Maternal Domain Annual Report

Please note, many activities were paused or slowed during 2020-2021 as a result of COVID-19 staff redirections and long-term staff vacancies. These activities are noted below by an asterisk (*) next to the activity. Where applicable, additional information is provided.

 

July 2021 – June 2022

 

WOMEN/MATERNAL Focus Area 1: Reduce the impact of chronic conditions related to maternal mortality.

Women/Maternal Objective 1

By 2025, reduce the pregnancy-related mortality ratio (deaths up to one year after the end of pregnancy) from 12.8 deaths per 100,000 live births (2019 CA-PMSS) to 12.2 deaths per 100,000 live births.

 

Objective baseline history

Story behind the baseline

California’s pregnancy-related mortality ratio was mostly stable from 2009 to 2019 and consistently lower than the U.S. pregnancy-related mortality ratio.1 The latest pregnancy-related mortality ratio for the U.S. was 17.3 deaths per 100,000 live births in 2017 (CDC PMSS), while California’s pregnancy-related mortality ratio was 13.1 (CA-PMSS). The U.S. pregnancy-related mortality ratio may be an underestimate of the true burden due to Centers for Disease Control’s (CDC) limitations for identifying and verifying pregnancy-related deaths compared with CA-PMSS.

Despite the lower overall pregnancy-related mortality ratios in California, racial and ethnic disparities persisted, aligning with national statistics. In 2017-2019, the pregnancy-related mortality ratio for Black women and birthing people was three-to-four times greater than the mortality ratios for Asian/Pacific Islander, Hispanics, and White persons.

Cardiovascular disease remained the leading cause of pregnancy-related mortality from 2009 to 2019. Other leading causes were hemorrhage, hypertensive disorders, sepsis/infection, thrombotic pulmonary embolism, and amniotic fluid embolism. In 2017-2019, the pregnancy-related mortality ratio for deaths due to hypertensive disorders declined significantly. As a result, hypertensive disorders were no longer among the leading causes of pregnancy-related mortality in 2017-2019.

Characteristics that trended with higher pregnancy-related mortality ratios for all racial/ethnic groups were older age, obesity, reliance on public insurance, and living in less advantaged communities. Geographic variations in pregnancy-related mortality ratios were also noted.2

California has made progress to reduce pregnancy-related mortality through investment in maternal health programs, strong leadership and engagement of the maternity care community, and targeted hospital quality improvement, but more needs to be done to narrow racial and ethnic disparities. A thorough public health investigation is needed to understand how systems and community-level characteristics interplay with patient, provider, and facility-level factors in contributing to pregnancy-related mortality and related disparities. Comprehensive case reviews to identify contributing factors (including discrimination and structural racism), improvement opportunities, and preventability are currently underway via the California Pregnancy-Associated Mortality Review (CA-PAMR).

1. Centers for Disease Control and Prevention Pregnancy Mortality Surveillance System (CDC PMSS) https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm . Accessed on January 15, 2022.

2. CA-PMSS. Data through 2016 were published in a report, and data from 2009-2019 will be published on MCAH’s Tableau dashboards in the Spring of 2022

Women/Maternal Objective 1: Strategy 1

Lead surveillance and research associated with pregnancy-related deaths (up to one year after the end of pregnancy) in California.

What did CDPH determine as activities that would work to bring about change?

1.   Lead and fund pregnancy-related mortality surveillance and public health investigation activities.

2.   Lead surveillance and reporting of pregnancy-related mortality as mandated by Senate Bill (SB) 464 – California Dignity in Pregnancy and Childbirth Act.

3.  Focus surveillance and reporting on disparities to inform MCAH programs and promote health equity in California.

4.   Lead, fund and disseminate data findings and products related to pregnancy-related mortality and improve clinical best practices in maternity care.

 

Narrative section

1. The Maternal, Child, and Adolescent Health Division (MCAH) of the California Department of Public Health (CDPH) initiated CA-PMSS in 2018 to conduct timely and accurate statewide surveillance of pregnancy-related deaths. In a span of three and a half years, the CA-PMSS committee of experts reviewed nearly 1,000 deaths that occurred from 2008 to 2019. Routine and accurate surveillance of pregnancy-related deaths is vital to inform timely public health action. In 2020, CDPH/MCAH also resumed in-depth case reviews of pregnancy-related deaths after a three-year pause to identify contributing factors, improvement opportunities, and preventability. Two expert committees were convened to review all deaths due to obstetric hemorrhage in 2014-2018 (a topic-specific review), and all-cause deaths in a four-county Southern California region beginning in 2019 and onward (a population-based, regional review). Findings from these comprehensive reviews will inform recommendations for improvements in maternity care/support and prevention of pregnancy-related deaths.
2. CA-PMSS satisfies the surveillance and reporting of pregnancy-related mortality as mandated by SB 464 – California Dignity in Pregnancy and Childbirth Act. CDPH/MCAH prepared the first CA-PMSS surveillance report describing pregnancy-related deaths among Californians from 2008-2016.
3. Findings from CA-PMSS and CA-PAMR data collection and case reviews are disaggregated by demographic and socioeconomic characteristics, such as race/ethnicity and delivery payer source, to identify which characteristics correlated with higher or lower pregnancy-related mortality ratios. California was also among the first states to examine pregnancy-related mortality by community conditions using the California Healthy Places Index, a validated measure that captures information on social determinants at the census tract level. Regional differences in pregnancy-related mortality ratios were also newly examined. CA-PAMR’s case review process was expanded to include deliberations of system- and community-level contributing factors as well as the contributions of discrimination and structural racism to pregnancy-related deaths and associated disparities. Finally, data collection and case review materials are being modified to capture the direct and indirect impacts of COVID-19 on pregnancy-related mortality.
4. MCAH and partners prepared three scientific conference presentations related to pregnancy-associated and pregnancy-related mortality and drafted a CA-PMSS surveillance report. MCAH and partners presented two posters at the American Public Health Association 2020 Annual Meeting. One poster showed pregnancy-associated deaths from suicide and homicide, and the other highlighted racial differences in maternal morbidity and mortality. In January 2021, MCAH presented on CA-PMSS and the strengths and limitations of the different methodologies for maternal mortality surveillance at the Society for Maternal and Fetal Medicine Annual Meeting. As of June 2021, the inaugural CA-PMSS surveillance report on pregnancy-related mortality in 2008-2016 was under internal review.

Success Stories

CDPH/MCAH initiated CA-PMSS in 2018 to provide timely and accurate surveillance data on pregnancy-related mortality in California. CDPH/MCAH set a target to review all pregnancy-related deaths within two years of the date of death. By June 2021, identification, verification, and review of pregnancy-related deaths through 2019 was mostly completed, and these activities are on track to meet this objective by the end of 2021. MCAH also set an objective to report surveillance data on pregnancy-related deaths, and this objective will be met with the planned release of the first CA-PMSS report on pregnancy-related deaths in 2008-2016 (under internal review, as of June 2021).

Challenges

Disruptions in filling vacant administrative and scientific staff positions due to COVID-19-related redirections and shifting priorities have limited CDPH/MCAH’s capacity to support communications and outreach activities to engage stakeholders and produce data products to reach wider audiences.

Women/Maternal Objective 1: Strategy 2

Partner to translate findings from pregnancy-related mortality surveillance and research into recommendations for action to improve maternal health and perinatal clinical practices.

What did CDPH determine as activities that would work to turn the curve of the baseline?

1.   Lead the development of recommendations for prevention of pregnancy-related deaths.

2.   Partner with community partners to update and/or develop toolkits based on data findings related to improving maternity care and supports.

