Women/Maternal Health – Annual Report Narrative (FY 2017-18)

Priority 1: Improve access and utilization to comprehensive quality health services for women.

Objective 1:

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

1. increase the rate of preventive visits among reproductive age women (18-44) from 61.9% (2013 Behavioral Risk Factor Surveillance System (BRFSS)) to 65.3%;
2. increase the rate of first trimester prenatal care initiation among women with a recent live birth from 83.6% (2013 BSMF) to 87.9%; and
3. increase the rate of postpartum visits among women with a recent live birth from 88.3% (2012 Maternal and Infant Health Assessment (MIHA)) to 92.9%.

 

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%).

 

Using data reported on California birth certificates, Objective 1b or the percent of infants born to women receiving first-trimester prenatal care increased slightly from 83.2% in 2014 to 83.6% in 2016. Births to women who identified as Whites, Hispanics, Asians, or Multiple Race were among those most likely to receive early prenatal care. The proportion of births in each of these race-ethnic groups was 80.0% or more across all three years. During the same time-period, the average percent of births to Black women with early prenatal care was 78.7%. The percent of births to American Indian women with early prenatal care had the lowest three-year average (68.5%) which was slightly lower than that for births to Pacific Islander women (69.5%).

 

Using data from the Maternal and Infant Health Assessment survey, Objective 1c or the percent of women reporting a postpartum visit remained stable at 88% between 2012 and 2014.

 

Objective 1: 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.

 

Local Health Jurisdictions (LHJs): LHJs develop and adopt local protocols to ensure that all clients in MCAH Programs have health insurance, are linked to a provider and complete a preventive visit.  LHJs utilized Title V funding, local funds and Title XIX funding, when appropriate, to meet this objective. In collaboration with the LHJs, CDPH/MCAH developed Guidelines for Protocols to link MCAH clients to Health Insurance and Preventive Visit(s). This resource was modified by the LHJ’s to address their regional needs. LHJs conducted quality assurance activities to ensure protocol implementation.

 

Through the CDPH/MCAH Year-End survey, 51 LHJs reported adoption of one or more protocols or policies that pertain to linking clients to health insurance for preventive visits. Of these, 49 adopted a policy to assist clients to enroll in health insurance, 46 LHJs adopted a policy to link clients to a healthcare provider for a preventive visit, and 22 developed tracking mechanisms to verify clients enrolled in health insurance completed a preventive visit (Source: 2017-18 Year End Survey).

 

In their local MCAH SOWs, LHJs included activities to improve insurance enrollment and increase access/utilization of health and social services. Listed are examples from the 2017-18 MCAH Annual Reports of LHJ activities:

• Alameda County - was awarded $250,000 in funding from local Tax Measure A for supportive services for Pacific Islander residents. These funds were to improve reproductive health outcomes and family members’ enrollment in health insurance, a priority health issue for Alameda County.
• Butte County - continued to collaborate with the earmarked every pregnant client’s application and routed it to two eligibility workers for processing. When the project began, approximately 30% of the applications were still pending after 45 days. At last count, only 5% of the applications were still pending after 45 days. 

 

California Home Visiting Program (CHVP): CHVP is 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, a healthy baby, and to prevent child maltreatment. During 2017-18, 92% of CHVP participants reported having insurance coverage, 4.7% did not have insurance, and 3.3% had an unknown insurance status (Source: CHVP).

 

American Indian Infant Health Initiative (AIIHI): The AIIHI was funded using Title V funds for home visitation programs for American Indian women that are pregnant or parenting to receive health education and psychosocial support services beginning with pregnancy until the infant reaches age three. The counties participating in the AIIHI home visitation program included: Humboldt, Riverside, San Bernardino, Sacramento, and San Diego. AIIHI clinics provided over 5,147 preventive care services to women seen at the American Indian clinics during FY 2017-18.

 

One of the objectives of the AIIHI program was to increase access to preventive health services for American Indian women. Clinic staff referred all American Indian women with a positive pregnancy test to the AIIHI home visitation program. AIIHI staff provided targeted outreach to identified high-risk American Indian women that were pregnant or parenting to provide prompt diagnosis, education, and support during the pre- and postnatal period. In addition, the Indian Health Program (IHP) expanded program availability by adopting an evidenced-base home visitation program called Family Spirit, which provided home visitation for all pregnant women pregnant and did not restrict the curriculum to only high-risk mothers.

 

During this funding period, preventive services were offered to 122 women enrolled in the AIIHI program. Of the 122 women who received AIIHI services, 13 reported pregnancies and 12 expectant mothers received first trimester prenatal care in FY 2017-18.

 

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 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, evidence-informed practices and frameworks utilized for this strategy

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

• CDPH/MCAH provided workforce development with instructional webinars and monthly technical assistance conference calls to LHJs.
• LHJs provided outreach to underserved populations to increase access and utilization of care.
• CDPH/MCAH facilitated systems change by including a requirement to develop protocols or policies.
• 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

Challenges for this strategy

Challenges and opportunities for improvement from the LHJs included:

• Napa County - 2017-18 was an extremely difficult year for multiple counties due to the widespread fires with significant damage and long-term effects. The Napa County Fire Complex began on October 8, 2017. Public health staff, including the local MCAH Director, MCAH Coordinator, and MCAH staff were involved in continuity of operations including locating and checking on vulnerable MCAH clients. Depending on the region, practices/hospitals burned down, communication infrastructure was limited and smoke from the fires contributed to breathing problems. Loss of revenue for County Departments had serious long-term consequences including budget cuts, program closures and loss of staffing. Many ongoing activities of public health and MCAH were postponed or delayed due to the demands created by the fire and the subsequent priority needs in the community. In addition, the MCAH Director, MCAH Coordinator and MCAH staff were involved in a pertussis outbreak that required prophylaxis of 150 MCAH clients in the community. This became a priority work assignment for over two months from July to September 2017.
• AIIHI - Timely postpartum care remained an ongoing challenge at AIIHI funded clinics. There were four AIIHI 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. Additional 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 OB provider. Other challenges included difficulty-locating mothers who did not have stable housing, or may have had substance use or mental health issues.

Objective 1: Strategy 2:

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.

