The Florida Department of Health (Department) identified the following priority needs for women/maternal health during the annual reporting year, as reflected in the State Action Plan Table: 

 

• Improve access to health care for women to improve preconception and interconception health, specifically women who face significant barriers to better health (National Performance Measure [NPM] 1: Percent of women, ages 18 through 44, with a preventive medical visit in the past year).
• Promote tobacco cessation to reduce adverse birth outcomes and secondhand smoke exposure to children (NPM 14.1: Percent of women who smoke during pregnancy).
• Reduce maternal mortality and morbidity (NPM 14.1: Percent of women who smoke during pregnancy).

 

The Department reassessed, updated, and aligned the strategies and objectives to address the state priority to improve access to health care for women to improve preconception and interconception health, specifically women who face significant barriers to better health. The NPM selected for this priority is NPM 1: Percent of women with a past year preventive medical visit. The realignment incorporates the Department’s State Health Improvement Plan (SHIP), Agency Strategic Plan (ASP), and Title V Maternal and Child Health (MCH) Block Grant strategies and objectives, providing a universal approach to addressing women’s health across the lifespan. The Department has also taken steps to revise current policies and technical assistance guidelines for county health departments (CHD) to incorporate the identification of barriers for women in their care who may have arrived at the CHD for service but did not have an annual well woman visit in prior years. This engagement strategy can help to identify additional service needs to ensure women receive an annual preventative medical visit.

 

In 2021, a total of 31.2 percent of women aged 18-44 in Florida did not have a routine checkup within the last year (Behavioral Risk Factor Surveillance System [BRFSS]). In 2021, a total of 35.0 percent of non-Hispanic white women, 19.6 percent of non-Hispanic Black women, and 32.9 percent of Hispanic women did not have a routine checkup in the last year (BRFSS, 2021).

 

The Department takes a comprehensive approach to women’s health care. There are a variety of contributing factors that affect a woman’s health such as genetic, social, cultural, economic, and environmental conditions in which she lives. As women move from childhood into early adulthood, an increasing number of women of childbearing age already suffer from chronic conditions or use substances that can adversely affect pregnancy outcomes, leading to miscarriage, infant death, birth defects, or other complications for mothers and infants. According to the 2021 Pregnancy Risk Assessment Monitoring System (PRAMS), among women aged 14-47 who recently gave birth in Florida, approximately 8.6 percent had asthma before pregnancy, 6.0 percent had hypertension before pregnancy, 1.9 percent had diabetes before pregnancy, 14.7 percent had depression before pregnancy, 53.0 percent were overweight or obese before pregnancy, 4.9 percent were underweight before pregnancy, and 9.0 percent smoked during the three months before pregnancy. Additionally, 24.0 percent of women aged 14-47 received information about how to prepare for a healthy pregnancy and baby prior to pregnancy. Furthermore, according to Florida’s Community Health Assessment Resource Tool Set (FL CHARTS), the number of syphilis cases among women aged 15-44 years increased from 1,768 in 2020 to 2,582 in 2021.

 

In 1991, the Florida Legislature enacted Healthy Start legislation, one of the most comprehensive MCH initiatives in the nation (Section 383.14, Florida Statutes). This legislation requires the Department to develop a universal screening process that includes a risk assessment instrument to identify pregnant women who are at risk for a preterm birth or other high-risk condition(s). Upon its enactment, the risk screen was developed by the Department in collaboration with the Healthy Start Advisory committee, which included representatives from Florida’s county health departments (CHDs), universities, the legislature, and the private health care sector. The primary maternal health care provider completes the risk screen and reports the results so that the woman is referred to appropriate health, education, and social services. The risk screen assesses risk factors for adverse health outcomes in order to refer identified individuals to appropriate services to best meet their needs. In Fiscal Year (FY) 22-23, 105,230 pregnant women were screened for potential risk of a preterm birth or other high-risk condition(s). If the screen indicates a pregnant woman is at risk, she is referred to Florida’s Coordinated Intake and Referral system, known as CONNECT. This serves as a single point of entry into home visiting programs in Florida and provides families with the opportunity to learn about and select the home visiting program that best fits their needs.

 

The current prenatal risk screening process is paper-driven and has not changed since its implementation in 1992. An electronic system will be more efficient and provide “real-time” assessment and referral, resulting in quicker identification and linkage to services and supports. Title V MCH Block Grant funds were used during the reporting year to continue development of an electronic screening system. In collaboration with the Department’s Division of Disease Control and Health Protection, the MCH Section conducted user acceptance testing (UAT) of the electronic screening system. During the UAT, the MCH Section was provided the opportunity to review the testing environment and receive a demonstration on the electronic screening process. Project staff in the MCH Section were assigned specific user roles in order to test the electronic process and provide feedback to the developers. Currently, the testing environment provides obstetric providers and their staff the ability to schedule prenatal risk screening appointments, send electronic versions of the screening tool to clients, and track the status of the screening utilizing the Prenatal Risk Screening Dashboard. Additionally, in the testing environment, MCH staff users have the ability to review and approve facility requests, and the ability to generate reports that can easily identify delays. Next steps for the electronic screening system includes partnering with identified providers to pilot the system for further feedback before implementation.