Narrative section

1. In October 2020, CDPH/MCAH and partners convened two CA-PAMR committees of experts to comprehensively review deaths from obstetric hemorrhage statewide (topic-specific), and deaths from all pregnancy-related causes in a defined Southern California region (population-based, regional). As of June 2021, CA-PAMR data collection and review activities were underway. Planned activities will include quantitative and qualitative analyses to inform recommendations for prevention of pregnancy-related deaths once sufficient reviews are completed. CA-PAMR committees deliberated factors that contributed to each pregnancy-related death, improvement opportunities, preventability (chance to alter the outcome), and make data-driven recommendations for prevention.
2. As of June 2021, CA-PAMR committee reviews are still underway. Partnering with clinical and community stakeholders to disseminate data-driven recommendations for best practices related to improving maternal health and support systems is planned once sufficient deaths are reviewed, data analyses are completed, and recommendations are prioritized. With dissemination and translation of findings in mind, CDPH/MCAH and partners convened CA-PAMR and CA-PMSS committees that include clinical and community experts with ties to provision of care, support services, and advocacy for pregnant and birthing people. Plans are underway to expand communications outreach in collaboration with MCAH’s Outreach and Communications team and MCAH programs directly or indirectly serving pregnant and birthing people.

Success Stories

Comprehensive reviews of pregnancy-related deaths are underway and on track. Findings from CA-PAMR committee reviews will yield information on contributing factors, improvement opportunities, preventability, and data-driven recommendations for prevention. CA-PAMR committees began reviews in November 2020 and have completed 45 case reviews by June 2021.

Challenges

COVID-related travel and meeting restrictions made it challenging to convene in-person CA-PAMR committee meetings. Both new and experienced committee members had to adjust to deliberating cases in a virtual space (Zoom meetings). CDPH/MCAH and partners had to adjust to facilitating these meetings efficiently, creating a safe space for committees and keeping committee members engaged. A few committee members were unable to meet the time demands of participation on the CA-PAMR committees due to competing demands from their work compounded by the pandemic.

WOMEN/MATERNAL Focus Area 1: Reduce the impact of chronic conditions related to maternal morbidity.

Women/Maternal Objective 2

By 2025, reduce the rate of severe maternal morbidity from 93.5 per 10,000 delivery hospitalizations (2018 PDD) to 88.8 per 10,000 delivery hospitalizations.

 

Objective baseline history

 

Story behind the baseline

Maternal chronic health conditions such as diabetes, hypertension, and asthma are major contributors to poor maternal and infant health outcomes. The rates of these conditions at the time of delivery hospitalizations continue to rise. One of the priorities identified in the 2021-2025 needs assessment is to reduce chronic conditions related to maternal morbidity. Addressing the burden of chronic conditions among reproductive-aged women is a goal of preconception health efforts, with screening and management occurring during a preventive medical visit (National Performance Measure (NPM) 1). As chronic conditions impact maternal morbidity at childbirth, severe maternal morbidity (SMM) was selected as an objective to monitor for this focus area. SMM is a Healthy People 2030 objective and National Outcome Measure (NOM 2). SMM has been steadily increasing with persistent racial/ethnic, geographic, and socioeconomic disparities. In addition to increasing rates of chronic conditions at delivery, SMM may be increasing due to increases in maternal age, pre-pregnancy obesity, and cesarean delivery. Tracking and understanding patterns of SMM, along with developing and carrying out interventions to improve the quality of maternal care are essential to reducing SMM.1

1 CDC Severe Maternal Morbidity in the United States (https://www.cdc.gov/reproductivehealth/maternalinfanthealth/severematernalmorbidity.html)m Accessed 1/3/22).

Women/Maternal Objective 2: Strategy 1

Lead surveillance and research related to maternal morbidity in California.

What did CDPH determine as activities that would work to turn the curve of the baseline?

1. Lead surveillance and reporting of maternal morbidity, including measurement of trends and disparities, and review of scientific literature to maintain current with respect to both scientific methods and emerging issues. Special focus will be given to any reference discussing the coding change from ICD-9-CM to ICD-10-CM, which began October 1, 2015, in patient discharge data.
2. Lead surveillance and reporting of severe maternal morbidity as mandated by Senate Bill (SB) 464 (now Health & Safety Codes 123630-123630.4), the California Dignity in Pregnancy and Childbirth Act.
3. Identify and partner with an academic subject matter expert to conduct complex population-based data analyses to inform decision-making for implementation of Levels of Maternal Care. This expert will develop a risk profile of women to look at the distribution of medically complex pregnancies throughout the state and identify where they give birth.

Narrative section

1. CDPH/MCAH reviewed the revised definition of severe maternal morbidity as described in the Health Resource Service Administration’s (HRSA) Federally Available Resource Document (FAD) version April 13, 2021. The definition was adapted for use with California Department of Health Cre Access and Information (HCAI) patient discharge data. The rate of SMM increased from 93.5 per 10,000 delivery hospitalizations in 2018 to 104.4 per 10,000 delivery hospitalizations in 2020. In 2020, Black women were more likely than all other racial/ethnic groups to have at least one severe maternal complication (168.7 per 10,000 delivery hospitalizations). Pacific Islander women were the next most likely to experience SMM (136.9), followed by Asian (118.8), Hispanic (103.8), American Indian and Alaskan Native (AIAN) (102.2), Multi-Race (87.5), and White women (87.1). CDPH/MCAH continues to review scientific literature to maintain currency with respect to both scientific methods and emerging issues related to maternal mortality and morbidity. Special focus was given to any reference discussing the coding change from ICD-9-CM to ICD-10-CM. Based on current findings, CDPH/MCAH has tentative ICD-10-CM coding definitions for hypertension, diabetes, asthma, substance use and mental health disorders for women hospitalized at time of delivery. Morbidity definitions and data continue to be refined or updated based on ongoing literature review and evolving subject matter experts’ knowledge.
2. CDPH/MCAH is in the planning and development phase for reporting conditions as mandated by statute. The first mandated publication is not required until June 2023.
3. CDPH/MCAH continued to work with the Maternal Quality Indicators (MQI) Workgroup, based out of the UCLA Department of Obstetrics, to conduct complex population-based data analyses to inform decision-making for implementation of a system of levels of maternal care. To date, the following main goals of this project have been completed:

 

• Identification of patient characteristics present before birth that are associated with severe maternal morbidity during delivery and calculation of the number of women affected in California hospitals.
• Identification of hospitals where:
  • the expected SMM risk is high indicating a hospital may be serving a medically complicated birthing population, and
  • the observed to expected ratio is high indicating a hospital may lack the resources needed to handle SMM patients.
• Analysis of SMM rates and hospital rankings, as described in the second goal above, but also while considering conditions reported as present on admission (POA).

Success Stories

As more scientific research that uses ICD-10-CM coding is now being published, CDPH/MCAH can increase and improve morbidity surveillance efforts. CDPH/MCAH’s work with MQI resulted in two journal articles. The first manuscript, “A scoping review of severe maternal morbidity: describing risk factors and methodological approaches to inform population-based surveillance,” was prepared and published in “Maternal Health, Neonatology, and Perinatology” as of January 2021. A second manuscript to evaluate California hospital performance based on a standardized SMM measure was prepared and under review for publication in “Joint Commission Journal on Quality and Patient Safety” as of June 2021.

Challenges

Lack of staffing, due to a combination of COVID-19 redirections or related assignments, shifting priorities within MCAH, and other staff vacancies have resulted in many activities being paused or slowed.

Women/Maternal Objective 2: Strategy 2

Lead statewide regionalization of maternal care to ensure women receive appropriate care for childbirth.

What did CDPH determine as activities that would work to turn the curve of the baseline.

1. Fund the Regional Perinatal Programs of California (RPPC) to focus on quality improvement in participating labor and delivery hospitals through the state and to coordinate and support a regionalized perinatal system.
2. Lead and fund data collection through the CDC Levels of Care Assessment Tool (LOCATe) survey to measure hospital Levels of Maternal Care, unless the data collection is postponed due to COVID.
3. Lead and fund the convening of key partners, such as RPPC Directors, birthing hospitals, California Maternal Quality Care Collaborative (CMQCC), etc., to identify opportunities to establish a Levels of Maternal Care system.
4. Fund CMQCC to coordinate a collaborative of perinatal experts to consider clinical medicine, population health, and systems of care that contribute to improvements in maternal health.
5. Partner with Comprehensive Perinatal Services Program (CPSP); Women, Infants, and Children (WIC) Regional Breastfeeding Liaisons; and Local MCAH programs to ensure a coordinated delivery system for women during and after their pregnancy.