 

The percent of uninsured women age 18 to 44 who are Medi-Cal eligible increased from 7% in 2014 to 9.2% in 2015 and 9.1% in 2016.

 

Data from the California Health Interview Survey (CHIS) showed that the percent of uninsured children age 1 to 17 years who are Medi-Cal eligible increased from 32.7% in 2014 to 42.9% in 2015 before decreasing to 34.3% in 2016.

 

In 2015, 83.3% of women had health insurance before pregnancy. A greater proportion of Asian/Pacific Islander women (92.8%) had pre-pregnancy health insurance followed by Black women (91.5%), White women (90.9%), and Hispanic women (75.1%). Women identified as other race/ethnicity were the least likely to have pre-pregnancy insurance (62.6%).

 

The percent of postpartum women without health insurance dropped to 12.1% in 2014. The three-year average over the previous three years was about 17.4%. Since 2011, postpartum Hispanics were most likely to be uninsured (15.2%). Blacks were least likely to be uninsured (2.7%).

 

Data from the American Community Survey showed that the percent of children age 0 through 17 without health insurance steadily decreased from about 8.1% in 2012 to 3.0% in 2016. In 2016, the concentration of children without health insurance was highest among those identified as American Indian-Alaska Native (9.2%), Native Hawaiian-Other Pacific Islander (5.1%), and Hispanic (3.8%). Data from the 2016 National Survey for Children’s Health show that 72.7% of all children age 0 to 17 years had adequate health insurance for their health care needs.

 

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 2017-18 Annual Reports, all 61 LHJs reported activities to increase access and utilization of perinatal care for pregnant women. Examples included:

 

• Kern County – Comprehensive Perinatal Health Worker staff informed all patients that transportation was available through Medi-Cal Managed Care. Collaborations with Managed Care, as well as Quarterly MOU meetings, aided in the dialogue and dissemination about the needs of patients and delivery of services. Incentives for early access to care, for completion of programs, and for simply attending meetings were made available by Managed Care to patients. These incentives appeared to generate more compliance in early entry into care and completion of programs offered. CPSP has been one such program to benefit from Managed Care incentives.

• Modoc County - Clients enrolled in the Perinatal Outreach and Education (POE) program who had Medi-Cal were able to receive gas vouchers through the MCAH program to their out of county prenatal/postpartum and dental appointments. Nineteen Medi-Cal eligible POE clients utilized transportation assistance. A total of 77 gas vouchers were provided. The percentage of appointments kept was 95% (73 appointments were kept and 77 were intended).
• San Francisco County – Developed and implemented a plan to prioritize enrollment of low-income pregnant women: A newly created video highlighting their work was made to help re-enforce this work https://vimeo.com/279131910/a15951b440. New brochures and other outreach materials were produced.

 

Comprehensive Perinatal Services Program (CPSP): CPSP is a Title V funded program that CDPH/MCAH leads in collaboration with the LHJs. In addition to standard obstetric services, women who see CPSP providers received enhanced services in the areas of nutrition, psychosocial and health education. CDPH/MCAH qualifies and trains providers who received an enhanced Medi-Cal fee for delivery of CPSP services as an incentive. 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.

 

Examples from the LHJs of CPSP activities included:

 

• Sutter County –The perinatal provider network improved greatly over the last year with the addition of Harmony Health as a new CPSP provider and Rideout Health joined adding three new perinatal providers in the County. In addition, California Health and Wellness improved access to care by executing a contract with Rideout Health.
• Yolo County - The CPSP program hosted two roundtables that focused on current issues effecting Medi-Cal eligible women’s access to prenatal care. They invited the local CPSP providers and staff, and other community partners that provide CPSP-like services to this vulnerable populations. CPSP Roundtable topics included increased STD rates in California, and Maternal Mental Health resources in Yolo County.

 

CDPH/MCAH received 52 CPSP provider enrollment applications and approved enrollment for six physician providers (solo), six physician groups, a certified nurse midwife provider (solo), an alternate birthing center, eight community clinics, and a community outpatient hospital.

 

The CPSP Executive Committee worked on projects to improve access to and quality of CPSP services. For example, they updated the CPSP provider application forms and instructions, developed a quality improvement/quality assurance (QA/QI) tool to improve the ability to describe the impact of CPSP, and planned meetings and trainings. The Executive Committee also brought forth concerns from their regions about access to perinatal care and Medi-Cal CPSP provider billing issues.

 

Department of Health Care Services/ Medi-Cal Managed Care (DHCS/MCMC): CDPH/MCAH collaborated with the 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. CDPH/MCAH, the CPSP Executive Committee, and DHCS worked on developing the necessary data indicators for a data report on provider reimbursement of CPSP services using aggregate CPSP service codes. PSCs used this information to monitor CPSP service delivery in provider offices and clinics and provided technical assistance as needed to improve the quality of CPSP services.

 

Black Infant Health (BIH): Local BIH Programs conducted presentations with Kaiser and Anthem Blue Cross for the purpose of enhancing collaborative efforts, creating referral partnerships and promoting awareness of BIH Program goals and services.

 

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. BIH continued to collaborate with MCMC and CPSP providers to improve and increase the rates of postpartum visits for moms. 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. For more information about AFLP, refer to Adolescent Health Domain Section.

Challenges for this strategy

Challenges and opportunities for improvement from the LHJs included:

• Calaveras County – does not have a birthing hospital or center, obstetricians, or FPACT providers, which required women to leave the county for services. However, MCMC plans were aware of the challenges and continued to work with local network providers to improve access.
• Placer County - There was only one CPSP provider enrolled in Placer County, which limited availability of quality prenatal care. Because few OB providers in Placer County accepted Medi-Cal, most women traveled long distances in order to access prenatal care services. In addition, no OB providers in Placer County accepted Presumptive Eligibility Medi-Cal, further deterring early access to quality comprehensive prenatal care. Case managers worked with clients to help navigate the confusing process of choosing a Medi-Cal Managed Care Plan and obtaining OB services. Chapa de Indian Health Service began offering prenatal care services to pregnant women up to 34 weeks gestation, after which time patients were transferred for the remainder of their pregnancy to a CPSP provider in Sacramento. While this offered the opportunity for residents to receive most of their prenatal care within Placer County, patients were still forced to transfer care and travel to Sacramento for delivery.
• Shasta County - Often women were not able to schedule prenatal appointments because Medi-Cal providers were limited and booked. Transportation was also a barrier. Obtaining dental care for pregnant women on Medi-Cal was also difficult.

