NPM 1: Percentage of women with a past year preventative visit. 

 

Objective 1: By 2020, increase the proportion of women who discussed preconception health with a health care worker prior to pregnancy to meet a target of 23.4% (PRAMS, 2012 baseline = 20.1%).  

Objective 2: By 2020, increase the proportion of women giving birth who attend a postpartum care visit with a health care worker to meet a target of 88.5% or higher (PRAMS, 2012 baseline = 85.4%).  

Objective 3: By 2020, reduce the proportion of women who self-report poor mental health for 5 or more days during the past month to meet a target of 19.0% (BRFSS, 2012 baseline = 24.4%). 

 

At the December 2017 Open Portion of the Texas Maternal Mortality and Morbidity Task Force Quarterly Meeting, DSHS announced its new Healthy Texas Mothers and Babies (HTMB) Strategic Framework. This framework is modeled after the Prevention Institute’s Spectrum of Prevention, and provides strategic direction for alignment, improvement, and development of existing- and new interventions to support the triple aim of healthy women, healthy mothers, and healthy babies. The HTMB Framework integrates all existing MCHS women’s, maternal, perinatal and infant health programming and, by elevating and amplifying an emphasis on women’s and maternal health and safety, the framework expands upon MCHS’ existing commitment, through the previous Healthy Texas Babies (HTB) Initiative, to reduce infant mortality and improve infant health outcome.

The HTMB framework includes the domains of Individual and Public Awareness and Knowledge, Professional Education, Community Empowerment, Community Improvement, and the Perinatal Quality Improvement Network, which includes a variety of interrelated and complementary initiatives that provide public health knowledge, partner mobilization, and implementation resources to drives system changes to support adoption and diffusion of quality improvements for maternal and infant health and safety.

 

To more accurately capture MCHS’ enhanced focus on women’s and maternal health, MCHS will replace reporting of NPM 1 in FY19 with new State Performance Measure, SPM 5: Percent of women of childbearing age who self-rate their health status as excellent, very good, or good. MCHS will continue to support improvement of the quality of women’s health and healthcare via integration of preconception/interconception care into routine primary and well-woman care. However, MCHS seeks to extend programmatic efforts to settings outside of the primary care visit to include systems level change to prevent and control chronic disease and to promote wellness starting in the preconception and interconception periods. Women in Texas experience increasing rates of obesity, diabetes, hypertension, substance abuse disorder and other morbidities, as well as low rates of health insurance coverage and access to care.  High rates in Texas of unintended pregnancy, preterm birth, maternal morbidity, and maternal mortality are often preventable outcomes of poor preconception health. Self-reported health status is a helpful measure to account for the multiple factors that impact a woman’s preconception and interconception health beyond the primary care visit. As described by Broussard et al (2011)[1], DSHS epidemiology and program subject matter experts had the opportunity to contribute, along with experts in other states, to a multi-state consensus-based selection process to develop of a set of Core State Preconception Health and Health Care Indicators. SPM 5 is a core preconception health indicator, and is the only indicator of general health status that was included by the Council of State and Territorial Epidemiologists in this core measure set. Lower rating of self-rated health status has consistently been associated with “increased mortality, incident adverse health events, health care utilization and illness severity, even after medical risk factors have been accounted for.”[2]

Effective August 2017, the Texas Legislature amended Texas Health and Safety Code Chapter 34 by adding Section 34.0156, which directs DSHS, in collaboration with the DSHS/Texas Maternal Mortality and Morbidity Task Force (MMMTF), to implement a maternal health and safety initiative. Specifically, the initiative must promote and facilitate the use of maternal health and safety informational materials among Texas health care providers. Materials may include tools and procedures related to best practices in maternal health and safety. DSHS, the TCHMB Executive Committee, and UT facilitators continued to explore severe maternal morbidity and mortality trends in Texas and considered THCMB’s potential role in supporting DSHS priorities related to maternal health and safety, including the MMMTF joint recommendations and the required maternal health and safety initiative.

In September 2017, DSHS was invited by the American College of Obstetricians and Gynecologists (ACOG) Alliance for Innovation in Maternal Health (AIM) Program to participate in a state collaborative on Maternal Opioid Use Disorder to share tools and best practices and to develop implementation strategies and national outcome and process measures. In October 2017, DSHS formed a multi-disciplinary team of public health champions, clinical champions, and key stakeholders including the Chief Health Officer, Maternal and Child Health (MCH) Title V Director, MCH Epidemiology, MCH staff, the Texas Hospital Association, Texas Medicaid leaders, members of the Texas Collaborative for Healthy Mothers and Babies (TCHMB), ACOG, Society for Maternal and Fetal Medicine, Texas Consortium of Texas Nurse Midwives, March of Dimes, Healthy Start, substance abuse subject matter experts, substance abuse treatment providers, and a patient and family advocate.

 

Given statewide data trends and to address recommendations of the MMMTF from the 2016 and 2018 Joint Reports, DSHS and its partners continued work to improve maternal health and safety in Texas. The TMA and DSHS, in coordination with HHSC, facilitated a Maternal Health Forum on September 30, 2017 to bring together invited physicians, health care professionals, and public health experts to review the recent findings of the state’s MMMTF and current state initiatives to address maternal health and safety. Three workgroups identified challenges and developed action plans to reduce maternal mortality and morbidity through the areas of systems of care, public health systems, and data. More information about the Forum is available on the TMA website at https://www.texmed.org/Template.aspx?id=45766.

 

To build upon much of the information and discussion at the Maternal Health Forum, the TMA hosted a Maternal Health Congress in March of 2018 that included an Overview of Texas Maternal Health Issues by the Commissioner of the Texas DSHS and the Chair of the Texas MMMTF.  Other topics included Access to Care and Health Disparities, Substance Use Prevention and Treatment, and Maternal Health Quality Initiatives – ACOG Alliance for Innovation on Maternal Health. The Associate Commissioner of the Community Health Improvement Division (CHI) was among the invited attendees.  

