Massachusetts had four Maternal and Women’s Health priorities for the reporting cycle ending in 2020:
- Promote equitable access to preventive health care including sexual and reproductive health services.
- Promote equitable access to dental care and preventive measures for pregnant women and children.
- Promote emotional wellness and social connectedness across the lifespan.
- Address substance use among women of reproductive age to improve individual and family functioning.
There are three priorities for the cycle ending in 2025:
- Strengthen the capacity of the health system to promote mental health and emotional well-being.
- Prevent the use of substances, including alcohol, tobacco, marijuana and opioids, among youth and pregnant women.
- Reduce rates of and eliminate inequities in maternal morbidity and mortality.
Because this is a transition year following the needs assessment, this report describes FY20 activities related to both sets of priorities.
Priority (2015-2020): Promote equitable access to preventive health care including sexual and reproductive health services.
Objective 1 (NPM 1): By 2020, increase the percent of women (aged 18-44 years) with a past year preventive visit from 76.3% (2014 BRFSS) to 77.5%.
According to the 2019 Behavioral Risk Factor Surveillance System survey (BRFSS), 78.5% of women had a preventive visit in the past year. This is an increase from 75.6% in 2018 and exceeds the 2020 objective. Because the BRFSS routine checkup item changed in 2018, this percentage is not comparable to previous survey years.
Sexual and Reproductive Health Program (SRHP)
In FY20, SRHP funded 20 agencies statewide to provide clinical family planning services at 102 sites. SRHP providers offer comprehensive family planning services to decrease unintended pregnancy and sexually transmitted infections (STIs). Vendors operate in communities with higher rates of teen births and STIs, and with low-income, uninsured, adolescent, and refugee and immigrant populations. Vendors must provide clinical family planning services on site or by referral, and may provide education on family planning, outreach to promote family planning services, and/or supportive services to assist priority populations to access clinical family planning services.
In FY20, through state funded sexually and reproductive health (SRH) clinics, MA continued to promote the Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs (QFP). These recommendations expand family planning to include preconception and other preventive health services, including screening for obesity, smoking, diabetes, violence, mental health, reproductive life planning, and screening for and treating STIs. Additional preventive health services include breast and cervical cancer screening, immunizations, and other services based on nationally recognized standards of care. Clients seeking contraceptive services at SRH clinics often do not have another source of primary health care. SRH services visits are opportunities for clinicians to offer broad preventive health services beneficial to overall health as well as to reproductive health.
MA Maternal, Infant, and Early Childhood Home Visiting Initiative (MA MIECHV)
MA MIECHV, funded by HRSA/MCHB, provides evidence-based home visiting services to pregnant and parenting families in 17 communities. MA MIECHV aims to improve the lives of children and families by supporting parenting, improving maternal and child health, and promoting child development and school readiness. Home visitors supported preventive health and prenatal practices for women by facilitating connections with the health care system, including connecting families to preventive care services when needed. Home visitors also received training on preconception and interconception care education, including how to support families with developing a reproductive life plan and facilitating access to reproductive health services.
Welcome Family
Welcome Family is a universal short-term postpartum nurse home visiting program funded by MA MIECHV. It offers a one-time nurse home visit and follow-up phone call to all mothers and caregivers with newborns in five MA communities. The goal is to promote optimal maternal and infant physical and mental well-being and provide an entry point into a system of care for families with newborns. Nurses identify and respond to family needs by providing brief intervention, education, support, and referrals to community services and resources.
During the Welcome Family visit, nurses screen participants for access to health care providers, assess barriers, and facilitate connection to providers. In FY20, 88% of Welcome Family participants had a health care provider after giving birth. A majority (83%) of caregivers with a health care provider reported that it was “easy” to access health care services. Among those who reported difficulty in accessing services, transportation (67%) was the main barrier. In the past, 94% of families reported transportation as the main barrier, suggesting that telehealth services offered during the COVID-19 pandemic have better enabled Welcome Family participants to access preventive health services.
Priority (2015-2020): Promote equitable access to dental care and preventive measures for pregnant women and children.
Objective 1 (NPM 13A): By 2020, increase the percent of women who had a dental visit during pregnancy from 54.9% (PRAMS 2016) to 57.2%.
During 2019, 58.8% of mothers had a cleaning during pregnancy, compared with 57.8% in 2018 (PRAMS). Inequities persist by race/ethnicity and education level. From 2018-2019, the percentage of mothers receiving oral health care during pregnancy increased modestly among Asian mothers (from 48% to 51.3%), Hispanic mothers (from 48.1% to 51.5%), and Black mothers (from 43.7% to 45.5%). The percentage of White mothers remained stable at 64.5%. Among women with a college degree, 70.2% had their teeth cleaned during pregnancy in 2019, compared with 48.7% among women with a high school degree.
Perinatal Oral Health Practice Guidelines
From 2016-2019, with funding from HRSA’s Perinatal and Infant Oral Health Quality Improvement (PIOHQI) Project, MDPH piloted the MA Perinatal Oral Health Practice Guidelines in five community health centers to integrate oral health care into primary care, address inequities in access to dental care, and reduce the prevalence of oral disease in pregnant women. MDPH and the Perinatal Oral Health Advisory Committee supported the pilot sites to implement the Guidelines and establish best practices that can be replicated statewide. The PIOHQI grant ended in November 2019 and data on the implementation of the Guidelines has not continued to be tracked. Members of the original MA Perinatal Oral Health Practice Guidelines development team have reconvened and are in the process of updating the guidelines and planning for dissemination of the updated version.
