Priority: Increase Access to Family Planning Services

 

MCH/Title V Funding: The family planning priority team is administratively led by the Reproductive and Women’s Health section within the Division of Family Health and Wellness of TDH. The Reproductive and Women’s Health (RWH) section includes family planning, presumptive eligibility, breast and cervical cancer (BCS) screening, and adolescent pregnancy prevention. The family planning program efforts are partially funded by MCH/Title V funds. Additionally, the RWH Section Chief and Breast and Cervical Cancer program director are partially funded by MCH/Title V, and the BCS Administrative Assistant 2 is fully funded by MCH/Title V.

 

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

 

SPM 1: Percent of new mothers whose pregnancy was intended 

The baseline for SPM1 was 62% based on a three-year average for 2016-2018. The objective for grant year 1 was to maintain this measure at 62% and for grant years 2 and 3 to increase this measure to 63%. Grant year 3 performance was based on 2021 PRAMS data, during which time the percentage of new mothers whose pregnancy was intended was 65%. Although this exceeded the objective for year 3, compared to baseline, the difference was not statistically significant. PRAMS data are not yet available for calendar years 2022 or 2023.

 

The number of family planning visits has not rebounded compared to pre-pandemic levels. While all local health departments are open and staffed, providing in-person outreach and education has continued to be difficult due to changes in leadership and the loss of Title X grant funding.

 

Accomplishments and Challenges (based on the FY2023 Action Plan):

 

Strategy 1: Increase knowledge, awareness, and usage of reproductive life plans through PATH across the state of Tennessee

 

Supporting Evidence for Strategy 1: A reproductive life plan (RLP) is a set of personal goals about having or not having children based on each individual’s values, goals, and resources1. Family planning providers play a key role in helping both women and men to reflect on their reproductive intentions, complete a RLP, and to access appropriate services to meet their RLP goals. PATH is a client-centered approach to assessing parenthood/pregnancy, attitude, timing, and the importance of pregnancy prevention. PATH can be used with any gender, sexual orientation, or age. PATH is designed to facilitate listening and efficient client-centered conversations about preconception care, contraception, and fertility as appropriate. PATH training is critical to ensuring a skilled family planning workforce that is able to provide client-centered, non-coercive, and culturally competent services2. 

 

Activity 1a: Facilitate training of approximately 500 Family Planning nurses through Essential Access’ Family Planning Health Worker Certification Program.

 

Report 1a: During the project period, 58 Family Planning staff completed Essential Access’ Family Planning Health Worker Certification Course. Most participants included staff from the FHW division and metropolitan health departments. FHW staff include state program managers, administrators, and clinicians. Metro health departments include clinicians and administrators working within or near the following counties: Davidson (Nashville), Shelby (Memphis), and Knox (Knoxville). Participants overwhelmingly expressed the benefit of the program. The training could not be made mandatory, so participation was strictly voluntary.

 

Activity 1b: Provide community outreach and education surrounding the importance of a reproductive life plan and birth spacing to faith-based communities and community partners.

 

Report 1b: During this project period, several regions conducted family planning outreach projects in local jails. Education provided included reproductive life planning, contraception, STI service, and information about community resources. Other outreach activities included attending a Latino baby shower and Tri-Pride event in Sullivan County. The Metro Nashville Health Department also participated in several events with local colleges and universities in which they discussed reproductive life plans, counseled on family planning, and provided on-site STI testing.

 

Activity 1c:  Ensure that PATH is integrated within TDH’s new electronic health record system to assist and remind providers and nurses to address reproductive life plans with clients.

 

Report 1c: No data to report on ESM WWV.1 (Create pre/posttests to assess provider knowledge of and confidence using PATH) for FY2023.

 

 The program plans to discontinue Activity 1c. PATH is integrated into the templates as a required field for family planning patients. Family Planning will not be able to assess knowledge and confidence of PATH through pre/post-test assessments in the local health departments due to limited capacity and provider time constraints.

Activity 1d: Increase the use of PATH with non-family planning clients within TDH by educating TDH’s Medical Leadership, Nursing Leadership, and Regional Leadership on tools available and processes that will assist providers with integrating PATH into non-family planning visits.

 

Report 1d: During the project period, the Reproductive Health National Training Center PATH resource was added to Public Health Nurse Family Planning Protocols for reference when counseling patients. Additionally, FHW staff on multiple occasions justified to Medical and Nursing Leadership teams within the Community Health Services (CHS) Division of the TDH the need for using PATH. Justification included the need to continue assessing patient’s reproductive life plan using the PATH framework, and as a documentation expectation within all reproductive and primary care health visits.

 

Challenges Issues Related to Implementation of Strategy 1: The Tennessee Family Planning Program (TFPP) had a significant change in leadership and staffing during the project period. The three (3) member core team comprised of an administrative, clinical, and financial lead decreased to just one (1) team member. The program faced considerable challenges due to this brief and abrupt staffing transition, hindering the ability to efficiently and effectively achieve the goals and activities outlined in the work plan. Moreover, managing the program became more challenging with notification of the loss of Title X funding just three days before the beginning of the new grant cycle. The short time frame created challenges for sites and providers to provide services and barriers to client care, and administrators to achieve outlined goals.