 

In October 2017, the TCHMB Executive Committee Meeting, rescheduled from August due to Hurricane Harvey, focused on exploring TCHMB’s role in implementation of AIM maternal safety bundles in Texas. Dr. John Hellerstedt, DSHS Commissioner, Dr. Lisa Hollier, the MMMTF Chair, Dr. Barbara Levy, Vice President for Health Policy for ACOG, and Barbara O’Brien, Program Director of the Office of Perinatal Quality Improvement at University of Oklahoma Health Sciences Center,  presented at the October 2017 TCHMB Executive Committee meeting to provide information and findings from the MMMTF and an overview of AIM maternal safety bundles, including the experiences of other states with implementation of the AIM bundles. In addition, Texas Medicaid staff presented information about plans to include a measure related to hospital implementation of AIM maternal safety bundles as an option for hospitals participating in the Texas Delivery System Reform Incentive Payment (DSRIP) Program. The Executive Committee began a discussion to consider implementation of a potential Texas Maternal Morbidity Quality Improvement Project by TCHMB. This discussion continued at the November 2017 TCHMB Executive Committee Meeting, and the TCHMB Executive Committee proposed and voted to support implementation of an AIM Patient Safety Tool, the Maternal Early Warning System (MEWS), which prompts early detection, diagnosis and intervention in cases of maternal health deterioration.

 

The Opioid AIM Bundle Collaborative kick-off meeting was held November 14, 2017 in Washington, DC. ACOG convened members of fourteen states —Illinois, Maine, Maryland, Massachusetts, New Jersey, New Mexico, New Hampshire, New York, Ohio, Oklahoma, Tennessee, Texas, Vermont and Virginia—to begin work on developing the AIM Obstetric Care for Women with Opioid Use Disorder Bundle for implementation. Texas team members worked with members from other states throughout FY18 through participation in four subcommittees—including Metrics, Community Engagement, Education, and Clinical Pathways/Quality Improvement (QI) Strategies—to identify strategies, resources and measures to support bundle implementation. Additionally, DSHS participated in monthly AIM Opioid State Implementation collaborative calls to share updates and learn from other states about implementing the bundles.

In December 2017, DSHS applied for enrollment as an “AIM State” to the ACOG AIM Program and was selected and named Lead Coordinating Entity for the implementation of AIM Maternal Safety Bundles in Texas, with a focus on implementing the Obstetric Care for Opioid Use Disorder, Obstetric Hemorrhage, and Severe Hypertension in Pregnancy bundles. DSHS developed a work plan for rolling out AIM bundles in Texas and convened the AIM Implementation Workgroup (AIWG) in January to guide and facilitate implementation of maternal safety bundles statewide. The Associate Commissioner for Community Health Improvement and the Chair of the MMMTF began serving as co-chairs of the group. AIWG membership includes representation from ACOG National and District XI , AIM, Texas Medical Association (TMA), THA, Texas Nursing Association (TNA), TCNM, HHSC Behavioral Health, Texas Medicaid, Healthy Texas Women’s Program, the MMMTF, the Perinatal Advisory Council (PAC), TCHMB, and other state agency and university partners. The AIWG members participate in monthly workgroup meetings to provide expertise and facilitate linkages to support successful statewide implementation of the initiative, and to promote recruitment and continued engagement of AIM participants. Also in January, THA offered to partner with DSHS to provide additional support with program implementation including collaboration on outreach and process improvement. Additionally, DSHS, THA, and the TCHMB Obstetrics and Data Subcommittees formed a TexasAIM Data Workgroup to develop a TexasAIM Maternal Safety Needs Assessment survey (TexasAIM Intake Survey) and monthly quality measures for hospitals that enroll in a TexasAIM Obstetric Plus Hemorrhage Learning Collaborative.

 

In February 2018, DSHS developed informational and recruitment materials, a mailbox, and a webpage for the TexasAIM initiative, and worked with the AIWG to draft a letter from the DSHS Commissioner, Dr. John Hellerstedt, to announce the launch of TexasAIM and to provide details about an informational webinar and the TexasAIM Intake Survey. Information about TexasAIM shared at the Regional Advisory Council (RAC) Chairs meeting in Austin.  

 

A Multi-stakeholder survey instrument, the TexasAIM Intake Assessment, was developed through collaboration between DSHS, TCHMB, THA, UT System, and AIM National.  The survey was administered to all AIM enrolled hospitals with findings used to establish baseline insights into obstetric quality and process improvement infrastructures in participating hospitals, identify areas of strength and areas for improvement, and to inform QI support strategies and content for TexasAIM Plus Learning Sessions and Action Period Calls.

 

In March 2018, DSHS began initial outreach to hospitals to participate in the AIM Obstetric Hemorrhage Bundle at either a Basic or Plus (Learning Collaborative) level, and also to invite selected hospitals to participate in the TexasAIM Opioid Bundle Pilot.

 

The DSHS Commissioner’s TexasAIM launch letter was both mailed and emailed in March to contacts from each hospital in Texas with an obstetric line of service and disseminated to maternal and child health stakeholders through the GovDelivery listserv and other networks. AIWG members and RAC Chairs were asked to distribute information about TexasAIM and the informational webinar through their networks. The informational webinar was held on March 28, 2018 with over 500 registrants, 332 attendees during the live webinar, and hundreds of additional viewings of the archived webinar.

 

DSHS and THA collaborated to draft a joint letter, signed by the President/CEO of THA and the DSHS Commissioner and disseminated by THA to hospital administrators, to announce a jointly hosted TexasAIM informational webinar and to encourage enrollment in TexasAIM. This letter was sent to hospital administrators in April 2018, and followed by an informational webinar on May 8, 2018 with over 200 registrants. Jeremy Triplett, MCH Title V Director, provided updates on TexasAIM to the RAC Chairs meeting on May 9, 2018, and a TexasAIM informational webinar was held for RAC Chairs, RAC Directors, and Perinatal Chairs for The RAC Perinatal Care Regions on May 30, 2018. 

