For reporting year 2020, the Bureau of Family Health (BFH) conducted activities in the Women/Maternal Health domain through Title V funding only and did not have additional federal or state funding to support these services. Taking into consideration the overall population needs and current partners, 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.

 

In 2019, there were over six million women living in Pennsylvania (PA). The racial composition of this population is 81% white, 12% black/African American, four percent Asian/Pacific Islander and two percent multi-race. Eight percent of women living in PA identify as Latinx. Several factors contribute to poor maternal and infant outcomes and particularly disparate outcomes for black/African American birthing people and babies. These factors include systemic racism, substandard housing, unsafe neighborhoods, stress, mental health issues, tobacco, and other substance use as well as intimate partner violence (IPV). Mental health, substance use (including substance use during pregnancy) and IPV have particularly negative consequences on a family. Between three and nine percent of birthing people experience IPV during pregnancy, which has been shown to increase the incidence of depression and substance use. Additionally, research has shown that birthing people abused during pregnancy are twice as likely to miss prenatal care appointments or initiate prenatal care later than recommended, supporting an association between insufficient prenatal care and adverse birth outcomes, including preterm delivery and low birth weight. Nationally, about five percent of pregnant people use illicit substances and one in ten birthing people experience symptoms of postpartum depression.

 

The COVID-19 pandemic has resulted in a host of additional challenges for birthing people in PA. Preliminary data suggests that birthing people – particularly individuals of color – have experienced disproportionately higher rates of mental health concerns and substance use disorders, while simultaneously facing reduced access to supports for IPV and behavioral health needs in comparison to pre-pandemic life. While comprehensive evidence is not yet available to conclude that the rate of IPV has increased during COVID-19, the pandemic has exacerbated traditional IPV risk factors. In addition, reports from maternal health advocates have indicated that pregnant individuals have experienced reduced access to doula care and family supports before, during, and after childbirth, due to hospital policies related to COVID-19 as well as the difficulty of providing in-person care while ensuring the health and wellbeing of all parties. Finally, birthing people with children have faced challenges due to school closures, hybrid in-person/virtual school schedules, lack of childcare, job insecurity and other economic factors. Although most of these issues – behavioral health concerns, access to timely and quality supports, childcare, and employment and economic security – have historically been an issue for at-risk populations, including pregnant and postpartum people, the increased prevalence of these concerns over the course of the pandemic, coupled with reduced access to services and supports, may have serious long-term consequences. For example, pregnant and postpartum people may be more likely to engage in unhealthy behaviors, such as increased drug or alcohol use, to cope with the stress of the pandemic; this uptick may be reflected in maternal and infant health outcomes over the coming months and years. The Department of Health (DOH) has attempted to address some of these concerns by establishing a Pregnant Women/Young Children subgroup of its interdepartmental COVID-19 Health Equity Response Team, and by direct communications with hospital systems and other maternal healthcare providers regarding the importance of ensuring doula access for pregnant and laboring people during the pandemic.    

 

Another increasingly challenging issue is that of maternal mortality and morbidity. Maternal mortality and morbidity are on the rise in the United States, with black/African American birthing people being most at risk for poor maternal health outcomes. The disparity between black/African American birthing people and white birthing people is unsettling, with black/African American birthing people three times more likely than white birthing people to die from pregnancy-related causes. Past and present experiences with racial discrimination shape black/African American patients’ interactions with their medical providers, and racism, stereotypes, implicit bias, and mistrust continue to interfere with care.

 

Despite pervasive racial disparities in maternal deaths, public attention has only recently focused on this issue as a public health crisis. Information and education regarding the incidence, causes and prevention recommendations regarding racial disparities among maternal deaths must be shared with health providers and the public to reduce the risk factors associated with these deaths. The Maternal Mortality Review Committee (MMRC), a requirement of the Maternal Mortality Review Act, will serve as the formal process to investigate the causes of death in this population and develop prevention strategies. The MMRC is made up of committee members from across the commonwealth in various specialties as laid out in the legislation, enacted in 2018. The committee includes obstetricians, maternal fetal medicine specialists, a certified nurse-midwife, an addictions medicine specialist, specialized gynecologic psychiatrists, social workers, coroners, an emergency medicine physician, and community voices such as home visiting programs. This expanse of knowledge and expertise will provide medical and clinical guidance, as well as a focus on social determinants of health, as the committee works to aid in eliminating racial bias and health inequity in the state. In 2019, the MMRC began reviewing maternal deaths from 2018. However, due to the complexity of the cases, staffing challenges, and the fact that all pregnancy-associated deaths in the commonwealth are included, regardless of cause, as well as challenges with COVID-19, all cases have not yet been reviewed. Due to reorganization within the DOH the MMRC will be changing leadership and be relocated to the BFH. Program staff are hopeful that this move will allow for positive changes that will help PA resolve the backlog of cases, and determine recommendations based on the present-day health system and the challenges currently facing birthing people in society.