 

The Department’s MCH Section contracts with 32 non-profit community agencies, known as Healthy Start Coalitions (Coalitions), for Florida’s Healthy Start program. Coalitions establish private and public partnerships that include state and local government, community organizations, and MCH providers, for the provision of coordinated community-based prenatal and infant health care. Florida’s Heathy Start program serves pregnant women, fathers, and infants from birth, up to age three, who score at-risk on the universal prenatal or infant risk screen. Self-referrals and referrals provided by health care providers and other agencies are also accepted. The priorities of Florida’s Healthy Start program are:

 

• Reduce the occurrence of infant deaths;
• Reduce the number of low birth weight and preterm births;
• Reduce the occurrence of maternal deaths; and
• Improve infant and toddler developmental outcomes.

 

Services provided by Florida’s Healthy Start program include: 

 

• Interconception education and counseling;
• Breastfeeding education and support;
• Care coordination;
• Childbirth education;
• Smoking cessation;
• Health and parenting education;
• Education, counseling, and referrals for access to care; and
• Nutrition counseling.

 

Florida’s Healthy Start program implements a coordinated intake and referral process for all home visiting programs in the state. The process, referred to as CONNECT, provides a one-stop entry point for services such as education and support for childbirth, newborn care, parenting skills, child development, food and nutrition, mental health, and financial self-sufficiency. In FY 22-23, CONNECT received 282,152 referrals for home visiting services (173,933 for prenatal clients and 108,219 for infant and children). During the same year, there were 70,859 prenatal home visiting services provided to families that chose the Healthy Start program. There were 86,526 home visiting services provided to infants and children enrolled in the Healthy Start program.

 

The MCH Section continued to adopt, implement, and integrate evidence-based practices (EBPs) into the Healthy Start program to address issues that affect the health of women, fathers, and infants. Florida’s Healthy Start program uses the Department’s Health Management System and the Coalition’s Well Families Data System to track the type and number of services provided to participants for data collection purposes. To improve these efforts and enhance data collection practices that increase the effectiveness of services provided statewide, the MCH Section worked in collaboration with procured consultants (ISF, Inc.) to continue the assessment of provider outcome performance objectives and ongoing quality improvement processes. During FY 22-23, ISF, Inc. explored how Florida’s Healthy Start program currently operates with regards to the performance management system and outcome measures, EBP designation, data collection, and organizational capacity. Utilizing this information, and information obtained through meetings with the Department’s MCH Section, the Florida Association of Healthy Start Coalitions (FAHSC), as well as public documentation related to best practices in performance management and EBPs, ISF, Inc. conducted gap analyses to provide recommendations for holistic programmatic improvement and monitoring. Completing the assessment allows the Department’s MCH Section to better measure and report the impact of Florida’s Healthy Start program.

 

The Department uses Title V MCH Block Grant funds to provide interconception care (ICC), which is not reimbursable by Medicaid, through Florida’s Healthy Start program. The ICC services are available to all women who participate in the program. During the prenatal participant’s third trimester, Coalitions ask participants, “Would you like to become pregnant in the next year?” Based on her response, the participant will complete either the Show Your Love Baby-to-Be plan, or the Show Your Love Healthy Woman plan. The goals she sets in her reproductive life plan will be the guiding factor for the curricular education provided during face-to-face visits.

 

In addition to contracting with Coalitions, the MCH Section contracted with, and provided oversight of, the following contracts to address maternal and women’s health priorities:

 

