Women/Maternal Health- Annual Report

Improving the domain of Women's/Maternal Health is crucial to the State Priority Need of Increasing Equity in Healthy Births (SPN #1) and the National Outcomes Measures (NOMs) 2, 3, 4, 5, 6, 8,9.1, 9.2, 9.3, 9.4, 10, 11,23 and 24.  The selection of NPM #1 (Well Women Visits) during the Five-Year Needs Assessment process recognizes the impact the life course approach will have on increasing healthy births and improving women's health across their life span. The Life Course Perspective to conceptualizing health care needs and services evolved from research documenting the impact of life events on the developing psyche, from birth through adulthood, and how the cumulative experience of these events contributes to the ultimate shaping of an individual’s health trajectory. The interplay of risk and protective factors, such as socioeconomic status, toxic environmental exposures, health behaviors, stress, and nutrition, influence health throughout one’s lifetime. NJ has prioritized improving women's health and has utilized several evidence-based strategies to increase preventive medical visits (NPM #1) including the HWHF, MIECHV, FIMR, and Maternal Mortality Review. The Murphy Administration has placed additional emphasis on reducing maternal mortality and morbidity through the Nurture NJ Initiative.

3.e.2.c.2.a - Annual Report - NPM #1 (Percent of women with a past year preventive medical visit)

Data Source: Behavioral Risk Factor Surveillance System (BRFSS) in NJSHAD. Visited a Doctor for a Routine Checkup in the past year (Age-adjusted).
** Data not available

Evidence-Based Informed Strategy Measure (ESM) 1.1 (Increase First Trimester Prenatal Care) was selected for its positive impact on National Performance Measure (NPM) #1 (Well Women Care) and State Performance Measure (SPM) #1 (Increasing Healthy Births).

In 2021, the overall percentage of adequate prenatal care based on the Kotelchuck Prenatal Care was 71.2%. However, racial/ethnic disparities are observed. Specific race/ethnicity-related rates for adequate prenatal care for 2021 were 77.6%, 60.7%, and 64.6% for White NH, Black NH, and Hispanic individuals, respectively. These existing disparities align with the need for TVP to improve NPM #1 by focusing on preconception care and early prenatal care. Improving access to prenatal care is essential to promoting the health of NJ mothers, infants, and families. Early and adequate prenatal care is an important component of a healthy pregnancy and birth outcome because it offers the best opportunity for risk assessment, health education, and the management of pregnancy-related complications and conditions. Prenatal care is also an opportunity to establish contacts with the health care system and to provide general preventive visits.

Moreover, preconception care is a critical component of prenatal and health care for all women of reproductive age. NJ has a targeted focus on preconception care through the family planning program. The NJ family planning grant delivers essential primary and preventative health care to patients. NJ’s family planning providers provide a full range of reproductive health and family planning services, including contraceptive counseling and provision; education, testing, and treatment for sexually transmitted infections; screenings for breast and cervical cancers; and other sex education. In the fiscal year 2023, additional funding was appropriated for abortion services and support to cover uncompensated costs, practical support, and a statewide needs assessment.

The main goal of preconception care is to provide health promotion, screening, and interventions for women of reproductive age to reduce risk factors that might affect future pregnancies. Given the relationship between pregnancy intention and early initiation of prenatal care, assisting women in having a healthy and planned pregnancy can reduce the incidence of late prenatal care and promote NPM #1 (Well Women Visits).

Through the HWHF initiative, TVP uses CHWs, postpartum doulas, and partners with Connecting NJ to focus on improving maternal and infant health outcomes, including women's health with preventive medical visits, preconception care, prenatal care, inter- conception care, preterm birth, low birth weight, and infant mortality. The primary focus of Connecting NJ is to assist pregnant people, caregivers (mothers, fathers, grandparents, kinship, foster parents, legal guardians), and young children (birth to five) in efficiently accessing the most appropriate services, with more than 80% of referrals made for pregnant women. On the Connecting NJ portal, reported data include but are not limited to health status, diagnosis, socio-demographic characteristics, and more.

TVP staff have access to data collected on this secure system. Connecting NJ is designed to simplify the referral process, improve care coordination, provide developmental screening, and ensure an integrated maternal, infant, and early childhood care system.  From July 1, 2018, to March 1, 2024, more than 111,420 pregnant individuals have been screened and there have been over 79,860 service referrals offered to these individuals. To better align the ESM with our current initiatives, ESM 1.2 (Number of individuals trained to become community-based doulas) was selected for its positive impact on National Performance Measure (NPM) #1 (Well Women Care) and State Performance Measure (SPM) #1 (Increasing Healthy Births).

In 2021, an RFA was issued to create a NJ Doula Learning Collaborative, which was awarded to Health Connect One. The Doula Learning Collaborative (DLC) focuses on reducing maternal and infant mortality and eliminating racial disparities in health outcomes by providing training, workforce development, supervision support, mentoring, technical assistance, direct billing, and sustainability planning to grow the community doula workforce.