 

Strategy 2: Increase rural access to family planning services through telehealth

 

Supporting Evidence for Strategy 2: TDH seeks to ensure that minority communities, individuals residing in underserved rural and urban areas, and individuals with disabilities can reap the benefits of telehealth by overcoming barriers. These barriers can include taking time off work, transportation, childcare and confidentiality among others. Telehealth has the potential to help clients overcome these barriers and improve access to care3.

 

Activity 2a: Promote Family Planning Telehealth services through key partners using flyers, posters, social media posts and other identified promotional materials. Efforts to engage partners with direct ties in counties that serve <21% of the eligible population will be prioritized.

 

Report 2a: The baseline for ESM WWV.2 was 0.2% based on federal fiscal year 2020. The objective for grant year 1 (i.e., fiscal year 2021) was to maintain this percentage at 0.2% and then to increase it to 0.4% in grant year 2 and 0.8% in grant year 3. The actual percentages for grant years 2 and 3 were 1.2% and 1.6%, respectively, which exceeded the objectives.

 

During the project period, the Family Planning (FP) program persistently marketed its telehealth (TH) program to the Community Health Services Division (CHS). CHS directly oversees and operationalizes all clinical services within the local health departments. Marketing strategies included presenting at state and regional leadership meetings, promoting fliers/posters for ordering and printing, updating the web-based referral website, and reporting patient satisfaction results from participants utilizing the FP TH. Additionally, FP worked with CHS to streamline medication administration and pick-ups for those who chose to obtain their prescription method from the local health department. Lastly, FP streamlined the counseling, navigation, and referral process for patients interested in sterilization through the TH program.

 

Activity 2b: Continue to disseminate and evaluate a telehealth client satisfaction survey to identify areas for program improvement.

 

Report 2b: 154 client satisfaction surveys were submitted during the project period. In October 2022, the RWH Epidemiologist conducted an analysis of FP telehealth patient satisfaction surveys and presented a review to the CHS Telehealth champions group. The review highlighted areas of success, improvements, and potential modifications needed for more robust data in future analyses. Respondents to the survey cited decreased wait times, decreased transportation costs, and flexibility around work and childcare as benefits of the program. They also felt that their privacy was respected and that their clinical care met their needs. The FP TH program was nominated for the RHNTC Grantee Spotlight, which subsequently occurred in December 2022.

 

Activity 2c: Continue to expand telehealth services in additional rural health regions by providing additional education and training to key staff.

 

Report 2c: During the project period, 67 of 95 counties had at least one FP TH encounter, and 1.6% of all family planning encounters were completed via telehealth. The percentage of FP encounters completed via telehealth increased by 0.4% from the previous project period (1.2%). Counties (54) that served less than 21% of their family planning eligible population that also showed no telehealth encounters during the past year were identified and targeted for an education and promotional intervention. In November 2022, RWH staff presented data to Regional Family Planning Administrators showing counties with no FP TH visits and served <21% of the eligible population. They were asked to assess the reason for low use and to develop a plan to increase FP TH utilizations. As of October 2, 2023, 529 family planning telehealth encounters within counties served <21% of the eligible population in 2019.

 

Activity 2d: Establish partnerships with health clinics at colleges and universities as well as non-traditional partners to refer clients for family planning telehealth services.

 

Report 2d: During the project period, the FP team discussed referrals to the FP TH program with the University of Tennessee at Martin (UTM) student health clinic. The UTM Director of Student Health indicated that UT Chattanooga expressed interest in implementing a similar family planning agreement as UTM. The UTM Director of Student Health is currently assessing and recruiting other UT schools for an additional partnership discussion.

 

Activity 2e: Partner with libraries and community spaces to provide designated space for telehealth appointments and research additional locations where family planning clients can access a safe space for telehealth visits.

 

Report 2e: RWH staff presented at the Tennessee State Library Association Partnership Fair during the project period. Results of this presentation include the following: one library made private space available along with providing FP TH information and promotion, one other agreed to provide FP TH information, and another library expressed interest in finding funding to purchase a privacy pod for its library.

 

Challenges Related to Implementation of Strategy 2: The significant change in staffing and uncertainty surrounding the continuation of FP TH stalled recommendations to the client satisfaction survey after December 2022. Additionally, limited staffing and significant programmatic changes affected the ability to pursue partnerships with universities, libraries, other community spaces, and non-traditional partners during this period.

 

Strategy 3: Increase access to women’s health services by addressing and eliminating barriers to care through client navigation.

 

Supporting Evidence for Strategy 3: There are many health inequities surrounding women’s health, obstetrics, and gynecology. Client navigation can support efforts to address barriers to care and help to reduce these disparities4.

 

Activity 3a: Provide navigation services according to identified scope while identifying and addressing disparities in care. 