• Fetal Infant Mortality Review (FIMR) activities through all 32 Coalitions for implementation of FIMR services to address the behavioral, environmental, and structural processes that may impact fetal and infant deaths, to learn more about why infants die and to propose and implement recommendations for change. These contracts were funded by the Title V MCH Block Grant until July of 2022 at which point state general revenue funds in the amount of $1,602,000 began to be used annually after 2022 legislation.
• The Family Healthline is a statewide, toll-free hotline that offers counseling information and community referrals about pregnancy, infant and toddler issues. The goal of the hotline is to improve the health status of Florida's pregnant women and their children by providing callers with information on helpful community resources and answering basic questions about pregnancy, breastfeeding, childbirth education and other pregnancy-related concerns. The Family Healthline is available in English, Spanish, and Haitian Creole. The contract is funded with Title V MCH Block Grant funds, state general revenue, and other funding sources.
• The Ounce of Prevention Fund of Florida funds and evaluates innovative prevention programs for at-risk children and families. They provide awareness of MCH initiatives such as safe sleep, Reach Out and Read, and Count the Kicks campaigns throughout the state, with a focus on television and radio advertisements. This contract is funded through state general revenue funds.
• The Florida Association of Healthy Start Coalitions to implement the Nurse Family Partnership Program in four counties of Florida (Brevard, Hillsborough, Orange, and Miami-Dade, respectively). This contract is funded through state general revenue funds.
• A Safe Haven for Newborns promotes the Safe Haven Law through a statewide outdoor advertising and community outreach campaign. This includes the use of materials that educate and inform the public about where to obtain support and the identification of safe venues for parents considering surrendering their infants. This contract is funded through state general revenue funds.
• The Florida Pregnancy Care Network implements the Florida Pregnancy Support Services Program (FPSSP). The program is a network of nonprofit pregnancy support centers that provide support and assistance to women, men, and their families primarily faced with unexpected pregnancies. Services include free pregnancy tests, peer counseling, and referrals. Most of the centers offer classes on pregnancy, childbirth, parenting, and personal finance management. Wellness services are also provided that include, but are not limited to, smoking cessation counseling, sexually transmitted disease testing, blood pressure screenings, diabetes screenings, and pap smears. Services were expanded in FY 23-24 to include nonmedical assistance that improves pregnancy or the parenting situation of families, including, but not limited to, clothing, car seats, cribs, formula, and diapers. The program is governed through section 381.96, Florida Statues, and funded through state general revenue funds.

 

The Department implements the statewide Florida Healthy Babies (FHB) program through all 67 CHDs. The purpose of the program is to ensure all counties have an MCH infrastructure in place to assure women and children have access to health care; and address broad social, economic, cultural, and environmental factors within their respective counties. The MCH priority areas for the FHB program are maternal mortality, infant mortality, well woman care, prevention of unexpected pregnancy, dental and oral health, and access to care. These priority areas were identified based on the Statewide MCH Needs Assessment, SHIP, ASP, MCH Program National Performance Measures, and Healthy People 2030. Each CHD submits an annual workplan detailing their selected priority areas and evidence-based programs and initiatives they plan to implement over the year. The workplan also includes the data and justification for the identified priority areas. Quarterly and annual reports summarizing the status of activities, updated data, and expenditures are submitted and analyzed by the Department. The Department is currently exploring technology options that can track and report FHB program outcomes at the county and state level. Title V MCH Block Grant funds are utilized to support the FHB program.

 

In FY 22-23, the 67 CHDs chose priority areas that were relevant for their county. Infant mortality was a great focal point for 50 counties. Other priorities took precedence such as unexpected pregnancy prevention/teen pregnancy prevention (37 counties), broad social/economic/cultural/environmental factors (27 counties), and dental and or oral health (25 counties). Well woman care (19 counties) and maternal mortality (4 counties) followed. The CHDs will be developing new workplans for FY 23-24 and are looking to explore and brainstorm new priority areas. 

 

The Department is committed to helping Florida residents reach their fullest health potential by living tobacco free lives through prioritization of NPM 14.1. Promoting tobacco cessation to reduce adverse birth outcomes and secondhand smoke exposure to children remains a priority for the Department. The Department selected NPM 14.1: Percent of women who smoke during pregnancy to address this priority.

 

In Florida, the percent of state resident live births for women who smoked during pregnancy was 2.9 in 2021 (FL CHARTS, 2021). However, the range by county varies, with Miami Dade’s rate being 0.3 while Dixie County’s rate is 15.3. Ten counties have percentages between 10.0 and 15.3 and thirteen additional counties have percentages between 7.2 and 9.9. The rate of state resident live births for women who smoked during pregnancy decreased by 21.6 percent from 2020 to 2021 (FL CHARTS, 2020; FL CHARTS, 2021). Smoking during pregnancy increases the risk of miscarriage and certain birth defects such as cleft lip or cleft palate. It can also cause premature birth and low birth weight and is a risk factor for sudden infant death syndrome (SIDS). Secondhand smoke exposure doubles an infant’s risk of SIDS and increases a child’s risk of respiratory infections and common ear infections. Children with asthma who are exposed to secondhand smoke are likely to experience more frequent and more severe attacks, which can put their lives in danger. 

