Pennsylvania (Pa.) is fortunate to have numerous funding streams and opportunities for coordination and collaboration within the Bureau of Family Health (BFH)’s Division of Maternal Health Services (MHS) as well as with other state and local partners to build a clear vision of maternal health needs and solutions. Through surveillance, identification of key issues and innovative programming MHS aims to improve the health outcomes of women and mothers in Pa.

 

For reporting year 2024, the BFH conducted activities in the Women/Maternal Health domain through Title V funding with additional federal funds from the Centers for Disease Control and Prevention (CDC) and Health Resources and Services Administration (HRSA) as well as state funds for support of maternal mortality and morbidity prevention initiatives. Taking into consideration the overall population needs, the BFH has developed strategies that do not duplicate other funding sources, and that fill gaps not addressed by the existing system of care and current partners.

 

The Maternal Mortality Review Program (MMRP) serves as the cornerstone of the Commonwealth’s Maternal Mortality Review Committee (MMRC) and Philadelphia MMRC. These dedicated teams play a pivotal role in reviewing pregnancy-associated deaths, creating actionable recommendations to prevent future deaths, and working to improve health outcomes. Philadelphia has administered a local MMRC since 2010 and the Pa. MMRC was established in 2018 as a result of the Maternal Mortality Review Act. The Pa. and Philadelphia MMRCs collaborate to collectively review all pregnancy-associated deaths in Pa. The MMRP teams are responsible for organizing and facilitating MMRC meetings, obtaining and reviewing relevant medical and social records, preparing and abstracting cases for review by the MMRCs, and analyzing program data. The work is instrumental in identifying trends, determining root causes, and recommending actionable steps to reduce maternal mortality and morbidity and factors that may contribute to poor health outcomes. Pa. MMRC membership includes obstetricians, maternal fetal medicine specialists, certified nurse-midwives, addiction medicine specialists, specialized gynecologic psychiatrists, social workers, coroners, emergency medicine physicians, and community voices.

 

The MMRCs review all pregnancy-associated deaths, defined as a death during pregnancy or one year following the end of pregnancy regardless of the cause of death or outcome of the pregnancy. A pregnancy-related death is defined as a death occurring during pregnancy or within one year of the end of pregnancy, from any cause related to or aggravated by the pregnancy or its management. In 2024, the PA MMRC reviewed pregnancy-associated deaths that occurred in 2021. In 2021, there were 129 cases of pregnancy-associated deaths in Pa. Nearly 33% were deemed pregnancy-related by the Pa. and Philadelphia MMRCs. In 2021, mental health conditions, including substance use disorder (SUD), accounted for 34% of pregnancy-related deaths, while cardiac/coronary conditions for 22% and hemorrhage 14%.

 

The MMRP continually seeks opportunities to collaborate with communities and share MMRC data to inform programming and initiatives. As part of the development of the first Pa. Maternal Health Strategic Plan, discussed in detail below, MMRC data was shared during listening sessions, which were held in communities across the state. The listening sessions gathered partners, providers, community members, people with experience, and elected officials to gather their insight on maternal health priorities and action. In other efforts to share data with communities, Pa.’s Regional Maternal Health Coalitions, detailed below, use MMRC data to inform their goals and implement MMRC recommendations. Coalition meetings involve bi-directional engagement among coalition members, which include partners from maternal health organizations, community members, and people with experience.

 

In 2024, Pa. MMRC membership was expanded to include more voices from the communities most impacted by pregnancy-related deaths. In September 2024, the Pa. MMRC onboarded 13 new members. Twelve of the new members represent populations disproportionately affected by pregnancy-related deaths. Of the 13 new members, the Pa. MMRC welcomed two members in the role of person with experience for the first time.

 

According to the Pa. MMRC, 69% of pregnancy-related deaths in 2021 occurred up to one year after the end of pregnancy with the majority of these deaths deemed to be preventable. Recognizing the need for collaboration within communities to impact maternal mortality and morbidity, MHS requested applications from organizations willing to establish coalitions comprised of individuals who work with the maternal population. Using state funds, four selected applicants (comprised of state university research experts, maternal health advocates, non-profit organizations, and family care professionals) were awarded and tasked with creating Regional Maternal Health Coalitions (RMHC). RMHC will identify the factors influencing deaths in the region while fostering community engagement and implementing recommended strategies identified in the 2024 Maternal Mortality Review Annual Report. These efforts focus on the need to reduce preventable death and disease related to pregnancy in Pa.

 

The project commenced in July of 2024, with planning phases, staffing, community outreach and data collection for the selected regions. Through the course of the project, grantees engage in routine meetings with subject matter experts, opening the door to share successful Coalition building practices and encourage longevity and resource development as well as opportunities to collectively participate in discussions to grow their network and create innovative partnerships.