Narrative section

1. CDPH/MCAH funds five contractors to serve the nine RPPC perinatal regions in California. The goal is to improve access to risk-appropriate perinatal care to pregnant women and their infants, regional quality improvement activities that promote an integrated regional perinatal system between public health and health care institutions, as well as local communities and state organizations. The RPPC Directors conducted annual hospital site visits to the labor and delivery hospitals in their regions with the exception of Kaiser Permanente hospitals. 92% of labor and delivery hospitals in California had a virtual site visit, despite hospital staff being redirected and busy addressing COVID-19 efforts.
2. CDPH/MCAH worked with CMQCC and CDC to finalize the LOCATe survey to meet California’s needs. With oversight from MCAH, CMQCC developed guidance for the hospitals to help facilities accurately answer the LOCATe survey. The LOCATe survey was pilot tested with a few facilities to identify issues and further refinement of the process. The final version will be rolled out to the field in early 2022.
3. The Maternal Risk-Appropriate workgroup did not convene in FY 20-21 due to the COVID-19 pandemic priorities and redirection of resources to support COVID-19 efforts. A subgroup identified several high-risk conditions that can be used to develop best practices to assist health plan providers in determining an essential package of evidence-based services. These high-risk conditions include placenta accreta, cardiac disease, neurologic (intracranial bleeds), and Extracorporeal Membrane Oxygenation ventilation. All facilities in Orange County were provided with matrices that outlined required services for preeclampsia, hemorrhage, cardiac disease, and obesity to evaluate their own resources in caring for this population. Suggested quality improvement measures for these high-risk conditions were provided for input. The process and resources will be shared with the other four regional directors for input and possible replication to other hospitals in their region. An informal interview was piloted and conducted with MCAH leadership in Orange County to help understand the challenges/barriers to maternal transport. This pilot interview will continue to assist and explore the challenges for Level IV facilities in Orange County. The pilot will be extended to the Central Valley region which has fewer facilities and limited resources.
4. A California Clinical Leadership workgroup was established and led by CMQCC to monitor data and identify and share best practices on managing COVID-positive pregnant patients admitted to labor and delivery. The workgroup met biweekly to address efforts to increase vaccination rates among pregnant women testing positive for the Delta variant. CMQCC continues to collaborate on the National Alliance for Innovation on Maternal Health (AIM) Program and participates in the National Network of Perinatal Quality Collaboratives (NNPQC) meetings to further quality improvement opportunities across all states. In addition, CMQCC convened monthly meetings with Illinois and New York to discuss birth equity strategies and shared opportunities for continued collaboration.
5. CDPH/MCAH RPPC Coordinators have made concerted effort to engage and invite partners to meet, discuss and coordinate local collaboration efforts with state partners such as WIC, SIDS and CPSP. The RPPC Chair and RPPC Coordinators attend and participate monthly Perinatal Service Coordinator (PSC) Executive and local MCAH meetings.

Success Stories

CMQCC’s successful partnerships with clinicians and hospitals across the state allowed an opportunity for the COVID Clinical Leadership workgroup to host and provide a venue for clinicians to talk and discuss the treatment and management of COVID-positive pregnant women. A void in clinical information for treating COVID-positive pregnant women led California clinicians from across the state to meet to share best practices, discuss what was working in their hospitals, and address challenges. These frontline leaders faced difficult times, and the meetings provided a safe and confidential space to track the surge, vent their frustrations, provide peer support, and talk through treatment options for their critically ill patients. The workgroup remains committed to meeting biweekly due to the surge in Delta variant cases.

Examples of success stories from the Local MCAH annual reports to ensure women receive appropriate care for childbirth include the following:

• City of Pasadena –MCAH and Black Infant Health (BIH) program staff in collaboration with RPPC worked to provide community events as members of the San Gabriel Valley African American Infant and Maternal Mortality Community Action Team. MCAH staff attended RPPC trainings and webinars.
• San Bernardino County – The RPPC Director was instrumental in providing expert opinion to the hospital Labor and Delivery staff on the creations of a SIDS video for families and assisted with distribution of “My Birth Matters” health education materials to reduce C-sections.

Challenges

RPPC Directors and CMQCC staff worked to identify creative solutions to work with their regional hospitals to ensure site visits and meetings added value and were not a burden. Hospitals are interested in quality improvement efforts to improve maternal outcomes, but many are currently focused on the care and treatment of COVID-positive pregnant women.

Women/Maternal Objective 2: Strategy 3

Partner to strengthen knowledge and skill among health care providers and individuals on chronic conditions exacerbated during pregnancy.

What did CDPH determine as activities that would work to turn the curve of the baseline?

1. Fund the California Diabetes and Pregnancy Program (CDAPP) Sweet Success Resource Center to train providers, develop educational materials, and produce a revised Guidelines for Care to improve and expand quality services for women with diabetes and during pregnancy.
2. Lead the development and dissemination of culturally appropriate materials to address chronic disease in disparate populations such as: overweight, diabetes, heart disease and tobacco use.
3. Lead the development and implementation of a work plan to reduce the rate of diabetes in pregnancy and overweight/obesity in childbearing parents.
4. Develop referral forms to CDAPP Sweet Success and from CDAPP Sweet Success to the DSMES and DPP programs to improve continuity of care.
5. Develop a social media campaign to disseminate information from the maternal overweight and obesity brief to women.
6. Promulgate the MCAH Healthy Weight for Health Birth and Beyond Brief to encourage preconception and pregnancy interventions to reduce perinatal weight.
7. Share statewide media campaign developed by local BIH sites with state and local partners to increase awareness of chronic health conditions affecting Black women during pregnancy.

Narrative section

1. The CDAPP Sweet Success Resource Center offered eight free new training modules in FY 20-21 for affiliates and non-affiliates across the U.S. All training modules are based on the fundamental components of diabetes management before, during, and after pregnancy established by CDAPP Guidelines for Care. Updated CDAPP Sweet Success Guidelines for Care will be released in 2022.
2. MCAH developed the “Healthy Weight for Healthy Birth and Beyond” data brief and social media toolkit. These resources were disseminated to local MCAH programs, internal and external stakeholders, and partners via email, the CDPH website, and other channels of communication. The data brief and social media toolkit address the increasing percentage of individuals going into pregnancy obese or overweight and an increasing percentage of individuals gaining excess weight during pregnancy. These resources were developed to promote and educate about the importance of maintaining a healthy weight before and during pregnancy to support birthing people and healthy babies.

3. The MCAH/CDAPP work plan encourages the Resource Center to send out email blasts with website links to all affiliates and those interested in CDAPP Sweet Success offerings (non-affiliates with national reach) to increase traffic to the CDAPP website and educational materials. The CDAPP Sweet Success Resource & Training Center has actively engaged organizations to reduce the rate of diabetes in pregnancy for overweight/obese parents.

4. CDPH/MCAH led the development of a social media toolkit which includes the CDAPP Sweet Success Program Profile and three social media messages. These messages target both public and the medical provider community. The materials are downloadable and shareable. The release of the toolkit in November 2021 aligned with National Diabetes Month.
5. CDPH/MCAH granted funding to two local health jurisdictions to develop a statewide campaign that promotes the BIH program and highlights chronic health conditions that particularly affect Black women. The campaign is still in its early stages but strives to generate interest in the newly developed website that maintains information about these chronic health conditions.

Success Stories

The CDAPP Sweet Success Resource Center updated numerous materials in the last fiscal year. There has been an immense push to update CDAPP patient and provider resources not just clinically but graphically. Revisions to resources ranged from one page patient education pieces to ~300 pages long care guidelines. The eight new training modules provide evidence-based trainings on topics that align with the care guidelines. CDAPP affiliates were eager to complete these training modules and shared that they were useful to everyday practice.