Women, Infants, and Children (WIC) Nutrition Program
WIC staff regularly screen women and children for dental care, offer oral health nutrition education, online nutrition education, and provide dental referrals as needed. Several WIC programs collaborated with community-based dental practices to offer screening and fluoride varnish in the WIC clinic setting. The WIC program distributed educational materials to local programs during National Dental Health Month in February. In FY18, “dental care during pregnancy” was added to the WIC data system as a prenatal education topic to distinguish between oral health education provided to the child versus the mother. From February-December 2020, 14% of pregnant women enrolled in WIC received oral health education, which was just short of the goal to reach 15% by 2020.
Priority (2015-2020): Promote emotional wellness and social connectedness across the lifespan.
Findings from the COVID-19 Community Impact Survey (CCIS) underscore the continued importance of this Title V priority due to the pandemic. According to the 2019 Behavioral Risk Factor Surveillance System (BRFSS), reports of poor mental health among CCIS respondents were three times higher than in 2019, with one third of adults currently reporting poor mental health. People experiencing persistent poor mental health were 2-3 times more likely to experience barriers to accessing care, such as appointment delays/cancellations, concerns about contracting COVID-19, not having a private place for a telehealth appointment, cost/insurance coverage and lack of safe transportation. Requests for suicide prevention and crisis management resources were as high as 11% among certain subpopulations, and highest among transgender people, non-binary people, and people questioning their gender identity.
People experiencing poor mental health are more likely to report having had a change in their work status because of childcare. They are also more likely to report being worried about basic needs like getting medication and paying bills. While there has been an increase in people reporting poor mental health across all demographic groups, some populations are still significantly more likely to report poor mental health: transgender people, non-binary people and those questioning their gender identity; people with disabilities; American Indian/Alaska Natives; Hispanic/Latinx community; people who identify as multi-racial; people between the ages of 25-44; people with lower income; and caregivers of adults with special needs.
Objective 1: By 2020, increase to 95.8% from baseline (95.6%, PRAMS 2017) the percent of women who reported being screened for depression by a health care worker during any prenatal or postpartum visit.
MA exceeded its target for this objective, with 96.6% of women screened for depression during a prenatal or postpartum visit in 2019. Title V contributes to this measure through both systems-level initiatives and enabling services provided by home visiting programs.
Pregnancy Risk Assessment Monitoring Systems (PRAMS)
MDPH added a social/emotional connectedness question to the MA PRAMS Phase 8 Questionnaire in FY16, and data collection is ongoing until 2023. In 2018, 89.5% of women reported that they have moderate or high social support, which decreased slightly to 83.4% in 2019. Using 2016-2019 data, MDPH will examine the characteristics of women with a lower score of social/emotional connectedness and the association of frequent postpartum depressive symptoms with this social connectedness question, to identify vulnerable populations and guide efforts to promote mental health and emotional well-being. This analysis is scheduled for FY22 due to competing priorities in addressing COVID-19 activities in FY21.
Perinatal Mental Health Training and Technical Assistance
MDPH continued to provide training and technical assistance on perinatal mental health (including maternal mental health and co-morbidities such as substance use and interpersonal violence) to state agencies (such as the Department of Children and Families [DCF] and the Department of Early Education and Care), providers (including home visiting programs and community health centers), and health plans. The training and technical assistance will contribute to increasing awareness and reducing stigma about perinatal mental health issues and will support continued implementation of the MA Postpartum Depression regulations.
Perinatal Mental Health Data Analysis Plan
During FY20, MDPH was awarded a budget earmark that instructed MDPH to expend funds to produce a report, in consultation with other state agencies and hospital systems, to define a set of measures to track the annual perinatal mental health outcomes for all deliveries in MA and to outline a process for the collection and reporting of said measures. Specifically, it required that:
- Measures shall include, but not be limited to, the rate of screening for postpartum depression, the identification of perinatal mental health diagnoses, and the incidence of postpartum psychosis.
- The report shall include, but not be limited, to the cost, timing, and feasibility of the data analysis plan.
- MDPH shall report to the clerks of the House of Representatives and Senate, House and Senate Committees on Ways and Means, the Joint Committee on Mental Health, Substance Use and Recovery, and the Ellen Story Commission on Postpartum Depression no later than March 1, 2021.
The Perinatal Mental Health Data Analysis Plan proposes a statewide, population-based data tracking system, recommends an ongoing linkage of three existing state perinatal databases, and contains specific aims, process and outcome measures, data sources, feasibility, costs, and timeline. The plan seeks to collaborate further with the MA Child Psychiatry Access Program (MCPAP) for Moms to investigate the effects of perinatal mental health care provider training, care coordination, and resource referrals on the health of birthing parents and infants in MA, as well as their access to and costs of health care. MDPH hired a consultant to support this work, and the plan will be completed in FY21.
MA MIECHV
MA MIECHV promotes emotional wellness and social connectedness among program participants in several ways. All MA MIECHV home visitors and supervisors attend training focused on common mental health concerns, strategies for supporting parents who struggle with mental health challenges, and mindful self-regulation skills to support home visitors when working with parents facing mental health challenges. The training incorporates reflective conversations and engages participants in help-seeking in response to episodes of mental distress, illness or crisis. A three-day Facilitating Attuned Interactions (FAN) training further supports staff to engage in reflective practice.