In 2018, the rate of maternal mortality in the United States was 17.4 deaths per 100,000 births. In PA in 2018, the maternal mortality rate was 14 pregnancy-related deaths per 100,000 live births, based on data from the National Center for Health Statistics. While the PA rate is lower than the 2018 national rate there is much room for improvement, particularly within the disparities associated with maternal mortality. Vital statistics data for all pregnancy-associated deaths (deaths occurring within one year of a pregnancy) indicated that Black/African American birthing people accounted for 23% of deaths in PA from 2013 to 2018, while only accounting for 14% of births during this period. Of the deaths with payment information for the birth, 53% of the births were paid by Medicaid, while only 32% of all births during this period were paid for by Medicaid. Further, nearly half of the deaths from 2013 to 2018 occurred among birthing people who did not receive adequate prenatal care. All these factors together show a stark racial divide. Additionally, accidental poisoning, which includes drug-related overdose deaths, accounted for 30% of deaths from 2013 to 2018; it was also the leading cause of death among both black/African American and white birthing people in PA from 2013 to 2018.

The preconception and interconception periods are times when having access to a trusted health care practitioner is valuable, and that present opportunities for important conversations to occur. Data analyzed through Pregnancy Risk Assessment Monitoring System (PRAMS) surveys suggest that when birthing people have a health care practitioner talk to them about health issues, there is recognition and value in those conversations as preventative measures or interventions. Pregnancy and the postpartum period present a window of opportunity for home visitors, obstetricians, pediatricians and other providers to assess and take steps to improve both the physical and mental health of birthing people and families, if the providers are able to connect with and gain the trust of the birthing people they are serving.

 

Unhealthy birth outcomes, such as low birth weight and preterm birth, are influenced by many factors both before and during pregnancy. Preconception care allows birthing people to talk to their provider about steps to take to promote a healthy pregnancy before conception or implement strategies to delay pregnancy. It also opens the door for early entry into prenatal care. Prenatal care continues to be a crucial method in identifying health issues throughout pregnancy, allowing for early intervention and healthier birth outcomes. Additionally, pregnancy intention is associated with several health outcomes. Studies indicate that unintended pregnancies are associated with a plethora of adverse physical health, psychological, economic, and social outcomes which impact birthing people, their families and society. The BFH focuses on preconception and interconception care and uses programming to provide tools and resources to the birthing people and families served by Title V. By implementing interconception and preconception care initiatives, the BFH intends to positively influence birth outcomes.

 

In 2019, 74.2% of all birthing people in PA received prenatal care in the first trimester. Of those who received prenatal care in the first trimester, 77.9% of birthing people were white, 64.2% of birthing people were black/African American, and 65.4% of birthing people were Latinx. Racial disparities are evident and continue to persist with 1.1% of white birthing people, five percent of black/African American birthing people and 3.7% of Latinx birthing people receiving no prenatal care. The BFH consistently ensures that services provided by Title V address the prevalence of disparities among specific at-risk populations that experience social and economic disadvantages related to race, ethnicity, sexual orientation, disability, mental health, immigration status or geographic location. These populations are often faced with discrimination and generally have poorer health outcomes. The BFH is working to address racial disparities by requiring that all grantees who serve Title V populations annually develop and implement a plan to identify, address and eliminate health disparities in their communities. Health disparities plans across grantees vary significantly and are dependent on the population being served. Several of the County Municipal Health Departments (CMHDs) have focused their plans around providing culturally appropriate materials and adequate interpreter services to better serve the diverse populations in their communities. Many CMHDs serve refugee populations and are dedicated to finding the best way to provide culturally relevant services to participants.

