Pre-/Interconception Health

Preconception health counseling has been identified and endorsed by the Centers for Disease Control and Prevention as a strategy to improve maternal health and birth outcomes, as well as to reduce unplanned pregnancies. Starting in May 2016 under the auspices of the MCH Coalition and the March of Dimes, who provided the financial support, Every Women Connecticut (EWCT) and the Every Women Connecticut Learning Collaborative (EWCTLC) were established. The main goal of this initiative is to increase provider expertise and self-efficacy in implementing routine pregnancy intention screening and appropriate care, education, and services to ultimately improve birth spacing, increase pregnancy intentionality, as well as increase the proportion of Connecticut women who deliver a live birth and report discussing pre-/interconception health with a healthcare worker.

The EWCT Advisory Committee is a group of well-known and respected individuals representing partner organizations, including state agencies; the state’s Medicaid ASO; the state’s Medicaid dental and behavioral health carve-outs; state-level private non-profits; and direct service providers, continue to guide EWCT’s efforts in increasing a general awareness around pre/interconception care and specifically around the One Key Question (OKQ) screening tool and in addressing social determinants of health and health equity.

In order to strengthen relationships with new partners, representatives from the Connecticut Coalition Against Domestic Violence (CCADV) have joined the EWCT Advisory Committee. EWCT co-chairs will also be extending an invitation to the Hispanic Health Council to join the Advisory Committee in 2022.

The EWCTLC has representatives from clinical and community-based providers in communities throughout the state and has expanded to include Department of Mental Health Addictions Services (DMHAS) providers.

The trainings done during this time frame continued the partnership with DMHAS, which is requiring the use of OKQ in their programs serving women and men in their childbearing years. Trainings for staff at DMHAS funded program were as follows: 

On Feb 10, April 26, and June 8, 2021 EWCT and DMHAS co-sponsored and the CWC hosted a workshop entitled Pregnancy Intention Screening, Sexual Health, Optimal Birth Spacing, and Effective Contraceptive Counseling. This workshop was conducted by Dr. Jordana Frost, former Co-Chair of EWCT and Sarah Gannon from Planned Parenthood of Southern New England (PPSNE). This training for implementers of OKQ focused on optimal birth spacing, an overview of different effective birth control methods, and ways in which staff can counsel women and their partners while ensuring a culturally sensitive and trauma-informed approach.

While these trainings were for DMHAS funded programs others, including Ashley Starr Frechette representing CT Coalition Against Domestic Violence (CCADV) on the EWCT Advisory Committee, were also able to attend. CCADV is the membership organization of CT’s 18 domestic violence service agencies that provides critical support to victims including counseling, support groups, emergency shelter, court advocacy, safety planning, and lethality assessment, among other services. Alison and Marijane will be presenting to CCADV leadership to discuss training opportunities for CCADV members in One Key Question later this year.

In addition to these three DMHAS sponsored trainings, a workshop requested by EWCTLC members on human trafficking, originally scheduled for March 2020 and canceled due to COVID, was held in August 2020.

EWCT contributes to the Department of Public Health’s State Health Improvement Plan (SHIP) through the participation of Alison Tyliszczak and Marijane Carey, as the MCH experts, on the SHIP Advisory Council. 

Reproductive Health Services

Despite the continuing challenges of COVID-19, Planned Parenthood of Southern New England (PPSNE) exceeded all its clinical service goals except number of teens served. PPSNE provided family planning/reproductive health services to 41,164 women, men and teens (goal of 35,000). Of these, 30,050 (73%) were low income (goal of 14,000); 22,935 were women of color (goal of 9,100) and 5,431 (13%) were teens (goal of 5,800). We were below our goal for teens by just 369 individuals; of note is that 9,903, or 24%, of this year’s patients were age 21 or under.