 

Report 3a: From October 1, 2022 to September 20, 2023, the Women’s Health Navigators (WHNs) have provided navigation services according to the identified scope. Relationships with Family Planning staff and community partners have strengthened. Staff have verbalized an increased uptake in referrals for family planning services.

 

Activity 3b: Identify and promote at least three (3) trainings to increase knowledge and workforce development in navigation efforts.

 

Report 3b: During the project period, monthly WHN Check-Ins occurred. Each included either a new topic to increase knowledge of services or a peer-to-peer discussion of successes and challenges to implement navigation efforts. Several resources were shared for workforce development, including Susan G. Komen’s Navigation Nation Summit and a free series from George Washington University regarding navigation basics. As part of the workforce development grant, TBCSP was awarded funds to pay for the WHNs to participate in an 8-week course to provide a certification for Health Navigation Fundamentals. All these efforts have had positive feedback.

 

Activity 3c: Monitor REDCap and generate reports to analyze navigation activities, identified barriers, client demographics, etc.

 

Report 3c: The use of REDCap for documenting navigation ended up being paused due to TBCSP obtaining a new data system. The new system will more quickly and thoroughly collect, track, and report on navigation data. Each WHN was encouraged to set up a temporary avenue to collect basic information to monitor their navigation activities, including demographic information. Knox County recognized that there were women who were coming to the Health Department for prenatal services and weren’t returning postpartum for care. Knox set up a process to track these women and provide approximately three navigation services (at the initial encounter, around 30 weeks if the initial encounter was not after this, and about two weeks after the estimated delivery date, plus any additional as indicated). In doing so, they have ensured that women are receiving postpartum care and access to family planning services as part of this postpartum care.

 

Activity 3d: Collaborate with internal and external partners to assist with navigation and ensure care continuation.

 

Report 3d: Grant years 1 and 2 were used to establish funding for women’s health navigators and implement contracts for these services; the objective was zero (0) in grant year 1 and 250 in grant year 2. Unfortunately, contracts did not go into effect until August 2022, and grantees did not have enough time to start providing navigation services before the end of the grant year (i.e., the number of women receiving navigation services in grant year 2 was zero). Although these services were expected to begin in grant year 3, further difficulties were encountered due to delays in hiring staff and implementing a new data collection system. Most positions are now filled, and the new data system is anticipated to go live by January 2024. In the absence of a dedicated data collection system, we roughly estimate that 900 persons were navigated in grant year 3 (ESM WWV.3).

 

The delay in using REDCap has hindered data collection for navigation outside of those enrolled in TBCSP.

 

Activity 3e: Promote the navigation program by marketing and developing community partnerships with traditional and nontraditional partners.

 

Report 3e: Each metro and WHN was tasked with promoting available navigation services. Many have used outreach strategies as a means of marketing the services. Many WHNs have partnered with local school districts to provide outreach and community engagements through back-to-school fairs. The TBCSP Hispanic Health Educator also connected with the WHNs to collaborate on several events throughout the year to further connect with the Hispanic community.

 

Challenges Related to Implementation of Strategy 3: The most significant challenge has been related to data collection. There was a delay in the implementation of full data collection due to the TBCSP obtaining a new data system. This delay is temporary and will result in a more streamlined, efficient data collection and reporting process.

 

Update on Other Women/Maternal Health Programs Supported by MCH/Title V:

 

Breast and Cervical Cancer: From October 1, 2022 to September 30, 2023, MCH funds assisted in funding salaries for regional TBCSP coordinators and local HD staff, TBCSP services, which include wellness exams and cervical cancer screenings, and clinic support.

 

Family Planning Clinics: During the project period, MCH assisted in funding salaries for Family Planning Central Office, Regional, and Local Health Department staff. Additionally, MCH assisted in funding direct family planning services in the local health departments. Services included family planning-specific office visits and procedures, contraception provided on-site, and referrals for family planning services outside of the health department when applicable.

 

 

 

 

 

 

 

 

 

 

 

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1. American College of Obstetricians and Gynecologists' Committee on Health Care for Underserved Women. Committee Opinion No. 654: Reproductive Life Planning to Reduce Unintended Pregnancy. Obstet Gynecol. 2016 Feb;127(2):e66-9. doi: 10.1097/AOG.0000000000001314. PMID: 26942389.
2. Hipp, S.L., Chung-Do, J. and McFarlane, E., 2019. Systematic review of interventions for reproductive life planning. Journal of Obstetric, Gynecologic & Neonatal Nursing, 48(2), pp.131-139.
3. McKenney, K. M., Martinez, N. G., & Yee, L. M. (2018). Patient navigation across the spectrum of women's health care in the United States. American journal of obstetrics and gynecology, 218(3), 280–286. https://doi.org/10.1016/j.ajog.2017.08.009
4. Polinski JM, Barker T, Gagliano N, Sussman A, Brennan TA, Shrank WH. Patients' Satisfaction with and Preference for Telehealth Visits. J Gen Intern Med. 2016;31(3):269-275. doi:10.1007/s11606-015-3489-x

Priority: Decrease Pregnancy-Associated Mortality

 

MCH/Title V Funding: The pregnancy-associated mortality priority team is administratively led by the Injury Prevention and Detection section within the Division of Family Health and Wellness of TDH. The Injury Prevention and Detection section includes SIDS/SUID prevention, fetal and infant mortality reduction, child fatality review, maternal mortality review, core violence and injury, traumatic brain injury, as well as suicide prevention. The maternal mortality reduction efforts are funded by state and other federal funds. While MCH/Title V does not directly fund these activities, it does fund staff who support maternal mortality reduction efforts, including the Section Chief and the program’s administrative assistant. Both the Co-Chairs of the Maternal Mortality Review Committee are funded by MCH/Title V.