The total number of attendees who completed any training module was 3,032 attendees. the total number of YouTube views was 5,871 views. Non affiliate attendees who completed the training modules accounted for 40%, while the remaining 60% were affiliate attendees. very training module showed improved post-test scores (average post-test score was 90%), with attendee participation representing 40 out of the 50 states.

Challenges

The elongated CDPH/MCAH review and approval process for the CDAPP Training Modules and other material resources postponed the time it took for CDAPP Affiliates to participate and utilize these trainings/materials.

 

Women/Maternal Focus Area 3: Improve mental health for all mothers in California.

Women/Maternal Objective 3

By 2025, increase the receipt of mental health services among women who reported needing help for emotional well-being or mental health concerns during the perinatal period from 49.6% (provisional 2018 MIHA) to 52.1%.

 

Objective baseline history

 

Story behind the baseline

It is estimated that approximately 20% of women will experience a perinatal mental health problem (PMHP).1 Mental health problems can range from mild depression and anxiety to mania and psychosis. Promoting mental health and healthy behaviors during pregnancy is important to optimize maternal and infant health outcomes. One of the priorities identified in the 2021-2025 needs assessment is to increase access to mental health services among women and birthing people who reported needing help for emotional well-being or mental health concerns.

1. Royal College of Obstetricians and Gynecologists (RCOG) 2017, Bauer et al., 2014.

Women/Maternal Objective 3: Strategy 1

Partner with state and local programs responsible for the provision of mental health services and early intervention programs to reduce mental health conditions in the perinatal period.

What did CDPH determine as activities that would work to turn the curve of the baseline?

1. Partner and collaborate with state departments and commissions responsible for the provision of mental health services (California Mental Health Services Authority, DHCS, Mental Health Services Oversight and Accountability Commission) to conduct an environmental scan to identify gaps and opportunities in the availability, quality, and use of mental health services for women of reproductive age.
2. Partner at the state and local levels to identify and promote best practices to address mental health, including stigma and discrimination due to mental health diagnosis.
3. Support state and local workforce development to address mental health with the populations we serve.
4. Lead to translate findings from the Maternal Suicide PAMR report into resources for use by health care providers, individuals, and communities. *

Updated Performance Measure Graph/Data specific to this strategy

In 2020, an estimated 49.0% of women who reported needing help for emotional well-being or mental health concerns during the perinatal period reported receiving mental health services. This estimate is about the same as that of 2018 (49.6%).

Narrative section

1. DHCS developed a web page about mental health programs for Children, Youth, Adults and Older Adults. The web page is promoted through local MCAH Programs. The page provides a link to mental health plan by county with a corresponding toll-free telephone line. Each county page provides information on services and resources available for individuals and providers.
2. CDPH/MCAH’s Adolescent Family Life Program (AFLP) partnered with Dignity Health to present the Mental Health QPR (Question, Persuade, Refer) webinar. The suicide prevention QPR training taught lay and professional gatekeepers the warning signs of a suicide crisis and how to respond. For more information, please refer to the adolescent health domain section.
3. All American Indian Maternal Support Services (AIMSS) program clinics have onsite behavioral services and connections to their local health departments, trainings and resources are sent out regularly, and all programs have access to Indian Health Service monthly TeleBehavioral Health training courses.

California Home Visiting Program (CHVP) local implementing agencies continued to embed home visiting into early childhood systems at local and state levels to support access to and awareness of mental health services.

4. *Activity Paused.

Success Stories

Examples from the Local MCAH annual reports to reduce mental health conditions in the perinatal period include the following:

• Amador County - A family with a newborn and two young children had recently moved into this rural county. After briefly meeting with the mother, it was noted she may be suffering from postpartum depression. A referral was instantly made to the Perinatal, Mood and Anxiety Disorder (PMAD) Coalition's small pool of therapists serving this population. Upon follow-up with the family, mom had received counseling services and was back to her usual self and was appreciative that someone in a strange town would have reached out with a healing hand.
• Placer County – A pregnant person, with limited family support was referred for Public Health Nurse (PHN) Home Visitation due to high PHQ-9 and suicide ideation during the sixth week of their pregnancy. The pregnant person was linked to mental health supports during pregnancy, as well as in postpartum period through connection to provider for counseling as well as medication management. PHN case management ensured the pregnant person had access to both prenatal care and mental health care. This eventually led to a positive birth outcome for the infant. The patient was also offered education and guidance around breastfeeding.

Challenges

With shifting priorities and staffing limitations, the development of materials and resources to support the Maternal Suicide PAMR report findings were paused.

Women/Maternal Objective 3: Strategy 2

Partner to strengthen knowledge and skill among health care providers, individuals, and families to identify signs of maternal mental health-related needs.

What did CDPH determine as activities that would work to turn the curve of the baseline.

1. Continue to partner with existing MCAH programs and other Title V-funded programs (BIH, Indian Health, AFLP, CHVP, CPSP) in raising awareness on mental health and promoting mental health resources.
2. Partner with local CPSP Perinatal Service Coordinators (PSCs) to support new state requirements for provider screening of mental health at least once during pregnancy and postpartum, and ensure CPSP providers receive the required training on mental health.
3. Partner with mental health funded programs to identify materials, training, and other resources to educate and inform individuals and families about maternal mental health signs, symptoms, and services.
4. Lead in promoting and disseminating mental health promotional messages through social media platforms and materials to educate women and families about how to recognize early signs and symptoms of mental health disorders.

Narrative section

1. CDPH/MCAH conducted a training workshop for the CPSP PSCs that focused on Maternal Mental Health. The Orange County Toolkit was presented with an opportunity for the PSCs to ask questions and devise their own Maternal Mental Health toolkit with their CPSP providers using the toolkit as a template. The PSCs remain an integral component to the success of the CPSP Program through maintaining updated referrals to WIC, BIH, and CHVP that providers can utilize for their clients.

 

CDPH/MCAH funds a mental health professional in BIH that assesses women for mental health issues upon enrollment and throughout their time in the program. This staff is also required to establish a network of mental health resources in each of their communities. BIH also encourages programs to be innovative in their approaches for meeting the mental health needs of Black women. Alameda County has contracted with a provider to provide therapy in addition to the services required by BIH.

 

Each grant year the AIMSS programs are emailed culturally relevant training opportunities that addresses mental health. The Indian Health Services offer monthly online courses for all provider types.

 

CPSP materials are used in all the clinic sites. Family Spirit addresses mental health in their curriculum such as postpartum depression, relationships, and substance use. A mental health module will be added in the coming year to address indigenous preventive approaches, related treatment options, and challenges.

 

CHVP local implementing agencies are encouraged to establish working relationships, formal agreements, and referral protocols with county behavioral health and community mental health organizations to support meeting the needs of home visiting program participants.

 

This activity was paused during the pandemic for AFLP.

 

2. CDPH/MCAH continued to partner with the CPSP PSCs to ensure CPSP providers used a state-approved template or developed their own perinatal and postpartum assessment and reassessment forms that focused on the following:

• Maternal Mental Health screening
• Development of an Individualized Care Plan (ICP) from the assessment and reassessment
• Determining interventions needed for the client
• Producing timely referrals

3. Most training programs to providers and their staff was offered. A technical assistance workshop was conducted for PSCs focusing on the Orange County Maternal Mental Health Algorithm. This algorithm may be customized by the CPSP providers and PSCs to meet the unique demands of their specific county.
4. The AIMSS program staff are provided education through Indian Health Services and First Five programs. Staff utilize tools such as the Edinburgh Postnatal Depression Scale and the “Five Ps” to screen for post-partum depression, domestic violence, substance misuse disorder, and tobacco use. In Humboldt County, First Five and the local tribal programs hosted Weaving the Wellness and presented lectures on mental health and substance abuse. All AIMSS program staff were invited to participate, and lectures and slides were provided to program participants.

Participant mental health is regularly assessed by CHVP home visitors using the Edinburgh Postnatal Depression Scale (EPDS) or Patient Health Questionnaire – 9 (PHQ-9) and appropriate referrals are made to mental health professionals as necessary.