 

Coalitions membership will include community members,  health experts, academia, and community champions who will unitedly serve as the project’s foundational support along with steering committees. Structured steering committees will evaluate data and administer customized action plans for their selected region in accordance with Pa. MMRC’s recommended strategies. They also aim to secure short- and long-term resources and apply evidence-based practices necessary to achieve success. Coalition project terms are contracted to conclude via a community meeting and/or other means, a public report detailing the successes, challenges, and impacted outcomes of the coalition’s work to address maternal health within the region, and recommendations for future planning.

 

BFH was awarded the HRSA State Maternal Health Innovation Program (MHIP) grant in September 2024. The purpose of the MHIP is to reduce maternal mortality and morbidity by improving access to care that is comprehensive, high-quality, appropriate, and ongoing throughout the perinatal period; enhance state maternal health surveillance and data capacity; and identify and implement innovative interventions to improve outcomes for populations disproportionately impacted by maternal mortality and morbidity.

 

This work will be accomplished by forming a Maternal Health Taskforce (MHTF) who will develop a Maternal Health Strategic Plan (MHSP) to identify and implement strategies. Prior to the grant award, Pa. had begun work on a MHSP through the collaborative efforts of the Pa. Departments of Health, Human Services, Drug and Alcohol Programs, and Insurance. The plan will be finalized in 2025. To gain public input on the plan, listening sessions were held in person at various locations across the commonwealth and virtually. Additional input was gathered through surveys. As the plan is a living document, it will continue to change and adapt to fit the needs of the MHTF and the five priority areas. The five priority areas identified through the plan are 1. Improve Detection and Treatment of Behavioral Health and Substance Use, 2. Improve Coordination and Access to Care in Rural Areas and Maternity Care Deserts, 3. Increase Access to High-Quality Care, 4. Integrate Initiatives to Address Health-Related Social Needs, 5. Expand the Maternal Health Workforce.

 

The Perinatal Telephonic Psychiatric Consultation Service Program (TiPS) was developed in partnership with the Department of Human Services and in response to MMRC recommendations to address SUD and other mental health conditions, which continue to be the leading causes of pregnancy-related deaths in Pa. The program was originally partially funded through the CDC but moving forward will be funded with HRSA MHIP and state maternal health funding. TiPS began as a pilot in December 2024 and is expected to be fully launched by July 2025. It connects primary care providers, obstetricians, midwives, family medicine practitioners, and other healthcare providers to expert teams of perinatal psychiatrists, addiction specialists, therapists, care coordinators, and administrative support. The program is available to all, regardless of insurance status, offering real-time consultation, case management, limited therapy support, and training to help providers enhance their skills in treating perinatal behavioral health conditions.

 

Regional Perinatal TiPS teams, in collaboration with UPMC Magee Women’s Hospital (Northwest and Southwest regions), Philadelphia Department of Public Health (Southeast region), and Penn State Health (Lehigh/Capital and Northeast regions), are modeled to respond to consultation requests, typically within 30 minutes. These consultations provide immediate advice, referrals to local behavioral health services, and assistance in connecting patients to specialized care, such as therapy, psychiatry, or addiction medicine. The program ensures timely, effective resources to support the mental health and substance use needs of pregnant and postpartum mothers.

 

State funding has been dedicated to expanding maternal health programming and supporting the implementation of prevention strategies to decrease pregnancy-associated deaths in Pa. Recommendations included in the MMRC 2024 report centered around the need for increased behavioral health supports, aligning with the Title V Block Grant priority (2026-2030) of “Behavioral health during pregnancy and postpartum" and the DOH State Health Improvement Plan (2023-2028).

 

Pa. has six Healthy Start sites: Hamilton Health Center, The Foundation of Delaware County, Maternity Care Coalition, Philadelphia Department of Public Health, Albert Einstein Medical Center, and Healthy Start, Inc. Pittsburgh. Together, Pa. Healthy Start sites provide home visiting services (including education, screening, and assessment) to approximately 1,850 pregnant, postpartum, and parenting participants annually. A new grant, initiated in late 2024, is promoting the use of behavioral health-specific supports and services at all six Pa. Healthy Start sites. These sites serve pregnant, postpartum, and parenting individuals at high risk of mental health and substance use concerns - significant contributors of preventable mortality - in eight counties. This initiative will increase Healthy Start network’s capacity to support the behavioral health needs of pregnant, postpartum, and parenting individuals in the counties served by the organization.

