Women/Maternal Health – Annual Report Narrative (FY 2018-19)

 

Women/Maternal Priority Need 1: Improve access and utilization to comprehensive quality health services for women (from 2015-20 plan)

 

Women/Maternal Objective 1a:

By June 30, 2020, increase the rate of women of reproductive age with appropriate preventive care, including:

• decrease the rate of uninsured women and children who are Medi-Cal eligible from 8.3% and 36.5% to 7.9% and 34.7% respectively, and postpartum women without health insurance from 16.7% to 16.2%.

 

Data from the American Community Survey showed that the percent of children ages 0 through 18 years old without health insurance was 3.1% in 2017. Additionally, in 2017, the concentration of uninsured children aged 8 through 18 years old was highest among those identified as American Indian-Alaska Native (12.9%), Hispanic (3.8%), and White (3.0%). Data from the 2016-17 aggregate National Survey for Children’s Health show that 73.4% of all children age 0 to 17 years had adequate health insurance for their health care needs.

 

In 2017, 10.1% of women were uninsured before pregnancy, a decrease from 2011-13 (24.4%). Hispanic women had the highest rate of being uninsured before pregnancy (16.6%). Rates among other groups were lower: White women (3.3%), Asian/Pacific Islander women (5.4%), and Black women (5.7%).

 

The percent of women who were uninsured postpartum in 2017 was 7.5%, a decrease from 2011-13 (17.4%). Hispanic women had the highest rate of being uninsured postpartum (12.3%). Rates among other groups were lower: White women (2.5%), Black women (2.9%*), and Asian/Pacific Islander women (4.3%). (*Estimate should be interpreted with caution due to low statistical reliability).

 

Women/Maternal Objective 1a: Strategy 1:

Provide technical assistance to LHJs to develop and implement a protocol to ensure all persons in MCAH programs are enrolled in insurance, linked to a provider, and complete an appointment.

 

California Home Visiting Program (CHVP): CHVP was administered and led by CDPH/MCAH and funded through the Health Resources and Services Administration (HRSA) Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program. CHVP collaborates with Title V funded programs and initiatives where there are common objectives and opportunities. CHVP funds agencies to implement evidence-based home visiting models, including Nurse-Family Partnership (NFP) and Healthy Families America (HFA). The primary goal of the CHVP is to help ensure a healthy pregnancy and a healthy baby. One of the ways this is accomplished is by linking all families to a medical provider and resources. Whenever the mother does not have health insurance, the home visitor helps the mother obtain managed care health insurance. The home visitor also helps the mother schedule doctor appointments with her provider and encourages the mother to attend regular prenatal appointments and to comply with her health care provider’s instructions. The home visitors’ follow-up with the mother about her prenatal care during each home visit. Home visitors provide information to the mother about the importance of attending regular prenatal appointments and provide educational materials and resources for a healthy pregnancy. During 2018-19, 91% of CHVP participants reported having insurance coverage, 4.9% did not have insurance, and 4.2% had an unknown insurance status.

 

At the local level, CHVP sites developed and maintained ongoing strategic partnerships with local service providers, including clinics and hospitals, and community based organizations to deliver needed services.

 

DHCS/American Indian Maternal Support Services (AIMSS): Prior to this funding cycle, the Indian Health Program (IHP) completed a community stakeholder process with the goal of improving California American Indian/Alaska Native perinatal health. The stakeholder process included review of statewide data and perinatal health status to examine infant mortality rates and maternal risk factors, as well as clinic perinatal service surveys. In addition, individual profiles containing general population data, American Indian birth rates, infant mortality and morbidity data, pregnancy related morbidity data, and health care utilization data were reviewed. Feedback from Statewide American Indian focus group sessions regarding community preferences for perinatal services were also reviewed prior to determining intervention priorities.

 

As a result of the needs assessment, the IHP released a Request for Application to support perinatal case management and home visitation services in targeted counties to improve American Indian perinatal outcomes. Eligible counties were determined through a review of statewide data utilizing a need-based formula. During the last quarter of FY 2018-19, IHP contracted with four new grantees to administer the AIMSS program.

 

The AIMSS program focused on the provision of case management and care coordination to assist pregnant American Indian women in receiving health care education, emotional support, and referrals to social services including health care coverage and community services. It also provided follow-up during pregnancy and 6 weeks post-delivery as well as through the first year of the infant’s life. Additionally, AIMSS grantees provide home visitation services using the evidence-based Family Spirit curriculum. Home visiting staff provide basic health education, referrals, transportation, and promotion of clinic or other community health provider services.

During the reporting period, AIMSS grantees provided services to 32 American Indian women and their infant’s ages 0-1. It should be noted that during this funding period, the IHP also provided transition funding for two Indian clinics to allow for continued support services for 27 families previously enrolled in the American Indian Infant Health Initiative program (which ended in the prior fiscal year).

 

Black Infant Health (BIH): CDPH/MCAH leads and funds the implementation of the BIH program in 15 LHJs. These LHJs also received California State General Funds, contributed local agency funds, and drew down Title XIX funds when appropriate. Local BIH programs conducted group sessions with complementary case management that provided social support while helping women develop skills to reduce stress, enhance emotional well-being, and develop life skills in a culturally affirming environment that honors the history of Black women. The BIH Program Policies and Procedures required that all local BIH Programs complete an intake assessment with all participants upon enrollment. Assessment questions included if the participant had medical insurance, had a medical/prenatal provider and if she had completed any appointments. Participants, who stated that any of these services had not been met, were provided assistance with follow-up. The BIH Efforts to Outcomes (ETO) data system was utilized to track the number of participants who enrolled in health insurance.

 

Adolescent Family Life Program (AFLP): CDPH/MCAH also led and funded the AFLP. Nineteen LHJs and community-based organizations received Title V funds to implement the program. Many also contributed local agency funds and drew down Title XIX funds, when appropriate. Similar to CHVP and BIH, AFLP case managers, who worked with expectant and parenting youth, supported and promoted access to health insurance and preventive health services. The case managers assessed need regularly, supported youth in building knowledge and skills, provided referrals and support for accessing services, and provided regular follow-up. For more information about AFLP, see the Adolescent Health Section.

 

Evidence-based and evidence-informed practices utilized for this strategy:

MCAH enabling services employed evidence-based or evidence-informed program models, including: Family Spirit, Nurse-Family Partnership, Healthy Families America, BIH, CPSP, and the AFLP Positive Youth Development Model.

 

Challenges for this strategy:

AIMSS - Challenges faced by American Indian mothers included difficulty accessing care and coordinating childcare especially when there were other children in the home and mom and infant must travel to be seen by an obstetrician. Other challenges included difficulty locating mothers who did not have stable housing, or may have had substance use or mental health issues.

 

Women/Maternal Objective 1a: Strategy 2:

Develop a competent workforce that meets the health needs of the population by maintaining work competencies and providing learning opportunities for our LHJs.

 

To improve access to quality health care and services, CDPH/MCAH provided educational opportunities and resources for the LHJs that address:

• Social determinants of health that impacted individuals and families’ ability to access health and social services such as institutionalized racism, lack of housing and transportation, food insecurity, and lack of educational attainment.
• Mental health and substance use services and resources, congenital syphilis, TdaP immunizations for pregnant women and heart disease.
• Quality assurance/improvement using evidence-based frameworks such as Results Based Accountability.
• Development and implementation of community-wide needs assessment.
• CDPH/MCAH hosted five in-person Comprehensive Perinatal Services Provider (CPSP) provider orientation trainings.
• CDPH/MCAH continued to provide online orientation trainings for new CPSP providers, staff and Perinatal Services Coordinators (PSCs).
• Local Perinatal Services Coordinators (PSCs) provided training, consultation, and technical assistance to CPSP providers on program implementation; assisted providers to develop or revise protocols and train staff, and monitored the local CPSP program by conducting CPSP quality improvement/quality assurance (QI/QA) activities.

