PRIORITY:  Increase Access to Family Planning Services

 

Interpretation of Performance Data on NPMs, ESMs, SPMs, and SOMs:

 

ESM 1.2: Create pre/posttests to assess provider knowledge of and confidence using PATH (Parenthood/Pregnancy Attitude, Timing, and How important is pregnancy prevention)

Pre/post tests have not yet been created.

 

ESM 1.3: Percent of family planning encounters that occur via telehealth

Baseline for this ESM was 0.2% based on federal fiscal year 2020. The objective for grant year 1 (i.e., fiscal year 2021) was to maintain this percentage at 0.2%. The actual percentage for fiscal year 2021 was 0.3% which exceeded the objective.

 

ESM 1.6: Number of women receiving patient navigation for women’s health services

Grant year 1 was used to establish funding for women’s health navigators, so the objective for number of women navigated was zero (0). No women received navigation services in grant year 1, but these services are expected to begin in July 2022.

 

SPM 1: Percent of new mothers whose pregnancy was intended

Baseline for this SPM was 62% based on a three-year average for 2016-2018. The objective for grant year 1 was to maintain this measure at 62%. Grant year 1 performance is based on 2020 PRAMS data during which time the percent of new mothers whose pregnancy was intended was 59%. Compared to baseline, the difference is not statistically significant, and the objective was therefore met.

 

NOM 3: Maternal mortality rate per 100,000 live births

The National Vital Statistics System does not provide state-level maternal mortality rates every year. For this NOM, the closest estimate we have is the pregnancy-related mortality ratio. In 2020, 46 Tennessee women died from causes aggravated by pregnancy, either during pregnancy or within a year from the end of pregnancy, and the pregnancy-related mortality ratio was 58.5 deaths per 100,000 live births. This was an increase compared to previous years. However, this increase may have occurred due to the increase in overall deaths in 2020 and the implementation of the Utah Criteria when determining the pregnancy relatedness of overdose deaths.

 

NOM 9.1: Infant mortality rate per 1,000 live births

The infant mortality rate decreased from 7.0 per 1,000 live births in CY 2019 to 6.3 per 1,000 in CY 2020. This rate exceeds the fiscal year objective. Potential mechanisms contributing to this decrease, including data quality issues, fetal deaths, and changes in program provision due to the COVID-19 pandemic, are being investigated.

 

Accomplishments and Challenges (based on FY2021 Action Plan):

 

Strategy 1: Remove barriers to care at Title X clinics across the state and provide high-quality, non-coercive, culturally competent family planning services to all clients

 

Activity 1a: Utilize the results of teen/male/LGBTQ+ friendly surveys that were conducted in all Title X clinics in FY20 to guide the implementation of strategies to reduce barriers to care among these vulnerable populations.

 

Report 1a: Results from the friendly surveys were presented to statewide Family Planning staff. Results were also shared with Family Planning Administrators, who were encouraged to implement strategies to address these results in their regions.

 

Activity 1b: Promote the use of reproductive life plan assessments at Title X clinics by training Tennessee Department of Health family planning providers.

 

Report 1b: Family Planning Providers know when to assess the client’s reproductive life plans. Quality Family Planning (QFP) training through RHNTC is recommended and encouraged. Many Family Planning providers have completed QFP training, but total uptake of QFP training is ongoing. 

 

Activity 1c: Deliver family planning services through telehealth as a means to reach underserved populations.

 

Report 1c: Family Planning gradually increased its telehealth services during this performance period with 224 encounters. There were 68 patient encounters in September 2021. Covid remained a challenge as health departments had competing priorities.

 

Activity 1d: Pilot the Person-Centered Contraceptive Counseling Measure survey at one Title X site. In order to ensure a racially/ethnically diverse sample, the pilot sight will be chosen based on the demographic distribution of family planning patients.

 

Report 1d: This activity was not completed due to challenges surrounding the Covid-19 Pandemic. It has been added to current work plans for completion.