 

With leadership and oversight of the grant from Healthy Start, Inc. Pittsburgh, all Healthy Start sites are poised to act quickly to increase their capacity to provide behavioral health services and supports to program participants. The collaborative nature of this grant is expected to strengthen the relationships between all Pa. sites, which will aid the sites in implementing future initiatives and securing funds to do so, which lends itself to increased sustainability of these community-based organizations, and the services and supports they provide. This collaboration will also enable the Healthy Start network and the BFH to develop a deeper understanding of the behavioral health needs of the perinatal population in the counties served by their sites, and potentially the state as a whole as the sites are scattered throughout PA, in different  geographic regions.

 

To address the priority related to reducing maternal morbidity and mortality, the BFH focuses on preconception, pregnancy, postpartum, and interconception care and uses programming to provide tools and resources to the women and families served by Title V and assesses progress using the preventive medical visit and postpartum visit National Performance Measures. Specific strategies are discussed below.

 

The BFH continued its partnership with the county and municipal health departments (CMHDs) to provide local services to residents in their communities. The eleven CMHDs are located in Allegheny County, Allentown City, Bethlehem City, Bucks County, Chester County, Delaware County, Erie County, Montgomery County, Philadelphia County, Wilkes-Barre City, and York City. The CMHDs have been longstanding partners for numerous reasons, one of which is direct access to Title V eligible participants at the local level. The CMHDs serve this population in many different capacities, and it is beneficial to the CMHDs as well as to the families they serve to provide services across a wide range of physical and behavioral health, and social services to improve and enrich the lives of families.

 

Various evidence-informed programs and best practices have been implemented to improve health outcomes, particularly among disproportionately affected populations served by the CMHDs. In 2024, 1,232 pregnant and parenting women were served through CMHD home visiting programs. Forty-seven percent of enrolled participants successfully completed home visiting programs, exceeding the Evidence-Based Strategy Measure (ESM) annual goal of 25% completing programs. The measure around home visiting will be changed in the 2026-2030 action plan. Home visitors have regular contact with families, which facilitates comprehensive, family-centered care. This care puts home visitors in an ideal position to identify and address physical, behavioral, or emotional challenges pregnant and postpartum women may be experiencing, as well as issues within the home, such as interpersonal violence (IPV), substance use, and social or financial challenges. Feedback from program participants was collected via client satisfaction surveys to help assess and continually improve the home visiting services provided by the CMHDs. Surveys were administered on paper or electronically via text or email. Survey results indicate that the majority of participants were highly satisfied with the home visiting services they received. Participants felt that they could trust their home visitor, they were listened to and that their home visitor understood their situation, offered necessary support, information, and access to other resources, and provided useful education about infant development and parenting. Response rates have historically been low but the CMHDs helped increase participation with reminder texts, emails, phone calls, or in person reminders during a home visit.

 

Ten of the eleven CMHDs serve prenatal and postpartum women and their infants through home visiting programs. Evidence-based or evidence-informed programming and curriculums, such as Parents as Teachers and Partners for a Healthy Baby, provide primary and preventative maternal and infant health services and education on a variety of health topics, such as substance use, healthy homes, safe sleep, fetal development, healthy nutrition during pregnancy, immunizations, birth control and family planning, parenting techniques, and breastfeeding.

 

Many of the CMHDs offer home visiting services in the postpartum period, with some following families until the child is two years of age. Connecting with postpartum individuals, especially during the fourth trimester, which is defined as the twelve-week period following an infant’s birth, is essential as the body experiences physical, hormonal, and mental changes, some which may be life threatening. The CMHDs offer postpartum screenings, including depression and IPV using validated screening tools, inquire if a six-week postpartum medical visit has been scheduled, and assist with scheduling, as needed. Education including reviewing post-birth warning signs and when to contact a health care provider or go to the hospital is also provided. Understanding what is abnormal can empower individuals to seek care more efficiently and reduce the risk of poor health outcomes.

 

In Pa., the Office of Child Development and Early Learning (OCDEL) is the lead agency for the Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV). OCDEL is a collaborative effort between the Pennsylvania Department of Education and Department of Human Services (DHS) focused on improving systems so all children can reach their full potential. Many of the home visiting models offered through MIECHV have specific requirements beyond poverty level and need, such as prenatal enrollment and first pregnancy, unlike the flexible enrollment requirements of the CMHDs. Many of the CMHDs have MIECHV home visiting programs administered out of the same office, which allows for collaboration and referral. The BFH requires the CMHDs to collect five outcome measures also collected by the MIECHV program to better understand the effectiveness of the CMHDs home visiting programs. The outcomes for 2024 reported by the CMHDs are as follows: 7.1% of infants were born preterm following program enrollment; 94.2% of primary caregivers enrolled in home visiting were screened for depression; caregivers were asked if they had concerns with their child’s development, behavior, and learning at 97.7% of home visits; 94.7% of caregivers were screened for IPV; and 100% of caregivers with positive screens for IPV received referral information. While the data has limitations due to the small number of families served, when compared to MIECHV data, the outcome measures for the CMHDs scored higher for all measures except caregivers asked if they had concerns with their child’s development, behavior, and learning. The CMHDs will continue to collect the five outcome measures, reporting on them annually.