 

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

 

Well-Woman Visit NPM: Percent of women, ages 18 through 44, with a preventive medical visit in the past year 

The objective established for FY2023 to have 76.5% of women, ages 18 through 44, with a preventive medical visit in the past year was surpassed by a margin of 5.4% points. In FY2023, the percentage of women with a preventive medical visit within the past year increased from 81.5% in FY2022 to 81.9% in FY2023.

 

Several reports indicate that physician offices exceeded patient visit volumes in 2022 compared to 2021, which could in part be attributed to the fact that telehealth has become a more widely accepted platform to seek care. Additionally, the Reproductive and Women’s Health program partners with other programs across the state to promote annual wellness exams for women on an ongoing basis.

 

SPM 2: Percent of facilities implementing patient safety recommendations 

Due to sustained progress, 88% of 115 acute care facilities have now implemented patient safety recommendations for FY2023. This notable increase is double the proportion of participating facilities compared to FY2022 when only 44% of facilities had adopted these recommendations. In FY2023, not only was the goal of having 66% of facilities implement patient safety recommendations met, but it was surpassed by a substantial 22% points.

 

Implementation of patient safety recommendations increased in FY2022 and continued in FY2023 due to varying opportunities offered through our partners at TIPQC and THA. Throughout this reporting period, birthing hospitals had the opportunity to participate in a variety of supplemental projects led by TIPQC, such as the distribution of blood pressure cuffs (45 hospitals), PSI handouts (45 hospitals), and AWHONN Post Birth Warning Signs magnets (37 hospitals), as well as completion of AWHONN Post Birth Education (10 hospitals). Since the last reporting period, TIPQC recruited an additional 6 birthing facilities to join the initial 6 pilot sites in implementing the Intraventricular Hemorrhage bundle. TIPQC also launched the AIM bundle: Promoting Vaginal Delivery in which 36 out of 58 birthing facilities are participants. The push for vaginal deliveries benefits moms with shorter recovery times, lower chances of infection and heavy bleeding, as well as fewer future pregnancy problems. During this reporting period, THA continued to support emergency department staff from 20 non-birthing hospitals by leading the Maternal Mortality Reduction project which includes face-to-face educational offerings related to the assessment and treatment of hypertensive disorders in pregnancy.

 

SPM 23: Number of community level recommendations implemented

The MMR team reviews deaths on a calendar year basis. During this reporting period, the team began reviewing maternal deaths that occurred in 2022; however, this review is not yet complete.

 

The most recent MMR annual report shows a reduction in the number of community-level recommendations implemented, decreasing from 18 in 2021 to 13 in 2022. Nonetheless, the implementation of 13 community-level recommendations surpasses the 2022 objective of having 6 community-level recommendations implemented.

 

TDH has worked diligently to address the 2022 community-level recommendations, which were distributed to the Maternal Health Task Force, THA, TIPQC, and uploaded to the MMR website. To highlight a couple of the major accomplishments that occurred in FY 2023, TDH:

• Organized 3 Mothers and Babies Training sessions, engaging a total of 84 participants. The goal of these trainings was to provide home visitors, care coordinators, and healthcare providers with training to meet the needs of pregnant and postpartum families related to maternal depression. The trainings equipped participants with the necessary information and strategies needed to administer the Edinburg Postnatal Depression Scale during their work with families.
• Partnered with Comcast Creative to create and broadcast PSAs and social media images related to maternal homicide and mental health/suicide. PSA efforts have been declared evidence-based interventions when combined with data to target audiences and spread education of resources to communities at large. This process took months to confirm copy, voiceover, casting, and messaging. Based on data, ad buys for the maternal homicide PSA we purchased in select markets throughout the state, with West TN and Shelby County markets having the most ad buys due to high rates of maternal deaths due to violence. The primary goal of this PSA was to raise awareness and educate pregnant and postpartum women about available resources, with the aim of promoting help-seeking behavior and reducing stigma. In the context of the maternal mental health and Suicide PSA, the data indicated a higher incidence of maternal-related suicides in Middle Tennessee. Ad buys were planned for select markets across the state, with the PSA airing most frequently in Middle Tennessee. The TLC-MAMA hotline was highlighted in the PSA.