 

DSHS held the TexasAIM Leadership Summit and Orientation June 4, 2018, to kick-off the TexasAIM initiative with participating hospitals. Approximately 400 clinical and administrative leaders, representing at least one representative from over 150 hospitals that had enrolled in TexasAIM, attended the Summit. Representatives from the TexasAIM Implementation Workgroup, MMMTF, Texas Collaborative for Healthy Mothers and Babies, Regional Advisory Councils, and national and state representatives of the American Congress of Obstetricians and Gynecologists also attended. Attendees learned from AIM experts from both in and outside the state, heard the stories of mothers and fathers who have experiences maternal mortality and morbidity, and shared strategies with each other about how to enact change through TexasAIM. Representatives from hospitals selected to participate in the TexasAIM Opioid Bundle Pilot met to discuss the bundle and activities that were underway in each hospital to begin implementing the bundle components.

 

In August 2018, DSHS hosted several TexasAIM webinars including:

• a TexasAIM Summit Make-Up Webinar to review the topics discussed at the TexasAIM Leadership Summit and Orientation on June 4th for hospitals and team members who were unable to attend.
• The TexasAIM Plus Obstetric Hemorrhage Learning Collaborative Kick-off and Pre-Work Call, which marched the beginning of the 18-month Learning Collaborative for hospitals enrolled in TexasAIM Plus.
• TexasAIM Data Collection and Basecamp Webinar to orient TexasAIM participants to the AIM Data Portal and, for hospitals participating in TexasAIM Plus, to the Collaboratives online sharing platform.

 

The DSHS Title V Medical Director and MCH Program Coordinator, Jeremy Triplett and Audrey Young, attended the national Alliance for Innovation in Maternal Health (AIM) Annual Meeting in Arlington, VA on August 6, 2018 to exchange ideas and learn from other states that participate in AIM about effective strategies to implement AIM maternal safety bundles. Texas was presented with an award at this meeting from the American College of Obstetricians and Gynecologists (ACOG) AIM Leadership Team to recognize the TexasAIM effort and significant progress in 2018. 

 

Hospital participation in TexasAIM is voluntary. Hospitals participating in the TexasAIM program have the opportunity to participate in two options:  TexasAIM Plus and TexasAIM Basic. Hospitals that participate at Basic level receive the fundamental tools and support to adopt AIM bundles. These hospitals complete an intake assessment, form a quality improvement team, and report structure and process measures to the TexasAIM data portal. TexasAIM Basic participants also have access to quality improvement webinars, networking events, and technical assistance.

 

TexasAIM Plus uses the Institute for Health Care Improvement (IHI) Breakthrough Series Collaborative Model for Achieving Breakthrough Improvement to accelerate uptake of the AIM bundle’s recommended practices by participating hospital teams and creates a network of support from partnering hospitals. Hospitals in TexasAIM Plus complete all of TexasAIM Basic data reporting requirements, but will also report on additional quality improvement measures. In the Learning Collaborative, hospitals receive specialized quality-improvement training from experts through in-person meetings, individualized coaching, peer-to-peer mentoring, and onsite technical assistance visits. Hospitals also identify goals and make plans to achieve them. TexasAIM Plus participants have access to peer-to-peer mentoring, targeted support, and access to additional resources and partnerships. The TCHMB provides targeted education and implementation of MEWS in participating hospitals in coordination with the TexasAIM Plus Learning Collaborative.

 

TexasAIM Plus hospitals are assigned to one of five geographic cohorts for in-person Learning Sessions. DSHS based cohorts on Public Health Service regions, Regional Advisory Council Perinatal Care Region territories, and enrollment (See Figure 1). Each cohort has approximately 30-40 participating hospitals.

 

In August 2018, planning for the first in-person Learning Session of the TexasAIM Plus Obstetric Hemorrhage Learning Collaborative and for recruitment of a TexasAIM Plus Clinical Faculty Team was underway. A total of 188 hospitals were enrolled to participate in the TexasAIM Obstetric Hemorrhage Bundle Initiative at the end of FY18, representing approximately 340,000 (89 percent) of the state’s annual births. Of these, 175 hospitals were enrolled in the TexasAIM Plus Obstetric Hemorrhage Learning Collaborative. Enrollment for TexasAIM Basic and Plus will continue into FY2019.

Figure 1. TexasAIM Plus Learning Collaborative Cohorts by Perinatal Care Region

 

DSHS continues to contract with the University of Texas Health Science Center at Tyler (UT) to facilitate the TCHMB, Texas’ perinatal quality collaborative. TCHMB’s mission is to advance health care quality and patient safety for all Texas mothers and babies through the collaboration of health and community stakeholders in the development of joint quality improvement (QI) initiatives, the advancement of data-driven best practices, and the promotion of education and training.

 

In January 2017, the TCHMB Annual Conference, Obstetrical and Neonatal Care Coordination Related to Infectious Diseases in Pregnancy, was held in Austin. Using the recent Zika response as an example, the event provided a forum for key local, state and national stakeholders and experts to discuss coordination of care for pregnant women and babies in response to established and emerging infectious diseases.  State and national speakers presented on topics related to Zika screening and care coordination, and then attendees broke out into working groups to develop recommendations to improve care coordination during emergent infectious disease outbreaks.  The conference was attended by approximately 75 community health and health care professionals. A report of the event is available from the TCHMB website at: https://www.tchmb.org/conference-care-coordination-infectious-diseases-in-pregnancy.