5.  CDPH/MCAH developed the following web-based resources to support Maternal Mental Health:

• The main Maternal Mental Health webpage offers resources for sharing information with local programs and their partners such as printable materials, and libraries for video and social media posts.
• The COVID-19 Manage Anxiety & Stress webpage has curated important information from a variety of public health outlets about coping with stress and anxiety during the pandemic.
• The “Healthy Mind” section of CDPH’s Preconception Health webpage offers resources for local programs and their partners to further explore topics like mindfulness and substance use.

Success Stories

The PSCs continued to collaborate with CPSP providers to ensure that not only Maternal Mental Health screenings were done as part of all assessments, but also that appropriate referrals were made, resources were provided to the client, and follow-up was documented. One technical assistance workshop for the PSCs that was provided by CDPH/MCAH focused on the Orange County Maternal Mental Health Algorithm. With assistance from the PSCs, this algorithm may be customized by CPSP providers to meet the unique demands of their clients specific to their county.

Challenges

Since the onset of the pandemic, many PSCs were redirected to COVID-19 county-specific activities, limiting the amount of time they were able to allow for technical assistance to the CPSP providers.

Women/Maternal Objective 3: Strategy 3

Partner to ensure pregnant and parenting women are screened utilizing standardized and validated tools and linked to needed services for mental health conditions in the perinatal period.

What did CDPH determine as activities that would work to turn the curve of the baseline?

1. Partner with MCAH-funded programs (CPSP, BIH, CHVP, Indian Health, ALFP, local MCAH) to utilize validated mental health screening tools.
2. Partner with Department of Health Care Services Mental Health Branch and the Mental Health Services Act Oversight & Accountability Commission to identify validated tools for mental health screening in the perinatal period. *
3. Partner with Department of Health Care Services Mental Health Branch and the Mental Health Services Act Oversight & Accountability Commission to ensure adequate and appropriate access to perinatal mental health services are made available at the local level.

Narrative section

1. In the BIH program, participants’ mental health is closely tracked by a mental health professional and the Edinburgh Postnatal Depression Scale (EPDS) is offered to every woman enrolled in the program.

For CPSP, clients are assessed for potential areas of risk in nutrition, psychosocial, and health education. From the assessments, the providers work with the client to develop an individual care plan with interventions unique to the client. The PSCs work closely with the CPSP providers to ensure providers have updated listings of referrals to community support systems and resources the client is able to utilize. The AIMSS program utilized CPSP and Family Spirit screening tools for initial assessments. If clients require further screening, additional tools are utilized such as the Warwick-Edinburgh Mental Well-being scale.

Participant mental health is regularly assessed by CHVP home visitors using the EPDS or Patient Health Questionnaire – 9 (PHQ-9) and appropriate referrals are made to mental health professionals as necessary.

AFLP developed the Comprehensive Baseline Assessment (CBA) and Youth Outcome Assessment (YOA), data collection tools which AFLP case managers completed to assess participant needs and connect them to resources. The CBA was completed within the first two months of program enrollment and the YOA is completed every six months thereafter. Both assessments include mental health questions from the PHQ-9, PHQ-9 Modified for Teens, and EPDS screening tools. Due to privacy concerns associated with telehealth visits during the COVID-19 pandemic, mental health questions were made optional. Case managers continued to monitor youth wellbeing, and provided screening and referrals as needed. 

Many local AFLP agencies engaged in supplemental activities to complement AFLP Positive Youth Development (PYD) case management services in supporting the well-being of youth and their families including the following:

• Developmental and social emotional screenings – Ages and Stages Questionnaires (ASQ-3 and ASQ-SE), Denver Developmental Screening tool, Parents’ Evaluation of Development Status (PEDS) screening tool, and Protective Factors Survey-2 (PFS-2)
• Maternal depression screenings – Patient Health Questionnaire-9 (PHQ-9), Columbia screening tool for suicide assessment, Perinatal Mood and Anxiety Disorders (PMAD) Screening and Care Pathway, and Edinburg Post-natal Depression Scale (EPDS).
• Domestic violence screening – Relationship Assessment Tool (RAT) 
  • For more information, please refer to the adolescent health domain section.

2.  *Activity Paused.

 

3.   Department of Health Care Services provided a webpage on Mental Health programs for Children, Youth, Adults and Older Adults. This webpage is promoted through our local MCAH programs. The page provides a link to Mental Health Plan by County with a corresponding toll-free line. Each County page provides information and on services and resources available for individuals and providers.

Success Stories

Examples from the Local MCAH annual reports to ensure pregnant and parenting women are screened utilizing standardized and validated tools include the following:

• Sonoma County – This program assessed evidence-based mental health screening tools currently used in the local health centers and in MCAH home visiting programs. In FY 20-21, Sonoma County MCAH developed an 11-question survey assessment for all CPSP providers. Evidence-based screening tools were identified through a literature review and a policy was implemented for the use of these tools through the home visiting programs. Through assessment of the home visiting programs, it was determined that all home visiting staff administer an evidence-based mental health screening for all clients admitted to the home visiting programs.

Challenges

Since the onset of the pandemic, many staff were redirected to COVID-19 county-specific activities, limiting the amount of time they were able to allow actively engaging in identifying new and/or validating existing screening tools for mental health during the perinatal period.

Women/Maternal Focus Area 4: Ensure optimal health before pregnancy and improve pregnancy planning and birth spacing.

Women/Maternal Objective 4

By 2025, increase the percentage of women who had an optimal interpregnancy interval of at least 18 months from 73.6% (2017 CCMBF) to 76.4%.

 

Objective baseline history

Story behind the baseline

Pregnancies spaced less than 18 months after a live birth are associated with delayed prenatal care and increased risk for adverse birth outcomes. Access to services that promote appropriate birth spacing can reduce the risk for poor birth outcomes such as preterm birth and low birthweight. Access to family planning counseling and contraception plays a key role in birth spacing and reduced risk for poor birth outcomes.

Women/Maternal Objective 4: Strategy 1

Partner to increase provider and individual knowledge and skill to improve health and health care before and between pregnancies.

 

What did CDPH determine as activities that would work to turn the curve of the baseline?

1. Lead the reconvening of the California Preconception Health Council to guide and inform statewide preconception efforts.
2. Lead a refresh of “Every Woman California” website to re-establish a platform for sharing preconception health information for the public and health professionals.
3. Support disseminating and promoting best practices, resources, and education from key preconception initiatives
4. Support local MCAH programs in identifying uninsured populations, conducting outreach and awareness of health insurance options, and implementing protocols to assist clients to enroll in health insurance and access services.

Narrative section

1. CDPH/MCAH developed a strategic plan and recruited members (local MCAH programs, community-based organizations, health plans, academia, professional associations, hospitals/health systems, funders) for the Preconception Health Council of CA (PHCC). The PHCC reconvened in November 2020 and continues to meet quarterly. The PHCC is a statewide forum for planning and decision-making whose goal is to integrate, develop, and promote preconception and interconception health, health care, sexual and reproductive health services, and psychosocial well-being.
2. The Preconception Collaborative Improvement and Innovation Network (CoIIN) led by University of North Carolina Chapel Hill provided funds to support with the redesign of the “Every Woman California” website. The redesign was started in FY 20-21 and will be completed in FY 21-22. The site is being re-established as a platform for sharing preconception and interconception health, health care, sexual and reproductive health services, and psychosocial well-being information for the public and health professionals. Site information promotes optimal interpregnancy interval of at least 18 months for the public and provides resources for health professionals to incorporate this recommendation into screenings.
3. PHCC partnered with American College of Obstetricians and Gynecologists (ACOG) to update Interconception Care Guidelines for postpartum visits that include provider algorithms and patient handouts. The guidelines will be published in FY 21-22 and recommend advising patients to wait 18 months before becoming pregnant again. Once published these guidelines will be promoted and disseminated to internal and external partners and shared on the “Every Woman California” website.