To date, almost 300 individuals have been trained to become community doulas, and as of April 2024, 767 births have been supported by NJ’s trained community doulas. Preliminary results from an evaluation conducted by researchers from Montclair State University in 2021 for the 3-year Doula Pilot Program indicate that positive birth and/or pregnancy outcomes (e.g., lower rate of cesarean deliveries, increase in breastfeeding rate) are linked to community doula services.

A mixed-methods outcome evaluation was conducted to examine the outcomes and benefits of the Doula Pilot Program as measured by quantitative data (i.e., program data from the Maternity Neighborhood database) and qualitative data (i.e., interviews with program stakeholders). Program outcomes and benefits were observed at three stakeholder levels: 1) client, 2) doula and grantee agency, and 3) NJDOH and state system levels (Figure 15).

Several actionable recommendations have emerged from the evaluation project on how to improve the implementation and outcomes of ongoing efforts related to the Doula Pilot Program. Overarching recommendations are provided, and specific actions that multiple stakeholder groups may take are offered to provide targeted guidelines for program improvement. The recommendations emphasize collaboration across stakeholder groups and are mutually reinforcing. To ensure the sustainability of community doula services in NJ, TV staff worked collaboratively with Medicaid to offer community doula services to women through NJ FamilyCare benefits. NJ FamilyCare Medicaid benefits have been expanded to cover community doula services. Presently, a doula can serve birthing people whom NJ FamilyCare covers as a covered benefit. In addition, NJDOH’s TVP works collaboratively with private funders in the state, including the Burke Foundation, to offer complementary doula training and apprenticeship programs.

Figure 15. Program Outcomes Across Clients, Doula and Grantees Agencies, NJDOH, and State Systems

Moreover, TVP established the Collette Lamothe Galette-Community Health Worker Institute (CLG-CHWI) through a NJ Department of Labor Apprenticeship program to infuse additional services in the communities. TVP collaborates with community colleges throughout the state to create a standardized community health worker training and certification program, resulting in a robust CHW workforce. This apprenticeship opportunity has allowed the state to educate an emerging and critical component of its workforce – creating a needed infrastructure to support CHWs, enhance CHW skill sets, and lead sustainable efforts to support this indispensable workforce. Graduation of the initial cohorts has already begun, with new cohorts continuously being enrolled, with over 600 CHWS trained through the CLG-CHWI thus far.

Moreover, CHWs and their supervisors, through Title V grantees, have received and continue to receive breastfeeding education. This unique training focused on women of color and was developed to address health disparities related to reproductive justice. Breastfeeding support is also being provided by International Board-Certified Lactation Consultants (IBCLC) either in groups or in one-to-one sessions.

The programs being implemented in the communities through the HWHF initiative allow TVP to implement specific activities to support communities with limited public health resources.  Additionally, the programs focus on the highest need where impacts will be greatest to improve population health outcomes and reduce health disparities. The HWHF Initiative addresses the disparities in birth outcomes through case management and assures that appropriate referrals are made and tracked including medical care referrals to promote NPM #1 (Well Women Visits).

To ensure that the HWHF initiative is successful, NJ TVP collaborates with the NJDOH Office of Population Health and the Population Health in Action Teams. Through this collaboration, TVP established linkages with sister agencies (Department of Labor, Department of Education, Department of Transportation, etc.) and sought to address some of the barriers that exist in the scope of social determinants of health. Additionally, efforts to reduce maternal mortality and morbidity have been and continue to be developed under First Lady Tammy Murphy’s Nurture NJ Initiative, whose goal is to “make NJ the safest place to give birth in the country.”

Annual Report - NPM #14:

Percent of women who smoke during pregnancy and Percent of children who live in households where someone smokes.

The adverse effects of parental smoking and vaping on children have been a clinical and public health concern for decades, first formally documented in the 1986 U.S. Surgeon General’s Report and ever since in public health and medical scholarship. Unfortunately, millions (more than 60%) of children are exposed to secondhand smoke in their homes. These children have an increased frequency of related hospital admissions during infancy; severe asthma and asthma-related problems; lower respiratory tract infections leading to 7,500 to 15,000 hospitalizations annually in children under 18 months; and sudden Unintended infant death (SUID). As a result of the many health consequences, the health costs of smoking during pregnancy are significant. Excess prenatal care costs and complicated births among pregnant women who smoke exceed $4 billion a year. (See NJ Pregnancy smoking rates in table below). It has been estimated that a 1% drop-in rate of smoking among pregnant women could result in savings to the US of $21 million in direct medical costs in the first year. Another $572 million in direct costs could be saved if the rates continued to drop by 1% annually over seven years. Secondhand smoke also has significant health effects on an infant.

Pregnant women exposed to secondhand smoke have a 20% increased risk of delivering an infant of low birth weight, and secondhand smoke exposure also increases the risk of infections in the infant possibility of death from SUID. Children living with smokers/vapers are also more likely to have more frequent and acute asthma attacks, ear infections, and serious respiratory illnesses like pneumonia and bronchitis due to second and third-hand smoke exposure (See NJ exposure in Table B below). The cost to care for childhood illnesses resulting from exposure to second and third-hand smoke is estimated at $8 billion annually. In addition to the effects during the perinatal period, health consequences for older children and adults (whether from direct smoking or second /third-hand exposure) are well documented in the literature and include respiratory infections, cancer, and death.