 

Objective 1: Strategy 3:

Collaborate with Text4baby to deliver messages to pregnant women and hospital partners about the importance of the postpartum visit during prenatal care and/or during hospitalization after labor/delivery.

 

Challenges for this strategy

CDPH/MCAH worked in partnership with Text4baby to share essential health information, tips and reminders with expectant women and new mothers, and their partners or loved ones. However, CDPH/MCAH has revised this activity and is no longer contracting with Text4baby. CDPH/MCAH worked to utilize social media platforms to develop and post messages and identify opportunities for education and outreach to pregnant mothers and hospital partners to have a broader reach. Resources can be found at www.cdph.ca.gov/Programs/CFH/DMCAH/Pages/Communications-and-Outreach.aspx

 

Objective 2:

By June 30, 2020, decrease the rate of postpartum women without health insurance from 16.7% (2012 MIHA) to 16.2%.

 

Objective 2: Strategy 1:

Provide technical assistance for local MCAH programs to improve access to needed health care services for postpartum women.

 

The percent of postpartum women without health insurance dropped to 12.1% in 2014  (the average from 2011 to 2013 was 17.4%). Postpartum Hispanic women were most likely to be uninsured (15.2%), whereas postpartum Black women were least likely to be uninsured (2.7%).

 

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:

• Amador County - The Perinatal Office screened for Perinatal Mood and Anxiety Disorders in all pregnant and postpartum women within their practice. They used the community-wide Edinburgh Maternal Depression scale at set intervals as part of their intake and standard of care policies. They referred women to community counseling services. The clinic hosted two Grandmother Teas providing birth and postpartum education to pregnant women and their mother/mother-in-laws.
• Santa Barbara County - MCAH field nursing served 1455 families. Of the 1455 families, 54% (790) were postpartum mothers, referred by the Health Care Center OB departments, which had a home visit for case management services.

 

Adolescent Family Life Program (AFLP): AFLP case managers supported pregnant and parenting youth with accessing health insurance and services, including postpartum care. For more details about AFLP, refer to Adolescent Health Section.

 

California Home Visiting Program (CHVP): The NFP model required mothers be enrolled before 29 weeks gestation. HFA required mothers be enrolled prenatally and no later than three months postpartum. Home visits began upon enrollment and continued until the child turned two for NFP and up to at least age three and no later than age five for HFA. 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. While the number of home visits offered is based on service level, the pace at which each family moves through the levels is individual; making the overall number of home visits widely varied from one family to the next. 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. A significantly decreased schedule over the course of the program or a “vacation” from the program may be used to meet the client’s needs and retain the client in the program when the nurse and client collaborate to establish an “Alternate Visit Schedule” that is approved by the NFP supervisor If the mother was without health insurance, she was linked with appropriate services.

 

Comprehensive Perinatal Services Program (CPSP): PSCs provided technical assistance to CPSP and 768 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. Six LHJs participated in the pilot project and sent their completed chart review tools to FHOP who reviewed each tool, created an Excel data entry template for data collection with LHJ input. CDPH/MCAH and FHOP continued to develop recommendations for improvement of QA/QI tools, CPSP data collection processes, and addressing common challenges of CPSP implementation in provider offices and clinics.

 

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

 

The following evidence-based or evidence-informed practices were utilized for this strategy:

• CPSP as an evidence-informed model for comprehensive prenatal/postpartum care.
• The models for case management (AFLP and BIH) and home visiting programs. One of the MIECHV Performance Measures highlighted the importance of timely postpartum care and tracked the number of mothers enrolled in home visiting prenatally or within 30 days of delivery who received a postpartum visit with a healthcare provider within eight weeks (56 days) of delivery.

Challenges for this strategy

Challenges and opportunities for improvement from the LHJs include:

• 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.

 

Objective 2: Strategy 2:

Increase knowledge of and facilitate collaboration between local MCAH programs and Regional Perinatal Programs to improve maternal and perinatal systems of care, including coordinated postpartum referral systems for high-risk mothers and infants upon hospital discharge.

 

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.

 

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

• Fresno County – The MCAH Director collaborated with RPPC to build out objectives for the Baby Friendly Hospital project, sat on the planning committee for the Central Valley Regional Perinatal Symposium which focused on Congenital Syphilis and Thromboprophylaxis in pregnancy, and was active in the RPPC leadership meetings along with the PSC.
• Mendocino County – The Regional PSC representative and the Local RPPC Director met with birthing hospitals in the county to review quality assurance data: California Maternal Quality Care Collaboration toolkits, breastfeeding, transport incidence, neonatal abstinence syndrome policy, immunizations, Zika virus, Safe Sleep, birth certificate data, maternal mental health, and hospital disaster evacuation policies.
• Santa Clara County - Participated in local RPPC site visits to local delivery hospitals. The PSC provided information on local perinatal initiatives and resources including Universal Prenatal Screening, Maternal Mental Health, and Breastfeeding as well as other perinatal resources for pregnant clients who received Medi-Cal.

 

Objective 3:

By June 30, 2020, decrease the rate of mental health and substance use hospitalizations for persons age 15-24 from 1436 per 100,000 and 1754 per 100,000, to 1318 per 100,000 and 1570 per 100,000, respectively.

 

The rate of mental illness hospitalizations among individuals age 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).

 

Objective 3: Strategy 1:

Increase local MCAH programs awareness of Maternal Mental Health (MMH) needs and wellness issues that impact MCAH target populations through various educational opportunities.

 

CDPH/MCAH led the implementation of an annual survey of women who had recently given birth in order to learn about their needs and barriers to health. The Maternal and Infant Health Assessment (MIHA), an annual, statewide-representative survey of women with a recent live birth in California, collects self-reported information about maternal and infant experiences and about maternal attitudes and behaviors before, during and shortly after pregnancy.

 

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.

 

In the summer/fall of 2017 and early 2018 MCAH staff from all of California’s 61 LHJs were surveyed to assess what Maternal Mental Health (MMH) activities had been implemented within their regions. In total, the survey was 22 questions long. We hoped to learn what resources, connections, and partnerships have been developed already and which are still needed.