MA MIECHV home visitors screen for depression and social connectedness according to evidence-based model requirements and make referrals to services as needed. Depression screens are conducted using the Center for Epidemiologic Studies Depression Scale (CES-D) or Edinburgh Postnatal Depression Scale (EPDS) within three months of delivery (for those enrolled prenatally) or within three months of enrollment (for those not enrolled prenatally). In FY20, 93% of MA MIECHV participants were screened for depression within the required time frame, an increase from 92% in FY19. In FY20, 53% of caregivers referred to services for a positive screen for depression were documented to have received one or more service contacts, an increase from 37% in FY19. MA MIECHV programs continue to report limited language and cultural capacity among mental health services in many MA communities as barriers to successful access to treatment.
Research suggests that social isolation contributes to stress and emotional fragility, particularly in populations served by MA MIECHV. All participants are screened for social connectedness at six-month intervals throughout the duration of program enrollment. Each model uses different tools to assess the extent to which the participant is connected to social networks. All MA MIECHV programs hold a six-week parent support group series to facilitate connections among families. MA MIECHV provides flexibility on topics for the group series to allow programs to better meet the needs of their participants and the larger community.
Welcome Family
The Welcome Family Learning Collaborative is a forum for the five local programs to plan and implement quality improvement projects and share best practices and lessons learned. There are two in-person meetings per year followed by a six-month action period, during which the programs carry out Plan, Do, Study, Act (PDSA) cycles. Past improvement projects have focused on topics such as increasing referrals to the program, reducing racial and ethnic inequities in home visit completion, and increasing domestic violence screening rates.
From July-December 2020, the Learning Collaborative focused on depression screening, a topic chosen in collaboration between MDPH and local Welcome Family staff due in large part to the growing mental health concerns and social isolation resulting from the COVID-19 pandemic. Specifically, programs tested using the EPDS for caregivers who screen positive on the Patient Health Questionnaire-2 (PHQ-2), the tool currently used in the Welcome Family program. This project focused on improving an existing process to identify mental health concerns and connect parents to services if needed.
The Learning Collaborative meeting was held virtually over two days and included training in perinatal mental health by the BFHN Director of Maternal Health Initiatives; breakout sessions by Welcome Family role (e.g., nurse or coordinator/supervisor) to reflect on what was learned during the training and brainstorm improvement ideas; and breakout sessions by program, to develop aim statements and tests of change to carry out over the action period.
For this project, the primary process measure was to increase the number of caregivers who pre-screen positive on the PHQ-2 to then be administered the EPDS. Local agencies tested changes such as developing scripts to introduce the EPDS, reviewing the EPDS verbally and in writing, and offering the EPDS to all clients with a history of depression regardless of PHQ-2 score. From August-December, this measure increased from 40% to 75%. The secondary measure was increasing referral acceptance to mental health services for caregivers for whom a concern is identified on the PHQ-2 or EPDS. There was no noted improvement on this measure following the project.
Following the Learning Collaborative, the local programs agreed that the PHQ-2 screen is effective in identifying symptoms of depression when coupled with the expertise from the Welcome Family nurses. Therefore, it was decided not to integrate the EPDS into standard program practice. The program will apply lessons learned through this project, such as the understanding that no screening tool is diagnostic, the ability for Welcome Family nurses to offer mental health support without a diagnosis, and the importance of a family-driven and culturally appropriate approach to the types of referrals offered.
Early Intervention Parenting Partnerships (EIPP)
EIPP is a home visiting program that uses a team approach to engage with and support families during pregnancy, continuing through the child’s first birthday. Maternal mental health is a key topic of discussion, education, support, and referral with EIPP families. In FY20, 51% of participants reported a history of depression, including postpartum depression (PPD) at enrollment. At the initial visit, 298 participants were screened for PPD using the EPDS with 7% screening positive for mild depressive symptoms and 12.4% screening positive for moderate or severe depressive symptoms. Fifty-eight EIPP participants were supported in maintaining a connection with their individual counselor and 48 participants were referred to individual counseling; of those referred, 35.4% were enrolled in services, 58.3% were placed on a waiting list, and 18.8% declined services.
EIPP participants are assessed on a three-question social connectedness screening tool at key prenatal and postpartum stages. At the initial visit, 298 women were screened, with 12.1% reporting that they do not have the support they need from others to care for themselves and their infant. Each EIPP site facilitates one 10-week support group annually for its participants. Topics include maternal mental health, mother/infant attachment, self-care, parenting skills and others. Transportation, childcare, and food are provided to facilitate attendance.
F.O.R. Families (Follow-Up Outreach Referral)
The F.O.R Families program serves families experiencing homelessness with complex medical needs, substance use disorder, safety concerns, and high levels of depressive symptoms. The program is a joint initiative between BFHN and the MA Department of Housing and Community Development (DHCD). During the intake assessment, and as needed in subsequent visits, home visitors assess women for symptoms of depression, identify any potential risks to the mother and baby, and make referrals to mental health services. Maternal mental health is a key topic of discussion, education, and support with families.