 

Both PSAs aimed to reduce the stigma by emphasizing messages such as “you are not alone” and help is available. The PSAs combined reached Davidson, Anderson, Blount, Montgomery, Dickson, Sullivan, Sumner, Rutherford, Shelby, Madison, Humphreys, and Wilson counties, while targeting women 14-44 years of age. A total of 4,000 commercials were delivered on traditional TV, with 954,516 traditional TV impressions and 1,593,478 streaming impressions delivered for a grand total of 2,547,994 total impressions across all platforms.

 

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

The MMR team reviews deaths on a calendar year basis. During this reporting period, the team began reviewing maternal deaths that occurred in 2022; however, this review is not yet complete.

 

The most recent MMR annual report noted an increase in pregnancy-associated mortality. Increasing from a rate of 124.5 deaths per 100,000 live births in 2020 to 164.0 deaths per 100,000 live births in 2021. The current known rate for pregnancy-associated mortality (164.0 deaths per 100,000 live births) exceeds the FY2022 objective of 93.2 deaths per 100,000 live births.

 

This increase may have occurred due to the overall increase in deaths from COVID-19 and acute overdose.

 

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

The MMR team reviews deaths on a calendar year basis. During this reporting period, the team began reviewing maternal deaths that occurred in 2022; however, this review is not yet complete.

 

The most recent MMR annual report noted an increase in pregnancy-related mortality. Increasing from a rate of 58.5 deaths per 100,000 live births in 2020 to 64.9 deaths per 100,000 live births in 2021. The current known rate for pregnancy-related mortality (64.9 deaths per 100,000 live births) exceeds the FY22 objective of 23.5 deaths per 100,000 live births.

 

This increase may have occurred due to the increase of deaths from COVID-19, acute overdose, and the implementation of the Utah Criteria when determining the pregnancy-relatedness of overdose deaths.

 

During the reporting period, TDH began the process of analyzing severe maternal morbidity (SMM) data and the disparities within these indicators. SMM analysis will help to understand the burden of specific morbidities as well as trends over time. Additionally, the analysis will extend understanding of SMM in Tennessee, not just at the delivery hospitalization but also in the postpartum period.

 

Accomplishments and Challenges (based on FY2023 Action Plan):

 

Strategy 1: Increase surveillance of maternal deaths

 

Supporting Evidence for Strategy 1: Moderate evidence to suggest maternal mortality review provides comprehensive information on causes of death, preventability, contributing factors, and leads to actions improving maternal deaths.

 

Activity 1a: Identify pregnancy-associated deaths and facilitate state Maternal Mortality Review Committee (MMRC) meetings. The Committee will identify age, race and place for each death reviewed to identify disparities.

 

Report 1a: MMRC meetings were planned and facilitated quarterly by TDH. By June 2023, all pregnancy-associated deaths occurring in calendar year 2021 had been reviewed. The review of death is a partnership with all the agencies represented on the committee, including TennCare, THA, various hospitals, March of Dimes, the Department of Mental Health and Substance Abuse Services, and TennCare MCOs.

 

The MMR Annual Report on calendar year 2021 deaths was released in October 2023 and includes data on age, race, and place of death. Due to the increased caseload due to COVID and the adoption of the Utah Criteria, the MMR program welcomed additional support from two temporary abstractors to assist the program through July 2024. Two new members were welcomed to the committee, Dr. Hannah Dudney, an OB/GYN, and Dr. Ursula Norfleet who practices emergency medicine.

 

Activity 1b: Through the Maternal Mortality Review Committee (MMRC), determine the relatedness of all deaths to pregnancy, contributing factors, cause(s) of death, and preventability of all deaths. For each pregnancy-related death determine age, race and place of death to identify disparities. For each pregnancy-related death, the MMRC will determine the cause as specified by Pregnancy Mortality Surveillance System.

 

Report 1b: Due to the increased caseload, the MMRC met five times to review and determine the pregnancy-relatedness of the 134 maternal deaths that occurred in the calendar year 2021. The most recent annual report was released in October 2023, highlighting data from the 2021 deaths. Two in five (40%) of all 2021 deaths were deemed pregnancy-related while 47% of all deaths were determined to be pregnancy-associated, but not related. Seven in ten (70%) pregnancy-associated deaths were deemed to be preventable, with 35% having a ‘good chance’ of being prevented and 65% having ‘some chance’ of being prevented. In 2021, 53 women in Tennessee died from pregnancy-related causes. The burden of pregnancy-related death is higher among non-Hispanic Black women, women covered by TennCare, and those residing in West Tennessee.

 

 While FY 2023 was mainly devoted to the review of calendar year 2021 maternal deaths, the MMRC also reviewed and determined pregnancy-relatedness of 36 calendar year 2022 cases.

 

The review of deaths is a partnership with all the agencies represented on the committee including TennCare, THA, various hospitals, March of Dimes, the Department of Mental Health and Substance Abuse Services, and TennCare MCOs.

 

Activity 1c: Analyze data for the annual maternal mortality report. Additional data on causes of death by race and place for each death reviewed will be included in order to identify disparities. Data will show the disparity in race, top causes of death by race and region of the states in which the death occurs. Qualitative data will also be included to identify gaps in care among these deaths.