 

Seventy-five MCAH staff took the survey, representing 52 out of the 61 LHJs in California (85%). Almost half (48%) of respondents had never conducted a MMH needs assessment. 76% of counties are participating in a local collaboration. Local Mental Health Services Act (MHSA) funding is only being used in 31% of LHJs to fund MMH programs. Over half (59%) of the LHJs do not provide training for providers on MMH, but over 86% of the LHJs that do train include how to screen and refer women for MMH disorders. When asked if there are adequate MMH treatment resources in their LHJ, only one respondent answered “yes” the remainder said “no” or were unsure.

 

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

• Santa Barbara County – the MCAH program created the 211 “Maternal Emotional Wellness Resource Guide,” which may be accessed in English and Spanish at the following web link: http://www.211santabarbaracounty.org/for-agencies/directories/. In addition, the PSC worked on a subcommittee of the Dignity Health Maternal Mood Disorders Project to create a “PMAD Screening and Care Pathway Guide” for local providers to use, which included suggested screening intervals, care pathway depending on the score of the EPDS or PHQ-9, and local resources.
• Tuolumne County – increased access to care, the rural health collaborative added Tuolumne Me-Wuk Indian Health Center Substance abuse counselors who worked with perinatal women. A brochure was updated and disseminated to Child Protective Services on “Marijuana Use Is Not Safe While Pregnant” with Tuolumne County Resources listed on the back of the brochure. Collaboration with providers for Substance Use resulted in an agreement for an immediate appointment for perinatal women who are using/abusing opioids.
• Ventura County - using the Edinburgh Postnatal Depression Scale and Postpartum Depression Screening Scale, 430 or 38.3% of the 1,123 screens administered identified scores of women with possible maternal depression or who had significant symptoms of postpartum depression. Out of 607 women screened, 200 screened positive for possible maternal depression or had significant symptoms of postpartum depression. 100% (200) of the women at risk or with significant symptoms of postpartum depression were referred for services. 75 of the 200 (37.5%) women that were referred for maternal or postpartum depression services accessed at least one of the services.
• Yolo County – the MCAH program formed a new project called “Roadmaps for Healthy Moms”. This project seeks to utilize the MMH Safety Bundle as a framework to integrate behavioral health into obstetrical settings across inpatient and outpatient settings.

 

Maternal Mental Health (MMH) Provider Survey: CDPH/MCAH and FHOP developed an electronic MMH Provider Survey on how providers screen for Perinatal Mood and Anxiety Disorders (PMADs). This survey was designed by FHOP and CDPH/MCAH to assess what activities concerning MMH and wellness had been implemented within each LHJ. More specifically, what resources, connections, and partnerships have been developed and which are still needed.

California Home Visiting Program (CHVP): Services that directly addressed emotional well-being included modules, support groups, socialization groups and mental health consultation. Home visitors tailored their efforts to each family’s needs,  including financial struggles, familial relationships, domestic violence, housing instability and navigating the health care system. CHVP developed nine social media posts on mental health, developed three mental health-related hashtags throughout the year and produced one Home Story (YouTube video) titled Faraha’s Story Giving Back to Her Community which explores her journey with depression triggered by her pregnancy.

 

American Indian Infant Health Initiative (AIIHI): During this funding cycle, 122 families participated in the AIIHI home visitation program. Staff at these clinics provided 1,626 home visits and conducted 42 screenings using the PHQ-9 assessment tool to screen for maternal depression. Home visitors utilized the evidence-based Family Spirit curriculum. Home visitors received training on conducting assessment screens for mental health concerns.

 

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

Challenges for this strategy

Challenges and opportunities for improvement from the LHJs include:

• City of Berkeley – There is a limited list of mental health providers that accept Medi-Cal in Berkeley, in addition to the stigma around mental health issues and accessing services.
• Modoc County - Screening using the PHQ-9 and GAD-7 during pregnancy testing has been challenging. The nurses encountered several clients who were not willing or unable to fill out the forms. In those cases, the PHNs verbally asked about their mental health concerns. Nurses stated that several clients did not appear to have any depression/anxiety but ended up having elevated scores.

 

Objective 3: Strategy 2:

Develop and distribute an evidence-based Maternal Mental Health and Wellness Toolkit for local MCAH programs.

 

Comprehensive Perinatal Service Program (CPSP): CDPH/MCAH has approximately 1600 CPSP providers enrolled throughout California. The CPSP Steps to Take Manual provides 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.

 

CDPH/MCAH and FHOP have collected evidence-based tools and are developing a repository for dissemination to local MCAH programs. Some examples include:

• SAMHSA’s Depression in Mothers: More Than the Blues, A Toolkit for Family Service Providers
• Mental Health America and SAMSHA’s Maternal Depression, Making a Difference Through Community Action: A Planning Guide
• U.S. Preventive Services Task Force’s Final Research Plan for Perinatal Depression
• Every Child Succeeds Moving Beyond Depression
• Massachusetts Child Psychiatry Access Project
• Postpartum Support International’s Feelings in Motherhood

Challenges for this strategy

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

 

Objective 3: Strategy 3:

Develop culturally and linguistically appropriate policies and protocols for LHJs and MCAH Programs to reduce discrimination, disparities, and stigmatization related to maternal mental health and wellness issues.

CDPH/MCAH Focus on Maternal Mental Health: Four CDPH/MCAH programs (BIH, CPSP, CHVP and AFLP) provided maternal mental health screening services. The BIH Program had masters-prepared mental health professionals at each site.

CPSP utilized PSCs in most LHJs to assist CPSP providers with the implementation of services. CPSP providers utilized the CPSP manual, Steps to Take, which includes updated sections on mental health screening and treatment guidelines and aligns with a recent new policy requiring health care providers and hospitals to screen for depression.

CHVP screened for maternal depression utilizing the EPDS or the PHQ-9, and provided referrals to mental health services for women who screened positive or presented with depressive symptoms. Within CHVP, 81.5% of participants were screened for depression within three months of enrollment in 2017-18. About half of the participants who screened positive for depression received the recommended services.

AFLP screened for maternal depression utilizing validated tools, and provided referrals for women who identified as having depressive symptoms.