 

The Smoking Cessation Reduction in Pregnancy Treatment (SCRIPT) curriculum, an evidence-based program for smoking cessation, has been incorporated in the Healthy Start program and coding specifications for smoking cessation have been revised to measure SCRIPT implementation. From the time SCRIPT was adopted as the tobacco cessation counseling intervention, provider training has been revised based on feedback from staff. In FY 22-23, 1,812 clients identified as current tobacco smokers from 17,961 tobacco screening forms from the Healthy Start program. Out of the 1,812 clients that identified as tobacco users, all were referred to Florida Quitline, 24 (1.3%) were referred to a local cessation counselor, 39 (2.2%) were referred to SCRIPT, 81 (4.5%) were referred to Let’s Talk About Tobacco, and no referral was provided for 763 clients. The Department is working with the Healthy Start program to identify opportunities to increase referrals to clients that participate in SCRIPT.  

 

The Tobacco Free Florida program brings awareness to the dangers of tobacco, while also providing free resources that help tens of thousands of Floridians to quit. The program has made remarkable progress in helping reduce tobacco use across the state. The Department also continued to promote Tobacco Free Florida’s Quit Your Way which allows participants to choose cessation services via phone coaching, digital coaching, or group coaching. Family planning providers across the state continued to screen clients for tobacco use and provide information on the Quit Your Way program.

 

The Florida Quitline is available 24 hours a day, seven days a week, offering telephone counseling in English, Spanish, and other languages through a translation service. Pregnant tobacco users who are ready to quit receive expanded services including 10 counseling sessions, and with a medical release they may receive a four-week starter kit of nicotine replacement therapy.

 

Tobacco users also accessed resources to help them quit through Florida’s Web Coach online service. Tobacco users can plan their quit date and even receive nicotine replacement therapy through the free online service.

Additionally, the Tobacco Free Moms and Babies Collaborative, established in 2019, and continued in FY 22-23, identified counties with elevated smoking rates and engaged them in targeted smoking cessation efforts. The Bureau of Tobacco Free Florida provides dedicated funding to these 26 identified counties and conducts periodic technical assistance calls to support their efforts. This initiative has successfully connected tobacco prevention staff with MCH staff to enhance tobacco prevention and cessation efforts. 

 

As a continuing component of FHB program, the MCH Section collaborated with the Bureau of Tobacco Free Florida on the Tobacco Free Moms and Babies Collaborative to expand existing tobacco cessation activities. The Bureau of Tobacco Free Florida provided additional funding to CHDs that could be used for staffing, education materials, and training that support cessation objectives.

 

Florida continues to demonstrate its ongoing commitment to support and promote tobacco use cessation through action in 2022 legislation. Found in Section 381.84, F.S., are additional steps that Florida will take to educate individuals, particularly pregnant women and women that may become pregnant to discourage the use of tobacco products. This campaign will include a public internet resource center for materials and information regarding tobacco use education, prevention, and cessation. The web address will be provided by all public and private educational institutions from kindergarten to university. This campaign will provide cessation programs, counseling, and treatment that includes a statewide toll-free cessation service.

 

The Department’s MCH Section is focused on improving the health of women of childbearing age in Florida, as well as improving maternal and infant birth outcomes by reducing maternal mortality. According to the Florida Maternal Mortality Review Committee, Florida’s total pregnancy-related mortality ratio (PRMR) increased from 21.0 in 2020 to 28.7 deaths per 100,000 live births in 2021. The overall leading causes of pregnancy-related deaths in 2021 were infection, hemorrhage, hypertensive disorder, cardiomyopathy, and amniotic fluid embolism. The leading causes of pregnancy-related deaths for non-Hispanic Black women in 2021 were infection, hemorrhage, and hypertensive disorder, thrombotic embolism, cardiomyopathy, and cerebrovascular accident; for non-Hispanic White women, the leading causes were infection, hemorrhage, and hypertensive disorder; for Hispanic women, the leading causes of death were infection, hemorrhage, amniotic fluid embolism, hypertensive disorder, and cardiomyopathy. In 2021, the leading preventable causes of death were infection, hypertensive disorder, and hemorrhage. Based on a preliminary review of 2022 cases reviewed to date, the state expects the PRMR to decrease in next year’s annual application.

 

Since 1996, the Florida MMRC has been operating as a formal review of maternal mortality in the state. The administrative functions, infrastructure, and medical record abstraction for Florida’s MMRC process is supported through the Title V MCH Block Grant. The Florida MMRC seeks to explain gaps in care, identify systemic service delivery issues, and make recommendations to facilitate improvements in the overall systems of care. The Florida MMRC involves data collection and examination of maternal deaths to promote evidence-based actions for individual behavior changes, health care system improvements, and prevention of pregnancy-related deaths. The Department uses Florida MMRC data, including contributing factors and care improvement recommendations, to prioritize areas for quality improvement. The Florida MMRC process begins by identifying all pregnancy-associated deaths within a specified period.