 

Strategy 2: Increase awareness of the availability of Title X family planning services in Tennessee and of how to access these services through community education and outreach

Activity 2a: Create an information packet with resources and information on birth spacing and on how to access postpartum family planning services for distribution during TennCare presumptive eligibility visits.

 

Report 2a: Although presumptive eligibility clients are provided local resources including family planning resources, a complete information packet was not completed. Presumptive Eligibility enrollments have decreased over the past four years. Due to the public health emergency, many pregnant women opted to complete applications online or by phone reducing the ability to share resources. 

 

Activity 2b: The Adolescent Pregnancy Prevention and Rape Prevention Education Program Directors will educate sub-grantees about family planning services available through the Tennessee Department of Health.

 

Report 2b: The Family Planning Director presented information on family planning services to 20 health promotion directors during a Rape Prevention Education Support call. Education to TAPPP, SRAE, and RPE sub-awardees regarding reproductive and women’s health services is ongoing.

 

Activity 2c: The Tennessee Breast and Cervical Screening Program will educate contracting providers outside of local health departments about the availability of family planning services through the Tennessee Department of Health.

 

Report 2c: TBCSP has included FP information in 2 quarterly newsletters that are distributed to TBCSP external vendors. The information included telehealth and the availability of services inside the HD. TBCSP plans to regularly include FP in newsletters as a means of promotion. TBCSP also plans to have a virtual meeting for external providers and will allow time for FP to promote services.

 

Strategy 3: Promote mental health and increase client confidence in care through the provision of client-centered, trauma-informed care

 

Activity 3a: Require completion of a webinar on providing trauma-informed care for Tennessee Department of Health family planning providers as part of the Title X annual training.

Report 3a: Trauma-informed care training was completed by all Family Planning staff. It was completed during orientation or through annual FP training. 

 

Activity 3b: Form a collaborative working group between the Tennessee Department of Health’s Family Planning Program and the Tennessee Department of Mental Health and Substance Abuse.

 

Report 3b: Progress on this activity has been limited due to competing priorities. Multiple attempts were made to connect with individuals at Mental Health. We plan to reach out to internal FHW partners for additional contacts at the Department of Mental Health.

 

PRIORITY:  Decrease Pregnancy-Associated Mortality

 

Interpretation of Performance Data on, NPMs, ESMs, SPMs, and SOMs:

 

ESM 1.8: Percent births covered by hospitals implementing data-driven, clinical recommendations

In FY2021, 55% of hospital statewide births were covered by facilities implementing data-driven, clinical recommendations.

 

ESM 1.9: Percentage of birthing hospital providers trained reporting a change in knowledge

The team is unable to report on this measure. TIPQC does not track change in knowledge. Therefore, ESM 1.8 has been retired.

 

ESM 1.10: Percent of non-clinical members participating in the action group

The percent of non-clinical members participating in the action group was higher than projected at 70%.

 

ESM 1.11: Percent of postpartum women with positive screenings for depression (using a validated screening tool) who will receive resources/education or referrals for professional services

This measure was not tracked in 2021 and should have been retired after the review with technical advisors from MCHB. ESM 1.11 has now been retired.

 

ESM 1.12: Percent of recommendations with who/what/when components

The percent of recommendations with a who/what/when component was higher than the projected objective at 68%.

 

SPM 2: Percent of facilities implementing patient safety recommendations

The percent of facilities implementing patient safety recommendations, was

higher than the projected objective with 54% participating in 2019 and 25% participating in 2020.

 

SPM 3: Number of community level recommendations implemented

The number of non-clinical recommendations implemented, was higher than the projected number with 53 for 2019 and 18 for 2020. Funding from other sources allowed us to fund community projects that address the recommendations. 

 

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

NPM 1, percent of women with a preventive medical visit was higher than projected with 82.4% for 2020 and 79.1% for 2021.

 

SOM 1: Rate of pregnancy-associated mortality to live births

The rate of pregnancy-associated mortality was lower than the projected  

objective for  2019 with a rate of 78.3 but higher than the objective for 2020 with

a rate of 124.5 per 100,000.