 

Evidence-based and evidence-informed practices utilized for this strategy:

CDPH/MCAH promoted evidence-based research and practice by March of Dimes, who provided a presentation and the Statewide PSC Meeting in February 2019. These evidence based models in the prevention of pre-terms labor and birth.

• 17 alpha-hydroxyprogesterone (17-P)
• Low Dose–Aspirin

 

CDPH/MCAH, in collaboration with PSCs, will continue to update assessment tools and resources such as the Provider Handbook, Steps to Take Manual, for PSCs and CPSP providers so that providers, provider staff, and PSCs will have up-to-date, culturally congruent, and relevant resources for client education and program implementation and evaluation.

 

Challenges for this strategy:

CPSP Provider Orientation trainings fill quickly. Providers continued to report difficulty in finding a training to attend.

 

Women/Maternal Objective 1a: Strategy 3:

State and Local MCAH to develop and implement protocols to ensure all clients in MCAH programs are enrolled in a health insurance plan, linked to a provider, and complete an annual visit.

 

Local Health Jurisdictions (LHJs): Through the CDPH/MCAH Year-End survey, 57 LHJs reported adoption of one or more protocols or policies that pertain to linking clients to health insurance for preventive visits. Of these, 52 adopted a policy to assist clients to enroll in health insurance, 55 LHJs adopted a policy to link clients to a healthcare provider for a preventive visit, and 26 developed tracking mechanisms to verify clients enrolled in health insurance completed a preventive visit (Source: 2018-19 Year End Survey).

 

In their local MCAH Scopes of Works (SOWs), LHJs included activities to improve insurance enrollment and increase access/utilization of health and social services. Listed are examples from the 2018‑19 MCAH Annual Reports of LHJ activities:

 

Mariposa County - worked to develop a relationship with Department of Human Services Eligibility Division and participated in quarterly meetings to provide education regarding oral health resources, assess MCAH clients for Medi-Cal eligibility, and develop protocols for referrals to other programs.

 

Los Angeles County - provided 16,000 referrals and individual instances of troubleshooting assistance to families accessing health coverage benefits and services. Worked on referring 36,319 client families to other health and social service needs and provided troubleshooting training to their staff.

 

Madera County - worked on increasing awareness in the community and providing client-centered comprehensive and timely coordinated, culturally and literary appropriate education materials for medical and oral healthcare. Case managers found that the preventive services were often not accessed by MCAH clients due to their lack of transportation to the providers or the client’s immigration status (fear of being deported).

 

Evidence-based and evidence-informed practices utilized for this strategy:

CDPH/MCAH enabling services employed evidence-based or evidence-informed program models, including: Family Spirit, Nurse-Family Partnership, Healthy Families America, BIH, and the AFLP Positive Youth Development Model.

 

Women/Maternal Objective 1b:

By June 30, 2020, increase the rate of women of reproductive age with appropriate preventive care, including:

• increase the rate of preventive visits among reproductive age women from 61.9% (2013 Behavioral Risk Factor Surveillance System [BRFSS] to 65.3%.

 

In 2017, California Behavioral Risk Factor Survey data show that 63% of women ages 18 through 44 had a preventive medical visit in the past year. This is down slightly from the 65.4% who reported having a preventive medical visit in 2016. Black women were most likely to have had a preventive medical visit in the past year (74.6%), followed by White women (62.1%) and Hispanic women (60.1%).

 

Women/Maternal Objective 1b: Strategy 1:

Based on their Local Needs Assessment, all 61 LHJs will implement a local objective(s) to address increasing access to and utilization of preventive health services for reproductive age women.

 

Local Health Jurisdictions (LHJs): CDPH/MCAH funded and required that all 61 LHJs conduct activities that promoted access to and quality preventive care. Many activities focused on collaborating with providers to increase utilization of services. Other activities ranged from building workforce capacity to ensuring program fidelity.

 

In their 2018-19 Annual Reports, all 61 LHJs reported activities to increase access and utilization of preventive women. Examples included:

 

Madera County - worked on increasing awareness in the community and providing client-centered comprehensive appropriate education materials for medical and oral healthcare. Case managers worked to improve client preventive care knowledge and skills giving clients education and resources to make informed decisions regarding their care. They also found that the preventive services were often not accessed by MCAH clients due to lack of transportation or the client’s immigration status (fear of being deported).

 

Kings County - had a goal of decreasing the rate of sexually transmitted infections (STIs) in women (ages 12-29) by 10%. They worked with an inter-agency intervention and prevention program to monitor STI trends and identify what populations were affected.

The county saw a decrease in the following STIs: 33% in Gonorrhea, 28% in syphilis, and 37% in chlamydia.

 

Inyo County - contacted former patients of the Family Planning Access Care Treatment (PACT) clinic who had not established care and assisted them with care coordination for a well-women visit.

 

Challenges for this strategy:

Calaveras County – did not have a birthing hospital or center, obstetricians, or Family PACT providers, which required women to leave the county for services. However, Medi-CAL Managed Care (MCMC) plans were aware of the challenges and continued to work with local network providers to improve access.

 

Women/Maternal Objective 1c:

By June 30, 2020, increase the rate of women of reproductive age with appropriate preventive care, including:

• increase the rate of first trimester prenatal care initiation from 83.6% (2013 BSMF) to 87.9%.

 

In 2017, 83.8% of infants were born to pregnant women who received prenatal care beginning in the first trimester. Although the overall state rate has remained relatively stable over recent years, racial/ethnic disparities persist. Infants born to American Indian/Alaska Natives and Pacific Islanders women had the lowest percent of first trimester prenatal care (67.9 and 70.4%, respectively). Infants born to White and Asian women had the highest percent (87.4 and 86.9%, respectively) followed by Hispanics and Blacks (81.4 and 79.0%, respectively).

 

Women/Maternal Objective 1c: Strategy 1:

Collaborate with other CDPH programs, DHCS, Medi-Cal Managed Care, and health plans to improve early entry into prenatal care.

 

Local Health Jurisdictions (LHJs): CDPH/MCAH funded and required that all 61 LHJs conduct activities that promoted access to and quality perinatal care. Many activities focused on collaborating with providers to increase utilization of services. Other activities ranged from building workforce capacity to ensuring program fidelity.

 

In their 2018-19 Annual Reports, all 61 LHJs reported activities to increase access and utilization of perinatal care for pregnant women. Examples included:

 

Fresno County - the Perinatal Service Coordinator (PSC) worked closely with the CDPH Immunization Program to deliver Prenatal Tdap Vaccine Toolkits to 40 CPSP Providers and reviewed the CDPH Tdap recommended administration guidelines.

 

Inyo County - the PSC frequently supplied the local perinatal provider with the most recent resources around topics of gestational diabetes, marijuana use during pregnancy, STIs in women of reproductive age, and maternal mental health. During FY 2018-19, the LHJ worked to assist providers in a community-wide referral and tracking system for maternal mental health.

 

San Bernardino County - collaborated with a Family PACT clinic on an all-day training session offered to 34 CPSP and Family PACT providers to improve long-acting reversible contraception knowledge and counseling skills.

 

Comprehensive Perinatal Services Program (CPSP): CDPH/MCAH, in partnership with the LHJs, led the CPSP Program. In addition to standard obstetric services, women received enhanced services in the areas of nutrition, psychosocial and health education. CDPH/MCAH enrolled and trained providers who received an enhanced Medi-Cal fee incentive for delivery of CPSP services.

 

CDPH/MCAH utilized data and reports to monitor Medi-Cal enrollment by county and provided technical assistance to the LHJs on CPSP.

 

CDPH/MCAH conducted the Perinatal Service Coordinators (PSC) Statewide meeting in February 2019, which provided training on the Comprehensive Perinatal Service Program (CPSP) and the provider enrollment process.

 

Department of Health Care Services/ Medi-Cal Managed Care (DHCS/MCMC): CDPH/MCAH collaborated with DHCS/MCMC staff to increase knowledge of one another’s priorities and to improve communication and relationships. CDPH/MCAH participated on the weekly DHCS Maternal Care and CPSP Code Conversion Team Status Meeting with stakeholders. CDPH/MCAH communicated regularly with Medi-Cal Medical Policy Section and fiscal intermediary.