 

Florida MMRC abstractors capture information from the medical, prenatal, labor and delivery, postpartum, emergency room, the Department’s prenatal risk screen, social service, care coordination, medical examiner, and terminal events records. The Florida MMRC meets quarterly to review and discuss the abstracted cases and concludes with a determination that each case is either pregnancy-related or not pregnancy-related. The Florida MMRC provided recommendations to the Department last year to improve the health care system and the quality of outcomes for all women. Examples of recommendations and actions based on Florida MMRC findings include establishing evidence-based initiatives that promote preconception health, screening for depression, screening for domestic violence, and the reduction of preterm births as well as promoting patient education to increase awareness of preventable risk factors and improve access to family planning, prenatal, and primary care services.

 

The Florida MMRC operates as a one-year retrospective review. Deaths to pregnant and postpartum women that occurred in 2020 were abstracted and reviewed by the Florida MMRC in 2021. The Florida MMRC data analyst completed the analysis of the 2020 maternal mortality data in 2022. The methods used included descriptive analysis for quantitative, and theme identification for qualitative analysis. In 2022, the data linkage process identified 298 Florida resident pregnancy-associated deaths from 2021. The Florida MMRC case selection subcommittee selected 76 cases to abstract and review. The multidisciplinary Florida MMRC met quarterly to thoroughly discuss each case, determine pregnancy-relatedness, identify contributing factors, assess preventability, and create recommendations for prevention. Upon review of the 76 selected cases, the Florida MMRC determined 62 (82%) were pregnancy-related deaths. Of the 62 pregnancy-related cases, 49 (79%) were preventable at either the individual, provider, facility, care system, or community level.

 

Opioid use in pregnancy has increased in recent years, paralleling the epidemic observed in the general population. According to a 2021 study published in the Journal of the American Medical Association, the rate of Florida maternal opioid-related diagnoses identified at admission for delivery almost doubled from 3.9 per 1,000 deliveries in 2010 to 7.8 in 2017. According to the Centers for Disease Control and Prevention (CDC) Pregnancy Risk Assessment Monitoring System (PRAMS, 2020), 7 percent of women reported using prescription opioids in pregnancy, and one in five of those women reported misuse. The Department completed the analysis of the 2020 Florida MMRC data in 2022. The Florida MMRC data is used to develop and distribute Urgent Maternal Mortality Messages (Message) on topics that are relevant to preventing maternal deaths to professional, clinical, and community organizations. The Florida MMRC periodically reviews and updates the Messages to keep aligned with any relevant changes in clinical guidelines. In 2022, the Department, in partnership with the FPQC, began working to update the Message on SUD, including opioid use during pregnancy. The Message includes Florida MMRC recommendations for prenatal care and screening, as well as recommendations for referrals and treatment. A recommendation was added to the Message for providers to engage in the new Coordinated Opioid Recovery (CORE) Network. In 2022, The Department partnered with the Department of Children and Families (DCF) and the Agency for Health Care Administration (AHCA) to pilot a substance abuse and recovery network aimed to disrupt the opioid epidemic in several Florida counties. CORE is a comprehensive approach that expands every aspect of overdose response and treats all primary and secondary impacts of SUD. CORE Network’s Connected Care Model aims to eliminate the stigma of addiction and treat SUD as a disease, with the same level of continuous care. The CORE network ensures patients are stabilized and treated for coexisting medical and mental health conditions. Patients may be referred for dental care, primary care, psychiatric evaluation, maternal care, and social support services. Social support services can address career training, housing, or food insecurity.

 

The Department’s partnership with the FPQC also resulted in the establishment of a workgroup to examine barriers and challenges that reduced access to Medication Assisted Treatment for pregnant and postpartum women with OUD. A series of listening sessions with obstetric providers identified training as an area of need to improve the number of obstetric providers who were willing and able to treat women for OUD, including normalizing conversations about SUD and increasing the number of providers trained in screening motivational interviewing, and treatment women with OUD.
 

To identify neonatal abstinence syndrome (NAS) cases, the Department currently uses a passive case ascertainment methodology that relies on linked administrative datasets and diagnostic codes indicative of NAS. First, birth certificate records from the Bureau of Vital Statistics are linked to the infant’s birth hospitalization record, which is provided as part of quarterly submission of inpatient hospital discharge data by hospitals to the AHCA. Each discharge record includes International Classification of Diseases, Clinical Modification diagnosis codes documented during the hospital encounter. Prevalence rates of NAS in Florida increased from 25.8 to 67.3 per 10,000 live births from 2008-2015. After 2015, the prevalence of NAS decreased to 53.5 per 10,000 live births in 2020. This prevalence rate equates to an average of 1,400 cases of NAS per year in Florida since 2011. According to data from the Healthcare Cost and Utilization Project, the most recent NAS rate for the nation was 6.3 per 1,000 newborn hospitalizations in 2020 compared with the Florida 2020 rate of 6.3 per 1,000 newborn hospitalizations.