 

Also in November 2017, the first Annual National Network of Perinatal Quality Collaboratives (NNPQC) Meeting was sponsored by the Centers for Disease Control and Prevention and the March of Dimes in Fort Worth, Texas, in support of the development and enhancement of the ability of Perinatal Quality Collaboratives (PQCs) to make measurable improvements in the statewide maternal and infant health care and health outcomes. The goal of the meeting was to “launch the national network, provide opportunities for sharing best practices and lesson learned, both organizational and functional, between PQCs across the country, and to determine the support PQCs need from the national network.”  Sessions included panels highlighting success stories in maternal and neonatal health quality improvement by state PQCs, and interactive sessions to share information about how to start a collaborative, how to launch initiatives, data and metrics, quality improvement models, and dissemination and sustainability of quality improvement projects.  The meeting was attended by the MCHS Women’s and Perinatal Health Coordinator, the TV MCH Medical Director, members of the TCHMB, and the Associate Commissioner for FCHS, who served on the Executive Committee for the NNPQC and helped plan the conference.

 

The TCHMB Executive Committee continued to meet quarterly throughout FY18 to work on and make updates to TCHMB QI projects, the TCHMB Communications Plan, stakeholder and membership engagement and annual meeting plans. The August 2017 Executive Committee meeting was rescheduled for October 12, 2017, just weeks before the November 9, 2017 meeting, due to Hurricane Harvey, so five Executive Committee meetings were held in FY18. The Executive Committee and Subcommittees met in person at the November 2017 Obstetrical and Neonatal Care Coordination Related to Infectious Diseases in Pregnancy conference, and teleconference calls were held monthly to quarterly for each subcommittee in support of planning or implementing subcommittee QI efforts.

 

The 85th Texas Legislature Budget Rider 198 requires HHSC to develop a five-year strategic plan to reduce barriers for Medicaid recipients and those with and without health benefit plan coverage who may be eligible for Healthy Texas Women, the Family Planning Program, or CHIP-Perinatal to access LARC. HHSC must collaborate with the TCHMB to develop the five-year strategic plan, and submit the plan by November 2018. The TCHMB Executive Committee provided input to and review of the draft strategic plan. The plan was finalized in November 2018, and is now posted on the HHSC website at https://hhs.texas.gov/sites/default/files/documents/laws-regulations/reports-presentations/2018/rider-105-larc-strategic-plan-nov-2018.pdf. 

 

DSHS and HHSC continued participation in the ASTHO Increasing Access to Contraception Learning Collaborative (ASTHO IACLC). In 2017, DSHS and HHSC also began participating in Phase II of the Centers for Disease Control and Prevention’s 6|18 Initiative. Under both programs HHS sought to increase LARC utilization, with the Centers for Disease Control and Prevention (CDC) 6|18 adding a focus on logistic and financial barriers. To best coordinate efforts under each program, DSHS and HHSC formed a LARC Team in 2017, participated in technical assistance and training, and developed a combined ASTHO IACLC/CHC 6|18 strategic action plan to increase access to contraception outlining major goals and objectives including to: increase education and awareness to providers regarding LARC; implement One-Key Question (OKQ); increase education and awareness to patients regarding LARC; and explore and develop creative solutions to solve logistical and financial barriers to LARC.

 

DSHS worked with the TCHMB through the Community Health Subcommittee to plan and implement a OKQ Initiative. The Community Health Subcommittee met in October 2017 to discuss options for quality improvement (QI) efforts to support and synergize with state initiatives related to LARC. In December 2017, TCHMB held a QI training with national experts in the IHI Breakthrough Series for the UT facilitation staff, two DSHS MCH staff members, and the TCHMB Community Health Subcommittee Co-chairs. The Subcommittee decided to use the training as a platform to initiate work on One Key Question (OKQ). A teleconference was held in January 2018 with the National Campaign to Prevent Teen and Unplanned Pregnancy to obtain more information about OKQ training, cost implication and implementation. The OKQ QI project driver diagram was created and approved by the subcommittee, and the scope of work and timeline for the project was developed. Community clinics were invited to join the OKQ QI project, and informational materials and a readiness assessment survey was sent to interested clinics.

 

DSHS and UT TCHMB Facilitators worked to arrange for a OKQ training from up to 20 individuals by the OKQ administrative organization, Power to Decide.  The OKQ Training of Trainers (ToT) protocol training for the first cohort of participants took place on July 10, 2018 in Austin. A total of 18 participants from the five enrolled clinics signed up to participate in the OKQ QI project and all five were represented at the training. As part of the training, each participant was required to develop a plan of action for OKQ implementation following the completion of training. Two clinics are located in Houston (Texas Children’s Hospital Center for Children and Women located at Southwest Houston and Greenspoint, Houston), and the rest are each located in Waco (The Heart of Texas Community Health Center), Fort Worth (JPS) and Longview (Zeid Women Health Center). Each clinic nominated a point person to serve on the OKQ QI Collaborative and participate in monthly calls. The first meeting of the TCHMB OKCQ Collaborative was held on August 23, 2018.

 

MCHS provided subject matter expertise to development of the second edition of HHSC’s Texas Long Acting Reversible Contraception (LARC) Toolkit. HHSC published the original toolkit in June 2016 to support providers in increasing availability of LARCs to all Texas women. The Toolkit offers suggestions and resources to support implementation of a policy to make LARCs available to women throughout their reproductive life, including prior to the first pregnancy, during the postpartum period (during the hospital stay or at the postpartum visit), and whenever family planning services are received. After the release of the Toolkit, work began on an updated second edition that is responsive to feedback received from providers and other stakeholders. The second edition, which includes a new section to support providers in addressing LARC myths, was released in June 2018 and distributed to Managed Care Organizations, health care associations, and stakeholders. The revised toolkit is available on the HHSC website at https://hhs.texas.gov/sites/default/files/documents/doing-business-with-hhs/providers/health/women/texas-larc-toolkit.pdf, and also linked to from the provider resources section of the Healthy Texas Women’s website. MCHS staff also contribute to HHSC’s ongoing efforts to increase access to LARCs by participating in bi-monthly LARC stakeholder meetings. These meetings include representation from major LARC manufacturers. HHSC also developed and published a LARC client fact sheet, and updated the Texas Medicaid & Healthcare Partnership with policy clarification about immediate postpartum LARC insertion.