MIHA Data Brief: CDPH/MCAH led the development of a Data Brief on “Depressive Symptoms During and After Pregnancy” based on MIHA data on perinatal depressive symptoms to describe the scope of the MMH burden. It contained trend data, statewide disparities and county-level prenatal and postpartum depressive symptom data among California women with a recent live birth. A brief narrative was included on key social determinants of health (race/ethnicity, income, insurance, stressors during pregnancy, and childhood hardships).

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

Utilization of validated screening tools, coupled with tailored support from case managers, home visitors, public health nurses, peer groups and others, supported prevention, screening and connecting new moms with needed services to address any mental health concerns and reduce stigma.

Challenges for this strategy

To be effective, CDPH/MCAH will strengthen partnerships with agencies providing mental health services at the state and local levels.

 

There is a lack of trained staff to screen clients for maternal mental health conditions. When there is a positive screen for a mental health issue, there are often not enough local mental health service providers available. Lastly, in communities of color, mental health disparities are greater and the stigma is greater, preventing many people from accessing needed mental health services.

 

Objective 3: Strategy 4:

Develop and implement evidenced based screening and brief intervention policies that require all Title V funded programs and initiatives to screen participating women and adolescents to determine if they are at risk for mental health and substance use disorders and refer, link, and provide a brief intervention to those who screen positive.

 

A list of the national clinical recommendations for maternal depression screening guidelines were distributed to local MCAH programs. These included:

• U.S. Preventive Services Task Force
• American Congress of Obstetricians and Gynecologists, Committee on Obstetric Practice
• Council on Patient Safety in Women’s Health Care
• American Academy of Pediatrics, Bright Futures and Mental Health Task Force
• AAP/ACOG Guidelines for Perinatal Care
• Centers for Medicaid and Medicare Services

 

Various guidelines and proposed legislation were distributed to the LHJs, in addition the following legislation will be implemented July 20, 2018, July 1, 2019, and January 1, 2020 respectively and will have an impact on California families. 

• Assembly Bill (AB) 1893: Requires the CDPH to investigate and apply for federal opportunities regarding maternal mental health.
• AB 2193: Requires obstetric providers to confirm screening for maternal depression has occurred or to screen directly, at least once during pregnancy or postpartum period. It requires private and public health plans and insurers to create maternal mental health
• AB 3032: Requires hospitals to provide maternal mental health training to clinical staff who work with pregnant and postpartum women, and to educate women and families about the signs and symptoms of maternal mental health disorders as well as any local treatment options.

 

Objective 4:

By June 30, 2020, 100% of parents/caregivers experiencing a sudden and unexpected infant death will be offered grief/bereavement support services.

 

For FY 2017-18, 174 out of 208 (84%) of families who experienced a sudden unexpected infant death were offered grief/bereavement support services.

 

Objective 4: Strategy 1:

Contact each local coroner office to review current practices and increase referral of parents of all babies who die suddenly and unexpectedly regardless of circumstances of death.

 

CDPH/MCAH funded through Title V and partnered with the 61 LHJs to increase communication with their local coroner office. Activities focused on the LHJ reaching out to and/or working with their local coroner office to encourage the referral of parents whose babies died suddenly and unexpectedly, regardless of circumstances at the time of death. Such collaboration is essential when offering grief/bereavement support services.

 

CDPH/MCAH tracked how the public health professional was notified of an infant death (i.e. coroner, child death review team, hospital, etc.). CDPH/MCAH also tracked receipt of notifications of infant deaths by the coroners and communicated with the SIDS Coordinators/public health professionals to ensure they were aware of the deaths.

 

Examples of LHJ efforts included:

• Del Norte - Experienced a delay in notification regarding infant deaths and identified that none of the cases were reported by the Coroner’s Office to the LHJ. The LHJ met and worked with the Sheriff and Coroner’s Office to increase communication regarding infant deaths and discuss an official referral process.

• Shasta - The LHJ provided SIDS training to partners and met with the Coroner’s Office during Coroner/Vital Records Meeting to clarify roles, responsibilities and contact methods for reporting activities.

Challenges for this strategy

Challenges with this strategy included the high turnover at coroner’s offices and SIDS Coordinators/public health professionals. To help resolve these challenges new SIDS Coordinators/public health professionals received training and education on how to work with the local coroner’s office. In addition, quarterly reports are sent by the CDPH/MCAH Research Scientist to the 61 SIDS Coordinators/public health professionals as a ‘check and balance’ system. The SIDS Coordinators/public health professionals can learn of deaths they were not notified of and likewise inform CDPH/MCAH of deaths in which CDPH/MCAH was not notified.

 

Objective 4: Strategy 2:

Make grief/bereavement support materials and peer support organizations available on the California SIDS Program website.

 

CDPH/MCAH provided grief and bereavement support materials, peer support organization information, and infant safe sleep resources on the California SIDS Program website for anyone experiencing the sudden unexpected loss of an infant. Additional resources such as information targeted to specific populations are provided as needed and requested.

Challenges for this strategy

CDPH/MCAH is working to make all approved grief/bereavement support and peer support organizations materials ADA compliant and accessible on the new SIDS Program website.

 

Objective 4: Strategy 3:

Provide training on grief and bereavement support services to public health professionals and emergency personnel who respond to sudden unexpected infant deaths.

 

CDPH/MCAH SIDS Program, in collaboration with the California SIDS Advisory Council, funds and leads annual spring trainings on grief and bereavement support services to public health professionals and emergency personnel. Topics included current research, risk reduction updates, role of the first responder, coroner, and medical examiner and investigative procedures, and exchange of knowledge and experience from public health professionals including support services. It also included information on community resources available to assist families who have lost an infant suddenly and unexpectedly.

 

Challenges for this strategy

 

One challenge is the lack of attendance of emergency personnel and other professionals who are involved when an infant dies suddenly and unexpectedly. Another challenge is the frequent turnover of SIDS Coordinators/public health professionals, resulting in the need for training on a regular basis. CDPH/MCAH worked on providing web-based trainings in addition to two annual trainings.

 

Objective 4: Strategy 4:

Track if LHJs contact families who experience a sudden unexpected infant death from which a referral was received from the local coroner’s office to provide grief/bereavement support.