The intake assessment does not capture data specifically for women during pregnancy or after delivery. Of the 142 families assessed in FY20, 49% reported that someone in the household had been diagnosed with depression, and 27% reported that a household member had been hospitalized for a mental health crisis. Home visitors provide support through reflective listening during their home visits and refer clients to mental health treatment in their community. Families are encouraged to maintain connections with their natural supports as a source of assistance when facing housing instability.
Findings from the CCIS indicated that two out of five people who reported using substances in the last 30 days reported increased substance usage since the onset of the pandemic. Respondents with a cognitive disability and parents and caretakers of persons/children with special needs were more likely to report increased substance use. Nearly half of respondents reported alcohol use, and of those, 38% reported increased use during the pandemic. Over half of those who reported using tobacco in the past 30 days reported increased use since prior to February 2020. People using substances were more likely to report poor mental health but delayed seeking mental health care. Respondents – particularly those using cocaine, heroin or other opioids – reported interest in accessing health services related to counseling, tobacco cessation, peer and recovery support.
Objective 1: By 2020, 50% of infants diagnosed with neonatal abstinence syndrome (NAS) will be enrolled in Early Intervention (EI) by 12 months of age.
Early Intervention
Based on 2018 data, 42.5% of infants diagnosed with NAS were enrolled in EI by 12 months of age, short of the goal to reach 50% by 2020. In FY20, EI led a taskforce designed to promote access to services for children diagnosed with NAS. In August 2020, eligibility criteria for EI services were expanded to include children who had a diagnosis of Substance Exposed Newborn (SEN) or had a sibling who had received a diagnosis of SEN or NAS. A decision was made not to confer automatic eligibility, but to add additional child and family eligibility factors (SEN, and previous child with NAS or SEN diagnosis) to better reach families affected by substance use disorder. Written guidance was provided to EI service providers to help identify these children and enroll them in EI services. In FY20, 653 children served by EI, representing 1.2% of all children served, had a diagnosis of SEN or NAS.
EI providers work to maintain ongoing relationships with their local DCF office to ensure that all DCF referrals receive follow up. Many EI providers also maintain relationships with their local birthing hospitals to ensure that children and families affected by substance use disorder have access to EI services and that hospital staff can accurately explain EI services to families upon discharge. These strategies also ensure that referral sources understand EI eligibility and will refer children diagnosed with SEN to their local EI for an evaluation/assessment.
Additional activities to address substance use among women of reproductive age to improve individual and family functioning
Birth Defects Monitoring Program (BDMP)
BDMP conducts population-based surveillance for birth defects in MA. In FY20, the BDMP began piloting active, population-based surveillance for NAS. Data collection began for infants born on or after April 1, 2020. BDMP medical record abstractors collect individual-level medical record data on maternal demographics, maternal medication history, infant symptoms, maternal and infant toxicology screens, infant treatment, information on plan of safe care, and information on to whom the infant was discharged. These data are instrumental in better understanding the impact and magnitude of opioid use and other substances that may lead to NAS in MA.
MA Perinatal Neonatal Quality Improvement Network (PNQIN)
PNQIN is a quality improvement collaboration founded on the idea of helping mothers and babies through the development of quality improvement and best practices. PNQIN receives financial and leadership support through MDPH. The spring 2020 in-person summit was cancelled due the COVID-19 pandemic and planning began to transition the summit to a virtual platform in fall 2020. With additional funding support from MDPH, in FY20, PNQIN partnered with the MA Screening, Brief Intervention and Referral to Treatment – Training & Technical Assistance (MASBIRT TTA) program to support hospitals with SBIRT and Medication Assisted Treatment (MAT) trainings. MASBIRT has been training outpatient sites on SBIRT; between April 2020 and March 2021, MASBIRT conducted meetings and trainings with 21 hospitals and 417 participants (not all unique). MAT waiver trainings were also conducted in partnership with the Office Based Addiction Treatment (OBAT) team at Boston Medical Center; fifty providers were waivered at 3 training sessions (2 in-person and 1 two-part virtual training) from January to June 2020.
WIC
In FY20, WIC screened all enrolling women for substance use both in the perinatal and postpartum periods during the certification process and referred families to community-based resources as needed. Screening tools were revised to capture more accurate data regarding past and current substance use and to align with updated substance use-related WIC nutrition risk criteria from USDA; staff received refresher training related to substance use screening and referrals as part of the revision process. New WIC staff completed a mandatory substance use training module as part of their new staff training.
Moms Do Care (MDC)
In FY20, MDPH continued to expand upon the lessons learned from all seven MDC Project sites (and their regional community partners) to build a peer led, seamlessly integrated, trauma informed continuum of care for pregnant, postpartum and parenting women with opioid use disorder. The MDC technical assistance (TA) team continued to provide extensive TA and training in building the program model and assisted the MDC health care systems to plan for ways to sustain the regional, integrated systems of support established by the program. MDC continued to advance the perinatal peer mentor workforce by assisting the health care systems to hire, develop and sustain this workforce. Activities included: identification and training of peer mentor candidates and supervisors; consulting on HR policies and procedures; assisting health care systems to understand and value the roles and competencies of peer mentors; implementation of statewide learning collaborative calls; and continued collaboration with the MDPH Bureau of Substance Addiction Services to assist peer mentors through the recovery coach credentialing process. MDC site staff met regularly to share resources and MDC training and TA teams expanded their trainings to include the staff and leaders of multiple hospital and health care center departments and community partners. Trainings focused on ways to develop trauma informed, family-focused and recovery-oriented systems of care. MDPH continued to share its lessons learned with MassHealth as the Commonwealth works to build a reimbursement structure for this program model.