 

Black Infant Health (BIH): Local BIH staff members provided follow-up telephone calls and home visits with participants within one week after delivery to encourage women to keep postpartum and other preventive health visits. The BIH SOW also included a process outcome measure for the purposes of tracking participant postpartum checkups.

 

Adolescent Family Life Program (AFLP): AFLP supported adolescent parents with accessing needed perinatal services and coordinated with CPSP and local health providers.

 

Evidence-based and evidence-informed practices utilized for this strategy:

DHCS/American Indian Maternal Support Services (AIMSS): The four new grantees used the California Perinatal Services Program (CPSP) training to develop educational information for pregnant American Indian women to promote the importance of prenatal care. In addition, three grantees used the Johns Hopkins evidence based home visitation curriculum called Family Spirit to provide education for pregnant women in their homes and to reinforce healthy behaviors to promote proper prenatal care.

 

Challenges for this strategy:

AIMSS: Challenges in implementing this strategy included a site that was unable to recruit a perinatal nurse in a timely manner. Another site experienced a delay in recruiting home visitation staff and there was a limited timeframe to obtain additional perinatal education for the staff working with pregnant women.

 

Women/Maternal Objective 1d:

By June 30, 2020 increase the rate of women of reproductive age with appropriate preventive care include:

• increase the rate of postpartum visits from 88.3% (2012 Maternal and Infant Health Assessment (MIHA)) to 92.9%.

 

In 2017, 90.1% of women giving birth in California reported a postpartum visit, slightly higher than 87.5% in 2013-14. A lower percentage of Latina and Black women reported a postpartum visit (87.1% and 85.8%, respectively) compared to White women (93.8%) and Asian/Pacific Islander women (93.8%).

 

Women/Maternal Objective 1d: Strategy 1:

Collaborate with DHCS, Medi-Cal Managed Care, and health plans to increase knowledge and referrals to state and local MCAH programs and identify local barriers, emerging issues and intervention opportunities to improve access to the postpartum visit.

 

Department of Health Care Services/ Medi-Cal Managed Care (DHCS/MCMC): CDPH/MCAH communicated with Medi-Cal Managed Care to learn about the new Medi-Cal Value Based Payment Program. The program proposes to provide incentive payments to providers for meeting specific measures aimed at improving care for certain high cost or high need populations. These risk-based incentive payments will be targeted at physicians that meet specific achievement on metrics targeting areas of behavioral health integration; chronic disease management; prenatal/postpartum care; and early childhood.

 

Local Health Jurisdictions (LHJs): CDPH/MCAH supported LHJs by providing technical assistance to help them develop and adopt protocols within their local MCAH programs to improve access to care for postpartum women. A few examples of LHJ activities to improve access to and utilization of the postpartum visit included:

 

Fresno County – The Central Area Perinatal Advocates collaborated with the Central Valley Regional Perinatal Programs of California staff to discuss plans for a postpartum discharge referral system for women diagnosed with a high-risk pregnancy.

 

Solano County – completed year two of a three year agreement with Solano County Mental Health Services Act to improve accessibility for the perinatal population to needed mental health services. Newly implemented services included in-home mental health therapy provided by a licensed Mental Health Clinician.

 

Black Infant Health (BIH): BIH Family Health Advocates and Public Health Nurses (PHNs) continued to provide follow-up telephone calls and home visits with participants within one week after delivery to encourage women to keep postpartum and other preventive health visits. BIH continued its efforts to collaborate with MCMC and CPSP providers to improve and increase the rates of postpartum visits for African-American moms. The BIH SOW continued to include a process outcome measure for the purposes of tracking participant postpartum checkups in order to provide assistance and ensure that participants understand the importance of keeping all appointments in order to address overall health care needs.

 

Adolescent Family Life Program (AFLP): AFLP case managers supported pregnant and parenting youth with accessing health insurance and services, including postpartum care.

 

California Home Visiting Program (CHVP): The Nurse Family Partnership (NFP) model required mothers be enrolled before 29 weeks gestation. For NFP, postpartum visits occur weekly for the first six weeks and then every other week until the baby is 21 months. From 21-24 months visits are monthly. To meet the needs of the individual family, the nurse home visitor may increase or reduce the frequency of visits, and is encouraged to visit in the evening or on weekends based on nursing assessment and client request. The Healthy Families America (HFA) model required mothers be enrolled prenatally and no later than three months postpartum. HFA participants are offered weekly home visits for at least the first six months of service. After this time, families progress through levels of service that correspond to increasing home visit intervals at a pace that best matches their needs and progress.

 

Comprehensive Perinatal Services Program (CPSP): Perinatal Services Coordinator (PSCs) provided technical assistance to CPSP providers and 647 quality assurance/quality improvement (QA/QI) site visits to CPSP provider offices to monitor implementation of CPSP. The QA/QI visit included an evaluation of the delivery of the required CPSP postpartum assessment, needed follow-up care and individualized care plan revisions.

CDPH/MCAH and the University of California San Francisco, Family Health Outcomes Project (FHOP), developed a QA/QI pilot project to identify common challenges and areas of improvement for CPSP services by developing a chart review tool.

 

Evidence-based and evidence-informed practices utilized for this strategy:

CPSP is an evidence-informed model for comprehensive prenatal/postpartum care.

The models for CDPH/MCAH case management (AFLP and BIH) and home visiting programs (NFP, HFA, Family Spirit) are all evidence-based or evidence-informed.

 

Challenges for this strategy:

DHCS/American Indian Maternal Support Services (AIMSS): Challenges included unexpected delays in recruiting the necessary staff to work with pregnant women and a limited timeframe to obtain perinatal education for staff recruited. Timely postpartum care remained an ongoing challenge at AIMSS funded clinics. There were four AIMSS clinics providing services in five counties. Only two clinics provided OB services on-site. Lack of OB services on-site at all Indian clinics contributed to the lack of postnatal follow-up in the community.

Marin County – gaps in services included the lack of access to mental health for clients who have only pregnancy-related Medi-Cal. The new Maternal Mental Health Collaborative in Marin is addressing these barriers.

 

Trinity County – there were limited providers for postpartum visits in the county.

 

Women/Maternal Objective 1e:

By June 30, 2020 increase the rate of women of reproductive age with appropriate preventive care include:

• increase access to providers that provide appropriate services and levels of care for reproductive age women.

 

Women/Maternal Objective 1e: Strategy 1:

Increase knowledge of and facilitate collaboration between local CPSP programs and RPPC to improve maternal and perinatal access to systems of care.

 

Regional Perinatal Programs of California (RPPC): The goals of RPPC were to ensure pregnant women and their babies had access to the most appropriate level of care and to implement quality improvement activities to reduce adverse maternal and neonatal outcomes. RPPC developed and maintained a network of providers and facilities within nine specific geographic areas and matched the needs of high-risk perinatal patients with the appropriate level of care.

 

CDPH/MCAH led the launch of the Maternal Levels of Care Steering Committee, which established hospital-level criteria for ensuring high-risk moms were delivering babies at the appropriate hospital. At the Maternal Risk-Appropriate Care and Transport Stakeholder meeting, neonatal and maternal care providers, health plan representatives and researchers came together and established four workgroups to address the need for a more comprehensive maternity care system in California.

 

CDPH/MCAH continued discussions with local MCAH Directors, PSCs and RPPC Directors to identify activities to strengthen state and local ties and provide continuity of care for at-risk pregnant women during pregnancy and upon hospital discharge. In addition, CDPH/MCAH designated an RPPC liaison who participated on the CPSP Executive Committee monthly calls.