Of all patients, 35% were white non-Hispanic/Latinx; 29% were Hispanic/Latinx; 26% were Black/African American non-Hispanic/Latinx; 2% were Asian; and 8% were “other” (Native American, mixed race, unknown/declined, etc.). The majority of patients (87%) were female. More than half (55%) were between the ages of 22 and 34; 13% were teens, and 11% were ages 20-21. Fifty percent of DPH family planning participants were covered by Medicaid; 28% were covered at least partially by private insurance; and 22% were uninsured and were charged according to PPSNE’s income-based sliding fee scale.

The program provided 18,000 pregnancy tests with options counseling, 1,305 Herpes tests, 53,534 chlamydia tests, 53,518 gonorrhea tests, 21,955 syphilis tests, and 22,793 HIV tests. PPSNE exceeded all its outcome measure goals except two: chlamydia and HIV screening. Seventy three percent of PPSNE’s DPH family planning patients received reproductive health care services regardless of ability to pay (goal, 60%). Ninety seven percent of female patients receiving a comprehensive reproductive health exam received a Pap test or were current with their Pap screening schedule (goal, 90%); 99% received a clinical breast exam (goal, 90%); and 100% discussed reproductive life plan with clinic staff (goal, 90%).

Seventy three percent of patients ages 15-25 received a screening for chlamydia and gonorrhea in the last year. This is short of our goal of 90%, but still well above national screening rates. Forty nine percent of patients received an HIV test and referral for care as indicated (goal, 65%).,

Between 86% and 92% of those not receiving an HIV test were offered but refused one. Work continues to provide more patients with HIV tests with an ‘opt-out’ service model and by trying to normalize HIV testing both in the clinical setting and through outreach and social media advertising. HIV testing numbers at PPSNE overall are going up—along with the provision of PrEP/PEP.

PPSNE’s education and training department reached 589 people, 488 of whom were teens with outreach and education in a variety of settings and venues, including in multi-session workshops to at-risk teens. Utilization of PPSNE education and training programs was greatly affected by by COVID-19 social distancing requirements and lack of in-person educational opportunities.

Starting in April and May, PPSNE’s Education staff began transitioning from in-person programming to virtual programming, focusing initially on the STARS peer education program, Teen Clinic, and the healthy relationship series for the Department of Developmental Services. Other virtual activities included sex ed "game nights,"--Quarantrivia: All Things Sex (with New Haven Pride Center) and Sex Ed Loteria (bilingual) -- and release of a Sex During COVID coloring book.

During the summer, the Education team revised the STARS curriculum using a reproductive justice lens. In September, PPSNE piloted a new, virtual sexuality education program, "Birds & Bees: Not Your Typical Sex Ed," to replace the in-person, "Teen Life. Real Talk." program.  Educators then reworked the monthly in-person Teen Clinics to incorporate virtual education workshops for teens facilitated by teens.  In the online version, participants receive a voucher for   a free visit to a PPSNE health center.

CT’s teen birth rate reached a historic low in 2018 at 8.3 per 1,000 which continues its 16-year pattern of decline. Teen birth rates declined among all race and ethnicity groups analyzed between 2003 and 2018. Despite declines, for 2014-2018, Hispanic women were 8 times and NH Black women were nearly 5 times more likely to have a teen birth than NH White women. 

In 2018, Connecticut’s teen birth rate was 8.3 births per 1,000 females aged 15-19 and marks the thirteenth year in a row that the state rate reached its lowest level. Between 2003 and 2018, the teen birth rate showed a consistent downward trend with a total decline of 66%. While the rate of decline was initially modest (averaged 1.2% per year), it fell sharply between 2008 and 2015 at 10.8% compared to the previous year and continued at an average annual decline of 7.3% from 2015-2018. The 7-year decline from 2008-2015 accounted for a 56% reduction in the state rate of teens births over that period.