In March 2020, MDC sites shifted to implementing the program in the context of the pandemic, rapidly adjusting their clinical protocols, service delivery and staffing models. MDC clinical teams, community partners and training/TA teams developed remote ways to engage and support program participants and their families and to continue the regional collaborations, while also supporting providers as they met critical needs of families during this challenging time.
The Journey Recovery Project
The Journey Recovery Project is an interactive, web-based resource for pregnant and parenting women with questions or concerns about substance use, or who are in recovery. In FY20, a vendor redesigned the Journey website and added new video and print content. Two new “milestones” were added, one for fathers and one for parents with older children, and the resources section was updated. A Group Facilitation Guide was developed, as well as a brochure for pregnant women affected by substance use. Content was developed for a two-part Birth Planning Kit, one part being the Recovery and Wellness Guide, and one part being the DCF portfolio to help pregnant women with current or past substance use prepare for child welfare involvement at birth. These materials can be accessed for free on the MA Clearinghouse site.
Plans of Safe Care (POSC)
The Child Abuse and Prevention Treatment Act mandates a POSC for every substance affected newborn. The purpose of the POSC is to support the prevention of ongoing substance use among pregnant women and new parents. POSC can also serve as a primary prevention strategy for a future generation of children, by connecting children with developmental services and helping parents access recovery, parenting, and concrete supports. In FY20, MDPH conducted trainings for substance use treatment providers on how to support families in need of a POSC. Materials to support POSC were developed by FIRST Steps Together (see below) and were shared with Moms Do Care sites. Materials were also developed through the Journey Recovery Project to support POSC development.
Intra-agency Pregnant and Parenting Women Opioid Workgroup
In FY20, an intra-agency workgroup was developed to address the priority area of opioid use among pregnant and parenting women, with representation from different bureaus within MDPH. This workgroup inventoried all funded initiatives for this population. A process to identify policy and direct service gaps was also conducted to be able to guide future funding opportunities. Workgroup members shared information about current projects to leverage expertise and minimize duplication of efforts.
FIRST Steps Together
In FY20, FIRST (Families in Recovery SupporT) Steps Together, funded by the State Opioid Response grant, continued services and expanded to a seventh site. The program is a home visiting initiative for opioid affected families, which provides parenting and recovery support by peer family recovery support specialists to prevent ongoing substance use and subsequent substance exposed newborns. Program services include: integrated home-based peer recovery support, evidence-based individual and group parenting interventions, care coordination, Plans of Safe Care, mental health services, dyadic therapy, and systems advocacy. Building capacity of the peer recovery perinatal/parenting workforce was supported through extensive curriculum development training and monthly learning collaboratives.
Approximately 225 parents were enrolled during FY20 and 600 groups were held. Clients readily engaged in services provided by peers in recovery from addiction and who often also had experience with the child welfare and criminal justice systems. Almost all clients had open or past child welfare cases and half did not have custody of their children. During FY20, sites transitioned quickly to remote service provision in response to COVID-19. The training and technical assistance team provided extensive support to sites so both individual and group services could continue. This included trainings related to supporting parent-child interactions remotely, supporting virtual Family Time for parents not living with their children (see webinar and accompanying tip sheet), and running virtual groups. Additionally, weekly formal and informal space was created for staff to gather virtually for personal support, as they contended with challenges posed by COVID-19 in both their personal and professional lives. Staff retention remained very high during this fiscal year, which is a testament to the support that staff received to work flexibly, efficiently, and effectively.
MA MIECHV
MA MIECHV continued to implement a pilot to provide cross-training and enhanced supervision for a Parents as Teachers (PAT) home visitor with lived experience with substance use and recovery. The goals of the pilot are to: 1) fill a gap in cohesive parenting support for families in recovery, 2) build capacity of home visitor/recovery coaches to support pregnant and parenting families with substance use disorder and supervisors’ capacity to support home visitor/recovery coaches; and 3) engage in cross-systems collaboration to support reunification and promote family stability. In FY20, 17 families were engaged in the pilot.
MA MIECHV also supports collaboration between home visiting and DCF offices at the state and local level to support services for families affected by substance use who are DCF-involved. Given racial inequities in the country’s child welfare system, policies that facilitate access to home visiting through transitions in custody arrangements would promote more equitable access to the benefits of home visiting. During custody disruptions, home visiting has the potential to support participants in their identities as parents, understand their children’s ongoing development, and allow for continuity of voluntary services through different stages of involvement with DCF. MA MIECHV programs identify strategies to enhance continuity of services for families who are working to regain custody of their children, including support and education for parents working toward reunification and support for families in which grandparents may have custody. To support families with varying custody arrangements, home visitors participate in supervised visitation at DCF offices and coordinate with DCF workers to support participants with their service plans.
Due to COVID-19, supervised visitation in many parts of the state were paused, adding significant stress and uncertainty for families working toward reunification with their children. MA MIECHV worked to provide opportunities for peer learning and idea sharing within and between models around this challenge. Home visitors have worked to provide ongoing support for parents through virtual visits and phone calls. Where virtual supervised visitation was possible, home visitors supported participants in preparation for and during these visits.