 

Comprehensive Perinatal Services Program (CPSP): MCAH continued to process, review and evaluate provider applications for CPSP to increase the number of providers and locations for CPSP services. For FY 2018-19, there were 81 CPSP applications received and 68 were approved:

• 1 community outpatient hospital
• 4 community clinics
• 40 FQHCs
• 9 OBGYNs
• 14 physician groups

 

CDPH/MCAH continued to facilitate coordination between the CPSP and RPPC programs to build relationships and improve connections between CPSP providers and birth facilities in their respective region. Local CPSP programs met and/or attended meetings with Regional Perinatal Programs of California Directors to assist and facilitate coordination of activities to improve care including referrals for high-risk mothers and infants upon hospital discharge.

 

LHJs collaborated with RPPC to improve maternal and perinatal systems of care. Examples from the LHJ Annual Reports include:

 

San Bernardino County - collaborated with March of Dimes “healthy babies are Worth the Wait” and RPPC to improve access/quality of prenatal care and decrease prematurity in the High Desert Region. In addition, the CPSP Program collaborated with the CDPH/STD Disease Control Branch and RPPC to facilitate and train hospital staff on the use of the Congenital Syphilis toolkit.

 

Sacramento - the CPSP program met with the RPPC Director to assess, plan and implement a training for the perinatal community on the effects of methamphetamine use during pregnancy, delivery, and postpartum, and the consequences for infants, children and families.

 

Women/Maternal Objective 2:

By June 30, 2020, decrease the rate of mental health and substance use hospitalizations per person age 15-24 from 1,436 per 100,000 and 1,754 per 100,000, to 1,318 per 100,000 and 1,570 per 100,000, respectively.

 

The rate of mental illness hospitalizations among individuals ages 15 to 24 steadily increased from 1,469 per 100,000 in 2013 to 1,533 per 100,000 in 2015. The three-year average rates were highest among Blacks followed by those identified as White (2,920 and 2,182 per 100,000, respectively). The average rate was lowest among Asian/Pacific Islanders (562 per 100,000).

 

Women/Maternal Objective 2: Strategy 1:

Increase local MCAH programs awareness of maternal mental health needs, wellness issues that affect MCAH target population through various educational opportunities with a special emphasis on primary prevention strategies.

 

CDPH/MCAH led and funded the Maternal and Infant Health Assessment (MIHA), an annual, statewide representative survey of women with a recent live birth in California. MIHA collected self-reported information about maternal and infant experiences and about maternal attitudes and behaviors before, during and shortly after pregnancy. MIHA routinely gathers data on symptoms of depressive symptoms during and after pregnancy. During 2018 and 2019, new questions were added to the MIHA survey to assess women’s perceived need for mental health services and their barriers to receipt of needed services. In addition, CDPH/MCAH partnered with the Centers for Disease Control and the ASTHO to fund a series of questions on prenatal prescription pain reliever (opioid) use for MIHA 2019. Data collection for these new measures will continue through December 2019 with preliminary analyses conducted in 2020-21. This data will provide a more comprehensive assessment of the need for behavioral health services among the birthing population.

 

CDPH/MCAH developed strategies to improve maternal mental health by raising awareness, developing resources, implementing screening and referral processes and enhancing collaboration. Over two-thirds of local MCAH Programs prioritized actions to improve maternal mental health systems of care.

 

Examples in the local MCAH Annual Reports to address maternal mental health are:

 

City of Berkeley - developed a provider survey to find out if clients were being screened for Perinatal Mood and Anxiety Disorders (PMADs), researched and identified provider referrals and resource networks for clients who screened positive. The LHJ was able to ensure that all women with more than one PHN home visit were screened for PMAD. Collaborations with community partners led to a new algorithm for PMAD as well as resource sharing with local CPSP and Help Me Grow sites. Roundtables were conducted to identify the following barriers: limited number of mental health providers, staff hesitancy to screen clients due to limited support if client screens positive and competing priorities during client visit.

 

Calaveras County - determined the number of women diagnosed with PMAD in order to provide resources for services and to assist clients with accessing services. The LHJ worked to maintain a record of outreach and completed assessments, and maintained a count of women who assessed, screened, and were diagnosed for PMAD.

 

Contra Costa County – worked on having staff complete at least one training on maternal mental health, developed a process to measure staff knowledge, and developed protocols to have all program participants screened for perinatal mental health issues and referred to services as needed. QA/QI processes were used to ensure that protocols were implemented as intended and results evaluated.

 

California Home Visiting Program (CHVP): Both the Healthy Families America (HFA) and Nurse Family Partnership (NFP) models included mental health training as required elements. HFA staff reviewed the online depression training module and had access to a free online course through the National Child Traumatic Stress Network. In 2018, all NFP Nurses completed a mental health training through the NFP community. Staff attended conferences and training related to depression, trauma informed practices and motivational interviewing to increase knowledge and provide high quality services to their participants.

 

CHVP screened for maternal depression utilizing the Edinburgh Postnatal Depression Scale (EPDS) or the Patient Health Questionnaire (PHQ-9), and provided referrals to mental health services for women who screened positive or presented with depressive symptoms.

 

CHVP provided referrals to mental health services for women who screened positive on validated tools administered or presented with depressive symptoms. Local Implementing Agency (LIA) staff embed home visiting into early childhood systems at both the local and state levels to promote screening, referrals and access to needed mental health services. Sites continually work on developing and maintaining partnerships with local agencies, working closely with their local behavioral health programs and other community agencies to coordinate and provide mental health services to families. In some instances, the county assigns mental health therapists to provide direct therapy to home visiting participants through non-MIECHV funds. County therapists may also facilitate meetings with home visitors such as case conferences and reflective debriefing to reduce secondary trauma for home visitors.

 

Adolescent Family Life Program (AFLP): The AFLP model integrated mental health questions into all assessments used with youth enrolled in the program. At each assessment point, it was recommended that additional depression screening was completed using one of the following: Patient Health Questionnaire-9 (PHQ-9), the PHQ-9 Modified for Teens, and the Edinburgh Postnatal Depression Scale (EPDS). The program incorporated other reflection and prevention activities to help young moms learn not only about how to take care of their child but also take care of their own physical, emotional and mental health. For more information about AFLP, see the Adolescent Health section.

 

Black Infant Health (BIH): BIH addresses the effect of chronic stress and discrimination as the underlying cause of preterm births and higher rates of maternal morbidity in the Black community. BIH had a mental health professional (MHP) at each site. The MHP was responsible for conducting initial assessments which included mental health questions, conducting case conferences for all participants, acting as a liaison to their local mental health services, providing mental health consultation to staff about participants of concern, providing Solution-Focused Brief Therapy on a limited basis, and participating in group sessions with a strong mental health component. All women received the EPDS postpartum. If a women screened positive for depression, she was referred to local mental health services.

 

Comprehensive Perinatal Services Program (CPSP): CPSP provided psychosocial, nutrition and health education services, in addition to obstetric care. CPSP providers screened for depressive symptoms throughout pregnancy and the postpartum period using validated tools or assessments and provided enhanced support to ensure women in need of additional services were linked to a provider.

 

Evidence-based and evidence-informed practices utilized for this strategy:

The PHQ-9, the PHQ-9 Modified for Teens, and the EPDS are all validated assessment tools to screen for depression and utilized through a variety of CDPH/MCAH programs. Case management and home visiting are strategies that supported prevention, screening and connecting new moms with services to address any mental health concerns. Social media was also an effective strategy for raising awareness about important maternal mental health issues. Several posts were shared on CDPH’s social media platforms during the month of May in honor of Maternal Mental Health Awareness Month.

 

Women/Maternal Objective 2: Strategy 2:

Assess and disseminate available resources, tools, and evidence-based maternal mental health and wellness toolkits for local MCAH programs.

 

MCAH established a list of screening recommendations from national organizations (e.g. ACOG) that are available to LHJs and support local efforts in referring women to appropriate services. MCAH will maintained a listing of evidence-based maternal mental health tools, wellness assessments and toolkits and disseminate to LHJ programs to ensure all women in MCAH programs are screened, referred and linked to appropriate services. These resources are made available through the CDPH/MCAH website.