 

CDPH/MCAH tracked notifications of sudden unexplained infant deaths through receipt of a Coroner Notification Card and/or receipt of a Public Health Services Report. The Coroner Notification Card provided basic demographic information about the infant and the Public Health Services Report provided demographic information, history (prenatal, infant, circumstances of death), assessment of family (coping status, environment), intervention, and plan (referrals) for support. CDPH/MCAH also collected information about when grief/bereavement services were offered, if the family declined, if a home visit was done, if grief/bereavement materials were mailed to the family and any follow-up.

 

Tracking of SIDS/SUIDS and corresponding with the SIDS Coordinators/public health professionals has helped to identify deaths that were not known to the jurisdictions and also not known to CDPH/MCAH. Through quarterly correspondence, infant deaths that were not referred were identified and immediate contact with the family was made.

Challenges for this strategy

Not having access to timely death data prohibits CDPH/MCAH from identifying SIDS/SUIDS deaths. Without timely access and notification of deaths, opportunities are missed for families to receive grief and bereavement support.

 

Objective 5:

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 8.0%, 10.0%, 0.54% and 4.4% (2013 Office of Statewide Health Planning and Development (OSHPD) Patient Discharge Data (PDD)) to 7.4, 9.5%, 0.51% and 3.9% respectively.

 

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 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%).

 

Objective 5: 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.

 

California Pregnancy-Associated Mortality Review (CA-PAMR): a comprehensive statewide maternal mortality examination designed to identify pregnancy-related deaths during pregnancy or within 1 year of the end of pregnancy, their causes, factors that contributed to the death, and improvement opportunities in maternity care and support, with the ultimate goal to reduce preventable deaths and associated health disparities. CA-PAMR is a coordinated effort between the CDPH/MCAH and its contracted partners, Stanford University’s California Maternal Quality of Care Collaborative (CMQCC) and the Public Health Institute (PHI).

 

CDPH/MCAH has lead the public health investigation in maternal deaths and the data has informed efforts to improve obstetric care and rally public interest.  The public health investigation method informed efforts across the country and California’s strategies for taking data to action have been similarly replicated. CA-PAMR recently completed in-depth case reviews of pregnancy-associated suicide in an effort to apply the same methodology to collect data, engage expert review and identify opportunities for improvement. In addition, CA-PAMR also examined deaths up to one year post pregnancy because although early deaths have decreased, later deaths (up to one year) have risen.

 

Major activities included the release of CA-PAMR’s report on obstetric-related deaths. This report was a culmination of work that spanned several years and informed the California Toolkits to Transform Maternity Care series that included the webinars on Improving Health Care Response to Cardiovascular Disease in Pregnancy and Postpartum and Maternal Venous Thromboembolism The report was shared via CDPH/MCAH’s email marketing tool Constant Contact to a list of 1,512 email subscribers in April 2018. Of that number, 570 subscribers opened the report. The report was viewed on the CDPH/MCAH website 3,464 times and downloaded 2,425 times since May 2019. The press release generated 13 media inquiries and at least three national news stories. Two social media posts promoting the report release were shared on the CDPH/MCAH Facebook Page, reaching 1,819 Facebook users.

 

In addition, the following toolkits were used by the RPPC Directors to assess and implement clinical best practices and quality improvement strategies to support the reduction in maternal morbidity:

• Improving Health Care Response Cardiovascular Disease (CVD) in Pregnancy and Postpartum
• Improving Health Care Response to Venous Thromboembolism (VTE) in Pregnancy and Postpartum
• Improving Health Care Response to Obstetric Hemorrhage
• Elimination of Non-medically Indicated (Elective) Deliveries Before 39 Weeks Gestational Age
• Improving Health Care Response to Preeclampsia
• CAN Neonatal Disaster Preparedness
• Care and Management of the Late Preterm Infant
• Delivery Room Management for the Very Low Birth Weight (VLBW)
• Infant Early Screening and Identification of Candidates for Neonatal Therapeutic Hypothermia
• Preterm Labor Assessment Toolkit

 

State and Local MCAH Efforts:

• The RPPC Director from the Southern Inland Region convened a Maternal Mental Health Roundtable and invited, hospital leadership, CPSP providers, Maternal Mental Health Coalitions, Mom2020, physicians, representatives from Behavioral Health, local programs and therapists. The Roundtable included formal presentations and opportunities for sharing and collaboration.

•   The RPPC Director from the Southern Inland County was invited to participate on the advisory Board of Choose Health LA, a local initiative of the Los Angeles County Department of Public Health to prevent and control chronic disease in Los Angeles County.
•   Santa Barbara County RPPC Director took the lead on gathering various stakeholders from Santa Barbara and Ventura Counties to form a regional collaborative focused on Perinatal Mood and Anxiety Disorders.
•   CDPH/MCAH collaborated with the Center for Healthy Communities and the Chronic Disease Branch to review the CPSP Steps to Take Manual section on Cardiovascular Disease and they offered to fund the development of a factsheet, “Are you at Risk for Heart Disease Following your Pregnancy” for three target populations. The Chronic Disease Branch contracted with a professor on Cardiovascular Medicine from UC Davis to develop the factsheet content and conducted a webinar for stakeholders on the importance of good cardiovascular health in pregnancy and the risk for complication with heart disease during and after a pregnancy.

 

The California Diabetes and Pregnancy Program (CDAPP) Sweet Success:

Provided technical support and education to medical personnel and community liaisons to assist in promoting improved pregnancy outcomes for high-risk pregnant women with pre-existing diabetes and women who developed gestational diabetes mellitus (GDM).

 

CDPH/MCAH contracted with the CDAPP Sweet Success Resource Center to develop and record training and education to medical personnel to assist in promoting improved pregnancy outcomes for high-risk pregnant women with preexisting and gestational diabetes. The Resource and Training Center trained about 2000 individual providers working in affiliate organizations through online trainings that covered a range of subjects, such as gestational diabetes, postpartum care, preconception care and Interconception care. The CDAPP Sweet Success Resource Center also provided educational resources for both providers and pregnant women with diabetes.

 

CDPH/MCAH monitored the percent of women hospitalized at time of delivery with Diabetes using Office of Statewide Health Planning and Development (OSHPD) patient discharge data.