MA MIECHV continues work to address model-specific barriers to supporting families through custody disruptions. Historically, PAT has specified that a parent and child be present during visits, disincentivizing programs from working with families experiencing custody disruptions despite a gap in parenting support services for this sub-group. PAT home visitors offer visits with parents and children during supervised visitation at DCF offices supplemented by visits with only the parent and report that these visits without children, although not historically counted, are central to reinforcing parenting topics and building parents’ confidence. MA MIECHV participated in a Home Visiting Applied Research Collaborative Preconference Workshop in January 2020 to develop a study idea focused on understanding how visits without children support this sub-group of families. Following the workshop, MA MIECHV and evaluators from Tufts Interdisciplinary Evaluation Research (TIER) met with leadership from PAT National to discuss next steps for this project and potential opportunities to pilot and study these strategies. In FY20, TIER submitted a proposal for a mixed methods implementation study to understand these strategies and inform potential PAT policy changes and implementation guidance, and the study was funded for FY21.
Title V’s focus on substance use continues through 2025. In the new reporting cycle, this priority focuses on substance use prevention. This includes primary prevention of substance use as well as overdose prevention, prevention of subsequent substance exposed newborns, prevention of substance use in the next generation, and prevention of more significant use/negative sequelae.
Title V plays an important role in preventing substance use during pregnancy, a critical period of development in the life course. Smoking during pregnancy increases the risk of complications, such as preterm birth, and increases an infant’s risk for low birth weight and congenital heart defects. NPM 14 tracks progress on reducing tobacco use during pregnancy to mitigate the high mortality, morbidity, and economic costs attributed to tobacco use. There was a decrease in the percentage of women who report smoking during pregnancy from 4.3% in 2018 to 3.9% in 2019. MA will consider revising the 2025 objective if the downward trend continues.
The ESM for this NPM is the percentage of women using the statewide smoking quit-line who are pregnant, with a goal of increasing to 6.2% by 2025 (from 0.6% [10/1,627] in FY20). 1-800-QUIT-NOW provides free and confidential services in English and Spanish, and translation for other languages, by a trained quit coach to stop smoking. Quit coaches connect callers with quit-smoking resources through the caller’s community programs, and callers may be able to receive free nicotine replacement therapy. According to the Surgeon General’s report, “…the evidence is sufficient to infer that proactive quit-line counseling, when provided alone or in combination with cessation medications, increases smoking cessation…and the evidence is sufficient to infer that tobacco quit-lines are an effective population-based approach to motivate quit attempts and increase smoking cessation.”[1]
PRAMS
MA PRAMS has been focused on administering a COVID-19 supplement via the PRAMS survey and will implement a COVID-19 vaccine supplement in April 2021. MA PRAMS plans to implement another supplement, with questions that include the use of cigarettes/e-cigarettes (vaping) in the first and second trimester of pregnancy. This supplement would add to the current Phase 8 survey questions on smoking during the months before pregnancy and the third trimester of pregnancy. Preparatory activities will begin in the fall of 2021 to implement the MA-specific supplement in April 2022, starting with January 2022 births.
New England PRAMS states recently discussed providing feedback to CDC regarding the core questions on the PRAMS Phase 8 survey. One concern noted is that although the current questions on e-cigarette and hookah use have very few responses, the current wording of the questions may not resonate with participants. MA recommends revising the wording to align with what users will recognize and be able to answer.
MA PRAMS conducted a study to assess agreement of the reporting of cigarette smoking between PRAMS and birth certificate (BC) during the last 3 months of pregnancy among a population-based sample of women who gave birth to a live born infant from 2012 to 2018. Women reported higher smoking prevalence in PRAMS than in BC for maternal smoking during the last 3 months of pregnancy, but both PRAMS and BC had significantly decreasing trends in the smoking prevalence from 2012 to 2018 (7.8% in 2007 to 4.3% in 2018 according to PRAMS; 4.4% in 2007 to 3.1% in 2018 according to BC). The overall percent agreement between PRAMS and BC was high (97.6%) and the Kappa statistics showed a moderate level of agreement (0.62) between PRAMS and BC. However, the Kappa statistics for subgroups including women who were Black non-Hispanic, Hispanic, younger than 20 years of age, had less than a high school education and a preterm birth showed a lower level of agreement for reporting smoking between PRAMS and BC, even after adjusting for bias and prevalence. A fact sheet and a manuscript based on the findings from this analysis have been developed and will be finalized in FY22. MDPH will continue to track the trends and level of agreement in smoking prevalence reported by PRAMS and BC and plan to share findings with the Registry of Vital Records and Statistics to support their quality improvement efforts around data collection on the BC Parent Worksheet.
MA Tobacco Cessation and Prevention Program (MTCP)
MTCP has eight regional tobacco-free community partnership programs that promote awareness of the risks of nicotine use as well as resources for quitting at various agencies that serve pregnant and parenting women, such as local WIC programs, food pantries, and community action programs. MTCP also provided WIC staff with technical assistance on making referrals to the MA Smokers’ Helpline Perinatal Program, which provides incentives for women to engage in treatment. The technical assistance session also included a presentation exploring the intersectionality of tobacco use and food insecurity using a racial equity framework. The session ended with a brainstorm of how using a racial equity framework when promoting tobacco treatment can increase quality of service and increase the chances of successful quit attempts. Due to staffing barriers, MTCP was unable to conduct focus groups for PRAMS that explore harm reduction messaging and perception about vaping.