 

The CDPH/MCAH Communications and Outreach Unit developed a Maternal Mental Health outreach toolkit, which can be used year-round to promote maternal mental wellness. The materials were sent to over 1,400 people and included a video public service announcement, fact sheet, symptoms of depression data brief, “In Her Words” digital story, color sheets and social media posts. Facebook and Twitter posts focused on different aspects of maternal mental health, such as signs and symptoms, stigma and the impact of maternal depression on the health and development of the infant. Local health departments shared the information on social media, as did other community partners. Materials were also translated into Spanish. A few key analytics on the materials include:

 

• 362 YouTube views of “In Her Words” maternal depression video
• 359 YouTube views of the “Maternal Depression Symptoms and Solutions” video
• 4,955 people reached on Facebook
• 4,267 people reached on Twitter

 

Posts were shared by a number of local health departments and stakeholder groups.

 

Comprehensive Perinatal Service Program (CPSP): CDPH/MCAH had approximately 1,600 CPSP providers enrolled throughout California. The CPSP Steps to Take Manual provided CPSP providers with information to effectively assess situations, provide interventions and refer appropriately. The psychosocial section of the manual was reviewed and updated by CDPH/MCAH’s Public Health Medical Officer to provide the most current evidence-based/informed practice and resources.

 

Challenges for this strategy:

CDPH/MCAH worked to identify, review and match the resources to the needs of the local MCAH programs. Therefore, CDPH/MCAH did not invested in a stand-alone toolkit, but rather focused on existing resources to meet the needs of the population in California.

 

Women/Maternal Objective 2: Strategy 3:

Develop new and strengthen existing collaboratives and partnerships with state and local agencies, mental health providers, professional associations, researchers, and universities to address maternal mental health and wellness.

 

CDPH/MCAH developed new relationships in the area of mental health and with First 5 Orange County and California Healthcare Foundation to understand mental health initiatives and the applicability within a public health system.

 

Women/Maternal Objective 2: Strategy 4:

Conduct surveillance and evaluation of maternal mortality related to mental health.

 

Pregnancy-associated suicide: In 2002-12, suicide accounted for 4.3% of all deaths among California women who were pregnant within the prior year (based on linked administrative data). The rate of suicide in this population remained stable between 2002 and 2012, with no statistically significant upward or downward inflections. The 3-year moving average of suicide rates ranged between 1.1 and 1.8 deaths per 100,000 live births over this time-period.

 

CDPH/MCAH’s California Pregnancy-Associated Mortality Review (CA-PAMR) led an in-depth investigation of deaths from suicide among California women who died while pregnant or within 365 days after the end of pregnancy. A review committee consisting of experts in mental and behavioral health, emergency medicine, maternity care, social work, public health, and forensic pathology reviewed 117 potential suicides (including selected overdose deaths) and found 99 to be true suicides. Findings of the 99 deaths from suicide revealed that preexisting and new onset mental health conditions were highly prevalent (62% with preexisting and 25% with new onset conditions). The most common conditions included depression (54%), psychosis (24%), and bipolar disorder (17%). Substance use – including illicit substances, abused prescription opioids, heavy alcohol use, tobacco, and/or marijuana – was common among women with mental health conditions. Most deaths (83%) from suicide occurred in the late postpartum period (>42 days after pregnancy ended) and 51% of cases had a good-to-strong chance of preventability. A comprehensive state report was under review during FY 2018-19, with official release in October 2019.

 

Women/Maternal Objective 2: Strategy 5:

Increase local MCAH programs awareness of maternal substance use (opioid, cannabis, and other drugs) needs and educational opportunities with a special emphasis on primary prevention strategies.

 

CDPH/MCAH continued to disseminate information and resources from a variety of sources on maternal substance use that included screening for maternal substance use and linking to services as needed. To assist women of reproductive age to have access to substance use facilities, each LHJ was required to develop and implement protocols to ensure access to needed services and to develop a comprehensive resource and referral guide of available health and social services.

 

During FY 2018-19, CDPH/MCAH worked to produce an opioids + pregnancy public health education toolkit as part of an ASTHO grant titled Opioid Project Jurisdictional Support. The toolkit included waiting room posters, one-sheet handouts, social media posts and a public service announcement. Outreach materials were designed to educate the reader about opioids – what they are, common names for them, effects on the developing baby, and what to do if they are concerned about opioids prescribed. Materials were shared at provider trainings, which were conducted by our partner, the University of California, San Francisco Family Health Outcomes Project (FHOP). Outreach materials are also housed on the CDPH website and shared with stakeholders, including local MCAH directors, via e-blast.

 

The CPSP Steps to Take manual was updated and expanded to include more information and client friendly education on maternal substance use. CDPH/MCAH and UCSF/FHOP continued to offer technical assistance calls with the LHJs addressing substance use.

 

Examples in the local MCAH Annual Reports to address substance use are:

 

San Benito County – partnered with the Opioid Task Force to identify data to demonstrate the scope of perinatal substance use and local treatment and support services options for women of reproductive age, pregnant and post-partum women.

 

Ventura County – collaborated with the Perinatal Substance Use Taskforce to provide training and education to OB/family practice providers and nurses on perinatal substance use and the importance of screening pregnant women a standard of practice. They contributed to the development of a screening Toolkit.

 

Orange County – referred 170 women to drug and alcohol treatment programs and behavioral health services through the county’s PSAS/ACT program. The PHNs linked clients to transportation services and provided follow up home visits to aid the facilitation of referrals and linkages. In fiscal year 2018-19, 46 women were referred to drug and alcohol programs, 100 women were referred to behavioral health services, 19 women accessed drug and alcohol services, 56 women accessed behavioral health services.

 

Women/Maternal Objective 2: Strategy 6:

Develop new and strengthen partnerships with national, state and local agencies to address maternal substance-use and wellness.

 

CDPH/MCAH collaborated with the Chronic Disease Prevention Branch to identify the best education and support models to provide services to opioid addicted women.

 

CDPH/MCAH worked with the California Department of Social Services on the role of health care providers and hospitals on child welfare reporting requirements regarding maternal substance use during pregnancy in light of recent federal CAPTA/CARA law changes and current state law.

 

The CDPH Center for Healthy Communities convened the Maternal/Neonatal Opioid Task Force team to address opioid use in all populations. CDPH/MCAH participated and worked on addressing perinatal issues.

 

CDPH/MCAH partnered with the California Health Care Foundation on a survey of California hospitals (conducted by the Urban Institute) to identify current practices on assessment, treatment, and follow-up for mothers and newborns on maternal opioid use and neonatal abstinence.

 

CDPH/MCAH worked with the California Maternal Quality Care Collaborative (CMQCC) and ACOG on implementation and dissemination of the AIM Opioid safety bundle at targeted hospitals.

 

In partnership with ACOG and the American Academy of Pediatrics, CDPH/MCAH participated in discussions on potential collaboration to facilitate a warm handoff to pediatric primary care providers after hospital discharge.

 

Women/Maternal Objective 3:

By June 30, 2020, MCAH will work with partners to reduce prevalence of hypertension, diabetes, cardiovascular disease and mental illness among women at labor and delivery from 8%, 10.0%, 0.54% and 4.4% (2013 Office of Statewide Health Planning (OSHPD) and Development Patient Discharge Data (PDD)) to 7.4, 9.5%, 0.51% and 3.9% respectively.

 

In 2015, the hospital discharge data showed that 8.9% of women at labor and delivery had a diagnosis of hypertension. A greater proportion of Black women (14.8%) and American Indian/Alaskan Native women (11.0%) had hypertension than Asian/Pacific Islander women (6.8%) or Hispanic women (8.7%).

 

In 2015, the hospital discharge data showed that 10.6% of women at labor and delivery had a diagnosis of diabetes. The percent of women with diabetes remained relatively unchanged from 2014. A greater proportion of Asian/Pacific Islander women (15.6%) and American Indian/Alaskan Native women (11.7%) had diabetes than White (7.6%) or Black (8.8%) women. One out of nine Hispanic women at labor and delivery had diabetes.