Perinatal Risk Assessment Data

*Majority of assessments completed by Medicaid recipients and not representative of the state overall

Initiated in 2001 with funding from the NJDOH-Comprehensive Tobacco Control Program, Mom’s Quit Connection (MQC) is NJ’s maternal child health smoking cessation and education program. Changes have occurred in service provision as the capacity of the statewide program has been based on availability of funds. MQC utilizes a proactive behavior modification model, offering face-to-face individual cessation counseling, telephone counseling, and texting support to assist clients in developing a customized quit plan. Through these direct services, both for consumers and professionals, MQC focuses on reaching the women and family members who need help to quit. They educate them about tobacco use's dangers and offer judgment-free, evidenced-based treatment methods by Nationally Certified Tobacco Treatment Practitioners and NJ Certified Tobacco Treatment Specialists.

The program was expanded during FY 2015 and Mom’s Quit Connection (MQC) developed a multi-pronged and comprehensive statewide approach to perinatal smoking cessation activities.

The new activities include:

• Promoting Mom’s Quit Connection (MQC) to further expand its reach to pregnant and parenting individuals in NJ.
• Increasing Mom’s Quit Connection's capacity with direct services for pregnant and parenting individuals statewide.
• Preventing relapse after delivery.

Additional Goals and Objectives of the program:

By June 30, 2024, train 150 clinicians to utilize the AAR Brief Intervention Model to identify tobacco users and refer birthing people, parents, and family members to MQCF/Quit for Kids and achieve a minimum 80% average confidence in utilizing the AAR model at the post training survey.

By June 30, 2024, provide education and encourage smokers to enroll in MQCF. This can include in person events, as well as print, digital, and social media education distribution about the dangers of tobacco exposure during pregnancy and the risk of second and third hand smoke or vapor exposure for infants and children.

In January 2018, the MQC database software program was redesigned and upgraded to a web-based system using the Salesforce platform to support more detailed reporting and integration of planned mobile technology. Given the declining rate of maternal smoking and the stagnant and, in some cases increasing numbers of postpartum women returning to smoking after delivery, MQC chose to rebrand to MQC for Families. According to PRAMS Briefs published by the NJDOH, living with other smokers represented the most prevalent indicator for postpartum relapse. Expanding the program to MQC for Families has enhanced its cessation population parameters to include parents and caregivers of children under 8 years old along with the pregnant woman to address not only the individual smoker but all smokers in the home environment. Helping clients quit smoking and vaping is a harm reductive effort that positively impacts all in the home. Multi-level interventions are standard, including mailing self-help materials, phone calls, texting, and direct individual cessation services. Relapse prevention interventions are an important part of the program to address the high relapse rates post-partum.

MQCF staff offer Orientations about the MQCF and the Quit for Kids programs to providers. These Orientations discuss program parameters, referral options and the cessation resources available, to help attendees successfully implement these programs as a resource for Smoking Cessation services in their organizations. Almost 1,200 professionals have been served this year to date (July 2023 – Jan 2024).        

MQCF's presence on social media remains strong. A total of 574 users visited the MQCF website, with 451 of them unique/new users. The website continues to be a source of referral to the program, with 9 online self and provider referrals this quarter. Through the connection with FindHelp.org, 13 individuals received information on MQCF services and through its website. Every effort is being made to continue social media outputs, which is the least expensive media venue.  MQCF information and website are also now included on the Tobacco Free for a Healthy New Jersey (TFHNJ) monthly infographic. Viewers can click on the MQCF/QFK information, and the link will take them to the website. MQCF program information and tobacco use during pregnancy information are also included on the Prematurity Prevention Initiative (PPI) website and Facebook pages. Staff work closely with PPI staff to post information as well as referral options to MQCF. There was a total of 349 users to the PPI website, with 247 new users. 560 pages were viewed on the PPI website. The PPI Facebook page had a post reach of 433.

MQCF staff discuss the tobacco resources available on the SNJPC Resource Webpage, and best ways to monitor and update the listings. This site provides an order form to select tobacco resources, and these are then mailed to the provider.  The site was updated to include a revised flyer in both English and Spanish of MQCF programs which provides a QR code to the MQCF website, as well as a smoking and diabetes MQCF brochure. From July 2023 to January 2024, MQCF had 1,549 completed client contacts, including phone, text or in-person session, counseling introductions, intakes, and providing materials. MQCF continues to offer Client Education through Zoom and In-person by request. So far this year, MQCF staff conducted 12 Formal Client Education programs with 175 participants and 9 Informal Client Education programs with 296 participants. MQCF attended 22 Health Fair/Community Partner Events with 622 participants.     

Tables NPM 14A & B:

Percent of women who smoke during pregnancy (last 3 months)

Notes - Data is from the NJ PRAMS Survey

Percent of children who live in households where someone smokes:

Data Source: National Survey of Children's Health (NSCH)