MA MIECHV
MA MIECHV and MDPH continue to provide training on substance use and trauma-informed practice, and all home visitors routinely screen participants for substance use. During federal FY20, 10% of the households enrolled in evidence-based home visiting services reported a history of substance use or need for substance use treatment, which is likely an under-report. During the same time, 13.8% of households reported that someone in the household used tobacco products in the home, down from 16% in federal FY19.
In FY20, 57% of primary caregivers enrolled in home visiting who reported using tobacco or cigarettes at enrollment were referred to tobacco cessation counseling or services within three months of enrollment. This represented an increase from 56% in FY19. MA MIECHV identified an opportunity for improvement within the performance measure and has worked to develop a toolkit to support home visitors with resources on tobacco cessation and strategies for having conversations with participants about tobacco use. MA MIECHV will disseminate the Tobacco Cessation Toolkit in FY21.
PRAMS
In 2019 (the first year that marijuana data was available through PRAMS), 4.1% of women reported any use of marijuana during pregnancy. The proportion of women reporting any marijuana use during pregnancy was 5.4% for White women, 2.3% for Black non-Hispanic women, 1.9% for Hispanic women, and 0% for Asian non-Hispanic women. Women with lower SES were more likely to use marijuana during pregnancy; among women with Medicaid, 7.4% used marijuana during pregnancy, compared to 2.3% with private insurance, and among women ≤100% FPL vs. >100%, rates were 9% and 3% respectively. MA PRAMS will continue to use the current opioid supplement to collect marijuana use during pregnancy with Bureau of Substance Addiction Services (BSAS) funding support. PRAMS data collection for 2020 is ongoing and will be completed by July 31, 2021. MDPH will present the PRAMS findings to prenatal and other providers at the PNQIN summits in fall 2021 or spring 2022 and develop a factsheet that can be posted on the MDPH and PNQIN websites.
Center for Birth Defects Research and Prevention
The Center for Birth Defects Research and Prevention (CBDRP) collects data on marijuana use during pregnancy through the Birth Defects Study To Evaluate Pregnancy exposureS (BD-STEPS) telephone interview, which is a population-based case-control study aimed at understanding the causes of birth defects and identifying potential risks for having a baby with a birth defect. As part of the study, women participate in an hour-long telephone interview on a wide range of topics, including but not limited to sociodemographics, medications used during pregnancy, illnesses in pregnancy, chronic medical conditions, treatments for infertility, physical activity, and occupational exposure. The interview includes questions on marijuana use in the month prior to pregnancy through the third month of pregnancy (i.e., the first trimester use). Women are asked the route of marijuana use (e.g., smoke, vape, eat, consume drinks, dab, or other methods), the frequency of use, and the reason for use (e.g., relieve nausea/vomiting, relieve stress/anxiety, etc.). Women who participate in this study include 1) control mothers who had a liveborn infant with no birth defect and 2) case mothers who had an infant with one of the 23 eligible birth defects. Control women are randomly selected from the birth population and their responses reflect marijuana exposures in the MA birth population.
The Stillbirth Study was incorporated into BD-STEPS to leverage the already existing study design to understand risk factors and interventions to reduce the occurrence of stillbirths. As part of this study, women whose pregnancies ended in a stillbirth and were not affected by a birth defect are recruited into the study and participate in the main interview, as well as a follow-up interview focused on risk factors for stillbirth. Women who participate in this study include 1) control women who had a liveborn infant with no birth defect and 2) case women who had a pregnancy that ended in a stillbirth (includes stillbirths with and without a birth defect). Women in this study are asked the same questions on marijuana use as above. Given this is a population-based study, responses among the women represent those in the general population.
Both the BD-STEPS and Stillbirth Study have been conducting interviews with women since 2014, with a one month pause during the pandemic while the interviewers shifted to teleworking. After the pause, the interviewing and data collection have resumed and are underway.
PRAMS
PRAMS does not currently have data on alcohol consumption during pregnancy. Since CDC has postponed the Phase 9 survey revision to 2023, MA PRAMS will focus on adding questions through a MA-specific supplement about alcohol consumption in all three trimesters of pregnancy; the current Phase 8 survey asks about alcohol consumption in the past two years and during the three months before pregnancy. The COVID-19 and COVID-19 vaccine supplements are being implemented in the field first; the MA-specific supplemental survey activities will begin in the fall of 2021 to be implemented in April 2022 (January 2022 births).
Fetal Alcohol Spectrum Disorders Task Force
Fetal Alcohol Spectrum Disorders (FASD) continues to be an invisible disability in MA. The main goal of the state FASD Task Force, co-chaired by the Title V MCH Director, is to highlight this developmental disability, and strategies to prevent FASD, support families with children diagnosed with an FASD and support children, youth, and young adults living with FASD. The Task Force convenes families, state agencies, academic institutions, and community agencies to address FASD at the policy, state, and community levels.