 

Hospital discharge data showed that the percent of women at labor and delivery with a diagnosis of heart disease remained stable at 0.6% for both 2014 and 2015. The percent with heart disease by race/ethnicity ranged from 0.4% among Hispanic women to 0.8% among both White and Black women.

 

The percent of women at labor and delivery with a diagnosis of a mental disorder increased from 4.8% in 2014 to 5.4% in 2015. Increases were evident among all women except those identified as American Indian/Alaskan Native. This group experienced a percentage point decrease from 10.6% to 9.6% in 2015. In 2015, a greater proportion of Black women (9.8%) and American Indian/Alaskan Native women (9.6%) had a mental disorder diagnosis followed by White (8.4%), Hispanic (4.1%) and Asian/Pacific Islander women (2.1%).

 

Women/Maternal Objective 3: Strategy 1:

Partner with disease-specific organizations to target prevention outreach to women of reproductive age for cardiovascular disease, hypertension, diabetes, and mental illness to ensure prevention strategies are culturally, linguistically, and age appropriate and match literacy level.

 

CDPH/MCAH collaborated with the CDPH/Chronic Disease Control Branch on the development of a factsheet, “Are You at Risk for Heart Disease While You are Pregnant”. Three versions of the factsheet were created to target pregnant women: who are monolingual Spanish speaking, are African American and the general English speaking population. The fact sheets are anticipated to be released in spring of 2020.

 

California Home Visiting Program (CHVP): CHVP conducted the following activities:

• Depression screening for primary caregivers enrolled in home visiting utilizing the EPDS validated tool
• Tobacco cessation referrals for primary caregivers who self-report using tobacco or cigarettes within three months of enrollment
• Completed depression referrals for primary caregivers with positive screen for depression

 

Evidence-based and evidence-informed practices utilized for this strategy:

CHVP utilized the validated screening tools, EPDS or the Patient Health Questionnaire (PHQ-9) for all participants.

 

Challenges for this strategy:

Design and approval of factsheet was a challenge during this reporting period, which delayed the release of the factsheet.

 

Women/Maternal Objective 3: Strategy 2:

Partner with Office of Health Equity, Health in All Policies (HiAP) Task Force to help develop policies and initiatives to address community risk factors for chronic cardiovascular diseases (e.g. healthy food availability, built environment for more active transportation, community safety that promotes active transportation), and ensure applicability of HiAP plans to women of reproductive age.

 

In 2018-19, CDPH/MCAH updated the Nutrition and Physical Activity Initiative’s Systems and Environmental Changes website with new graphics, new resources including a section that now includes data. Some data sources used included those from California partners: the California Health and Human Services Open Data Portal, Let’s Get Healthy California, and the Health Disparities in the Medi-Cal Population Fact Sheets.

 

Women/Maternal Objective 3: Strategy 3:

Establish self-identified maternal levels of care for all birthing facilities to ensure high-risk moms are delivering in the right level of care.

 

CDPH/MCAH led the launch of the Maternal Risk-Appropriate Care Stakeholder steering committee to advance the establishment of hospital-level criteria for ensuring high-risk moms delivered babies at the appropriate hospital. At the Maternal Risk Appropriate Care Stakeholder meeting, neonatal and maternal care providers, health plan representatives and researchers came together and established four workgroups to address the need for a more comprehensive maternity care system in California. The four workgroups met to formulate recommendations to advance the establishment of Levels of Maternal Care (LoMC) in California. Additionally, each workgroup focused on one priority area identified by the Maternal Risk-Appropriate Care Stakeholder Group. The culmination of these workgroups meetings led to the development of a strategic plan that will guide the work for the next three years that included the following recommendations:

 

• Payment Reimbursement workgroup recommendations: develop best practice standards for high-risk maternal conditions that allow health plans to understand and negotiate payment structure that supports maternal-risk appropriate care and continue collaboration and conversations with Medi-Cal and third party payers to move the work already accomplished forward.
• Building relationships between lower and higher level hospitals to promote transfer of women to the right level of care workgroup recommendation: garner information on current maternal transports to identify barriers to transport between facilities utilizing the completed transport survey tool and develop a plan to address concerns.
• Data to Support Levels of Maternal Care Recommendation: develop a primary data collection system that will provide data for a descriptive report regarding such questions with subsequent committee review of the results.
• Pilot test a hospital verification process: utilize the ACOG/SMFM consensus criteria to verify ten hospitals for their LoMC with the goal of determining feasibility of a voluntary process.

 

Women/Maternal Objective 3: Strategy 4:

Conduct surveillance and evaluation of maternal mortality and morbidity including measurement of trends and disparities in chronic disease and the quality maternal care related to chronic disease, etc.

 

Maternal Morbidity: Data from the national Healthcare Cost and Utilization Project revealed that rates of severe maternal morbidity increased from 127.5 per 10,000 delivery hospitalizations in 2012 to 147.4 per 10,000 delivery hospitalizations in 2014. In 2015, the rate decreased to 135.2 per 10,000 delivery hospitalizations.

 

CDPH/MCAH reviewed 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 which began October 1, 2015 in patient discharge data.

 

CDPH/MCAH monitored the percent of women hospitalized at time of delivery hospitalizations with hypertension, diabetes, cardiovascular disease and mental illness using Office of Statewide Health Planning and Development (OSHPD) patient discharge data. In addition, MCAH will monitor the rate of severe maternal morbidity at the time of hospitalization and delivery.

CDPH/MCAH staff initiated an in-depth assessment of gestational diabetes at time of delivery among women of reproductive age, including measurement of trends and disparities using hospital discharge data from 2004 through the first three quarters of 2015. This project focused on measuring trends and disparities to inform educational needs and provider practices related to gestational diabetes. Data were also mapped to highlight geographical areas of greatest need for targeted efforts on gestational diabetes prevention.

 

CDPH/MCAH continued to work with the University of California, Los Angeles (UCLA) on a Maternal Quality Indicator Project whose focus is to conduct complex population-based data analyses to inform decision-making for implementation of a system of maternal levels of care. The grantee will develop a risk profile of women in order to understand the distribution of medically complex pregnancies throughout the state and identify where they give birth.

 

Maternal Mortality: CDPH/MCAH implemented new statewide maternal mortality surveillance methodology, called the California Pregnancy Mortality Surveillance System (CA-PMSS), to more accurately track deaths among California women while pregnant or within one year of the end of pregnancy from causes related to or aggravated by pregnancy or its management. CA-PMSS is a rapid-cycle case review process that uses linked administrative data (birth and death files, patient discharge data, and emergency department data) that are supplemented with coroner/autopsy reports and medical records. A review committee of seven experts identifies the cause of death, the underlying mechanism(s), and whether the death was related to pregnancy. These data are used to derive pregnancy-related mortality ratios, a more precise measure of maternal deaths than maternal mortality ratios (MMR), which rely on death certificate data alone. CDPH/MCAH identified data concerns (e.g., misclassified cause of death, incorrect timing of death) with using death certificate data alone. CA-PMSS is a collaborative effort between CDPH/MCAH and its partners, the California Maternal Quality Care Collaborative (CMQCC) at Stanford University and the Public Health Institute (PHI). The surveillance methodology was developed in consultation with the CDC. CA-PMSS completed rapid-cycle case reviews of 510 deaths in 2008-2013 and began reviewing deaths in 2014.

 

Women/Maternal Objective 4:

By June 30, 2020, California will reduce the prevalence of mistimed or unwanted pregnancy among black and Latina women with live births from 45.4% and 38.2% to 43.4% and 37.1%.

 

The percent of women reporting mistimed or unwanted pregnancy decreased from 29.1% in 2015 to 26.3% in 2017. Latina and Black women had higher rates of mistimed or unwanted pregnancy (30.0% and 31.4%, respectively) compared to White women (19.5%) and Asian/Pacific Islander women (18.1%).