 

The Florida MMRC also supported implementation of an innovative maternal mental health initiative called the Florida Behavioral (BH) Improving Maternal and Pediatric Access to Care and Treatment (IMPACT) program. This is a collaborative initiative by the Department, Florida State University College of Medicine, University of Florida (UF), and the Florida Maternal Mental Health Collaborative. The goal of the Florida BH IMPACT program is to improve the identification and treatment of pregnant and postpartum women who experience behavioral health and SUDs in the state of Florida. The program currently operates and engages and trains providers throughout the state. The Florida BH IMPACT program promotes MCH by building the capacity of health care providers through professional development, expert consultation and support, and dissemination of best practices. The program has five main components: 1. Access for patients and clinicians to comprehensive referral resources and services in the region for mental health and substance use. 2. Clinician access to telephone consultation with a psychiatrist during normal business hours. 3. The use of brief, valid screening tools for depression, anxiety, and substance use. 4. Tracking and reporting of information and measures related to the programs processes and outcomes. 5. Training of obstetric providers in best practice maternal behavioral health screening, treatment, and risk issues. The BH IMPACT program is supported with funds received from the Health Resources and Services Administration grant.

 

During the reporting period, the Department received the CDC grant, “Preventing Maternal Deaths: Supporting Maternal Mortality Review Committees”. The purpose of the grant is to support agencies and organizations that coordinate and manage MMRCs to identify and characterize maternal deaths for identifying prevention opportunities. The grant period is September 30, 2021, through September 29, 2024. Florida is using the grant to support the following activities:

 

• Expand maternal mortality reviews in mental health cases, such as suicide and substance abuse deaths.
• Develop an outreach campaign that empowers pregnant and postpartum women to be self-advocates.
• Develop a peer-to-peer, comprehensive outreach campaign for health care providers on the 2020 five leading preventable causes of pregnancy-related deaths.
• Contract with a licensed clinical social worker to develop and implement an informant interview process based on guidance from the CDC, during case abstraction.
• Contract with a data analyst to identify system improvement to correct inconsistencies on death certificates (i.e., check box, ICD code errors).

In 2022, the Florida MMRC formed a Mental Health Subcommittee to address the pregnancy-associated mental health deaths related to substance use and suicide. The Mental Health Subcommittee reviewed abstracted suicide deaths and deaths involving substance use to assess pregnancy-relatedness and to identify common themes and areas for care improvement.

 

In alignment with the American College of Obstetricians and Gynecologists (ACOG) Committee Opinion Number 736, the Florida MMRC recommended that postpartum care be an ongoing process rather than a single encounter. As a result, the Department funded a project using Title V MCH Block Grant funds for early and ongoing postpartum screening through UF. The Department provided financial and technical assistance to UF to develop and pilot the UF Gator MOMitor™ smart phone application (app). The app provides daily risk assessments of women up to six weeks postpartum by their health care team, with the goal to reduce maternal morbidity and mortality. The app continues to expand and pilot additional interventions for participants seen at the UF Health Shands Hospital in Alachua County. The app presents users with assigned questions based on their identified risk factors. These questions are designed using ecological momentary assessment technology, which offers repeated sampling of participants’ experiences and possible symptoms in real time. Questions are created using a focused approach to assess participants and notify the health care team based upon the user’s response. Customized risk assessment plans for each participant are created prior to discharge from UF Shands to identify relevant screening questions based on individual risk factors and health conditions. However, every woman participating in the pilot is screened for postpartum depression. Other conditions the app monitors include hypertension, surgical wound infection, and diabetes. Women who experience hypertension are also provided a blood pressure cuff for home monitoring free of charge. This past year, the project was expanded to include monitoring of women that are breastfeeding and those diagnosed with cardiovascular disease. Women diagnosed with cardiovascular disease receive a scale and pulse oximeter for home monitoring free of charge.

 

The initial group of patients were enrolled in November 2021. As of March 1, 2023, 1,198 women have participated in the pilot. Between July 1, 2022, and March of 2023 there have been 658 participants enrolled. Of those, all were enrolled to receive assessment questions for postpartum depression, 240 were enrolled for Cesarean delivery assessment questions, 28 for diabetes, 253 for hypertension, 20 for cardiovascular disease, and 570 for breastfeeding. Within this same time period, a need for elevated care was identified 340 times. A single participant may have received more than one referral. Of those, 39 were referred for an office visit and 7 resulted in hospitalization. This is potentially 7 lives saved and a reduction in health care costs due to timely identification of a postpartum complication. 