 

Report 1c: The MMR team reviews deaths on a calendar year basis. During this reporting period, the team began reviewing maternal deaths that occurred in 2022; however, this review is not yet complete. However, the latest MMR annual report includes a comprehensive analysis of all pregnancy-associated deaths reviewed, highlighting disparities, the top causes of death by race, and pinpointing regional patterns in Tennessee where these fatalities occurred. Also included was a map that displayed the geographical distribution of the incidents, qualitative data that delves into the contributing factors and recommendations for each death, and demographic information encompassing the race and age of the decedents.

 

Activity 1d: Develop recommendations for preventing subsequent maternal deaths based upon MMRC findings and for inclusion in the Maternal Mortality annual report and dissemination to relevant stakeholders quarterly. These recommendations include reference to specific disparities, contributing factors, and cause(s) of death identified in the reviews.

 

Report 1d: The MMR team reviews deaths on a calendar year basis. During this reporting period, the team began reviewing maternal deaths that occurred in 2022; however, this review is not yet complete.

 

Recommendations are developed after each quarterly meeting highlighting key themes seen throughout each review meeting. The latest MMR annual report noted much improvement in the comprehensiveness of recommendations, including details regarding the individuals involved, actions required, and timing. This increased from having 68% with who/what/when components in 2020 to 94% with who/what/when components in 2021, surpassing the FY2022 goal of 79% (ESM WWV.8).

 

The MMR Annual Report identifies specific opportunities for prevention of maternal mortality and promotion of women’s health at Patient/Family, Provider, Facility, System and Community levels. In addition, notifications are developed and published after each MMRC quarterly meeting. These recommendations are based on the deaths reviewed during the meetings, thus creating a more real-time alert on emerging issues (e.g., for deaths with substance use disorder as a contributing factor) being seen during reviews. During this reporting period, the alerts were sent to hospitals and posted on the maternal mortality program website in December 2022, March 2023, July 2023, and September 2023.

 

Strategy 2: Increase evidence-based education at hospitals on topics identified by the Maternal Mortality Review Committee (MMRC).

 

Supporting Evidence for Strategy 2: Moderate. Provider education, such as continued medical educational opportunities appear to be effective.

 

Activity 2a: Contract with Tennessee Hospital Association (THA) and Tennessee Initiative for Perinatal Quality Care (TIPQC) to provide training to birthing and non-birthing hospitals on top causes leading to maternal death as identified by the MMRC. THA will use claims data to identify areas of the state with the top causes of death and then provide simulation training on the top causes at non-birthing hospitals located in those areas. TIPQC will offer birthing hospitals education on pre-eclampsia. Areas of the state with the highest numbers of deaths due to pre-eclampsia will be prioritized. Birthing hospitals in West TN will be given top priority for training provided by THA and TIPQC since the highest disparities in maternal deaths overall are observed in this region.

 

Report 2a: The percent of statewide births covered by hospitals implementing data-driven, clinical recommendations increased from 55% in FY 2022 to 81% in FY2023, surpassing the annual objective of 75% (ESM WWV.4).

 

Implementation of patient safety recommendations increased in FY2022 and continued in FY2023 due to varying opportunities offered to hospitals in Tennessee in partnership with TIPQC and THA.

 

Throughout this reporting period, birthing hospitals had the opportunity to participate in a variety of supplemental projects led by TIPQC, such as the distribution of blood pressure cuffs (45 hospitals), PSI handouts (45 hospitals), and AWHONN Post Birth Warning Signs magnets (37 hospitals), as well as completion of AWHONN Post Birth Education (10 hospitals). Since the last reporting period, TIPQC recruited an additional 6 birthing facilities to join the initial 6 pilot sites in implementing the Intraventricular Hemorrhage bundle. TIPQC also launched the AIM bundle: Promoting Vaginal Delivery in which 36 out of 58 birthing facilities are participants. The push for vaginal deliveries benefits moms with shorter recovery times, lower chances of infection and heavy bleeding, as well as fewer future pregnancy problems. TIPQC continued with its “Healthy Mom, Healthy Baby” Podcast which has released 90 episodes since its inception and had over 86,000 unique downloads during this reporting period.

 

A concern not unique to Tennessee is the closure of birthing hospitals, resulting in births occurring at non-birthing hospitals on occasion. In partnership with THA, emergency department staff from 20 non-birthing hospitals participated in the Maternal Mortality Reduction project which includes face-to-face educational offerings related to the assessment and treatment of hypertensive disorders in pregnancy. Blood pressure simulators are utilized to demonstrate proper blood pressure measurements as that is a critical piece in identification and treatment. 

 

Strategy 3: Increase access to services through community agency involvement to improve maternal health outcomes.

 

Supporting Evidence for Strategy 3: Moderate: There is evidence to suggest that expanded insurance coverage is effective.

 

Activity 3a: Convene a Maternal Health Task Force, with a minimum of 25 members, quarterly to highlight innovative and best practices for preventing maternal death. The advisory board will include membership from the Office of Minority Health and Disparities Elimination to represent vulnerable populations. Analyze membership to determine whether additional participants are needed to represent top causes of maternal death such as homicide and cardiovascular disease. Collaborate with the Office of Health Disparities to identify new members who represent/serve individuals who are at the highest risk of dying from the leading causes of maternal death.