 

SOM 2: Rate of pregnancy-related mortality to live births

The rate of pregnancy-related mortality, increased from the projected objective with a rate of 28.6 in 2019 and a rate of 58.5 from 2020.

 

NOM 2: Rate of severe maternal morbidity per 10,000 delivery hospitalizations

This measure is not actively tracked by the program. There are plans to start tracking this measure in Year 2.

 

NOM 3: Maternal mortality rate per 100,000 live births (WHO definition)

The program does not use the WHO definition to calculate the maternal mortality rate for Tennessee. This measure is not actively tracked by the program.

 

NOM 4: Percent of low-birth weight deliveries (<2,500 grams)

The percent of low birthweight deliveries (<2,500 grams) (NOM 4) did not change significantly between CY 2019 (8.8%) and CY 2020 (8.6%).

 

NOM 5: Percent of preterm births (<37 weeks)

The percent of preterm births (<37 weeks) (NOM 5) did not change significantly between CY 2019 (10.8%) and CY 2020 (10.6%).

 

NOM 6: Percent of early term births (37, 38 weeks)

The percent of early term births (37, 38 weeks) (NOM 6) did not change significantly between CY 2019 (28.6%) and CY 2020 (28.5%).

 

NOM 8: Perinatal mortality rate per 1,000 live births plus fetal deaths

The perinatal mortality rate per 1,000 live births+ fetal deaths in CY2019 (6.0) remained the same in CY2020 (6.0).

 

NOM 9.1: Infant mortality rate per 1,000 live births

In FY2021, 495 Tennessee children under 1 year died. The FY2021 infant mortality rate of 6.3 deaths per 1,000 live births represents a decrease, though not statistically significant, from the FY2020 rate of 7.0 deaths per 1,000 live births. The 10% decrease in IMR between FY2020 and FY2021 may be explained by a decline in perinatal mortality. From FY2020 to FY2021, there was a 19% decrease in early neonatal mortality (death within the first seven days of life) and 10% reduction in perinatal mortality (fetal death at 28 or more weeks of pregnancy to first seven days of life).

 

NOM 9.2: Neonatal mortality rate per 1,000 live births

The neonatal mortality rate per 1,000 live births in CY2019 fell from 4.54 to 3.89 in CY2020.

 

NOM 9.3: Post neonatal mortality rate per 1,000 live births

In FY2021 and FY2020, there were 102 and 101 post-neonatal deaths (death between 28 days and 1 year of life) in Tennessee. Due to a minimal difference in deaths and a similar total of live births across both years, the FY2021 post-neonatal mortality rate of 1.3 deaths per 1,000 live births is no different than the FY2020 rate of 1.3 deaths per 1,000 live births.

 

NOM 9.4: Preterm-related mortality rate per 100,000 live births

The preterm-related mortality rate per 1,000 live births in CY2019 fell from 3.64 to 2.94 in CY2020.

 

NOM 24: Percent of women who experience postpartum depressive symptoms following a recent live birth

The percentage of women who experience postpartum depressive symptoms following a recent live birth decreased to 15.1% in Year 1 from 15.7% in FY 2020. This percentage exceeds the Year 1 objective of 16.1%.

Accomplishments and Challenges (based on FY2021 Action Plan):

 

Strategy 1: Increase evidence-based practice implementation at hospitals on topics identified by the Maternal Mortality Review Committee (MMRC)

 

Activity 1a: Contract with Tennessee Hospital Association to provide simulation training to birthing hospitals on the leading causes of maternal death as identified by the MMRC. Birthing hospitals in the grand region of the state with highest disparities will be given top priority for simulation training.

 

Report 1a: A contract was in place with THA to provide the 20 non-delivering hospitals with education for emergency department personnel on the signs and symptoms of cardiovascular disease in pregnancy. The training included simulation on proper blood pressure measurement and education about maternal early warning signs. Hospital staff were trained by the regional perinatal nurse educators.

 

Activity 1b: Contract with Tennessee Initiative for Perinatal Quality Care (TIPQC) to develop a speaker’s bureau to train birthing hospital staff on topics identified by the MMRC. Birthing hospitals in the grand region of the state with the highest disparities will give given top priority for training.