 

MCHS supports creation and strengthening of local perinatal coalitions (formerly HTB Coalitions, and now HTMB Coalitions) in the state through provision of funding and technical assistance. HTMB Coalitions bring together health professionals, local health departments, hospitals, community-based organizations, and stakeholders to create a collaborative network of partners to address perinatal health issues relevant to their community. HTMB Coalitions convene periodically, coordinate health assessments, training, and outreach activities.

 

A new grant period for HTMB Coalitions began in FY18. The HTMB Community Coalition 2018-2022 Program will provide support and technical assistance for local perinatal coalitions in Texas communities with the greatest disparities in infant mortality. Each coalition will carry out a community needs assessment, review and assessment of infant mortality data including Perinatal Periods of Risk mapping, and a strategic planning process to develop, implement and evaluate interventions and programs tailored to its population to address the specific risk factors identified. Specific program support will also be focused on preconception health awareness, community outreach and education.

 

Work began in FY18 to identify a contractor through a competitive Request for Proposal process to provide technical assistance to the HTMB Coalitions and to support the coalitions with evaluation, training, and capacity building for reducing disparities and increasing equity in maternal and infant health.

 

Coalition are located in the counties with the greatest rates of infant mortality and most significant disparity in infant mortality and perinatal health outcomes among racial/ethnic groups. All of the four (4) Healthy Start sites in Texas are part of these Coalitions.
 

• Dallas County – Parkland Health and Hospital System
• Tarrant County – Tarrant County Public Health Department
• McLennan County - Waco-McLennan County Public Health Department
• Smith County – Northeast Texas Health District
• Randall County – City of Amarillo Public Health Department
• Webb County – City of Laredo Health Department
• Jefferson County – City of Port Arthur Public Health Department
• Bexar County – San Antonio Metropolitan Health Department
• Cameron County – City of Brownsville Health Department

 

MCHS worked with partners to expand preconception/inter-conception health and health care outreach efforts across MCHS and stakeholder programming. Visitation to the Someday Starts Now (SSN) bilingual public awareness campaign website, originally released in November 2012, had declined substantially since its original release. In FY17, it was noted that there was concentrated use patterns in web traffic seen in Austin, Waco, Dallas and Fort Worth, TX where MCHS supports HTMB Coalitions. The Coalitions used the SSN platform in their preconception health outreach efforts by adapting SSN materials to their local community, consistently promoting the SSN preconception health messages through their own websites and material development and utilizing the SSN tools and resources in strategic implementation activities. In early 2018, DSHS identified a need to assess and evaluate the campaign for redesign. The campaign is being redesigned to align with current DSHS priorities and research. The redesign aims to improve messaging, materials, and community outreach strategies. Work began to plan and procure formative research to inform development of the new campaign. Research will begin in Fall 2018, and will include review of existing campaigns across the country, key informant interviews, and focus groups with preconception and interconception women, women who experienced a high-risk pregnancy, preconception men, fathers of young children, and health care professionals.

 

FY18 was the final year of the three-year contract between MCHS and the University of North Texas Health Science Center (UNTHSC) for implementation and spread of the Preconception Peer Educator (PPE) program across all nine Texas historically black colleges and universities (HBCUs).  FY18 PPE campus training events included training 12 Wiley College students and three Paul Quinn students.  A #PPEPtalk Training was facilitated by existing peer educators at Prairie View A&M University.  Additionally, five Level 1 Certified Peer Preconception Educators were trained for Huston-Tillotson College and 15 Level 1 Certified Peer Preconception Educators were trained for Wiley College.

 

A weekly #PPEPtalk Texas Weekly Newsletter was launched in September 2017. Two Texas PPE representatives were recruited by the Office of Minority Health Research Coordination (OMHRC) to participate in workgroups, including recruitment of Brandon Hoff, MPH to participate on the OMHRC male curriculum task force and Marcy L. Paul, PhD appointed to OMHRC PPE Expert Panel. Paul Quinn College presented on PPE at the 10th Annual Infant Mortality Awareness Summit in Dallas, a #PPEPtalk Texas Poster session was presented at the 11th National Health Disparities Conference in Philadelphia, PA, a presentation was given at the U.S. Public Health Service Symposium in Dallas, TX in partnership with Wiley College We Care, and a poster was accepted for presentation at the 2018 American Public Health Association annual meeting in San Diego, CA. A #PPEPtalk Texas Networking Workshop, including 39 members from the Waco, Dallas, Laredo, San Antonio, Tarrant County, Port Arthur and Amarillo HTMB Coalitions, previously trained student PPE’s, DSHS staff, and the coordinator from OMHRC was held in August 2018 to share the Texas PPE work to date and to prepare local coalitions for the opportunity to coordinate and oversee PPE programming within their local communities.

 

In the summer of FY17 and first quarter of FY18, MCHS staff participated as members of the CVD and Stroke Plan Steering Committee to provide input into development of the Texas Plan to Reduce Cardiovascular Disease and Stroke Plan. Julie Stagg, MCHS’ Women’s, Maternal, Perinatal and Infant Health Team Lead, lead a workgroup for Goal 1 of the plan, Strategies that Support/ Reinforce Healthy Behavior including members of the Texas Council on Cardiovascular Disease and Stroke. She also participated as a member of the workgroup for Goal 3-Health Systems Interventions. The workgroups met in person, by phone, and via email to review, develop, and propose objectives, metrics, and strategies. The workgroups’ proposals were submitted at the beginning of FY18 to the DSHS Heart Disease and Stroke Program.

 

MCHS continues to share information and subject matter expertise for health care providers and other health care professionals to improve the quality of women’s and maternal preventive care services. Dr. Manda Hall, the Associate Commissioner of CHI, began serving as a consultant for the TMA Committee on Reproductive, Women’s and Perinatal Health in FY18.