 

Report 3a: In October 2023, TDH was advised by its legal office that unless created by statute, all groups referred to as a “Task Force” would need to be renamed; thus, the Maternal Health Task Force is now known as the Maternal Health Advisory Board.

 

Tennessee was awarded the HRSA Maternal Health Innovation (MHI) Grant during this reporting period; and to better align efforts, it was determined that coordination of the Maternal Health Advisory Board would transition from the MMR program to the MHI program. During this reporting period, there was a slight interruption in the frequency of meetings due to this transition; however, the larger Maternal Health Advisory Board convened twice and welcomed 38 new members to the group. There are plans to reconvene the board in November 2023 to present the MMR Annual Report.

 

During the November 9, 2022 Maternal Health Advisory Board meeting, Dr. Jona Bandyopadhyay presented on Medicaid Postpartum Expansion and Dr. Pamela Talley presented on the rise of congenital syphilis. The Maternal Health Advisory Board convened for a second time during this reporting period, on March 8, 2023. During this meeting, community grant recipients had the opportunity to share their accomplishments that occurred during their funding period. Presenters included the following: TIPQC, Renewal House, East Tennessee State University Pediatrics, and THA. TDH provided a historical overview of its maternal health efforts, which included the establishment of the advisory board. A very interactive portion of the meeting included breakout sessions to discuss how members envision the advisory board as part of the strategic planning process, how to center equity, and ideas for community listening sessions.

 

A strategic planning subcommittee was developed to guide the development of the maternal health strategic plan. The subcommittee collectively identified key maternal health priority areas to drive Tennessee’s first maternal health strategic plan. Strategic planning subcommittee meetings were held on May 15, May 30, June 13, June 27, July 18, and August 22.

 

Activity 3b: Fund a minimum of 3 community agencies to implement MMR recommendations on top causes of maternal death identified by the MMRC. Funded community agencies will be tasked with implementing recommendations to address the leading causes of maternal death (i.e., cardiovascular diseases and violent death) among the most at-risk populations. Applicants will be asked to describe how the proposed project addresses disparities (race and/or place). Proposals will be evaluated on how well they are addressing at-risk populations.

 

Report 3b: An RFA to fund at least 3 community grants was issued in October 2022; however, due to a lack of quality applicants, the MMR program was only able to award one community grant. In January 2023, Metro Drug Coalition received a $20,000 grant to implement a project to reduce the contributing factors of poor pregnancy outcomes by educating pregnant women about the effects of substance use and misuse through healthcare professionals in Knox County and throughout the East Tennessee region. In addition, they provided outreach to medical providers on the science of addiction, SBIRT process, treatment options, and counseling women to prevent pregnancy while on a controlled substance.

 

Activity 3c: Increase the number of women of childbearing age participating in family planning and well-woman visits by expanding and promoting telehealth to better reach those people in areas at risk for pregnancy-associated deaths.

 

Report 3c: Baseline for percent of family planning visits that occur via telehealth (ESM WWV.2), was 0.2% based on federal FY 2020. The objective for grant year 1 (i.e., FY 2021) was to maintain this percentage at 0.2% and then to increase it to 0.4% in FY 2022 and 0.8% in FY 2023. The actual percentages for FY 2022 and FY 2023 were 1.2% and 1.6%, respectively, which exceeded the objectives.

 

During the project period, the Family Planning (FP) program persistently marketed its telehealth (TH) program to the Community Health Services Division (CHS). CHS directly oversees and operationalizes all clinical services within the local health departments. Marketing strategies included presenting at state and regional leadership meetings, promoting fliers/posters available for ordering and printing, updating the web-based referral website, and reporting patient satisfaction results received from participants utilizing the FP TH. Additionally, FP worked with CHS to streamline medication administration and pick-ups for those who chose to obtain their prescription method from the local health department. Lastly, FP streamlined the counseling, navigation, and referral process for patients interested in sterilization through the TH program.

 

Activity 3d: Increase the number of women applying for presumptive eligibility by implementing an outreach plan and collaborating with community partners to reach vulnerable populations.

 

Report 3d: During the reporting period, the number of enrollments from the previous reporting period decreased by 180 enrollments across the state. Challenges during this period that could have contributed to the decrease include the following: staff turnover, loss of Title X funding, and Medicaid redetermination that began in May 2023. From April 2020 until May 2023, anyone on full Medicaid coverage was not dropped from their current coverage. This means that if someone who should have been dropped from Medicaid then became pregnant again, that individual would not be re-enrolled through the Presumptive Eligibility (PE) Program.

 

In response to the decreased enrollment numbers, the PE program developed and implemented an outreach plan alongside its community partners. Outreach plan activities include:

• ETSU Johnson City Community Clinic has agreed to implement the PE clinic at its main site to reduce barriers to enrollment, allowing patients to complete enrollment where they receive prenatal care. The paperwork for this contract was completed during this reporting period, but the contract will not take effect until January 2024.
• Information about the PE program was distributed to community partners who serve vulnerable populations, such as minorities or immigrants with pregnancy-related care.