 

Home visiting programs have achieved positive outcomes in reducing the incidence of low birthweight babies and repeat pregnancies. These programs have also resulted in improved child development and increased immunization rates. Beginning in July of 2020, the Department of Human Services (DHS) expanded home visiting services for all first-time mothers and at-risk mothers covered by Medicaid. These services will be provided in collaboration with the physical health Medicaid managed care organizations (MCOs) and numerous CMHDs are in negotiations with MCOs to provide these services. The MCOs refer the expectant or parenting mother to an evidence-based or evidence-informed maternal home visiting program who will complete the assessment and determine the needs of the family. Further, the parent can elect to be enrolled in the program even if it’s her third or fourth child. DHS is still working to evaluate the first year of this program. BFH staff will continue to work with DHS to collaborate and ensure services are not duplicated between agencies. 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). 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. In 2019, the BFH made it a requirement that the CMHDs collect five outcome measures also collected by the MIECHV Program. This initiative was implemented to have a better grasp on the effectiveness of the CMHDs home visiting programs as compared to the MIECHV Program. The outcomes for the initial six month collection period reported by the CMHDs were as follows: 9.7% of infants were born preterm following program enrollment; 76.7% 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 93% of home visits; 69.4% of caregivers were screened for IPV; and 94.9% of caregivers with positive screens for IPV received referral information. Once data has been collected for an entire year, BFH staff will compare to the MIECHV outcomes. The CMHDs will continue to collect the five outcome measures, reporting them on a yearly basis.

 

Priority: Adolescents and women of child-bearing age have access to and participate in preconception and interconception health care and support

 

NPM 1: Percent of women, ages 18 through 44, with a preventive medical visit in the past year

 

Objective 1: Annually increase the percent of adolescents/women who talked with a health care professional after delivery about birth spacing or birth control methods

 

Objective 2: Annually increase the percent of adolescents/women who are engaged in family planning after delivery

 

ESM: Number of women served through evidence-based or -informed home visiting

 

ESM: Number of families served through Centering Pregnancy Program

 

ESM: Percent of adolescents/women engaged in family planning after delivery

 

ESM: Percent of adolescents/women who talked with a health care professional about birth spacing/birth control methods

 

The BFH continued its partnership with the CMHDs to provide local services to residents in their communities. The ten CMHDs are in Allegheny County, Allentown City, Bethlehem City, Bucks County, Chester County, Erie County, Montgomery County, Philadelphia County, Wilkes-Barre City and York City. Each of these locations is affected by poverty, racial and health disparities and greatly benefit from the maternal and child health (MCH) services provided. 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 to provide services across a wide range of physical health, mental 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 and to reduce health disparities among at-risk and underserved populations served by the CMHDs. The CMHDs provide preconception and interconception care, home visiting, and smoking cessation programs, among others, to improve the health of families. In 2020, 1,161 pregnant and birthing people were served through CMHDs home visiting programs, below the annual goal of 1,800. As of a result of COVID-19, the number of pregnant and birthing people enrolled in and served by home visiting programs decreased due to discontinuation of in-person visits in response to stay-at-home orders, adjustment to connecting virtually, and CMHDs emergency response to the pandemic. In addition, particularly early in the pandemic, many CMHDs nurses were called upon to work on COVID-19 programming within their county or municipality, reducing the number of staff available to carry out Title V program activities. Program numbers typically fluctuate annually due to the number of families enrolled, nurse capacity and other factors. 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, mental, or emotional challenges pregnant and birthing people may be experiencing, as well as issues within the home, such as IPV, substance use, and social or financial problems.

 

Each of the 10 CMHDs home-visiting programs serve prenatal and postpartum birthing people and their infants. 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 for pregnancy, immunizations, birth control and family planning, parenting techniques, and breastfeeding.

 

Despite continued efforts to educate birthing people about the health benefits of services for themselves and their babies, barriers to delivering services remain. Challenges presented include birthing people refusing services, excessive missed appointments, staff turnover, and language barriers. Several of the CMHDs were unable to fill vacant home visiting-related positions because of COVID-19 hiring freezes enacted by counties and municipalities. Additionally, high-risk families that face multiple challenges related to young age, single parenting, lack of parenting education, lack of family support, social and emotional issues, intellectual disabilities, and substance use were most likely to leave home visiting programs early or discontinue services. The CMHDs continually work to identify and address these issues among their patients.