Connecticut ranked 3rd lowest among 50 states and the District of Columbia in 2018 for teen birth rates and remains well below the Healthy People 2020 national targets for ages 15-17 (36.2 per 1,000 females 15-17 years) and 18-19 (104.6 per 1,000 females 18-19 years). Between 2003 and 2018, declines in teen birth rates were evident among all major races and ethnicities in the state, but the patterns of change varied. For non-Hispanic white women, the existing rate of decline of 5% per year on average from 2003 to 2009 shifted to 12% per year for 2009 to 2018. Among Hispanic and non-Hispanic black women, initial rates of decline were more modest at about 2% per year on average but shifted to about 13% annually beginning in 2008 and then tapered in the most recent 4- 5 years (6.9% and 4.6%, respectively). For non-Hispanic Asian women, the rate of decline was steady averaging 10.8% per year from 2003-2018.

The City of New Britain had the 2nd highest teen birth rate in the state at 24.2 per 1,000 women ages 15-19 in 2015-2019.  There were 355 births to mothers aged 15-19 out of a female (aged 15-19 years) population of 14,660.

The Family Wellness Healthy Start Program used this data to expand services in New Britain when the grant renewed in 2019 and continues to serve the New Britain pregnant women population.  The New Britain pregnant teen population is being served by a new intensive teen intervention and prevention program, the Reproductive Education and Comprehensive Health (REACH) program.

Breast and Cervical Cancer

During the program period for fiscal year 2022 the Breast and Cervical Cancer Early Detection program enrolled and screened 4385 women while the WISEWOMAN program screened 700 women despite closure and delays due to the COVID-19 Pandemic. The CEDPP added the Colorectal Cancer Screening Program (CRC) to its integrated services. The program continues to provide funding for 15 Community Health Workers (CHW) who navigated women to no-cost screening programs for cancer screening and cardiovascular screening. These CHWs also provide baseline cardiovascular services (blood pressure, blood glucose, cholesterol, height and weight) using a mobile equipment, connected participants with abnormal readings to providers and supported participants to improve their lifestyles to reduce their risk of cancer and heart diseases.

Genomics

The Genomics Office continued to increase public awareness of the importance of knowing their family health history and sharing this information with their family and healthcare practitioners, promoted the use of Family Health History collection by promoting the US Surgeon General’s “My Family Health Portrait” tool; continued partnering with CEDPP and the mandatory collection of patient and family B&C health history, provision of free patient information resources, and encouraging staff healthcare provider genomics education through online training on hereditary cancer syndromes such as Hereditary Breast and Ovarian Cancer (HBOC) and Lynch Syndrome, and the appropriate use of genetic services.

Oral Health

Due to COVID-19, the CT Governor’s Office strongly advised dental practices to voluntarily limit procedures to emergency care to mitigate transmission and scarcity of personal protective equipment. Beginning May 2020, dental offices had the option to expand their services to beyond emergency-only care. By Fall of 2020 full preventative services and routine care resumed. Despite delays by COVID-19, the Office of Oral Health (OOH) continued implementing oral health activities, making adjustments where necessary, and collaborating with community partners virtually.

The OOH participated on the CT Maternal and Child Health Coalition (MCH) and remains a member to ensures oral health is represented as a critic function of overall wellness.

The OOH continued implementing two federal awards, 1) a Centers for Disease Control and Prevention (CDC) cooperative agreement, and 2) a Health Resources and Services Administration (HRSA) grant. The two grants support CT’s efforts to improve oral health outcomes, reduce oral health disparities, and conduct ongoing surveillance of oral health. The CDC grant includes two components:

Component One (3 strategies)

Implement and expand school-based sealant programs -

Hartford Public Schools and New Haven Public Schools continued to provide dental sealants to students through the SEAL CT! Program. COVID-19 did impact the delivery of services as sealants could only be offered while students were attending ni person learning. One program offered parents the opportunity to receive dental services during online learning periods, by appointment only. OOH worked with the SEAL CT! contractors to develop a parent handout that conveyed the importance of dental sealants and how to safely return to the dentist given COVID-19. The handout was translated into Spanish and distributed electronically by both programs. The CT Dental Sealant Advisory continued to meet on a quarterly basis, but meetings were shifted to virtual instead of in person.