 

BFH continues to monitor the home visiting services provided by the CMHDs to avoid the duplication of services while continuing to fill gaps for those not eligible for other programs.

 

In 2024, Centering Pregnancy Programs (CPP) located at WellSpan Health (WSH) York and Albert Einstein Health Network (AEHN) provided group prenatal care to 67 pregnant women. The CPP aims to improve birth outcomes as well as improve the knowledge base of the participants related to pregnancy and parenting.

 

The CPP grant for AEHN, located in Philadelphia, ended on September 30, 2024. To encourage attendance and participation, healthy food options, infant supplies, and transportation, which was identified as a major barrier, were provided to participants. Additionally, participants’ partners or family members are welcome to attend sessions. The WSH York CPP grant will continue through September 30, 2025.

 

The CPPs submitted data related to family planning and birth spacing, specifically how many adolescents, and women talked with a health care professional about birth spacing and birth control methods. Although they did not meet the ESM annual objective of 87.7%, over 86% of participants enrolled in CPPs talked with a health care professional about birth spacing and birth control methods. Delaying pregnancy allows women in Pa. the opportunity to choose when they are ready to begin or expand their families. It also affords them the opportunity to improve their own health and habits prior to becoming pregnant.

 

Interconception care (ICC) is the use of medical and behavioral interventions to address individuals’ risk factors between pregnancies, with the aim of improving future maternal and infant health outcomes. ICC has the capacity to reduce differences in maternal and infant birth outcomes. The leading underlying causes of infant mortality are low birth weight and preterm birth, factors which are often connected. By offering biomedical, psychosocial, and behavioral interventions prior to pregnancy, the influence of risk factors for adverse pregnancy outcomes, such as preterm birth, can be minimized.

 

Family physicians are ideally positioned to lead health care system change related to ICC; even parents that lack providers of their own are likely to take their infants to well-child visits (WCVs). Working within the WCV framework provides an opportunity for family health providers to address maternal health during the interconception period.

 

In 2024, the BFH continued to partner with the University of Pennsylvania and the Innovations for Maternal and Perinatal Care Improvement (IMPLICIT) Network to strengthen and expand the Title V-funded IMPLICIT ICC Program, wherein maternal screenings are conducted at WCVs. Since 2012, the IMPLICIT ICC model of care has been successfully implemented in a variety of sites in several states and is showing promising results in reducing unintended pregnancies and improving preconception health. In 2024, the IMPLICIT team worked with the March of Dimes to update the ICC Toolkit to include new evidence and workflows. The toolkit, which is freely available on the March of Dimes website, is intended to help disseminate the ICC model more broadly.

 

The effectiveness of the ICC model of care is measured by how many women are screened for modifiable maternal risk behaviors (smoking status, depression, contraception use, and multivitamin with folic acid use), and how many of those with positive screens receive either an intervention or a referral to services. In 2024, IMPLICIT programs in Pennsylvania had 16 active sites reaching 3,274 unique parent-baby dyads who may not have received care otherwise. ICC screening was performed at 5,802 of the 6,893 well-child visits where the mother was present, falling slightly shy of the ESM annual objective of 84.8%. Of the individuals that received ICC screening in 2024, 13.9% screened positive for tobacco use, 6.5% for depression, 29.6% for lack of contraception use, and 42.2% for lack of multivitamin with folic acid use. In 2024, to improve effectiveness of screening, IMPLICIT shifted the contraceptive risk screening to a more patient-centered approach.

 

Interventions for positive screens were documented at the following rates: 81.5% for tobacco use, 94% for depression, 75.5% for contraception use, and 63% for multivitamin with folic acid use. IMPLICIT surpassed grant goals for smoking, depression, and multivitamin interventions, but continued to fall shy of meeting the targeted intervention rate for contraception.

 

Studies conducted since IMPLICIT’s ICC model was implemented in Pa. continue to demonstrate the potential benefits of incorporating interconception care models into primary and pediatric care settings, particularly for pregnant and parenting teens and Medicaid-insured women. In 2024, 1,999 individuals (61.1%) that received IMPLICIT ICC screening were insured through Medicaid or uninsured, and 168 individuals (5.2%) were under age 20, indicating that IMPLICIT’s ICC screening is reaching these critical populations.