 

In 2019, the Philadelphia Department of Public Health (PDPH) developed the Doula Support Program (DSP). The DSP focuses on low-income prenatal and postpartum people with a history of a substance use disorder (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 specifically serve pregnant people with substance use issues. The program, which began in 2020, falls under the 2021-2025 State Action Plan strategy to implement community-based, culturally relevant maternal care models and will be described in more detail in the Application section. Due to COVID-19, in person visits with doulas had to be changed to virtual connections with program participants and the program was only able to serve four people in the first year. Of these participants, 25% identified as black/African American, 50% identified as Latinx and 25% identified as Native American or other. 100% of program participants were covered by Medicaid. To foster a sense of community among program participants, the DSP started a virtual bi-monthly parent group to offer support and facilitate connections among program participants.

 

Numerous CMHDs utilize the One Key Question® initiative developed by the Oregon Foundation for Reproductive Health. One Key Question® is a pregnancy intention screening tool used to decrease unintended pregnancies and improve the health of wanted pregnancies. It was designed to proactively address some of the root causes of poor birth outcomes and disparities in maternal and infant health and is used to open a dialogue with patients to identify pregnancy intention within the next year. As nearly half of all pregnancies are unintended, this initiative allows the CMHDs to educate and develop a reproductive life plan with the individuals they serve. The initiative helps individuals to choose when they are ready to begin or expand their families.

 

Additionally, reproductive health planning helps individuals obtain optimal health before pregnancy, leading to healthier birth outcomes. However, limited research suggests that changing the wording of the question may increase its effectiveness. Asking the question, “Can I help you with any reproductive health services today, such as birth control or planning for a healthy pregnancy?” reflects patients’ preference for being offered services without needing to identify or specify their reproductive life plan or pregnancy intentions. BFH staff will explore and discuss this option with CMHDs that utilize the One Key Question® initiative. The One Key Question® initiative helps the BFH meet its objectives around family planning and birth control. In 2020, 148 individuals were screened by the CMHDs using the One Key Question® and engaged in conversations with their provider about pregnancy intention and birth control.

 

The BFH continued its partnership with two hospitals, Lancaster General Hospital (LGH) in Lancaster City and Albert Einstein Medical Center (AEHN) in Philadelphia County, to provide Centering Pregnancy Programs (CPP). AEHN CPP Grant ended in June 2020. LGH and AEHN both struggle with high rates of low birth weight babies and racial disparities in infant health outcomes. In Lancaster City from 2017-2019, 9.2% of infants were born with a low birth weight; for the same period, 11.1% of babies born in Philadelphia County had a low birth weight. Both rates are higher than the overall percentage for that period in PA of 8.4%. Among Lancaster City and Philadelphia’s black/African American populations, 13.1% and 14.7% of babies, respectively, were born with a low birth weight. PA’s overall rate in that period was 14.1%. The CPPs in these areas aim to improve birth outcomes as well as improve the knowledge base of the participants related to pregnancy and parenting.

 

LGH also administers a group specifically for pregnant people with substance use disorder (SUD). Sessions are facilitated by a Licensed Social Worker who is certified in addictions counseling. The group follows the traditional CPP model of prenatal care but incorporates education specifically related to SUD and pregnancy, such as how to calm an infant going through withdrawal, stress management, and what to expect if your infant must stay in the Neonatal Intensive Care Unit. In 2020, 30 pregnant people enrolled in the SUD CPP group Challenges to participation included fear of stigma and Children and Youth services involvement, transportation issues, and scheduling conflicts with counseling and medication dosing appointments. However, despite challenges, the program continues to be successful with 100% of participants reporting satisfaction with their care. Due to isolation because of COVID-19, the SUD CPP group had an increase in referrals, with staff making more frequent contact with participants to provide additional support surrounding anxiety and higher likelihood to relapse. Combined, these programs served 248 families with a continued emphasis on improving birth outcomes and reducing disparities among at-risk populations in Lancaster City and Philadelphia County. Of those served, 47% were white, and 38.7% were black/African American, with 26.8% of participants identifying as Latinx. Program outcomes were positive. LGH saw higher than expected rates for full-term births with 92.5% of their participants delivering at full term.