 

The CDAPP Sweet Success Evaluation Plan work group focused on evaluating postpartum follow-up rates and preconception tying in the topic of weight before and after pregnancy. CDPH/MCAH promoted the California My Plate document for pregnant and parenting women and adolescents, as well as women with diabetes in pregnancy.

 

Evidence-based/Evidence Informed Practices utilized for Sweet Success strategy

 

The following key literature and published guidelines were utilized to support 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. 2015. Available at http://health.gov/dietaryguidelines/2015/guidelines/
• Institute of Medicine and National Research Council of the National Academies. Weight Gain During Pregnancy Reexamining the Guidelines. 2009. Available at: http://nationalacademies.org/hmd/reports/2009/weight-gain-during-pregnancy- reexamining-theguidelines.aspx

 

Challenges for CDAPP Sweet Success

 

Due to limited funding and minimal Affiliate requirements, the CDAPP Sweet Success Resource Center has barriers in terms of being able to collect more data and analyze it to prove improved client outcomes. With that lens, the CDAPP Sweet Success Stakeholder, Evaluation Plan Working Group considered focusing on postpartum care and follow up rates for our Affiliate sites.

Another challenge faced was the inability to have CDAPP Sweet Success resources and materials translated into other languages by the State. CDAPP Sweet Success Affiliates have diverse client populations and the CDAPP Sweet Success and Resource Center is not able to meet that need.

 

Objective 5: 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.

 

During 2017-18, CDPH/MCAH participated in the Health in All Policies (HiAP) Task Force. MCAH Division was specifically focused on Intimate Partner Violence and disseminated the HIAP Taskforce Report on Promoting Violence-Free and Resilient Communities: Summary Report of Stakeholder Recommendations (2016).

 

In 2017-2018, CDPH/MCAH staff was selected by Office of Health Equity to work with the HiAP team via their Governor’s Alliance on Race and Equity (GARE) Capitol Cohort whose overall goal is to eliminate race as a predictor of health, which includes examining and addressing CDPH policies. As part of this, CDPH/MCAH has been instrumental in piloting the CDPH Racial and Health Equity Glossary of Terms (Glossary). The Glossary was designed to provide a common language for understanding and talking about racial and health equity concepts.

 

Challenges for this strategy

 

The challenge has been identifying the CDPH/MCAH role within the HiAP group and the best ways to maximize the support for MCAH populations.

 

Objective 5: Strategy 3:

Disseminate the National Preconception Curriculum & Resources Guide for Clinicians training module 5 and the Interconception Care Project of California materials to health care providers to help ensure women with risk factors receive appropriate interconception and follow up care.

 

Challenges for this strategy

 

CDPH/MCAH provides a link from the CDPH/MCAH Preconception Website to the Before, Between, & Beyond Pregnancy Website by the National Preconception Health and Health Care Partnership. The website contains resources, toolkits, and patient education material as well as education modules for CME Credits. Additionally, CDPH/MCAH redirected its efforts towards leading a three-year HRSA Preconception Collaborative Improvement & Innovation Network (COIIN) project focused on the development of a preconception health risk screening tool and clinic implementation process using a human-centered design and approach. Two clinics participated, a Sacramento Family Planning Residency Program clinic and a Federally Qualified Health Center in Riverside. As CDPH/MCAH moves forward, the team will examine the capacity for broad rollout of the preconception strategy inclusive of protocols, tools, workforce development, resources and an evaluation or quality assurance/improvement plan in collaboration with local MCAH Directors.

 

Objective 6:

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% (2012 MIHA) to 43.4% and 37.1%, respectively.

 

The percent of women reporting mistimed or unwanted pregnancy steadily decreased from 31.9% in 2013 to 29.1% in 2015.

 

The percent of mistimed or unwanted pregnancy among Black women of reproductive age increased from 39.7% in 2013 to 40.9% in 2014 before decreasing to 39.7% in 2015.

 

The percent of mistimed or unwanted pregnancy among Hispanic women of reproductive age decreased 1.4 points from 39.1% in 2013 to 37.7% in 2014 before dropping another 3.4 points to 34.3% in 2015.

 

Hispanic women (57.7%) and White women (23.9%) were most likely to report unwanted pregnancies, whereas Asian/Pacific Islander women (9.9%) and Black women (7.5%) were among those least likely to report unwanted pregnancies.

 

Objective 6: Strategy 1:

Broadly disseminate the concept of a Reproductive Life Plan by developing or disseminating culturally and linguistically appropriate tools for integration into existing MCAH programs and public health departments.

 

CDPH/MCAH has been able to support LHJ implementation of these activities by providing technical assistance and dissemination of resources and materials, including data as needed. Many LHJs utilize reproductive life planning in their local programs.

 

A few examples of LHJ activities related to reproductive planning are:

• Sacramento County - A Roundtable Training on Preconception and Inter-conception care titled “Misconceptions; Teaching Preconception Care in a Digital World” was conducted by Jaqueline Sawyer from CSUS school of Nursing. Printed handouts on Reproductive life planning, pregnancy spacing, and healthy weight before and after pregnancy, nutrition (Folic Acid), managing chronic medical conditions and Healthy relationships were provided to the Audience.
• Shasta County – 97 clients have received education on reproductive life planning and where to get these services within the community. The reproductive life planning services information on the womensconnectshasta.com program website is accessible to 100% of the clients that visit the website 24 hours per day, 365 days per year.
• San Diego County - Focus groups were conducted with various segments of the target population to obtain input on the developed inter-conception health education tool. The inter-conception tool is in the form of a booklet and includes a planner. The tool provides culturally and linguistically appropriate health education messages, interactive self-reflection activities, resources, and supports users to track health status and share information with their healthcare provider. The tool is currently being finalized and will be routed for approval FY 18-19. For the tool to be successful, an integration of authentic relatable images mixed in with health content is necessary components to capture the interest of the target population.

 

California Home Visiting Program (CHVP): Home visitors/nurses provide information about family planning choices and birth control options during their home visits. They talk with mothers about their plans for another baby and discuss baby spacing benefits. Resources and educational materials are disseminated in a variety of languages consistent with surrounding area population.