Support and increase access to community water fluoridation –

The OOH along with the DPH Drinking Water Section (DWS) conducted the annual Community Water Fluoridation: Principles and Practices training in December 2020. The training was given virtually and certified water operators were eligible to receive free CEUs if they received a passing score of 70% or better on the post-assessment. Presenters included a CDC Division of Oral Health water engineer, a dentist from UConn’s School of Medicine and Dentistry, and a managing certified water operator from a CT public water system. OOH continued to work with DWS to ensure timely and accurate submission of fluoridation data into CDC’s Water Fluoridation Reporting System (WFRS).

Conduct oral health surveillance –

OOH began planning the 2021-2022 Every Smile Counts survey. Every Smile Counts surveys a randomized sample of kindergarten and 3rd grade students across the state. This is conducted in collaboration with the CT State Depart of Education (SDE), the CT Oral Health Initiative and the Association of State and Territorial Dental Directors (ASTDD). In June 2021, DPH OOH executed an MOU with SDE and ASTDD to exchange data. The survey will take place from September 2021-May 2022. 

Component Two

The OOH continued to implement the Medical Dental Integration Project (MDIP) in collaboration with the Community Health Center, Inc. (CHCI), a federally qualified health center. The project aims to address common modifiable risk factors for childhood obesity and dental caries in pediatric patients and identify adult patients with prediabetes in dental settings. The project utilizes two different provide toolkits to identify at risk patients, included motivational interviewing training for medical and dental providers, and includes system level change to incorporate bidirectional referrals and care coordination. The project began implementation in five CHCI sites in April 2021. The Medical Dental Integration Advisory continued to meet on a quarterly basis virtually.

Personal Responsibility Education Program

The CT Personal Responsibility Education Program (PREP) has expanded its focus to include young people in towns with high rates of teen pregnancy and in the juvenile justice system.  In the tenth year of funding for fiscal year 2020-2021, the CT PREP program delivered evidence-based and evidence-informed prevention programs to high risk youth ages 10 to 19 by trained facilitators.  The PREP programs were implemented in the following locations: Capitol Regional Education Council (CREC) an alternative high school, City of Bridgeport high school, Klingberg Family Centers in programs funded by Department of Children and Families (DCF), Greater Bridgeport Area Prevention Program in one middle school and by Birth Support Education and Beyond in community-based programs.  PREP programs include The Be Proud! Be Responsible!, Making Proud Choices, and Reducing the Risk.  These programs are medically accurate and have been shown through rigorous evaluation to reduce risk-taking behavior, delay sexual activity, increase condom or contraceptive use for those who are sexually active, and reduce unintended pregnancy.  Deidentified entry and exit surveys are collected from each participant immediately prior to starting the program and upon completion.  Analysis of survey results are used to measure behavior change.

Undoubtedly, the COVID-19 pandemic presented significant obstacles to program implementation.  As a result of COVID and schools doing remote learning, the Department converted all PREP programming to virtual learning and trained the health teachers and other facilitators. Electronic entry and exit surveys were provided to sites to collect participant pre and post data.  In 2020-2021, 275 youth participated and completed PREP program entry surveys.  The entry surveys identified that 37% of the youth reported that they were sexually active at one point in their lives, 20% of the sexually active youth reported that they used a condom in the past 3 months.  Of those that used condoms with in the past 3 months, 9% used condoms all of the time and 7% used condoms none of the time.

Following the program, the exit surveys reported that 51% of youth said they were much or somewhat more likely to abstain from sex.  Reasons for abstinence, in the order of importance, included the risk of contracting an STI, the risk of becoming or getting someone else pregnant, possible social consequences, plans for the future, and emotional consequences. 

The Department provides Facilitator training, the curriculum, educational materials, ongoing technical assistance, and training on trauma, gender and identity, birth control and motivational interviewing. The program sites are monitored for fidelity to assure that all program delivery is trauma informed, medically accurate, inclusive, age appropriate and implemented with fidelity. The program educates youth on adult preparation subjects such as healthy relationships, Adolescent development and healthy life skills, necessary for transition into adulthood.