 

Breastfeeding rates were also positively affected by the CPPs, with 86% of participants breastfeeding at birth versus 76% of birthing people prior to the implementation of the CPPs. CPP participants were screened for depression and referrals were made to mental health professionals as necessary. The CPPs had high patient satisfaction rates, with LGH reporting that 100% of birthing people that completed the program were satisfied with the experience. Additionally, a Request for Application (RFA) was posted in May 2020 for current CPP to expand their established programs in more focused areas or populations depending on the communities they serve. Potential expansion areas for the RFA included, but were not limited to, better serving disparate populations or birthing people with SUD, and increasing access to health care services such as transportation, mental health counseling, or dental care. The two awarded applicants were AEHN, who will focus on behavioral health screenings and referrals, and WellSpan York, who will serve their Spanish-speaking population by offering culturally and linguistically relevant group prenatal care. The BFH did not meet its goal of serving 350 families through CPP; however, the BFH anticipates that when the new grantees have fully implemented their expanded CPP, the goal will be met in the coming years.

 

The CMHDs and CPPs submitted data related to family planning and birth spacing. Currently, 82.6% of birthing people of child-bearing age, including adolescents, being served through these programs are engaged in family planning after delivery, not meeting the goal of 84%. However, 88% of birthing people talked with a healthcare professional about birth spacing/birth control methods exceeded its goal of 84% for this objective. Delaying pregnancy allows birthing people 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.

 

The BFH continued its partnership with the Alliance of Pennsylvania Councils, Inc. (Alliance) in an initiative to reduce the rate of unplanned pregnancies in birthing people with opioid use disorder (OUD). The unintended pregnancy rate for birthing people with OUD is 86% compared to the national average of 45%. Unfortunately, due to the rise of unintended pregnancies in birthing people with OUD, the number of infants affected has increased. According to the DOH’s Neonatal Abstinence Syndrome: 2018 Report: a total of 2,140 PA infants were diagnosed with opioid related NAS after birth. The Alliance is currently comprised of three family planning councils, each serving a region within PA. A fourth council, located in Western PA, has since ceased its participation in the Alliance and this initiative. Due to the diversity in the population of PA, each region was tasked with developing a pilot program to serve specific needs in the region. Projects include training behavioral health providers to assess pregnancy intention and contraceptive needs, facilitating access to family planning services for people in treatment facilities, conducting screenings in schools to identify youth in need of services, and educating communities about addiction. As a result of this initiative, in 2020, 783 birthing women with OUD received services and 36 behavioral health providers were trained in the ability to assess for pregnancy intention. In addition, 1,358 men with a substance use disorder (SUD) received limited scope contraceptive care and sexual and reproductive health education from the Alliance to improve men’s preconception health and reduce rates of unintended pregnancy. Due to the COVID-19 pandemic, the Alliance experienced challenges in providing in-person services, counseling, education, and training throughout 2020, resulting in lower numbers served than initially anticipated. Although efforts are being made to engage populations of color through this initiative, across the state, the majority of clients served by this program are white (75.1%); however, the percentage of white clients ranges between the pilot projects, from a minimum of 39.1% to a maximum of 82%. Overall, the program population is slightly less majority-white than the state of PA (75.1% compared to 81.6%). The program also serves slightly more Latinx clients than the state population (8.9% compared to 7.8%). If, after the current initiative ends, the BFH selects to replicate elements of the pilot projects in future partnerships, a focus on serving communities of color will be key. By providing integrated sexual and reproductive health services for people with, or at-risk for, SUD, the BFH hopes to reduce the incidence of unintended pregnancy and improve birth outcomes for birthing people with OUD and their babies.

 