 

MCHS collaborated with THSteps Online Provider Education to promote its MCHS-supported suite of continuing education modules focused on preconception and prenatal health. The modules equip health care professionals with knowledge and resources to improve the health of Texas women before and during pregnancy. Hundreds of health care professionals completed modules in FY18. The modules, and the number of health care professionals (HCPs) completing each module in FY18, included: Preconception and Prenatal Health-Overview (869 HCPs); Preconception and Prenatal Health-Managing Chronic Health Issues Before and During Pregnancy (654 HCPs); Preconception and Prenatal Health-Identifying and Intervening in High-Risk Behaviors (836 HCPs); Preconception and Prenatal Health-Cytomegalovirus (352 HCPs); and Preconception and Prenatal Health-Promoting and Maintaining Women’s Oral Health (195 HCPs). MCHS staff supported review, revision, and redesign of the modules as part of the continuing education renewal process. Revised courses that will be available in FY19 will include Preconception Health: Screening and Intervention, Prenatal Health: Screening and Intervention, and Oral Health and Dental Services for Pregnant Women The modules may be accessed at www.txhealthsteps.com. 

 

MCHS staff incorporated mental and emotional health content from the Eunice Kennedy Shriver National Institute of Child Health and Human Development’s Mom’s Mental Health Matters campaign, into the WIC breastfeeding promotion campaign Breastmilk: Every Ounce Counts. The campaign’s website, www.Breastmilkcounts.com, includes information, tips and resources on self-care for women during pregnancy and after birth, information for women and their support networks about identifying the signs of perinatal depression and anxiety, and where to get help. This mental health content can be accessed in the Self-Care: Mental and Emotional Health section and the For Dad, For Grandma, and Friends and Family sections of Every Ounce Counts website at http://www.breastmilkcounts.com/self-care/mental-and-emotional-health/ and http://www.breastmilkcounts.com/teamwork/. This content was viewed 20,999 times in FY18, and information about self-care was viewed 11,500 times.

 

MCHS staff reviewed and provided maternal and infant health subject matter expertise toward revision of the HHSC Postpartum Depression Toolkit.  To help increase awareness and provide additional educational resources on PPD, HHSC first launched the Texas Clinician’s Postpartum Depression Toolkit in May 2017, and updated it in August 2018. This toolkit serves as a resource for Texas clinicians on screening, diagnosis, and treatment of PPD. The toolkit is available at: https://hhs.texas.gov/sites/default/files/documents/doing-business-with-hhs/providers/health/women/tx-clinicians-ppd-toolkit.pdf

 

MCHS-funded Lactation Support Centers (LSCs) in Austin, Dallas, Houston, and McAllen incorporated use of the Edinburgh Postnatal Depression Scale into their intake- and follow-up assessment and referral procedures and workflow. 

 

In September of 2015, DSHS began collaboration with HHSC, including the Center for the Elimination of Disproportionality and Disparities, on the Healthy Families Project (HFP), a women’s health disparities and infant mortality risk reduction project.  The purpose of the HFP is to increase access to family planning services and decrease the risk for infant mortality among Black and Hispanic women by providing communities with very flexible resources they can use to implement customized health care interventions within a health equity awareness framework.  Through data analysis by MCHS, Hidalgo and Smith counties were targeted for pilot projects with a focus on Hispanic women of childbearing age and African American/Black women of childbearing age, respectively. Regional meetings were held in each community to gather information from stakeholders to inform project planning. In Smith County, CHWs were identified as one resource to facilitate early identification of pregnancy, navigation of pregnant women into prenatal care services, and improving continuity of care and postnatal care. Opportunities also exist in provider education and training and incorporation of cultural competency. The Hidalgo County intervention focuses on partnering with the Nurse-Family Partnership to promote education, engagement and evaluation of prenatal care.  At the end of FY16, the HFP began contracting with the University of Texas Health Center at Tyler to facilitate the project and begin implementation of project activities. This work continued through FY18.

 

A team of MCHS staff applied for and was selected to attended the 2018 MCH Strategic Skills Institute in the last week of FY18 to develop strategic skills while addressing a complex public health issue. Specifically, the team wanted to learn and strengthen strategic skills that could be applied to developing an action plan to address racial health disparities in Texas among children and youth with special health care needs (CYSHCN), women, and infants. Goals of the action plan will be to change programmatic culture to integrate an equity framework, create effective initiatives to increase medical home access, and reduce disparities among Texas MCH populations. The team will work together to develop the action plan during FY19.

 

MCHS staff continued to participate in the HHSC Better Birth Outcomes Workgroup that works to improve access to women's preventive, interconception, prenatal, and perinatal health care. The workgroup coordinates efforts to create coordination, collaboration, and alignment on efforts including Healthy Texas Women Coverage; 17-P Progesterone Treatment; Texas NICU Project, Substance Use Disorder Treatment Increases; Mommies Program and Pregnancy and Postpartum Intervention Services Expansion; Neonatal Abstinence Syndrome Training and Research Initiatives; DSRIP Program; Texas Targeted Opioid Response / State Opioid Response;  the Someday Starts Now Campaign; Alliance for Innovation on Maternal Health Maternal Safety Bundles; MMMTF; the HTMB Initiatives; Hospital Levels of Care Designations; Long-Acting Reversible Contraception; Early Elective Deliveries; Healthy Families Initiative; PPD; and Zika Virus Prevention.

 

Regional Pop-Based Services

DSHS staff in 4/5N provided technical support on Reproductive Life Planning through educational support, one-on-one meetings with peer educators, and consultation to the Preconception Peer Educators (PPE) program at Texas College. Staff promoted Human Papilloma Virus (HPV) Awareness through educational posters and pamphlets and provided education to the campus nurse. Staff also delivered a presentation on top health risks for Black males between the ages 18-24 which included dating violence and homicide.  Four college students were chosen as trainers of trainers to replicate the PPE program in their outreach activities. Staff made periodic visits to the campus to provide education and to enhance the program with positive feedback. 

The Leadership Encouraging Activity and Nutrition (LEAN) coalition in Rusk County partnered with PHR 4/5N staff to initiate Walk with a Doc to encourage cardiovascular health and stroke prevention through education, nutrition and physical activity. Walk with a Doc is a walking initiative where a doctor offers educational information such as cardiovascular health, diabetes management, obesity, and nutrition to those attending while leading the group on a walking excursion.