In FY20, the Task Force worked to reduce stigma and raise awareness of strategies for prevention and support for families of children with an FASD. Prevention strategies include addressing barriers that substance-using women encounter in trying to access services. The Task Force developed strategies for supporting parents and their children with FASD, working with early childhood systems, including Early Intervention, and with school departments. In FY20 a group of families started a Zoom Support Group with the support of the MA FASD State Coordinator. Zoom FASD trainings were held for staff from health care, addiction/clinical/social service groups, and criminal justice sectors and were offered to addiction provider treatment agencies on universal strategies for working with adults who may have cognitive impacts from prenatal alcohol exposure.
Priority (2020-2025): Reduce rates of and eliminate inequities in maternal morbidity and mortality.
Since 1997, MDPH has convened the Maternal Mortality and Morbidity Review Committee (MMMRC) to review maternal deaths, study the incidence of pregnancy complications, and make recommendations to improve maternal outcomes and eliminate preventable maternal death. Understanding the causes of these deaths provides insight into the factors that contribute to maternal morbidity and mortality. The performance measure for this priority tracks efforts to improve the timeliness of the review process and the efficiency with which review findings can be translated into strategies to address inequities in maternal health outcomes.
Objective 1 (SPM 1): By 2025, the MMMRC will increase the percent of pregnancy-associated deaths that are reviewed within two years of occurrence from 0% to 25%.
Objective 2: By 2025, develop a structure for community input to the review process that is authentic and addresses the power dynamics between medical providers and community stakeholders.
Maternal Mortality and Morbidity Review Committee
MDPH aims to link birth and death files and other datasets (such as MassHealth) to identify pregnancy-associated and related deaths in a timely manner, strengthen and increase the number of memoranda of understanding and data sharing agreements with key stakeholders to ensure timely access to data, improve the process and timing for data abstraction into the Maternal Mortality Review Information Application (MMRIA) and establish a process/mechanism for community engagement in the review process.
Competing demands associated with the COVID-19 pandemic have caused delays in progress on these objectives. In FY20, 0% of pregnancy-associated deaths were reviewed within two years. MDPH is seeking funding to hire staff to support this goal. MDPH members of the MMMRC had also planned to participate in a Lean Six Sigma quality improvement training to identify activities to improve the timeliness of identification and review and community contribution to the review process. This training was postponed for a year and will begin in FY21.
Objective 3: By 2025, leverage collaborative partnerships to inform practice and policy changes and disseminate findings including MMMRC recommendations.
Maternal Mortality and Morbidity Review Committee
The MMMMRC has identified, among other factors, barriers to accessing care, racial inequities, and the absence of systemic coordination of care contributing to maternal deaths in MA. In addition, the MA Maternal Mortality Initiative released several data briefs outlining areas of concern in maternal mortality. MMMMRC members, PNQIN leadership, legislators, and community stakeholders used the data briefs, as well as national data, to develop a workgroup charged with drafting legislation to make recommendations to address barriers resulting in racial inequities, including persons of color dying of pregnancy-related causes. As a result of the leadership of this workgroup, A Resolve reducing racial inequities in maternal health was signed into law in FY21.
A Resolve reducing racial inequities in maternal health creates a legislative commission to make recommendations to address barriers that result in racial inequities, including women of color dying of pregnancy-related causes. The Racial Inequities in Maternal Health Special Legislative Commission is charged with gathering statewide data on maternal mortality and making recommendations to eliminate racial barriers to accessing equitable maternal care. A final report, due to legislators on March 31, 2022, will include findings of the data and draft legislation necessary to carry out the Commission’s recommendations. Representatives from MDPH and the MMMMRC Chair have been appointed to this Commission and will present a summary of current activities and identify gaps in services, which include limited legislative authority and staff capacity to support further community engagement in the process.
Alliance for Innovation on Maternal Health
PNQIN’s efforts to address maternal Severe Morbidity and Mortality (SMM) include the implementation of the Alliance for Innovation on Maternal Health (AIM). AIM was launched in spring 2019 and data collection on process and structure measures at each hospital began in summer 2019. Process measures were collected by review of maternal prenatal and hospital records with the goal of using data to support reports showing performance on key measures related to care of mothers with Opioid Use Disorder (OUD). In partnership with MDPH and the Betsy Lehman Center for Patient Safety, PNQIN generated SMM reports (with data stratified by race/ethnicity) for the 21 hospitals that were participating in the AIM OUD bundle. Between July 2019-September 2020, PNQIN also held a series of webinars combining quality improvement teaching with OUD care topics.
Levels of Maternal Care
PNQIN continues to lead MA’s efforts around Levels of Maternal Care. Monthly workgroup meetings for the Levels of Maternal Care project were held throughout spring 2020 and will continue. Three Task Forces were convened: CDC Levels of Care Assessment Tool (LOCATe) Task Force, Site Visits Task Force, and Implementation and Access Task Force. Quarterly Task Force meetings were held in January and April 2020. Staff from BFHN and the Betsy Lehman Center have worked with the LOCATe Task Force to prepare for the dissemination of the LOCATe tool, a self-assessment of maternal level of care at all MA obstetric units. In June 2020, state-specific questions related to racial equity and implicit bias were added to the LOCATe Version 9 survey, which the hospitals completed.
The original timeline for rolling out the LOCATe survey was April-May 2020, but due to the pandemic this timeline was pushed back to February-March 2021. PNQIN negotiated a Research Electronic Data Capture (REDCap) database (managed by staff from the Betsy Lehman Center where the data will be housed) and will continue to work with hospital partners about who to contact to complete the LOCATe tool and timing the release of the survey.
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