Through Title V funds, the BFH partnered with the Shadyside Hospital Foundation to continue implementation of the IMPLICIT Interconception Care (ICC) Program, wherein maternal screenings are conducted at well-child visits (WCVs). This interconception care project works within scheduled child well visits to check on the health of birthing people. Each visit addresses four behavioral risk factors to assess birthing people’s health: (1) smoking status, (2) depression, (3) contraception use, and (4) multivitamin with folic acid use. Birthing people are counseled and referred for services as necessary. This initiative is focused on increasing the number of birthing people who see their medical providers in the interconception period as well as changing maternal behaviors to improve overall health and birth outcomes in subsequent pregnancies. Working with this population is an opportunity to address mother’s health, as many birthing people do not follow through on postpartum visits. Instead, they are focused on the health needs of their child and likely to take their children to WCVs. In the first five years of this program, 9,103 birthing people were screened for ICC behavioral risk factors at twelve sites across PA, with a 78.8% screening rate across all sites. Of those served, 54.2% were white, and 30.6% were black/African American, with 20.7% identifying as Latinx and 75.3% as non-Latinx, demonstrating that this initiative is effectively reaching those at higher risk of poor birth outcomes. Upon initiation of this program, the IMPLICIT Network began following a cohort of 1,184 mother/baby dyads born in 2016 to measure maternal behavior change following intervention. Of this cohort, mothers attended 4,555 of the babies’ 5,189 WCVs. During the first five years of the program, 31.1% of this cohort screened positive for tobacco use, 26.6% screened positive for depression, 48.8% screened positive for lack of contraception use, and 76% screened positive for lack of multivitamin with folic acid use. Maternal behavioral change following intervention was reported at 39.2% for tobacco use, 49.6% for depression, 56.1% for contraception use and 52.3% for multivitamin with folic acid use. In 2020, the BFH worked with the grantee to develop a plan for a 4th trimester model of care. In the coming year, the program will work with the University of Pennsylvania to continue to expand the IMPLICIT Network, increase utilization of the ICC Program, and implement the newly-developed 4th trimester model of care to decrease rates of maternal mortality in the early postpartum period.

 

Priority: Women receiving prenatal care or home visiting are screened for behavioral health and referred for assessment if warranted

 

Objective 1: Annually increase the number of women receiving Title V funded prenatal care or home visiting who are screened for behavioral health

 

ESM: Number of Title V funded women who are screened for behavioral health

 

The BFH understands the strong connection between physical health and behavioral health and has worked to ensure that birthing people are screened for behavioral health issues during home visits. Early in this grant cycle, the BFH made it a requirement for all Title V funded CMHDs home visiting programs to utilize the Institute for Health and Recovery’s 5Ps (5Ps) screening tool, an evidence-informed screening tool. By assessing behavioral health issues during the perinatal period, 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. The 5Ps is a quick, non-threatening conversational tool that assesses risk for alcohol dependency, substance misuse, interpersonal violence, and depression based on five domains (Parents, Peers, Partner, Pregnancy, and Past). The tool guides health professionals to make referrals or recommendations based on responses. The tool asks questions about drug or alcohol use by parents or peers to open the conversation about substance use. Birthing people, especially during pregnancy, may be hesitant to talk about their own substance use but are often willing to share about the habits of their parents or peers. In 2020, the BFH made the decision to no longer require the use of the 5Ps tool. The BFH is asking the CMHDs to utilize evidence-based tools for screening and the 5Ps tool is not considered an evidence-based tool it lacks published, peer-reviewed research studies a. To remain consistent, BFH staff have allowed the CMHDs to discontinue use of the 5Ps if it was not working for their organization. As of 2021, seven CMHDs continue to use the 5Ps screening tool.

 

For agencies or staff who wish to continue using the 5Ps tool, the BFH provides online training and resources to assist them in identifying appropriate referral sources for further assessment and treatment as needed. The BFH has chosen to measure the number of birthing people receiving Title V home visiting services who are screened for behavioral health, in order to expand the number of opportunities for support and referral for birthing people who need behavioral health services. CMHDs home visiting programs also utilize Motivational Interviewing (MI) to elicit behavioral changes that can help to improve the health of PA’s families. MI is a goal-oriented, client-centered counseling style for eliciting behavioral change by helping individuals understand the need for change. Home visitors have the unique advantage of being trusted enough to spend time with pregnant and birthing people and their families in the home. By integrating proven tools into the work that is done in the home, the BFH anticipates an improvement in the number of pregnant and birthing people who are screened for behavioral health issues and the likelihood that they will receive needed follow-up services. In 2020, 1,001 or 86% of pregnant and birthing people enrolled in the CMHDs home visiting programs were screened for behavioral health issues not meeting the goal of 1,550. While the goal of 1,550 participants was not met, the percentage of pregnant and birthing people enrolled in the program that are screened for behavioral health issues continues to increase. Reasons pregnant and birthing people may not be screened include refusal or early withdrawal from the program.