 

Black Infant Health (BIH): The BIH Program team continues to ensure that resources, tools and materials are 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 permits them to factor in when the ideal time might be to consider expanding their family. Local staff also report that this opens up lines of communication with their partner in order to have viewpoints discussed freely.

 

Adolescent Family Life Program (AFLP): AFLP integrates the program’s My Life Plan and My Goal Sheet tools to support youth to set goals around reproductive life planning. For more information about AFLP, refer to the Adolescent Health Section.

Challenges for Reproductive Life Planning

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

 

Objective 6: Strategy 2:

Integrate One Key Question (OKQ) into Title V programs and partner programs to promote appropriate contraception counseling to match pregnancy desire and timing.

CDPH/MCAH supports LHJ implementation of these activities by providing technical assistance and dissemination of resources and materials, including data as needed.

Fifteen out of the 60 LHJs (25%) state that they have been trained on One Key Question to promote appropriate contraception counseling.

CDPH/MCAH continues to partner with the local PSCs in the promotion of and education to provider on promoting pregnancy spacing. Additionally, CDPH/MCAH is supporting the Every Woman California, Preconception Health Council of California website. The site includes FAMILIA, a text-messaging program, developed to provide tips on family planning, contraception options and other health topics. Each message links to the FAMILIA website form more information, apps, blogs, and videos related to that topic. A person will receive three healthy living texts each week for three months promoting preconception health in English or Spanish.

Objective 6: Strategy 3:

Standardize the content of the postpartum visit by collaborating with existing partners such as Medi-Cal Managed Care Plans and each LHJ’s Perinatal Service Coordinator to use the National Preconception Curriculum & Resources Guide for Clinicians training module 4 "In Between Time: Interconception Health Care Part 1: Routine Postpartum Care for Every Woman."

 

Comprehensive Perinatal Services Program (CPSP): CDPH/MCAH staff updated the CPSP Steps to Take (STT) Manual that provides information on prenatal and postpartum care, nutrition, health education and psychosocial issues that health care provider staff can use with their CPSP clients. STT also contains patient handouts in English and Spanish on important and common health issues. A few examples related to preterm birth are; If Your Labor Starts too Early; Did You Have Complications During Pregnancy; Signs and Symptoms of Heart Disease; Diabetes While You are Pregnant; Welcome to Pregnancy Care, and Drugs and Alcohol When You Want to STOP.

 

Objective 7:

1. By June 30, 2020, at least 30 out of 61 LHJs (2013-14 MCAH Annual Reports) will adopt elements of the MCAH’s Intimate Partner Violence (IPV) Toolkit.
2. By June 30, 2020 all MCAH programs (i.e., AFLP, BIH, CHVP, I&E, PREP) will adopt elements of MCAH’s IPV Toolkit.
3. By June 30, 2020, all funded Title V Indian Health sites will adopt elements of MCAH’s IPV Toolkit.

 

Objective 7: Strategy 1:

Identify, and provide opportunities to attend culturally congruent webinars and trainings, and provide resources to all MCAH Title V programs.

 

Black Infant Health (BIH): The BIH Program features a curriculum focused on Empowerment and Social Support inclusive of 10 Prenatal and 10 Postpartum sessions each. Session 9 of the Prenatal Sessions promotes healthy relationships and Session 17 of the Postnatal Sessions promotes effective communication to promote healthy relationships. Program participants are encouraged to discuss any issues or concerns they have or are experiencing at any time throughout their program participation. Additionally, the BIH Program provides an overview of IPV and Reproductive Coercion strategies that participants can utilize to assist them with having healthy relationships. The BIH Program has collaborated with partner agencies to provide IPV trainings to local BIH Mental Health Professionals and Pubic Health Nurses for providing additional supportive services when IPV issues are revealed by participants.

The BIH Program collaborated with a local partner agency to provide a training related to IPV and healthy relationships to approximately 30 BIH MHPs and PHNs. The training provided an overview of healthy relationships, intervention protocols, referral processes and safety planning. The training also provided strategies that staff could utilize in the areas of vicarious trauma and self-care to decrease stress and burn-out.

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 includes key assessment questions around IPV, with support for linking to support when needed. The model also incorporates standardized activities around healthy relationships and all local agencies distribute and discuss Futures Without Violence resources with all youth in the program. For additional details about AFLP refer to Adolescent Health Domain

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.

Objective 7: Strategy 2:

Develop and implement an IPV Initiative Performance and Quality Improvement (PQI) tool to evaluate the effectiveness of the elements within MCAH’s IPV Toolkit.

CDPH/MCAH recognizes that there are other experts working in this area with established toolkits and resources. Therefore, activities have been redirected and this strategy is revised in the next fiscal year plan.

Objective 7: Strategy 3:

Build and sustain internal and external collaborations to share practices and support MCAH’s IPV efforts.

CDPH/MCAH is committed to identifying, disseminating and promoting resources for effective assessments and responses by advocates and health care providers. Such guidelines will support the expansion of routine screening for IPV to include assessment for reproductive and sexual coercion.

Examples of LHJ activities to address IPV:

• Glenn County - MCAH Director met with Glenn Medical Center (GMC) Nurse Director to discuss IPV policies. GMC and other entities are aware of referring to Westside Domestic Violence Shelter or Catalyst in Butte Co. GMC as a whole are trained on domestic violence and child abuse reporting to the Sheriff Office and county CPS department.
• Merced County - The Commercially Sexually Exploited Children (CSEC) tool was developed in partnership with the Merced County Human Services Agency. Utilizing the developed tool, 85% or more of all clients in the MCAH programs are assessed for the presence and extent of human trafficking. The CSEC tool is used by AFLP/Young Parents Programs staff when there is a suspicion. In addition, both AFLP and HFA, and field nursing home visiting programs assess for Intimate Partner Violence. One hundred percent (100%) of MCAH clients are assessed for IPV.
• Santa Clara County - Public Health Employees received education and training on domestic violence/intimate partner violence, healthy relationships, its impact on health, and vicarious trauma including current resources and tools. Employee evaluations and pre and post surveys were completed. The pre-post surveys completed after the IPV training showed increased comfort with PHD staff talking with clients about healthy and unhealthy relationships. The pre-post survey results also showcased staff’s increased confidence in knowing local and national resources that are available to assist clients if they have experienced IPV.