 

Local Black Infant Health Program staff promoted reproductive life planning with participants during the following sessions:

• Life planning meetings when setting short and long-term goals
• Individual Case Management
• Prenatal group sessions to discuss the importance of family planning/birth control options for consideration
• Development of a Birth Plan with the Family Health Associates (FHA) and/or Public Health Nurse (PHN) to discuss birth control options with their clinician prior to hospital discharge

The California Home Visiting Program (CHVP) funds three evidence-based home visiting models (Healthy Families America, Nurse Family Partnership, and Parents as Teachers), all of which provide guidance, education, and support to program participants around interconception care, contraception, and family goal planning.

CDPH/MCAH updated Adolescent Family Life Program (AFLP) materials, including the “Family Planning and Safer Sex” section of the “My Life Plan” booklet to ensure medical accuracy and gender inclusivity, using best practices to discuss reproductive goals and life planning. Updates were made to the “My Goal Sheet” and “My Life and Me” materials to ensure medical accuracy and gender inclusivity, and all program materials were translated to Spanish.

CDPH/MCAH hosted a live virtual training on Family Planning and Safer Sex in January 2021. The goal of this training was to support case managers with AFLP in building skills, knowledge, and comfort in discussing family planning as a core program priority of the AFLP PYD program. CDPH/MCAH sponsored a live virtual training primer on reproductive justice in April 2021. The focus of this training was to create awareness of the reproductive issues that impact how youth engage in conversations about family planning and understand barriers to health care.

4. CDPH/MCAH collaborates with local MCAH programs to develop and adopt protocols to ensure that all clients in local MCAH programs have health insurance, are linked to a provider, and complete a preventive visit(s). Local MCAH programs facilitate access to care and appropriate use of services including, but not be limited to oversight of CPSP, patient/client outreach, services for CYSHCN, education, community awareness, referral, transportation, childcare, translation services, and care coordination. They continue to develop and revise policies in response to COVID-19 in areas such as telehealth.

Success Stories

Examples from the Local MCAH Annual Reports to improve pregnancy planning and birth spacing include the following:

• Santa Clara County - Local Perinatal Equity Initiative (PEI) Program staff in Santa Clara County used a personal support intervention where the Maternal Health Navigator routinely shared information with the perinatal patient regarding the optimal interpregnancy interval of at least 18 months during their one-to-one sessions.
• Los Angeles County - Local PEI Program staff in Los Angeles County contracted with Essential Access Health to provide trainings to providers (primarily primary care clinicians, as well as BIH staff, doulas, etc.) on how to have respectful, culturally attuned pregnancy-intent conversations with anyone of reproductive age. Alongside the trainings, they will be launching a campaign to promote/normalize having these conversations for both patients and providers. The conversation opens the door to providing appropriate education and resources about birth spacing, contraception, nutrition, and anything someone might need to have a healthy pregnancy if/when they desire it.
• City of Long Beach - The local health jurisdiction created an Integrated System of Care called Akido which facilitates access to health care services. It's a kiosk questionnaire that clients check-in to when going to any of the clinics in the health department. This helps with referrals to other programs such as Medical Outreach, WIC, and more.

Challenges

Local MCAH programs procedurally increased health education efforts to offset the negative impact and avoidance of routine preventive well-visit appointments due to the pandemic. Issues associated with the lack of accessibility of medical appointments and fears associated with coming to health care facilities caused many delayed medical services.

Women/Maternal Objective 4: Strategy 2

Lead a population-based assessment of mothers in California, the Maternal and Infant Health Assessment Survey (MIHA), to provide data to guide programs and services.

What did CDPH determine as activities that would work to turn the curve of the baseline?

1. Partner with the University of California San Francisco (UCSF) Center for Health Equity (CHE) to create a survey and revise the MIHA sampling plan as needed to ensure representative data at the state, regional, and county levels.
2. Support the UCSF CHE to implement data collection activities and maximize participation among individuals selected to participate in the survey.
3. Support the UCSF CHE to weight the study data and prepare an annual MIHA analytic dataset and codebook.
4. Partner with the UCSF CHE to conduct analyses of CDPH/MCAH priority topics, develop surveillance products, and design and implement scientific research studies.
5. Lead the dissemination of findings in a variety of MIHA data products.

Narrative section

1. CDPH/MCAH collaborated with UCSF CHE to revise the sampling plan for the MIHA 2021 survey. Revisions were made to remove changes that were made for MIHA 2020 due to the COVID-19 pandemic and revert to the pre-2020 sampling plan. The total sample remained the same at approximately 10,000 to allow for representative stable data at the state, region, and county levels. Survey development for MIHA 2021 occurred from September 2020 through March 2021 and involved collaboration between MCAH subject matter experts and leadership and UCSF CHE, as well as input from other CDPH programs, CDC, and key MCAH/MIHA stakeholders. New topics added in MIHA 2021 included the following:

• Respectful maternity care
• Receipt of the COVID-19 vaccine during pregnancy and postpartum, and reasons for not receiving the vaccine during pregnancy
• Provider communication about the Newborn Screening Test and results

2. CDPH/MCAH supported UCSF CHE in MIHA data collection for the MIHA 2020 and 2021 surveys and had regular meetings to discuss data collection implementation. Data collection for MIHA 2020 began in June 2020 and was completed in February 2021, and data collection for MIHA 2021 began in May 2021. MIHA 2020 had an overall response rate of 63.6% (6,365 participants), a slight increase from previous years.
3. In collaboration with UCSF, CDPH/MCAH reviewed the MIHA weighting procedures and supported UCSF in creating final weights and finalizing the dataset for MIHA 2019 in December 2020. CDPH/MCAH supported UCSF in creating provisional weights for MIHA 2020 data. Using the Vital Records Business Intelligence System, final weights will be calculated when the final California Comprehensive Master Birth File is available for 2020. MCAH collaborated with UCSF in validating constructed variables for raw MIHA 2020 data from May 2021 to June 2021 and updated the MIHA variable database.
4. CDPH/MCAH collaborated with UCSF on the development of two sets of MIHA data snapshots using 2016-2018 MIHA data. These surveillance products contain many key MCAH indicators by different maternal demographics for the overall birthing population and for the prenatal WIC participant population at the statewide, regional, and county levels.
5. Research findings using MIHA data were disseminated through scientific papers and presentations. A manuscript using MIHA data to analyze the effect of the Affordable Care Act on women’s health insurance coverage was published in Public Health Reports in October 2020. There were nine oral and poster presentations done at the CityMatCH Leadership and MCH Epidemiology conference in September 2020, the American Public Health Association annual conference in October 2020, the California Breastfeeding Summit in January 2021, and the National Conference on Health and Domestic Violence in April 2021. The presentations shared the MIHA data on the topics of maternity leave, workplace breastfeeding support, racial discrimination and mental health, American Indian and Alaska Native maternal and infant health, breastfeeding practices, and intimate partner violence.

Success Stories

CDPH/MCAH partnered with UCSF on the following analytic projects:

• Development of the Black Maternal and Infant Health report
• Developmental analyses and conceptualization of a series of data briefs focused on the secondary impacts of the COVID-19 pandemic using MIHA 2020 data
• Development of a coding scheme and an assessment of the need for, receipt of, and barriers to mental health care series on MIHA
• Conceptualization of additional analyses focused on other priority MCAH topics such as substance use and breastfeeding

Challenges

Not applicable

Women/Maternal Objective 4: Strategy 3

Lead the implementation of the Comprehensive Perinatal Service Provider (CPSP) program to ensure access to comprehensive prenatal care for Medi-Cal Fee-for-Service clients

What did CDPH determine as activities that would work to turn the curve of the baseline?

1. Lead in establishing standards for an applicant to become a CPSP provider, review applications, and notify the applicant if their application is accepted.
2. Support local Perinatal Service Coordinators (PSCs) to identify and recruit providers in medically underserved areas to increase access to perinatal care.
3. Continue to support locals by providing technical assistance and training on the CPSP provision of services and quality of care.
4. Continue to fund CPSP Provider Orientations to ensure CPSP providers understand the role and responsibilities of becoming a CPSP provider in addition to provision of services.*
5. Continue to lead in monitoring and providing oversight of CPSP, including quality improvement efforts to monitor providers and ensure quality of care for CPSP.