 

DSHS Public Health Region 6/5S staff conducted 18 classes using the March of Dimes Becoming a Mom® (BAM) curriculum in FY 18.  Information was presented to 28 women on prenatal care, nutrition, stress, things to avoid during pregnancy, labor and birth, postpartum care and newborn care. Additional topics included during BAM sessions were: Text4Baby, The Period of Purple Crying, safe sleep, breastfeeding, and car seat safety.

The nurse who provides Hepatitis B training to the childbirth facilities in PHR 8 routinely included women’s health and stressed the importance of postpartum care information in her outreach. PHR 11 staff partnered with Managed Health Care Plans to provide education from the Comenzando Bien/Becoming a Mom curriculum on postpartum care. Staff also promoted Tex4baby, assisted with enrollment in health insurance, and addressed questions on contraception options among 438 moms. 

 

PHR 8 staff combined population-based preconception goals with provision of sexually transmitted infection (STI) testing and treatment, and offered 538 clients counseling on preconception care, contraceptives, and medical home. They also assisted women to find providers they can trust and explored insurance options with clients. PHR 8 staff also partnered community organizations such as the Christian Women’s Job Corp, schools and after-school programs, like Boys and Girls Clubs to deliver presentations on accessing preconception care, establishing a medical home, contraception, and STI prevention. Life Planning Tools were promoted during 10 of these presentations in FY 18. Community collaborations are especially common in border areas of PHR 8 where staff participate in the Tri-National Council and Office of Border Public Health activities. Del Rio staff presented on preconception care and contraceptives monthly to participants in the Ama Tu Corazón heart health and wellness community project. In Seguin, the nurse promoted preconception and contraception during STI clinics.

PHR 11 staff partnered with Cameron County Mental Health Task Force (CCMHTF) to bring awareness of mental health services in the county. Staff assisted the Task Force to offer scholarships to two high school students and two college students who plan to obtain degrees in the mental health field and who plan to provide services in the Cameron County area.  Staff also worked on the “End the Stigma” campaign, posting billboards in the Cameron County on mental health awareness and recruited social work interns to conduct outreach information regarding mental health services and CCMHTF members’ services at health fairs.

 

Objective 4: By 2020, increase by 10% the proportion of maternal mortality deaths reviewed by the Texas Maternal Mortality and Morbidity Task Force.   

 

The Texas MMMTF, with the support of MCHS, continued to review cases of maternal mortality to gain a more in-depth picture of the causes and risk factors to make recommendations for prevention. The 85th Texas Legislature 1st Called Session (85th (1)) instituted several new legislative charges through Senate Bill 17 (SB1), that build upon past and current efforts to decrease maternal mortality and severe morbidity. Among other changes, the bill amended Texas Health and Safety Code Chapter 34 to extend the MMMTF’s charge to continue its work through September 1, 2023, and expanded the scope and responsibilities of the MMMTF to study other state's efforts to reduce pregnancy-related deaths, study trends, rates, and disparities in pregnancy-related deaths and severe maternal morbidity, and implement maternal safety initiatives to inform best practices for maternal health and safety in Texas. In addition, the MMMTF required membership composition was expanded from 15 to 17 multi-disciplinary members, adding a nurse specializing in labor and delivery and a physician specializing in critical care.

 

The DSHS commissioner appointed two new MMMTF members in July 2018: Dr. Lavannya Pandit, a physician specializing in critical care and Dr. Christina Murphey, a nurse specializing in labor and delivery.  In addition, Dr. Manda Hall, Associate Commissioner of CHI was appointed to serve as the DSHS representative on the MMMTF.

 

MCHS worked throughout FY18 with the University of North Texas (UNT) to ensure high quality case redaction and case abstraction reporting for MMMTF review. MCHS program staff worked to coordinate strategies to support UNT’s internal quality assurance process and met weekly with UNT program staff to optimize contract efficiencies and ensure completion of 15-25 cases per quarter for review by the MMMTF. MCHS program staff provided ongoing subject matter expertise for additional quality assurance oversight and feedback and worked to connect abstractors with up-to- date resources from the Review to Action website, a resource developed by the Association of Maternal and Child Health Programs (AMCHP) in partnership with the CDC Foundation and the CDC Division of Reproductive Health. To ensure consistent additional expertise for critical care cases, UNT began the process of recruiting and hiring a critical care nurse to provide ongoing expertise and consultation services for reporting of complex medical and critical care cases. The UNT contract was renewed July 2018 to continue redaction and abstraction services for the MMMTF.

 

The MMMTF met in-person quarterly and the MMMTF case call teams met by phone monthly for preliminary review and analysis of each case. Quarterly MMMTF meetings included programmatic updates from DSHS programs relevant to the MMMTF, presentation of data on severe maternal morbidity and mortality trends in Texas, refinement of MMMTF processes, and closed session confidential case review.

 

The MMMTF completed the review of the 89 cases of maternal mortality comprising the 2012 case cohort in March of 2018, and began reviewing cases for 2013. Findings from MMMTF case review for the 2012 cohort revealed that nearly 40 percent of maternal mortality cases reviewed were identified as pregnancy-related and leading causes of these deaths included cardiovascular and coronary conditions, obstetric hemorrhage, infection/sepsis, and cardiomyopathy.  The MMMTF determined that there was at least some chance for preventability in almost 80 percent of these pregnancy-related deaths and a complex interaction of personal, provider, facility, systems and community factors contributed to maternal mortality. 

In addition to providing ongoing support for MMMTF operations, MCHS continued providing data analysis of statewide trends for maternal mortality, trends for the most at-risk populations, and statewide trends for severe maternal morbidity. Based on the results of a timeline analysis of data trends among identified maternal mortality deaths from 2012 – 2015, it was determined that the majority of deaths occurred more than 60 days postpartum with drug overdose being the leading cause of maternal mortality among Texas women dying from delivery to 365 days. Opioids, either alone or in combination with other drugs, were associated with more than half (58 percent) of these deaths and most (77 percent) of drug overdoses deaths involved a combination of more than one drug.