 

Women/Maternal Objective 4: Strategy 1:

Provide local data by age/ethnicity to Local Health Jurisdictions of mistimed or unwanted pregnancy.

 

CDPH/MCAH provided LHJs data on unwanted and mistimed pregnancies for the local needs assessment via a release of MIHA Snapshots. This data were also part of the USCF Family Health Outcomes Project community health profiles. With the assistance of the CDPH/MCAH Surveillance team and FHOP, CDPH/MCAH provided technical assistance in the interpretation of the analysis of the data for mistimed and unwanted pregnancies.

 

Women/Maternal Objective 4: Strategy 2:

Conduct/Update an environmental scan of reproductive life planning and preconception health efforts within the state-level MCAH Program, local MCAH programs, and other statewide efforts to identify best practices, areas of need and opportunities.

 

Not completed.

 

Challenges for this strategy:

The State Preconception Health Coordinator position was vacant during this reporting period. CDPH/MCAH is currently recruiting for this position which will lead efforts to identify evidence-based or informed initiatives, resources and tools.

 

Activities such as conducting key informant interviews and focus groups with stakeholders to identify areas of need will be ascertained once a Preconception Coordinator is hired. The Coordinator will utilize stakeholder input and select the highest priority to inform strategic planning efforts.

 

Women/Maternal Objective 4: Strategy 3:

Assess framing around reproductive life planning and preconception health efforts, in collaborations with members of the target population including youth, to improve relevance and effectiveness of messaging.

 

Not completed.

 

Challenges for this strategy:

CDPH/MCAH is currently recruiting for the Preconception Health Coordinator, who will work closely with the CDPH/MCAH Outreach and Communication Unit and with various stakeholder groups including adolescents around framing messages, needed tools and trainings around reproductive life planning and preconception health efforts.

 

Women/Maternal Objective 4: Strategy 4:

Identify National, State, and Local programs/initiative that address reproductive life planning and asses available resources, and disseminate culturally and linguistically appropriate tools.

 

CDPH/MCAH continued to maintain relationships with CDC and identified research and articles to address racial/ethnic disparities that included chronic disease, mental health and substance use among reproductive age women and the role preconception/interconception care.

 

The BIH Program promoted collaborative activities with partner agencies such as MCMC and Perinatal Service Coordinators in order to utilize the National Preconception Curriculum & Resources Guide for Clinicians training module with BIH participants during Life Planning meetings and group sessions.

 

During Folic Acid Awareness Week, the CDPH/MCAH Outreach and Communications Unit released a video highlighting the benefits of taking folic acid, targeting women of reproductive age. The video was viewed on Facebook over 2,000 times and was downloaded 25 times by LHJs for local public health education and promotion.

 

Women/Maternal Objective 4: Strategy 5:

Integrate pregnancy intention into the Title V program (BIH, AFLP, CHVP, CPSP, Adolescent Health, and CDAPP) to promote appropriate contraception counseling to match pregnancy desire and timing.

 

CDPH/MCAH supported LHJ implementation of activities by providing technical assistance and dissemination of resources and materials, including data as needed. Many LHJs utilized reproductive life planning in their local programs. A few examples of LHJ activities related to reproductive planning are:

 

Humboldt County - participated in the county’s Transition-Aged Youth Collaborative to provide education, case coordination, and preconception health for 30 clients and 15 staff.

Tuolumne County - aimed to increase the number of followers, website hits, views and shares specific to preconception health and family planning from their social media pages and to generate requests for referrals to appropriate resources. They also promoted the MCAH Playground, which encouraged and gave incentives for prenatal care appointments, well women and child check-ups. Over the last fiscal year, the page had an increase of followers from 1,294 to 2,332.

 

California Home Visiting Program (CHVP): Home visitors/nurses provided information about family planning choices and birth control options during their home visits. They talked with mothers about their reproductive goals and options, and discussed how to optimize postpartum and interconception health. Resources and educational materials were disseminated in a variety of languages consistent with the surrounding area population.

 

Black Infant Health (BIH): The BIH Program continued to ensure that resources, tools and materials were culturally appropriate for the BIH target population. This is evident in the group curriculum as well as in the various trainings conducted each year. Many BIH Participants set long-term educational and career goals as part of overall Life Planning. Having a Reproductive Life Plan permitted them to assess and implement their reproductive health goals.

 

Adolescent Family Life Program (AFLP): AFLP integrated the program’s My Life Plan and My Goal Sheet tools to support youth in setting goals around reproductive life planning.

CDPH/MCAH made available resources on evidence-informed models, best practice interventions and tools to work with MCAH programs and identify opportunities for technical assistance. Efforts included hosting webinars and sharing local community practices, attendance at local collaborative meetings, and presenting at the MCAH Director’s meetings.

 

Challenges for this strategy:

The challenges faced included difficulty in recruitment and hiring the preconception staff and ensuring that the BIH Program utilized materials and tools that were culturally appropriate and relevant for the BIH population.

 

Women/Maternal Objective 4: Strategy 6:

Integrate preconception health into the well-woman visit.

 

CDPH/MCAH received funds from HRSA to lead a three-year Preconception CoIIN (Collaborative Improvement & Innovation Network) focused on clinic implementation processes using a human-centered design approach. The goal was to identify tools to integrate preconception care seamlessly into well-woman visits.

 

CDPH/MCAH worked with participating clinics in Riverside and a Family Practice Residency Program in Davis. Survey results about clinic structure, available services, staff composition informed how preconception health counseling and messaging can be integrated into the well-woman visit, including the design of the clinical team.

 

Women/Maternal Objective 5:

Train MCAH LHJ workforce to address IPV at the community level.

 

Women/Maternal Objective 5: Strategy 1:

Create or adapt a range of culturally competent, evidence-based, and trauma-informed education materials on IPV for LHJs public health professionals.

 

CDPH/MCAH compiled a list of evidence based/informed IPV practices and resources to assist local MCAH in their efforts. CDPH/MCAH reviewed annual report progress and facilitated peer-to-peer connections and cross-sharing of evidence-based best practices that have been employed by LHJs.

 

The BIH Program materials included an overview of strategies that participants can utilize to assist them with having healthy relationships.

 

Examples in the local MCAH Annual Reports of intimate partner violence activities included:

 

San Benito County - educated and empowered community partners to advocate for and link women to domestic violence resources in the community. Approximately 400 resource guides were distributed throughout the community in day care centers, schools, migrant centers and through other community partners. They also worked with law enforcement to review protocols.

 

Women/Maternal Objective 5: Strategy 2:

Identify training/technical assistance opportunities to support MCAH funded Programs and LHJs in implementing IPV, Reproduction, and Sexual Coercion activities.

 

Black Infant Health (BIH): The BIH Program featured a curriculum focused on Empowerment and Social Support inclusive of 10 prenatal and 10 postpartum sessions. Session 9 of the prenatal Sessions promoted healthy relationships and Session 17 of the postnatal Sessions promoted effective communication to promote healthy relationships. Program participants were encouraged to discuss any issues or concerns they had or were experiencing at any time throughout their program participation. Additionally, the BIH Program provided an overview of strategies that participants could utilize to assist them with having healthy relationships. The BIH Program collaborated with partner agencies to provide IPV trainings to local BIH Mental Health Professionals and Public Health Nurses for providing additional supportive services when IPV issues were revealed by participants.

 

Local BIH Programs continued to assist with ensuring that participants understood the characteristics of healthy relationships and provided resources that helped participants deal with abuse, reproductive coercion or birth control sabotage and also provided referrals and promoted linkages to family planning providers including the Family Planning, Access, Care, and Treatment (Family PACT) Program.

 

The BIH Program utilized resources and tools from partners such as Futures Without Violence in order to provide additional assistance and support to BIH Participants experiencing IPV. The tools were used by local BIH staff as guidance to promote discussions and implement strategies for participants experiencing IPV, reproductive coercion and birth control sabotage.

 

Adolescent Family Life Program (AFLP): The AFLP model included key assessment questions around IPV, with support for linking to support when needed. The model also incorporated standardized activities around healthy relationships. Local agencies distributed and discussed Futures Without Violence resources with all youth in the program.