 

The IMPLICIT Interconception Care (ICC) Program, mentioned earlier in this report, includes maternal depression screenings at well-child visits (WCVs). Birthing people are counseled and referred for services as necessary. This initiative is focused on increasing the number of birthing people who see their medical providers in the interconception period and changing maternal behaviors to improve overall health and birth outcomes in subsequent pregnancies. In 2020, 2,895 birthing people received a depression screening, of the 522 positive screenings, intervention was documented at 396.

Through a technical assistance grant from the Center for Law and Social Policy, BFH staff collaborated with the PA DHS’ Office of Mental Health and Substance Abuse Services and other agencies on a maternal depression initiative, Moving on Maternal Depression (MOMD). The formal grant has concluded but work continues in partnership with the Jewish Healthcare Foundation. The initiative aims to improve prenatal and postpartum depression screening and follow-up services as well as reduce racial and ethnic disparities associated with perinatal depression screening and follow-up rates. To accomplish this, the Pennsylvania Perinatal Quality Collaborative (PA PQC) will recruit, train, and coach 10 birthing hospitals and their affiliated outpatient perinatal offices, birth centers, and pediatric offices to adopt tactics, protocols, toolkits, and resources and implement depression screening and follow-up services. All the PA PQC MOMD provider sites will track prenatal and postpartum depression screening and follow-up rates by race and ethnicity.

Pennsylvania, 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 by 25% by 2023, and by 50% by 2025. BFH staff sit on the Maternal Health Subgroup, which is focusing on extending Medicaid access to postpartum services, ideally for 12 months; advancing behavioral health screenings for prenatal and postpartum people; ensuring that those with a positive screen receive needed services; and advancing reimbursement for doulas in the Medicaid program.

 

Objective 2: Annually increase the percentage of women with a home visitor who have a conversation about intimate partner violence (IPV)

 

ESM: Percent of women who talk with a home visitor about IPV

 

The 5Ps include a question about feeling unsafe in one’s relationship. The Title V home visiting programs have adapted their curricula or models to include the use of the 5Ps and provide appropriate follow-up recommendations and referrals. Additionally, several of the CMHDs have selected evidence-based screening tools in lieu of using the 5Ps to screen for IPV. These tools include the Hurt, Insult, Threaten, and Scream (HITS) and the Humiliation, Afraid, Rape, Kick (HARK) screenings. In 2020, 818 out of 1,161 or 70.4% of pregnant and birthing people enrolled in Title V home visiting programs talked to a home visitor about IPV; this is lower than the goal of 90%. Enrolled pregnant and birthing people may not have spoken to a home visitor about IPV if they were newly enrolled or if they lacked a private location in which to have this conversation.

 

NPM 14: A) Percent of women who smoke during pregnancy

 

Objective 1: Annually decrease the percentage of women who report smoking during pregnancy

 

ESM: Percent of women who report smoking after confirmation of pregnancy

 

ESM: Percent of grantees who implement evidence-informed tobacco free programs

 

The BFH has opportunities to impact pregnant and birthing people through home visiting programs. Utilizing MI, home visitors may be able to address tobacco use in the prenatal and postpartum periods.

 

Two of the CMHDs offer evidenced-based or evidence-informed smoking cessation programs aimed at pregnant and postpartum people, not meeting the 2020 goal of 4. The programs being offered are Baby & Me - Tobacco Free (BMTF) and Smoking Cessation & Reduction in Pregnancy Treatment. In 2020, 6.5% of birthing people participating in a CMHD home visiting program reported smoking after confirmation of pregnancy.

 

The BMTF smoking cessation program has received the National Association of City and County Health Officials’ Model Practice Award. The program addresses the high prevalence of tobacco use by birthing people during pregnancy. It provides counseling, support, and resources to pregnant people and their partners to help them quit smoking and maintain smoking cessation. The program is successful in helping birthing people quit and abstain from smoking, resulting in improved birth outcomes and long-term positive outcomes for birthing people, children, and their families. In 2020, although no new enrollment sites were added, 30 individuals completed recertification. Garnering interest from local obstetrics practices and local Women, Infants, and Children program offices continues to be a challenge; however, efforts continue with these organizations. Despite challenges, 22 birthing people were enrolled in the program in 2020. The Department of Health’s Tobacco Prevention and Control Program, funded in part through tobacco settlement funding, has continued to operate the PA Free Quitline using a specialized protocol for pregnant and postpartum people.