 

Community-based doulas provide pregnant women and their partners with low-cost or free education, support, and counseling during pregnancy, birth, and the postpartum period; focus on eliminating health barriers; and promoting healthy bonding between  women  and their babies. In contrast to conventional doulas, community-based doulas share the same background, culture, and language as the pregnant women they support. They also have training in community health factors that supplements the traditional doula education curriculum.

 

The Philadelphia Department of Public Health (PDPH) provides care through the Doula Support Program (DSP) to Philadelphia residents. The DSP focuses on prenatal and postpartum women with a history of a SUD, including opioid use disorder (OUD). The program utilizes a community-based doula model to offer support to enrolled individuals up until one year postpartum. Due to a rise in cases of infants born with neonatal abstinence syndrome (NAS), PDPH saw a need to design this program to serve pregnant or parenting women with substance use issues. The doulas address community health factors by discussing housing, employment, and mental health. In 2024, the program served 187 pregnant or parenting women. To foster a sense of community among program participants, the DSP holds a virtual parent group that meets twice a month to offer support and facilitate connections among program participants. The DSP held their first National Recovery Month event in September 2024 to celebrate the strength and courage of participants in the program. As of December 2024, the Community Doula Support Program had eight  contracted doulas who were trained as community-based doulas in 2024, and three of those doulas became Certified Lactation Specialists.

 

In 2024, Delaware County Health Department (DCHD) trained 41 doulas in partnership with Pettaway Pursuit Foundation, Maternity Care Coalition, and Foundation for Delaware County. Prenatal, birth attendance, and postpartum doula services were provided to 89 women. The Foundation for Delaware County had doulas participate in Black Maternal Health Week, Big Latch on events, and childbirth advocacy training. The doulas provided education, information, and self-care bags at events. The doulas participated in the Swarthmore College Black Maternal Health Doula panel. In June 2024, the doulas supported the development of a sudden infant death syndrome prevention and education series. As of June 2024, Maternity Care Coalition chose to no longer contract with DCHD. As a result, in Fall 2024, DCHD contracted with CocoLife, a project aimed to increase the awareness of doula services among pregnant and postpartum women residing in Delaware County. By offering parenting and childbirth education sessions, pregnancy and postpartum doula services, connection to social emotional resources, along with health plan and system navigation, CocoLife aims to foster stronger community connections to these crucial services, in an effort to improve pregnancy, birth, and postpartum experiences.

 

The BFH continues to work with Healthy Start Pittsburgh’s community-based doula program. The program provides culturally competent doula services to women in Allegheny and Westmoreland counties, in areas with high rates of preterm birth and infant mortality. In 2024, 121 individuals enrolled to receive services through the program.

 

Healthy Start Pittsburgh’s doula program emphasizes early, regular, and sustained doula-client visits throughout pregnancy and the postpartum period, although not all potential clients request or desire the maximum number of visits that the program offers. Of the 84 individuals that had a doula at their birth in 2024, 55% began doula services by 28 weeks gestation; 18% received doula services until 12 weeks postpartum; 20% received at least six prenatal and eight postpartum visits, in addition to labor and delivery; and 26% received at least two in-person home visits within the first two weeks postpartum. By connecting women and their families to support early in pregnancy, they are able to build a trusting relationship with their doula, and receive critical, life-saving information, resources, and self-advocacy skills.

 

Doula care improves maternal health outcomes by reducing unnecessary medical procedures that can result in serious short- and long-term complications. Of the 84 doula-supported clients, 31% delivered by cesarean section; eight percent of infants were born at less than 2500 grams and/or at less than 37 weeks gestation; and 82% of women initiated breastfeeding with their infant. In addition, of the 38 clients with diagnosed hypertension disorder of pregnancy, 100% received heart-health specific blood pressure management. Hypertension disorders of pregnancy continue to be a risk factor for maternal mortality and morbidity.

 

The nature of Healthy Start’s doula program ensures each client has a competent support person with whom they can feel safe disclosing symptoms of behavioral health crisis during pregnancy, birth, or the postpartum period, increasing opportunities for timely treatment. In 2024, 100% of doula clients were screened for depression and unmet social needs, and 100% of those who screened positive were referred to mental health or social supports.

 

In 2024, Healthy Start Pittsburgh trained 11 individuals to become doulas, including eight community members, two doulas, and one doula supervisor. In addition, as part of a doula-guided heart health research partnership with a local health institution, all Healthy Start Pittsburgh doulas completed the American College of Obstetricians and Gynecologists  Heart Health for Pregnant Patient training. The training has been added to their onboarding process for doulas, to support competency and service delivery protocols.