 

Findings from the Florida MMRC have noted Florida’s pregnancy-related deaths are on the rise with an increase in deaths occurring postpartum after discharge from the hospital. The most common causes of deaths during postpartum after discharge are cardiomyopathy, other cardiovascular conditions, infections, and thrombotic embolism. According to the Florida MMRC findings, more than two-thirds of these deaths were considered preventable. Currently, it is estimated that roughly 40 percent of new mothers do not see a provider for their recommended postpartum follow-up care. Proposed recommendations based on these findings are in concert with the ACOG’s Committee Opinion 736 on “Optimizing Postpartum Care”. This includes scheduling an early postpartum visit, a “two-week post-birth health check” for patients prior to being discharged from the hospital. The days and weeks following birth are a critical intervention period that set the stage for women and their infants for both short and long-term health outcomes. Prior to discharge, it is imperative for patients to receive postpartum education, screening for high-risk postpartum complications, assistance with scheduling a “two-week Post-Birth Health Check”, and linkages to other applicable community and health resources. Mothers must know when medical concerns and issues are occurring and where and how to get the timely risk-appropriate care that may be needed.

 

In the beginning of 2022, the FPQC began developing the Postpartum Access and Continuity of Care (PACC) initiative to improve maternal health through the continuum of postpartum care by providing respectful, timely, and risk-appropriate, coordinated care. The PACC initiative hospital kick-off was held in October 2022, with 77 birthing hospitals participating, representing over 80 percent of births in Florida. The FPQC developed and distributed a package of education materials to each hospital that included posters, patient handouts, and other materials to assist with implementation. In addition, the PACC toolbox has a plethora of materials for hospitals to use during the initiative. FPQC also developed materials and a webpage specifically focused on Emergency Rooms (ER), given that almost a third of mothers are seen in the ER and discharged prior to dying. This includes ER staff postpartum mortality prevention education slides, an ER poster to remind about screening, QR codes for diagnosing and treating the seven leading causes of death related to postpartum conditions, and the FPQC Postpartum Mortality Brief.

 

The Department and the AHCA recognized hospitals during the reporting year that achieved the Healthy People 2030 goal of low-risk, primary C-section rates at or below 23.6 percent. In the fall of 2022, the State Surgeon General, Secretary for the AHCA, and other state leadership toured the state to hand deliver awards to the 26 hospitals that achieved the Healthy People 2030 for first-time, low-risk pregnancies based on 2020 data. This included a presentation on the importance of the reduction of low-risk, primary C-section rates and provided an opportunity to meet the medical staff and administration who implemented strategies to achieve the goal. In the summer of 2023, the Department and the AHCA recognized hospitals that achieved the Healthy People 2030 goal of low-risk, primary C-section rates at or below 23.6 percent in 2021. Awards were presented at the Florida Hospital Association statewide conference which included administration from hospitals that both achieved and did not achieve the goal.

 

Since 2014, the Florida MMRC assesses the level of preventability for the cases reviewed and determined to be pregnancy-related deaths. First, the Florida MMRC reaches consensus on whether the death appeared to have been preventable and to what degree the death was preventable by asking the following question: If specific actions had been implemented, to what degree would these actions have changed the woman’s trajectory and led to her survival? Second, for each pregnancy-related death, the Florida MMRC identifies whether health care provider, facility, or patient and community factors contributed to the death with the following question: Did the factors identified in the improvement categories contribute to the maternal death? The Florida MMRC has found that some pregnancy-related deaths may have been prevented if hospitals were optimally prepared for the challenging pregnancy complications and has recommended that Florida hospitals participate in a program that verifies ACOG's levels of maternal care.

 

In 2022, the Department in collaboration with the FPQC, began implementing a Levels of Maternal Care (LOMC) verification pilot project. LOMC designations were developed to enable women to receive risk-appropriate maternal care, a key strategy to reducing maternal mortality and morbidity. The intent is to avert preventable pregnancy-related deaths by establishing standardized systems of maternal care aligned with ACOG recommendations. The LOMC is a voluntary process that allows hospitals to self-designate as one of the four designations, Level I Basic Care, Level II Specialty Care, Level III Subspecialty Care, and Level IV Regional Perinatal Health Center. The FPQC partnered with The Joint Commission to conduct site visits and to complete the verification process with participating hospitals. By December 2022, 14 Florida birthing hospitals applied to participate in the LOMC verification project and were in the process of completing the applications for The Joint Commission (TJC). Thirteen hospitals participated in the TJC Maternal Level of Care Verification with the following results: 1 Level I hospital, 5 Level II hospitals, 4 Level III hospitals, and 3 Level IV hospitals met national standards.
 