 

Report 1b: TIPQC has trained birthing hospitals on topics identified by the MMRC. On June 7-10, 2021, a simulation training was held on maternal hypertension and maternal hemorrhage. On June 22-24, 2021, a simulation training was held on hemorrhage and hypertension with 141 attendees from 49 hospitals. On June 23,2021, a presentation on Disparities was recorded and made available on the TIPQC website. Maternal mental health videos were recorded in July 2021 and shared with the speaker’s bureau.

 

Activity 1c: Provide real-time alerts quarterly to hospitals and other healthcare providers on emerging issues as identified by the MMRC with a minimum of 1 recommendation in each alert focused on disparities.

 

Report 1c: Recommendations are developed after each quarterly review meeting.  These recommendations are based on the deaths reviewed during that meeting thus creating a more real time alert on emerging issues (e.g., for deaths with covid-19 as contributing factors) being seen during reviews. The alerts were sent to hospitals and posted on the maternal mortality website on January 11, 2021, April 12, 2021, July 15, 2021.  For the meeting that occurred in September 2021, the recommendations were posted on October 13, 2021.

 

Activity 1d: Provide consultation and education on high-risk OB care to health care providers through the regional perinatal centers with the highest number of educational consults being in the grand region with the most disparities.

 

Report 1d: Throughout the year, MCH staff have continued to work closely with the five Regional Perinatal Centers and the Perinatal Advisory Committee. In state fiscal year 2021, the five Centers provided direct care for 3,406 high-risk neonates and 16,206 high-risk maternal patients; provided 101,842 consultations; and 7,133 hours of education and training were provided to staff at community hospitals to help them prepare for recognizing and treating complex medical conditions.

 

  Updates were made to the maternal care sections of the perinatal regionalization guidelines. The Perinatal Advisory Committee met three times during the year; members heard data presentations on pregnancy and COVID in Tennessee and continued to monitor hepatitis C work.

 

Strategy 2: Increase community involvement to improve maternal health outcomes

 

Activity 2a: Convene a maternal health task force, with a minimum of 25 members, quarterly to highlight innovative and best practices for preventing maternal death. The task force will include membership from the Office of Minority Health and Disparities Elimination to represent disparate populations.

 

Report 2a: Maternal health task force meetings were held quarterly through a virtual platform. The task force has 89 multidisciplinary members representing 68 different organizations in all parts of the state including the Office of minority health. Meetings highlighted best practices for implementing recommendations to improve maternal health.  Best practices highlighted have included interpersonal violence and risk assessment and maternal mental health.

 

Activity 2b: Fund up to 5 community agencies to implement MMR recommendations related to top topics identified by the MMRC including substance abuse, domestic violence and mental health issues.  Proposals will be evaluated on how well they are addressing disparate populations.

 

Report 2b: In January 2021, four community agencies were funded to implement MMR recommendations through a competitive request for applications. These agencies included Vanderbilt University Medical Center, East Tennessee State University, St. Thomas Medical Center, and Erlanger Medical Center. Projects that implemented MMRC recommendations included implicit bias training, training for staff on recognizing and addressing substance use disorder and mental health disorders, developing cardiovascular disease educational materials and implementing a cardiac screening tool, and developing a toolkit of information on preventing firearm injuries and drug overdose.

 

Strategy 3: Improve mental health among women of childbearing age

 

Activity 3a: Screen women enrolled in CHANT and evidence-based home visiting (EBHV) for depression with a specific emphasis on Middle Tennessee participants.

 

Report 3a: In FY2021, 88.3% of EBHV and 95.2% CHANT participants were screened with the Edinburgh postnatal depression scale. For CHANT the number of enrolled families for October 1, 2020 – September 30, 2021=5,992. For EBHV there were 2,641 participants. The proportion of EBHV participants screened for depression increased by 4% between FY2020 and FY2021 while the already high proportion of CHANT participants changed minimally between FY2020 (95.8%) and FY2021 (95.2%).