 

The ESM annual objective to train 4 doulas was exceeded. All doulas trained with grant funding are being supported in completing the Commonwealth’s process to become a Certified Perinatal Doula, so that their services will ultimately be eligible for Medicaid reimbursement if desired. In recent years, a state-level voluntary credential was created to establish the Certified Perinatal Doula (CPD) credential. As of March 27, 2025, Pennsylvania had 185 active CPDs. Medicaid reimbursement is anticipated to provide a critical role in the long-term sustainability of this and other community-based doula programs in Pa.

 

In 2022, 12.4% of women experienced postpartum symptoms following a recent live birth in Pa. Behavioral health conditions are often overlooked and undertreated, often leading to worsening of symptoms and potentially death. In 2020, behavioral health conditions far surpassed any other cause of maternal mortality, encompassing 45% of all pregnancy-related deaths reviewed by the MMRC.

 

The BFH understands the strong connection between physical and behavioral health and has worked to ensure that women are screened for behavioral health issues when receiving care through Title V funded programs. The BFH requires all Title V funded CMHD home visiting programs to utilize evidence-based/informed screening tools to assess behavioral health issues during the perinatal period. By doing so, the BFH aims to identify and address potentially risky behaviors or circumstances to improve pregnancy outcomes, as well as improve health for children and families in the same household. Many of the CMHDs and the CPPs use the Edinburgh Depression Scale, a validated tool comprised of ten questions that can be used in both the prenatal and postpartum periods.

 

The IMPLICIT ICC Program, mentioned earlier in this report, includes maternal depression screenings at their child’s WCVs. Women are screened, counseled, and referred for services as necessary. This initiative is focused on increasing the number of women who see their medical providers in the interconception period and changing maternal behaviors to improve overall health and birth outcomes in subsequent pregnancies.

 

Although the IMPLICIT ICC Program provides a method of screening women for four risk factors, not all women are screened for all four risk factors at every visit they attend, due to time constraints and/or needing to focus on other areas of importance. In 2024, IMPLICIT Network ICC providers completed depression screens at 4,759 (58.6%) of the WCVs in which postpartum women were in attendance; 6.5% of these screens indicated a positive risk, and interventions were provided 94% of the time. This met the 2024 grant goal of increasing the rate of depression intervention to 85% or greater.

 

Given the importance of providing follow-up services for behavioral health issues, the BFH chose to measure the percent of women enrolled in home visiting, CPP, or IMPLICIT programs that are referred for behavioral health services, following a positive screening. Warm handoff referrals, where the home visitor or health care provider assists the participant in setting up a behavioral health appointment, help to increase the likelihood that the participant will follow through with the appointment. In 2024, 90.7% of pregnant and postpartum women enrolled in the home visiting, CPP, or IMPLICIT programs were referred for behavioral health issues following a positive screening. The focus on providing referrals for behavioral health services following a positive screen helped to exceed the 2024 ESM annual target of 82.4%. Reasons pregnant and postpartum women may not be screened include refusal or early withdrawal from the program.

 

Pa., through the Pennsylvania Partnership for Children, was awarded the Pritzker Children’s Initiative Prenatal-to-Age-Three Implementation grant. The overall goal of the project is to increase the number of children and families receiving high-quality services. Research has shown healthy moms are more likely to raise healthy babies, as such, maternal health is a vital component to ensuring Pa.’s youngest children have the opportunity to succeed. This work consists of expanding access to critical services, such as health care while pregnant and the first year following birth, as well as increasing depression and anxiety screenings, and access to doula services. BFH staff sit on the Maternal Health Subgroup, which originally focused on extending Medicaid access to postpartum services, accomplished in October 2022, and advancing reimbursement for doulas in the Medicaid program, accomplished February 2024.

 

Pregnancy care has traditionally been organized into three trimesters, with a single postpartum visit at approximately six weeks postpartum. However, many postpartum concerns occur within one to two weeks postpartum. The optimal timing for postpartum visits should be individualized and person-centered occurring no later than 12 weeks from birth. In Pa, approximately 89% of respondents surveyed via PRAMS in 2022 reported having attended a postpartum checkup within 12 weeks after giving birth. The BFH will continue to monitor the rates of postpartum checkup attendance to identify trends and opportunities for intervention.

 

The “fourth trimester (4TM)” generally refers to the first three months postpartum. The mainstream maternal health framework does not provide routine care for women until six weeks after childbirth, halfway through this period. However, women experience significant biological, psychological, and social changes during this time that can lead to poor outcomes if not promptly and adequately addressed. In the weeks following childbirth, preexisting conditions and new health concerns that go unaddressed can result in the exacerbation of health issues and, in some cases, death. By ensuring individuals receive a postpartum visit in the early fourth trimester – before 28 days have elapsed – women can be connected to the care they need, and rates of maternal mortality and morbidity will decrease.