 

California Home Visiting Program (CHVP): Mothers enrolled in home visiting continued to be screened with a validated IPV tool and all staff continued to receive training on IPV issues. When IPV was a risk factor, the home visitor continued to provide resources and referrals as well as provide support and build protective factors.

 

Examples from local MCAH Annual Reports of intimate partner violence activities included:

 

Contra Costa County - MCAH Home Visiting program clients screened for IPV at least once annually and positive screens were referred to appropriate health and social services.

 

Challenges for this strategy:

Many IPV resources were not written in a culturally sensitive manner. The BIH Program reviewed resources and materials to find culturally and linguistically appropriate materials.

Priority Need: Increase the proportion of children, adolescents and women of reproductive age who maintain a healthy diet and lead a physically active life (from 2015-20 plan)

 

Women/Maternal Objective 6:

By June 30, 2020 increase the percent of women with recommended weight gain during pregnancy from 34.3% (2013 BSMF) to 36.1%.

 

In 2017, the percent of women having weight gain within IOM recommendations was 34.7%, which was the same as 2016. Asian women (40.1%) and White women (35.2%) were among those most likely to be within the recommended weight gain. Pacific Islander women and American Indian women were least likely to be within the recommended gain (25.2% and 27.3%, respectively) followed by Black and Hispanic women (28.0% and 33.3% respectively).

 

Women/Maternal Objective 6: Strategy 1:

Conduct surveillance of preconception weight and weight gain during pregnancy, including measurement of trends and disparities.

 

CDPH/MCAH Epidemiology, Surveillance, and Federal Reporting Branch led surveillance of maternal preconception weight status and weight gain during pregnancy, including measurement of trends and disparities using the MIHA Survey and BSMF datasets. CDPH/MCAH staff initiated an in-depth assessment of maternal preconception weight status and weight gain during pregnancy, including measurement of trends and disparities using BSMF data from 2010 through 2017. This project focused on measuring trends and disparities by maternal characteristics to inform educational needs and provider practices related to maternal weight. Data were also mapped to highlight geographical areas of greatest need for targeted efforts on maternal weight.

 

CDPH/MCAH Nutrition and Physical Activity (NUPA) Initiative led development of nutrition and weight gain guidelines, educational materials, resources and assessment forms that were utilized by multiple MCAH Programs.

 

Women/Maternal Objective 6: Strategy 2:

Improve capacity for nutrition and physical activity for women of reproductive age including optimum preconception weight and prenatal weight gain through collaboration and technical assistance, especially by sharing science-based resources with key partners such as CPSP, WIC, CMQCC, BIH, AFLP, and CHVP.

 

CDPH/MCAH NUPA Initiative promoted the National Dietary Guidelines for Americans and Physical Activity Guidelines via email and web. CDPH/MCAH promoted California MY Plate resources for pregnant and parenting women and teens, as well as women with diabetes in pregnancy through the State’s CDPH/MCAH website, the CPSP Steps to Take Manual, the AFLP nutrition guidelines, the CDAPP Sweet Success guidelines, and related program trainings.

 

CDPH/MCAH AFLP continued to support young mothers with nutrition, physical activity and breastfeeding through strengths based case management with integrated life planning. AFLP case managers promoted and disseminated evidence-informed, medically accurate, and developmentally appropriate materials to raise awareness and support youth with improving their health and wellbeing.

 

CDPH/MCAH NUPA led the work in identifying and disseminating nutrition and physical activity for women of reproductive age including optimum prenatal weight gain information and tools through key partners (NEOP and WIC) to help the women of reproductive age meet the dietary guidelines for Americans. CPSP and CDAPP Sweet Success Programs continued to promote specific guidelines to address perinatal weight gain including four weight gain grids in the CDAPP Sweet Success Guidelines for Care and the Steps to Take Manual.

The CDAPP Sweet Success Resource Center posted a new Nutrition and Exercise online training in June 2019.

 

CDPH/MCAH reviewed and updated links on the Systems and Environmental Changes toolkit (hosted on the MCAH website) to support optimal nutrition, physical activity, and breastfeeding through fostering partnerships between LHJ MCAH Programs and existing organizations to promote healthy policy, systems and environmental changes.

 

CDPH/MCAH encouraged programs and community health care providers to screen for food insecurity using a 2- question validated screening tool as recommended by AAP. MCAH networked with CDPH nutrition partners such as NEOPB, WIC, GDSP, CDSS, UC Davis, and Emergency Medical Services Authority (EMSA) to have a collective impact on reducing food insecurity and Identify or develop and disseminate information and tools through key partners to help low-income children meet the dietary guidelines for Americans.

 

Examples of local MCAH health jurisdictions use of Title V funding include:

 

Humboldt County - CPSP provider clinic hired a nutritionist and nutritionist referrals and follow-ups increased for CPSP clients.

 

City of Berkeley - provided resources for nutrition for pregnancy and post-partum to their CPSP providers.

 

Kings County - provided best practice information regarding maternal nutrition to CPSP clinic CPHWs.

 

Los Angeles County - provided referrals to 8,616 families to access health coverage benefits and services, including nutrition information.

 

Evidence-based and evidence-informed practices utilized for this strategy:

Shields, L and Tsay, GS. Editors, California Diabetes and Pregnancy Program Sweet Success Guidelines for Care. Developed with CDPH; Maternal Child and Adolescent Health Division; revised edition, updated September 2015.

U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th Edition. December 2015. Available at http://health.gov/dietaryguidelines/2015/guidelines/

Institute of Medicine and National Research Council of the National Academies. Weight Cain During Pregnancy Reexamining the Guidelines. 2009. Available at:

http://nationalacademies.org/hmd/reports/2009/weight-gain-during-pregnancy- reexamining-theguidelines.aspx

 

Challenges for this strategy:

Moving to a new CDPH web site was time consuming; CDPH/MCAH developed multiple new web pages and prioritized which materials to convert to ADA compliance and to move to the new web site. CDPH required all web resources to be ADA compliant yet very few staff were initially trained in how to do this which lead to delays in posting materials across the Department.

 

Women/Maternal Objective 7:

By June 30, 2020 increase the percentage of women who took a vitamin containing folic acid every day of the week during the month before pregnancy from 34% (MIHA) to 35.9%.

 

In 2017, 36.5% of women reported taking a multivitamin, a prenatal vitamin or a folic acid vitamin every day of the week during the month before pregnancy. A lower percentage of Latina and Black women reported taking folic acid daily during the month before pregnancy (27.8% and 29.9%, respectively) than White women (45.6%) and Asian/Pacific Islander women (47.5%).

 

Women/Maternal Objective 7: Strategy 1:

Provide review and technical assistance of all materials in state programs to ensure culturally congruent messaging and education regarding folic acid intake among women of reproductive age.

 

CDPH/MCAH lead the promotion of daily preconception intake of 400 mcg folic acid through multiple partners, such as MCAH programs, WIC and nutrition email distribution lists. CDPH/MCAH promoted the January 2018 National folic acid week to encourage use of state and national resources. CDPH/MCAH distributed English and Spanish folic acid posters and pamphlets to local agencies. BIH distributed Folic Acid information to all potential and enrolled participants.

 

CDPH/MCAH NUPA Coordinator maintained the CDPH/MCAH Folic Acid web page as a central location to disseminate resources including a new CDPH/MCAH developed video to promote daily preconception intake of 400 mcg folic acid. Additionally, CDPH/MCAH NUPA promoted folic acid through multiple partners and distributed English and Spanish folic acid posters and pamphlets to local agencies to promote daily preconception intake of 400 mcg folic acid. CDPH/MCAH supported and promoted folic acid by partnering with the Inter-conception Care Project, Every Women of California and the Before, Between and Beyond website.

BIH Program continued to distribute Folic Acid information to all potential and enrolled participants. CPSP and AFLP also promoted program specific information on folic acid.