 

Activity 3e: Disseminate recorded domestic violence trainings to community groups in Shelby County to increase awareness of DV resources. Domestic (intimate partner) violence is a contributing factor to many maternal deaths by homicide. Therefore, this activity addresses the disparity in place of maternal deaths by homicide (almost half of maternal homicide deaths occur in Shelby County).

 

Report 3e: In partnership with TN Family Justice Center, 72 individuals participated in Domestic Violence Trainings and Domestic Violence Danger Assessment for Healthcare Providers training on March 23, 2023. It’s worth noting that one of the 13 Family Justice Centers is located in Shelby County. Additionally, these trainings are also available at any time on the TDH Maternal Violent Deaths (MVD) program website for anyone across the state to access.

 

During this reporting period, TDH collaborated with Comcast Creative to produce and air public service announcements (PSAs) and share social media visuals addressing maternal suicide and homicide. This comprehensive endeavor involved several months of work, finalizing copy, voiceovers, casting, and messaging.

 

Informed by data analysis, the MVD program made strategic decisions to prioritize the broadcast of these materials in West Tennessee and specifically Shelby County, where maternal homicide rates were notably high. The PSA campaign's central objective was to raise awareness and educate women about available resources, with the overarching goal of encouraging them to seek help and reducing associated stigma. In support of this mission, community partners have been invited to assist in distributing and promoting the PSA static images and social media posts.

 

Activity 3f: Contract with agency to provide training on the danger assessment and work with local community agencies to implement the assessment. Community agencies within Shelby County/West TN will be prioritized to address the place-based disparity of maternal death by homicide (almost half of maternal deaths by homicide occur in Shelby County and firearms were the lethal weapon used in 74% of maternal homicides).

 

Report 3f: The MVD program partnered with TN Voices to provide multiple Danger Assessment trainings throughout the state to healthcare workers and domestic violence advocates. During the reporting period, the MVD program did not partner with any Shelby County-specific agencies, however, the attendees were geographically diverse.

 

Update on Other Women/Maternal Health Programs Supported by MCH/Title V:

 

• The TDH Maternal Mortality Review Program received supplemental funding as a part of the FFY 2024 CDC Enhancing Reviews and Surveillance to Eliminate Maternal Mortality Program grant award. This funding will be utilized to hire a social worker to lead the implementation of the newly amended Maternal Mortality Review and Prevention, Review Procedures Rule (1200-15-04), allowing the program to contact family members to request their voluntary participation in an informant interview. Voluntary informant interviews will provide the MMRC with greater context around the factors and events leading up to the maternal death.

 

• During state FY 2023, the five Regional Perinatal Centers played a crucial role in addressing pregnancy-associated mortality. Collectively, the Centers completed a remarkable 113,947 outpatient consultation visits, providing essential care to expectant mothers. In addition, they dedicated an impressive 8495.45 hours to educating healthcare professionals and patients alike, fostering awareness and understanding. Notably, new perinatal funding was secured as part of the Governor's budget for state FY 2024, ensuring ongoing support. Additional funding was provided for the development of 3-5 pilot projects offering perinatal telehealth.

 

• The efforts of the Perinatal Advisory Committee, which convened three times during this reporting period, further reinforce the commitment to improving maternal and infant health. Their agenda, which included updates on topics such as TennCare, congenital syphilis, doula support, and neonatal abstinence syndrome reflects a comprehensive approach to addressing maternal health concerns. The establishment of a workgroup for updating the Social Work Manual, with an upcoming vote in October 2023, demonstrates an ongoing commitment to refining the tools and resources available to support pregnant women and their families. These achievements collectively mark substantial progress in the ongoing mission to enhance perinatal care, reduce mortality, and ensure the well-being of mothers and infants in our communities.

 

• In September 2023, HRSA announced that TDH was a recipient of the Maternal Mental Health and Substance Use Disorder grant in the amount of $750,000 annually for five years. TDH plans to increase routine behavioral health screening for pregnant and postpartum women, routine detection, assessment, brief intervention, treatment, and referral for maternal mental health conditions. TDH will also establish a regional maternal mental health teleconsultation service that will provide on-demand telephone consultations between women’s health providers and the maternal mental health team once developed. TDH also plans to expand maternal mental health and substance use disorder resources in FindHelpNowTN.org, which is a public-facing online, near-real-time database of substance use disorder and mental health treatment providers in Tennessee.

 

• The Doula Services Advisory Committee held its first meeting on September 27, 2023. The Doula Services Advisory Committee is required to create core competencies and standards for doula services, propose multiple options for a Medicaid reimbursement plan, including rates and fee schedules, propose incentive-based programs such as fee waivers, examine outcomes, findings and reports from existing doula-related pilot programs, and produce a report to the Legislature within 18 months of the first meeting. The committee comprises one representative from TDH, one from TennCare, and three community doulas.