 

The IMPLICIT Network, with support from BFH, has been piloting an innovative 4TM model of care, to address gaps in postpartum care and decrease rates of maternal morbidity and mortality in the early postpartum period. The IMPLICIT 4TM model aims to identify patients who may have conditions that make them at higher risk of postpartum morbidity or mortality, such as mood concerns, obesity or wound concerns, thyroid disorders, hypertensive disorders, endocrine disorders, renal disease, or substance use disorders. 4TM providers create a postpartum registry of anyone who received prenatal care at the practice or delivered with providers in the practice and prioritizes getting patients back into the office to see their providers between seven and 21 days after delivery. Ideally, 4TM providers develop a plan for the early postpartum visit when the patient is between 28 weeks gestation and delivery.

 

4TM providers collect patient data from multiple encounters, including prenatal visits, immediately after delivery, and during the early postpartum visit. At the early postpartum visit, 4TM providers connect patients with any needed psychosocial, biomedical, and other wraparound services or referrals. 4TM screenings assess for biomedical risk (hypertension, preeclampsia, cardiovascular, diabetes, and postpartum hemorrhage) and psychosocial risk (depression, tobacco use, and substance use). In order to reduce fragmentation of care across providers and settings, providers establish a care team, which may include a primary care provider, specialty physician, lactation consultant, mental and behavioral health providers, and a case manager.

 

In 2024, IMPLICIT supported continued implementation of the 4TM model at four sites (Lancaster General Family Medicine Residency (FMR), UPMC Williamsport FMR, UPMC McKeesport FMR, and University of Pennsylvania FMR (Philadelphia)) and the addition of a fifth participating site, at UPMC Shadyside (Pittsburgh). The baseline data for the related ESM was established in 2022, with 58.2% (336) of 577 eligible women having received an early postpartum visit (within 21 days postpartum) through the 4TM program. In 2023, 81.1% (368) attended a visit within 21 days postpartum, versus 70.1% (372) in 2024. Although this fell short of the ESM annual objective of increasing the percent of individuals that receive early postpartum care by at least three percent annually, two sites (UPenn FMR and UMPC Shadyside) have experienced continued data collection and/or sharing issues, so these numbers may be lower than the actual people served through their efforts. Additional barriers to implementing the 4TM model across sites have included the lack of postpartum visits as a standard practice, and variation in screening tool implementation and utilization. The IMPLICIT Network continues to provide education, training, and technical support to all 4TM sites to assist in continued and strengthened implementation of the 4TM model.

 

The Pa. Maternal Mortality Review Program is described above. The Pa. and Philadelphia MMRCs play a critical role in reviewing deaths that occur during or within one year of pregnancy to better understand the circumstances, assess whether the death was related to pregnancy, and create actionable recommendations to prevent similar fatalities in the future. Understanding the factors that contribute to pregnancy-associated deaths is a first step in providing reasonable interventions for death prevention. In total for 2021 cases, the Pa. and Philadelphia MMRCs made 481 recommendations to improve the care of pregnant and postpartum individuals. The recommendations identify prevention opportunities grouped by priorities that mirror the Pa. Maternal Health Strategic Plan. Committee members identified opportunities for improved health outcomes with recommendations that address the patient/family, provider, facility, system, and community as groups that interact with pregnant women. The recommendations advocate for necessary improvements to decrease pregnancy-related morbidity and mortality in Pa.

 

Seven MMRC recommendations were implemented in this reporting year, exceeding the ESM annual objective of implementing one recommendation. The first recommendation, addressing the need for increased expert consultation on behavioral health, particularly SUD, was addressed through the implementation of the Perinatal TiPS pilot, which is described in detail above. Launched in December 2024 as a pilot by the Jewish Healthcare Foundation, Perinatal TiPS is a network that provides real-time behavioral health consultation for perinatal care providers. This pilot aims to enhance the ability of clinicians to identify and manage behavioral health issues such as SUD, depression, and anxiety, which are common factors in maternal morbidity and mortality in Pa. By facilitating timely, expert guidance, the Perinatal TiPS program aims to improve the quality of care and ensure that providers are better equipped to address complex behavioral health concerns in the perinatal period.

 

The second implemented recommendation, which focuses on enhancing access to support services for pregnant and postpartum women, led to a significant policy change regarding Medicaid reimbursement for doula services. Recognizing the positive impact that doulas can have on maternal health outcomes, the MMRC recommended that insurers cover doula services during the perinatal period. In response to this recommendation, the Pa. DHS began reimbursing certified doulas for their services during pregnancy and up to one year postpartum starting in January 2025. This policy change ensures mothers covered by Medicaid can access the continuous, personalized support of a doula, which has been shown to improve birth outcomes, reduce the likelihood of preterm births, and enhance overall maternal well-being.