 

Activity 3b: Provide Question, Persuade, and Refer (QPR) training to CHANT and evidence-based home visiting staff with a particular emphasis on Middle Tennessee participants.

 

Report 3b: Six one-hour trainings were provided virtually. Ninety-nine staff in CHANT and EBHV completed the QPR training during this reporting period.

 

Strategy 4: Improve preconception and prenatal health through increased enrollment in both family planning and presumptive eligibility

 

Activity 4a: Increase the number of women of childbearing age participating in family planning by expanding and promoting telehealth to better reach those people living in rural areas.

 

Report 4a: Since implementation of telehealth services in late 2/2020, participation increased from 182 in 2020 to 305 in 2021. Every rural health clinic has a laptop reserved for client use in telehealth appointments. Satisfaction surveys show that 95% of respondents stated they were very satisfied with telehealth services, and 99% of the survey respondents stated they were able to obtain their 1st choice of contraceptive method. Challenges to telehealth services include low reimbursement rates from Insurance, regulations that change frequently, staff & provider resistance to change and feel that telehealth creates a competition for client service, lack of access to internet, and connectivity services.

 

Activity 4b: Increase the number of women applying for presumptive eligibility (PE) by developing an outreach plan and collaborating with a minimum of 1 partner to reach disparate populations.

 

Report 4b: Successes around Prenatal PE include making new connections with community members and continuing to identify new community organizations. The program has begun working with the Firefly program at Vanderbilt, which provides services for pregnant and new mothers experiencing opioid use disorders.  The PE program also works with Choices Chattanooga, which provides pregnancy related services for unexpected pregnancies. To increase enrollment, the PE program is contacting other Pregnancy Centers around the state and looking at other partners such as housing authorities around the state and Catholic Charities in Tennessee.

 

 Some challenges the PE program has encountered is another drop in PE enrollments over the last fiscal year.  There can be several explanations for the decrease in PE enrollments.  Pregnancy rates have declined since the start of the COVID-19 pandemic.  TennCare/CMS has not been dropping TennCare recipients who receive full TennCare due to the Public Health Emergency of the

 

Strategy 5: Increase surveillance of maternal deaths

 

Activity 5a: Identify pregnancy-associated deaths and facilitate state Maternal Mortality review Committee meetings.  The Committee will identify age, race and place for each death reviewed to identify disparities.

 

Report 5a: Pregnancy-associated deaths were identified monthly, and Maternal Mortality Review Committee (MMRC) meetings were held quarterly. Key indicators—including age, race, and the place of residence—were identified and assessed to better understand the health and demographic characteristics of decedents. A total of 98 deaths occurring in 2020 were identified and reviewed in calendar year 2021. Many of the decedents were ages 30-39 (52%), non-Hispanic White (59%) and resided in Middle Tennessee (37%).

 

Activity 5b: Through the Maternal Mortality Review Committee, determine proportion of deaths that are pregnancy related along with contributing factors. For each pregnancy-related death determine age, race and place of death to identify disparities.

 

Report 5b: The MMRC reviewed all deaths to determine whether they are pregnancy-related deaths. Out of the 98 deaths reviewed in 2021, 46 (47%) were determined to be pregnancy related.  The team also assessed factors contributing to each death such as mental health (27%), substance use disorder (26%) and obesity (24%).

 

Activity 5c: Develop recommendations based upon MMRC findings for inclusion in the Maternal Mortality annual report and dissemination to relevant stakeholders. These recommendations will include reference to specific disparities identified in the reviews.

 

Report 5c: The 2021 annual Maternal Mortality Review Report was released in March 2021 and includes recommendations for prevention based on the findings in the reviews. The report was disseminated to the maternal health task force and posted on the MMR website. Examples of recommendations include: 1. Facilities should implement diversity training to prevent interpersonal racism and bias; 2. Healthcare payors should extend insurance coverage for pregnant women to one year postpartum, including coverage for case management services and home-based services and 3. Healthcare providers should educate staff on trauma-informed care in marginalized populations with substance use disorder. The MMR Report is available on TDH’s website, and the PDF version of the report was disseminated to stakeholders across the state and federal partners.