Narrative section

1. MCAH/CDPH developed a new Enrollment Application Form (4448) that will be incorporated in early 2022. The new Enrollment Application Form streamlines the application process for providers and gives guidance to the PSCs for reviewing the application to ensure a successful provider enrollment. Along with the new Enrollment Application Forms, the CPSP/MCAH Policies and Procedures (P&Ps) were revised to reflect these new changes. Through accordance with Title 22, the P&Ps outline the application process and notification to providers about the acceptance of applications, or the reason for declined applications.
2. CDPH/MCAH supports efforts by the PSCs when leading community outreach efforts that encourage recruitment of providers to CPSP in medically underserved areas. PSCs are encouraged to collaborate and share ideas with other PSCs in the areas of recruitment and retainment during monthly technical assistance (TA) workshops.
3. CDPH/MCAH conducted 10 monthly TA workshops for the PSCs. While not mandatory, out of the 71 PSCs, an average of 37 PSCs attended these TA workshops. Topics included: 1. Quality Assurance/Quality Improvement (QA/QI) Overview: Discussed the PSCs role in conducting Administrative Reviews, Chart Reviews, and Protocol Reviews. This TA workshop aimed to equip the PSCs with a better understanding of what is required by CPSP providers to successfully implement the CPSP Program. 2. Medical Billing: This presentation by our Medi-Cal Liaisons instructed the PSCs on how to best assist the providers with Medi-Cal questions, included the top ten denied claims and how the PSCs can help the CPSP providers remedy billing problems. 3. Orientation to new Perinatal Dietary Food Recall tool and MyPlate tool: presented by MCAH Nutritionist, this was an overview of the new dietary recall tool and MyPlate tool that CPSP providers will be able to utilize when assessing dietary needs of their clients. 4. Regional Perinatal Programs of California (RPPC): presented by our RPPC chair, this presentation focused on how the PSCs can network with their regional RPPC representative to ensure high-risk individuals have the follow-up care needed. 5. Maternal Mental Health: The Orange County Toolkit was presented to the PSCs. Discussion included how the PSCs can use this toolkit to adapt to the needs of their individual counties. 6. Childhood Lead Poisoning Prevention Branch (CLPPB): presented by CDPH’s CLPPB, the focus was on educating the PSCs to better inform the CPSP providers on resources available in their community to prevent childhood lead poisoning in clients who may be pregnant or become pregnant. 7. Data Visualization Project: presented by CDPH’s Epi team, this workshop focused on the new data visualization tool and how PSCs may access the information that is provided specific to their county. 8. CA Quits (California Quits): presented by researchers at UC Davis, this workshop focused on new and emerging data that continues to shape the CA Quits program. Additional resources were provided to the PSCs, along with a robust question and answer period. 9. Women, Infants and Children (WIC): presented by our CDPH WIC program, the workshop focused on continued collaboration between the PSCs and their county’s WIC program. 10. New CPSP Provider Enrollment Application: presented by CDPH/MCAH, this workshop introduced the PSCs to the new CPSP provider enrollment application and the steps required to assist a new provider in completing the application form.
4. Activity paused.
5. Due to Covid restrictions many PSCs were unable to perform provider onsite visits, but virtual chart reviews at some provider sites were completed by PSCs to ensure the integrity of the CPSP program.

Success Stories

The PSCs continued to recruit CPSP providers during the pandemic. For 2020, 38 CPSP provider applications were approved, an increase from 33 approved provider applications in 2019. Despite the restrictions during the pandemic, many CPSP providers reported to their PSCs that clients were satisfied and felt they had their obstetrical, nutritional, psychosocial, and health educational needs met with virtual visits. To find the best fit for their clients’ participation in the CPSP program, providers stated they will continue to offer both face-to-face and virtual office visits to promote successful completion of the CPSP program.

Challenges

Serving medically underserved regions through California continues to be challenging. Not all counties have CPSP providers or PSCs. While more CPSP applications were approved in 2020 than 2019, the overall enrollment and participation of Fee-For-Service (FFS) providers has decreased. MCAH continues to work with the PSCs in counties with few or no CPSP providers to encourage recruitment into the CPSP program. However, because of the pandemic, many PSCs were redirected to COVID-related activities which prevented the PSCs from performing CPSP duties.

Women/Maternal Objective 4: Strategy 4

Fund the DHCS Indian Health Program (IHP) to administer the American Indian Maternal Support Services (AIMSS) to provide case management and home visitation program services for American Indian women during and after pregnancy.

What did CDPH determine as activities that would work to turn the curve of the baseline?

1. Fund DHCS IHP to conduct perinatal case management and care coordination to support pregnant American Indian individuals to receive health care, education, emotional support, and referrals to social, health, and community services.
2. Fund DHCS IHP to provide maternal health training for AIMSS grantees and Indian health clinics through meetings, webinars, or conferences.
3. Fund DHCS IHP to collect and monitor program data to include in Title V reporting.
4. Support DHCS IHP to screen and refer American Indian pregnant individuals for mental health and substance use disorder services.
5. DHCS IHP to educate women and families to recognize early signs and symptoms of mental health and substance use disorders through health promotion messages.

Narrative section

1. Through the AIMSS grant, the AIMSS program continued funding to four Indian health clinics to provide perinatal case management and home visitation services. Three of the four programs provide home visitation, although COVID-19 led to visits in most areas utilizing telephonic or virtual modalities instead of face-to-face appointments.
2. A CEU Case Management online course was offered to all AIMSS case managers. This course prepares case managers to manage a case from start to finish and includes addressing cultural, ethical, behavioral, and psychosocial issues in the field. All materials were available for review for future reference. All programs participate in a weekly call with the AIMSS grants manager to discuss their program problems or successes.

        All programs receive regular updates via email and are invited to participate on weekly State/IHS COVID-19 calls. Toolkits are emailed out to all participants that include the latest information from the CDC on vaccination during breastfeeding and pregnancy that aligns with ACOG recommendations.

         All AIMSS program staff working on the AIMSS grant are required to have California Perinatal Services Program (CPSP) training. New AIMSS staff in need of training will participate in the next virtual CPSP training.

3. AIMSS programs are required to submit monthly data on perinatal clients and their infants. This information is gathered each trimester and is used to design a care plan and to track clients through their pregnancy and is also shared with clinic providers.
4. The AIMSS programs utilized CPSP guidelines, with three of the four programs using the Family Spirit home visiting model. The programs also utilize Lippincott Policies and Procedures for guidance to improve client outcomes which helps with a workflow blueprint. The programs are also members of ACOG. One program is a CPSP provider and the other three have part-time obstetrician contracted providers available.

Upon registration into the AIMSS program, each client is given the Maternal Prenatal Screening Guide to complete upon enrollment. At each trimester they are screened for mental health and substance use. If further assessment is needed, the Edinburgh Mental Well Being or another tool will be used. After delivery, the Post Pregnancy Screening Guide is used which includes client risk factors that address behavioral health and substance misuse.

Other screening tools used include Patient Health Questionnaire-9, (PHQ-9), and ACE’s screening tools. Data gathered from these tools go directly in the patient’s electronic health record. Once a client is identified as needing mental health or social services, a referral is made within the clinic to the Behavioral Health Department who will follow up with clients and begin the referral process to the local county mental health department, or begin services provided at the clinic. The client could be referred to a treatment center if they are willing to go.

5. All AIMSS grantees employ mental health and substance use counselors in the clinic. Clients are also able to use offsite resources, if needed. The Northwest Portland Area Indian Health Board hosts monthly, national meetings for Indian health clinics with a multidisciplinary team focused on improving outcomes for clients with substance use disorder. Education is provided at these meetings to Tribal and Urban Indian health care clinicians who treat and manage patients with substance use disorder. This monthly virtual meeting is focused on a culturally responsive approach to mental and behavioral health in a primary care setting. AIMSS participants are encouraged to participate and bring a current case to the call to discuss and receive advice from professionals.