 

Philadelphia implemented a third recommendation that addresses the need for education to be provided to the public on pregnancy and postpartum complications, warning signs, and the importance of early and ongoing prenatal care. By developing two training programs, Philadelphia, through The Organized Voices for Action (The OVA), the action arm of the Philadelphia MMRC, aims to improve public education on pregnancy and postpartum complications. The training titled “Continued Early Warning Signs of Postpartum Complications” equips individuals in both clinical and non-clinical settings with the knowledge to recognize postpartum health complications and encourage care-seeking behaviors. This one-hour session is available virtually or in-person and is co-facilitated by a Clinical Expert and a Lived Experience Expert. Additionally, the training titled “When Joy Feels Heavy: Perinatal Mood and Anxiety Disorders (PMADS)” focuses on educating those who may interact with mothers, empowering them to recognize the warning signs of perinatal mood and anxiety disorders and support individuals in seeking care. Both trainings aim to increase awareness, promote early intervention, and improve health outcomes for postpartum women in Philadelphia.

 

The fourth implemented recommendation’s focus aims to address the public health need for awareness campaigns that disseminate evidence-based information identifying and recognizing warning signs during pregnancy and postpartum for conditions such as preeclampsia, venous thromboembolism, hemorrhage, infectious diseases, and others. To ensure city-wide information is available to the community, Philadelphia launched the Severe Maternal Morbidity (SMM) surveillance program aiming to provide a report that outlines the overall rate of SMM in Philadelphia, leading indicators of SMM, and differences in SMM rates among different groups of women. In addition, The OVA created brochures, magnets and social media campaigns to educate the public. The campaigns focused on three different topics that impact maternal mortality: IPV, postpartum depression, and early warning signs of post-birth complications. According to the IPV campaign report, nearly 200,000 Philadelphia women saw the campaign in their social media feeds an average of 5.5 times and 43.5% of ad clicks came from women ages 18-34.

 

The fifth implemented recommendation sought to address that healthcare systems need to develop meaningful collaborations with local IPV programs. These collaborations need to include education for providers on the unique intersection of IPV and pregnancy, including strategies for screening and responding to disclosures. In response to this need, Philadelphia implemented the “IPV Implementation Team- Transforming Philadelphia’s Response to IPV and Sexual Violence in Obstetric Settings”. This initiative seeks to enhance the capabilities of local delivery hospitals and emergency departments to effectively identify and respond to IPV and sexual violence, while also establishing infrastructure for a sustainable, city-wide coordinated response to IPV.

 

The sixth recommendation, that focuses on systems, stressed the need for payors to make funding available for community-based organizations (CBOs) that provide mental health, substance use, and IPV services to engage in screenings and respond to all needs related to community health factors. The Community Investment Implementation Team in The OVA, which plans to continue support of CBOs in Philadelphia with a new round of mini-grants totaling $20,000, aim to strengthen community-based maternal health efforts. Funding CBOs aims to empower local community members with the knowledge and skills needed to improve maternal health outcomes by encouraging health-seeking behaviors among women in their networks.

 

The final implemented recommendation came from the Pennsylvania Perinatal Quality Collaborative (PA PQC) which is considered the action arm for clinical MMRC recommendations. In response to the MMRC’s recommendations, the PA PQC led OUD, NAS, and sepsis quality improvement initiatives across 76 hospitals in Pa. in 2024 and sustained the immediate postpartum long-acting reversible contraceptive quality improvement initiative. Ninety percent of pregnant women were screened for substance use. Twenty-six hospitals had a system to provide naloxone to patients at-risk for substance use prior to discharge, which was an increase in hospital participation from 2023. As part of the PA PQC’s OUD and NAS initiatives, the PA PQC organized trauma-informed trainings and workshops for eight hospitals in partnership with The Empowerment Equation and the PA Coalition Against Domestic Violence. The number of hospitals with a trauma-informed protocol in place increased from three hospitals in 2022 to 12 hospitals in 2024.

 

Together, these initiatives represent crucial steps forward in addressing the multifaceted needs of pregnant and postpartum women, with the goal of reducing maternal mortality and promoting healthier pregnant and postpartum women across the state.

 

Effective collaboration and coordination are important to create a high-quality system of support for women and families in Pa. Collaboration across agencies and programs ensures better coordinated services and reduces the duplication of services across agencies. BFH staff met the ESM annual objective of convening with DHS and MIECHV quarterly in the 2024 calendar year. The intent of these meetings is collaboration among agencies to understand the programs and initiatives offered through the systems of care for pregnant and postpartum women in Pa. This knowledge and understanding aids in the development of gap filling programs offered through Title V.