support families with substance use disorder (SUD). A few examples include:

• Prior to COVID, Vermont MCH along with our partners in the Health Department completed a formative evaluation regarding substance use in pregnancy in Vermont to inform future messaging efforts with prenatal providers and families. These efforts resulted in the development of the “One More Conversation” campaign which was stalled due to COVID, but will be formally launched this fall. One More Conversation encourages prenatal providers and patients to continue to dialogue around substance use in non-stigmatizing and supportive conversations.
• Vermont’s HRSA funded initiative described above: Screening and Treatment for Maternal Depression and Related Behavioral Disorders Program aims to increase screening rates for maternal depression, anxiety and substance use and test innovative referral and treatment strategies.
• Vermont is participated in ASTHO’s Opioid Use, Maternal Outcomes, and Neonatal Abstinence Syndrome Initiative (OMNI) Learning Community and is currently developing an action plan to address postnatal support for families with SUD, including more streamlined referral into services such as evidence-based home visiting and early intervention.
• Vermont is one of several states to implement DULCE (Developmental Understanding and Legal Collaboration for Everyone). Project DULCE is a national demonstration project in pediatric practices, sponsored by the Center for the Study of Social Policy in Washington D.C. DULCE is an innovative intervention through which pediatric primary care clinical sites proactively address social determinants of health, including SUD, to promote the healthy development of infants from birth to six months of age and provide support to their parents. A key feature of the DULCE intervention is a Family Specialist, who is a member of the pediatric team, and connects families to resources based on parents’ needs and priorities. DULCE employs the Medical-Legal Partnership model to provide families more intensive assistance obtaining concrete supports, when needed. The DULCE intervention incorporates a Strengthening Families Protective Factors approach and provides optional home visits.
• The Improving Care for Opioid-exposed Newborns (ICON) project at VCHIP partners with the Vermont Department of Health and the University of Vermont Children's Hospital to improve health outcomes for opioid-exposed newborns. Improved health outcomes are achieved by provision of educational sessions on up-to-date recommendations and guidelines to health care professionals who provide care for opioid-dependent pregnant women and their infants.
• Hub and Spoke is Vermont’s system of Medication Assisted Treatment, supporting people in recovery from opioid use disorder. Nine Regional Hubs offer daily support for patients with complex addictions. At over 75 local Spokes, doctors, nurses, and counselors offer ongoing opioid use disorder treatment fully integrated with general healthcare and wellness services. This framework efficiently deploys opioid use disorder expertise and helps expand access to opioid use disorder treatment for Vermonters. Pregnant individuals are a priority population in Vermont’s system.
• Vermont's CHARM (Children and Recovering Mothers) Team, led by KidSafe Collaborative, is cited as a case model for collaboration in working with pregnant women with an opioid abuse history in this new SAMHSA publication. KidSafe convenes this team in partnership with UVM Medical Center, UVM Children's Hospital, Howard Center, LUND, VT Department of Health, VT Department for Children and Families/Family Services Division, and others.

Partnerships

Vermont’s tobacco control programming sits within the Division of Health Promotion and Disease Prevention. We work closely on tobacco-use in pregnancy strategies. Likewise, we work closely with our Office of Local Health and the regional MCH Coordinators.

For more than 10 years, a monthly Primary Care and Public Health Integration meeting convenes the leadership of MCH, VCHIP, VT AAP, VT AAFP, Planned Parenthood, ObGyn physicians, and primary care internal medicine providers, to coordinate various projects that cross borders. This group is and will continue to be a strong partner in advancing women’s and maternal health in Vermont.

The American Congress of Obstetricians and Gynecologists (ACOG) can be an exceptional partner in moving these strategies forward. In the past, Vermont’s Chapter of ACOG was not well coordinated or integrated with public health. In recent years (pre-COVID) years we have worked closely with ACOG members to assess their needs to strengthen the state ACOG chapter. As a result, a quarterly webinar series was developed to support members connecting with each other and with public health colleagues across both clinical and public health topics. Topics included presentations on screening and referral for domestic violence, an update on the Blueprint for Health’s Women’s Health Initiative and how to get involved, smoking and alcohol use during pregnancy, maternal depression, among other important public health topics. These were placed on hold during COVID and are currently being reevaluated.

As described throughout this report, a key partner across all population domains is the Vermont Child Health Improvement Program (VCHIP). VCHIP is a population-based child and adolescent health services research and quality improvement program of the UVM.

Title V works collaboratively with WIC and Vermont’s MIECHV program staff and families to ensure that preconception health planning and pregnancy spacing counseling is incorporated in client visits. Likewise, we plan to work closely with leadership of Vermont’s other home visiting programs to disseminate this messaging.