When compared with other races and ethnicities, Black women continued to be at greatest risk for maternal mortality, with this increased risk existing regardless of income, education, marital status, or other health factors. In review of data related to Severe Maternal Morbidity, obstetric hemorrhage was the leading cause of severe maternal morbidity in 2014, and Black women were at a higher risk of severe maternal morbidity involving obstetric hemorrhage.

 

In April of 2018, researchers in MCH Epidemiology published a study entitled Identifying Maternal Deaths in Texas Using an Enhanced Method, 2012 that found the number of deaths occurring during pregnancy or within 42 days postpartum in Texas in 2012 was actually less than half the number reported in national statistics. The peer-reviewed research, published in the journal Obstetrics & Gynecology, determined there were 56 deaths among Texas residents that were confirmed to have occurred during pregnancy or within 42 days postpartum compared with 147 reported using the standard method. Researchers attributed this partly due to errors associated with death certificate coding.

 

The findings from the reviews of maternal mortality cases and data trend analysis informed the  Maternal Mortality and Morbidity Task Force and DSHS Joint Biennial Report, 2018  that was submitted to the Texas legislature in August 2018. The MMMTF determined through case review that four leading causes of pregnancy-related death among identified cases in the 2012 case cohort accounted for 76 percent of identified pregnancy-related deaths. These leading causes of pregnancy-related death were cardiovascular and coronary conditions, obstetric hemorrhage, infection or sepsis, and cardiomyopathy.

 

MMMTF recommendations included in the report were to:

1) Increase access to health services during the year after pregnancy and throughout the interconception period to improve the health of women, facilitate continuity of care, enable effective care transitions, and promote safe birth spacing. 2) Enhance screening and appropriate referral for maternal risk conditions. 3) Prioritize care coordination and management for pregnant and postpartum women. 4) Promote a culture of safety and high reliability through implementation of best practices in birthing facilities. 5) Identify or develop and implement programs to reduce maternal mortality from cardiovascular and coronary conditions, cardiomyopathy and infection. 6) Improve postpartum care management and discharge education for patients and families. 7) Increase maternal health programming to target high-risk populations, especially Black women. 8) Initiate public awareness campaigns to promote health enhancing behaviors. 9) Champion integrated care models combining physical and behavioral health services for women and families. 10) Support strategies to improve the maternal mortality review process.

 

Work continued to improve the quality of death certificate data to better identify maternal mortality in Texas at a system-level. Senate Bill 17, which passed in the 85th Texas Legislative Session, included the requirement to study the process and procedures of collecting cause of death information including any challenges relating to maternal mortality, and to submit a legislative report by December of each even numbered year and will be submitted in early FY19.

 

DSHS may examine: issues relating to the quality of death information collected, including the accuracy and completeness of the information; the role of medical certifiers in death information collection; the perception of individuals collecting death information regarding the information’s integrity; required training for individuals collecting death information; and structural, procedural, and technological issues of collecting the information.

 

In their study, DSHS is directed to examine national standards and may convene a panel of experts to advise the department, and work with the Maternal Mortality and Morbidity Task Force in developing recommendations. The MMMTF provided expert consultation to the State Registrar about challenges related to maternal mortality and morbidity review and completion of the death certificate and DSHS asked the MMMTF for recommendations to improve the death registration process as it relates to maternal mortality.

 

DSHS continued the process of replacing the existing electronic system for registering and collecting birth, death, fetal death, marriage, and divorce records in Texas, known as the Texas Electronic Registrar, with a new electronic system, Texas Electronic Vital Events Registrar (TxEVER), to be launched January 1, 2019.  Features will include a verification of the pregnancy check-box to improve the quality of death certificate data, and hence, the identification of maternal mortality in Texas.  

  

DSHS and MMMTF members continued to contribute to and learn from national conversations about reducing maternal mortality and severe maternal morbidity. The MMMTF Chair, Dr. Lisa Hollier, participated in the CDC Grand Rounds “Meeting the Challenges of Measuring and Preventing Maternal Mortality in the United States” in November 2017. The Grand Rounds is archived and available for viewing at https://www.cdc.gov/grand-rounds/pp/2017/20171114-maternal-mortality.html. The Associate Commissioner of CHI, Dr. Manda Hall, participated in the invitation only HRSA Maternal Mortality Summit-Promising Global Practices to Improve Maternal Health Outcomes, in June, 2018. Plenaries from the Summit are available via webcast at https://www.hrsa.gov/maternal-mortality/2018-summit.html, and a technical report of the proceedings is available online at: https://www.hrsa.gov/sites/default/files/hrsa/maternal-mortality/Maternal-Mortality-Technical-Report.pdf. The Association for State and Territorial Health Officials (ASTHO) worked with DSHS to develop a state highlight document about its efforts to address maternal mortality. The document will be disseminated on the ASTHO website in FY19.

 

Challenges / Opportunities: The SSN public awareness campaign was not active during FY18, thus limiting outreach efforts to promote preconception and interconception health. There is significant momentum in Texas to implement MMMTF recommendations and improve maternal health and safety, including through engagement of healthcare professionals and other key stakeholders to implement AIM maternal safety bundles through TexasAIM. The new Healthy Texas Mothers and Babies Framework supports strategic alignment across programs to improve health outcomes for women and mothers. Identification of a new state women’s and maternal health performance measure will further support programmatic alignment and will better reflect impact of state efforts to improve women’s and maternal health.

[1] Broussard DL, Sappenfield WB, Fussman C, Kroelinger CD, Grigorescu V. Core state preconception health indicators: a voluntary, multi-state selection process.

 Matern Child Health J. 2011;15(2):158-68.

[2] CSTE, Core State Preconception Health Indicators, General Health Status Domain, Self Rated Health. September 2009. Avialable online at https://www.cste.org/page/PreconIndicators