The increase in congenital syphilis cases remains a concerning trend in Florida. In 2015, 17.7 infants per 100,000 births were diagnosed with congenital syphilis. By 2021, this rate reached 82.7 infants. Despite prenatal syphilis screening mandates, gaps in preconception and prenatal care persist. In June 2022, a Graduate Student Epidemiology Program intern began working on an analysis using Pregnancy Risk Assessment Monitoring System data to identify preconception factors associated with maternal syphilis diagnoses. Results from this analysis will help to identify where these gaps in care exist, as well as best strategies for diagnosing and treating syphilis prior to pregnancy.

 

Section 383.2163, Florida Statutes, was established on July 1, 2021, requiring the Department to establish telehealth minority maternity care pilot programs in Duval and Orange counties. The purpose of the pilots is to use telehealth to expand the capacity for positive maternal health outcomes in racial and ethnic minority populations. The Florida legislature provided funding for the project in FY 22-23. The Department identified organizations in each respective county to implement the pilot project through a competitive procurement process. Each pilot program (program) used telehealth to assess the service needs and gaps of pregnant and postpartum women who were at high-risk for severe maternal morbidities. This included screening and treatment of common pregnancy-related complications, including, but not limited to, anxiety, depression, substance use disorder, hemorrhage, infection, amniotic fluid embolism, thrombotic pulmonary or other embolism, hypertensive disorders relating to pregnancy, diabetes, cerebrovascular accidents, cardiomyopathy, and other cardiovascular conditions. Additionally, the programs used telehealth, or coordinated with prenatal home visiting programs, for the following services:

 

• Referrals to Healthy Start's coordinated intake and referral program to offer families prenatal home visiting services.
• Services and education addressing social determinants of health, including, but not limited to:
  • Housing placement options.
  • Transportation services or information on how to access such services.
  • Nutrition counseling.
  • Access to healthy foods.
  • Lactation support.
  • Lead abatement and other efforts to improve air and water quality.
  • Childcare options.
  • Car seat installation and training.
  • Wellness and stress management programs.
  • Coordination across safety net and social support services and programs.
  • Evidence-based health literacy and pregnancy, childbirth, and parenting education for women in the prenatal and postpartum periods.
  • Connection to support from doulas and other perinatal health workers.
  • Tools for prenatal women to conduct key components of maternal wellness checks (e.g., scales, blood pressure devices with verbal readers, blood glucose tests).

During FY 22-23, a total of 2,533 pregnant and postpartum women participated in the pilot (1,327 in Orange county and 1,206 in Duval county). Patients were monitored for diabetes if they indicated they had preexisting or gestational diabetes. Data available from Duval county indicated approximately 7 percent of patients self-reported having hypertension, and 8 percent of their patients self-reported having diabetes. Roughly 11 percent of Orange county’s patients were identified as having hypertension, and about 12 percent were identified as having diabetes. Both counties utilized telehealth services to deliver an added layer of care and support to patients diagnosed with hypertension or diabetes. Remote medical monitoring devices were provided to patients, regardless of hypertension or diabetes diagnostic status. These devices provided real-time vitals data to the care management team and allowed them to employ proactive measures to reduce the risk of severe complications. Based on individualized assessments, 100 percent of program participants in Orange county required wrap around services and education and 90 percent in Duval county. The programs leveraged local partnerships to address the additional needs of pilot participants which prioritized childcare, employment, food, utilities, and housing. Additionally, Title V Block Grant funds were used to purchase scales and blood pressure devices for women enrolled in the program. Quantitative and qualitative data used to evaluate the pilot provides supporting evidence that in its first year, the program has already yielded major health outcome improvements to the community that includes the following:

 

• Services have positively intervened in cases of hypertension for multiple women, avoiding serious complications, such as placenta abruption and restricted fetal growth, which would require emergency medical care resulting in possible maternal and infant death.
• Through lifestyle changes promoted through this program, participants maintained optimal blood sugar levels, effectively managing gestational diabetes, and improving overall maternal health and increasing likelihood of healthy normal weight infants.
• Continued support through the post-partum period ensures that the mental health needs of mothers are met, increasing their capacity as caregivers, as well as providing additional care during the critical early-life stage of infants born to program participants.
• Positive experiences engender trust in the medical system leading to a greater likelihood of engaging in preventative medical care for infants.
• Low-cost preventative prenatal care not only saves lives, but benefits mothers, infants, and the health care system by avoiding costly emergency care.