Success Stories

In this funding year, an emphasis was placed on recruitment and outreach services. It was found that program flyers, postings on Facebook and other social media platforms, public service announcements, and program incentives work well and are successful in increasing enrollment.

Challenges

AIMSS programs experienced natural disasters such as wildfires and rockslides, as well as difficulty in retaining and hiring staff in Tribal programs located in both rural and non-rural areas. One program reported more than 30 administrative and clinical job vacancies.

 

Women/Maternal Focus Area 5: Reduce maternal substance use.

Women/Maternal Objective 5

By 2025, reduce the rate of maternal substance use from 20.7 per 1,000 delivery hospitalizations (2018 PDD) to 19.7 per 1,000 delivery hospitalizations.

Objective baseline history

Story behind the baseline

Maternal substance use disorder (SUD), the chronic abuse of any drug or alcohol during pregnancy, is widely recognized as a significant public health issue. SUD data is collected from hospital discharge diagnosis codes at delivery as defined by Agency for Healthcare Research and Quality's (AHRQ). Substances included in this analysis are: Opioids, cocaine, other stimulants, including psychostimulants and other substances: alcohol, cannabis, sedative, hallucinogen, inhalant, psychoactive substance, and lysergide. The most recent Needs Assessment indicated a pattern of significant racial/ethnic disparity related to maternal substance use during pregnancy.

Women/Maternal Objective 5: Strategy 1

Lead research and surveillance on maternal substance use in California.

What did CDPH determine as activities that would work to turn the curve of the baseline?

1.  Lead surveillance of maternal substance use, including measurement of trends or disparities, and review of scientific literature to remain current with respect to both scientific methods and emerging issues.

2.  Lead the dissemination of data findings (reports, presentations, social media posts, etc.) to raise awareness about maternal substance use and provide data to guide programs and services.

Narrative section

1. CDPH/MCAH continues to monitor maternal substance use at time of delivery using patient discharge data and among birthing individuals using the Maternal and Infant Health Assessment survey (MIHA). For this objective, the rate of maternal substance use increased from 20.7 per 1,000 delivery hospitalizations in 2018 to 21.1 per 1,000 delivery hospitalizations in 2020. In 2020, American Indian and Alaska Native (AIAN) women were more likely than all other racial/ethnic groups to have a substance use diagnosis (80.9 per 1,000 delivery hospitalizations). Black women were the next most likely to have a substance use diagnosis (60.8), followed by Multi-Race (31.6), White (28.3), Pacific Islander (17.3), Hispanic (16.9), and Asian women (3.1).

MIHA conducts self-reported surveillance of alcohol, tobacco, and cannabis use among birthing individuals, including NOM 10 on prenatal alcohol use. MIHA continues to collaborate with the CDC in their ongoing analyses of 2019 data on prescription opioid use during pregnancy.

CDPH/MCAH continues to review scientific literature to remain current with respect to both scientific methods and emerging issues related to maternal substance use.

2. CDPH/MCAH is currently planning and developing data dashboards and MIHA data snapshots to disseminate surveillance findings. Maternal substance use is one of many key indicators to be highlighted.

Success Stories

As more scientific research that uses ICD-10-CM coding is now being published, CDPH/MCAH is well positioned to increase and improve maternal substance use surveillance efforts.

Challenges

Lack of staffing, due to a combination of COVID-19 redirections or related assignments, shifting priorities within MCAH and other staff vacancies, has resulted in many activities being paused or slowed. This includes monitoring substance use among individuals aged 18-44 years.

Women/Maternal Objective 5: Strategy 2

Partner at the state and local level to increase prevention and treatment of maternal opioid and other substance abuse/overuse.

What did CDPH determine as activities that would work to turn the curve of the baseline?

1. Support Family Health and Outcomes Project/UCSF in the local dissemination of the Association of State and Territorial Health Officials (ASTHO) Public Health Perinatal Opioid Toolkit, targeting counties of greatest need.
2. Support ACOG in promoting education of obstetricians and gynecologists in perinatal substance use.*
3. Lead the dissemination of consumer opioid education materials through social media.*
4. Support local MCAH programs in identifying resources on treatment and best practices to address substance use and opportunities to collaborate and improve linkage to services at the state and local level.
5. Lead the development of a social media campaign related to maternal opioid use.*

Narrative section

1. The ASTHO Public Health Perinatal toolkit and associated training was distributed to the 24 counties with the greatest need, and to an additional three counties that requested the training and toolkit. The toolkit was also disseminated during regional/state trainings. Approximately 1,760 public health and related staff participated in the trainings.

2. *Activity Paused.
3. *Activity Paused.
4. The ASTHO Public Health Perinatal Toolkit and associated trainings were provided to local MCAH programs and included resources on treatment, as well as information on best practices to address substance use. During the trainings, information on additional local treatment resources were solicited from and shared with training participants.

AIMSS program clinics have substance abuse and mental health services/resources available at funded Indian health clinics and are also connected to local county mental health departments. Case managers work closely to meet the mental health needs of the clients and help make appointments, arrange transportation, and offer support during appointments. All AIMSS programs received an invitation to participate in a three-part webinar series titled “Weaving the Wellness” that addressed opioid use in the community. A collaborative approach was discussed in addressing the needs of infants and families affected by substance use disorder. Resources and training opportunities are also shared regularly with AIMSS grantees.

      CHVP local implementing agencies continued to collaborate with early childhood systems to improve substance use screening and linkage within home visiting. However, it is challenging for home visitors to access appropriate care for pregnant and parenting people who need support and treatment related to substance use. 

5. *Activity paused.

Success Stories

Examples from the local MCAH Annual Reports to increase prevention and treatment of maternal opioid and other substance abuse/overuse include the following:

• Del Norte County - While there are many substance use programs present in Del Norte County, only three local programs have identified perinatal substance use (PSU) and address it specifically. One of these programs is the Plan of Safe Care (POSC), a new PSU initiative being directed through the Yurok Tribe Joint Family Wellness Court. MCAH representatives were present in the system walkthrough of the care-continuum and in choosing a model to use, as well as members of the working group for POSC, which met monthly before the start of the COVID-19 pandemic. The working group was focused on creating a working continuum of care that provides healing opportunities for Karuk/Hoopa/Yurok families through increased awareness of substance use, early identification of infants exposed prenatally to substances, early engagement of community services, and decreased exposure to trauma for the impacted family. Progress was made in the creation of the POSC program, but the stress of COVID-19 response has slowed the process down considerably and there has been turnover in the roles of different partners.
• Santa Clara County - The plan for FY 21-22 is to conduct an environmental scan of the use of the 4Ps Plus tool and provide training to MCAH staff, nursing staff, and CPSP Providers on maternal mental health and substance use as well as use of the 4Ps Plus screening tool. Additional outreach is planned for FY 22-23.

Challenges

AIMSS programs report that certain outside agencies can be difficult to navigate for their clients. They report long wait lists and difficulty keeping appointments. The AIMSS staff offer support in these cases by making appointments, offering support during appointments, and transporting clients to appointments.

 

 

WOMEN/MATERNAL Domain Partners

Who are our partners?

Partners: Adolescent Family Life Program (AFLP) Black Infant Health (BIH) California Diabetes and Pregnancy Program (CDAPP) California Home Visiting Program (CHVP) California Pregnancy-Associated Mortality Review (CAPAMR) Comprehensive Perinatal Services Program (CPSP) Department Of Health Care Services/ Medi-Cal Managed Care (DHCS/MCMC) DHCS/American Indian Maternal Support Services (AIMSS) Family Health and Outcomes Project (FHOP) Local Health Jurisdictions (LHJS) Maternal and Infant Health Assessment (MIHA) Nutrition And Physical (NUPA) Initiative and Partners Regional Perinatal Programs of California (RPPC) Preconception Health Council of California Perinatal Equity Initiative CDPH/Nutrition Education Obesity Prevention Branch CDPH/Chronic Disease Control Branch CDPH/Office of Oral Health