Massachusetts has three Maternal and Women’s Health priorities for 2020-2025:
- Strengthen the capacity of the health system to promote mental health and emotional well-being.
- Prevent the use of substances, including alcohol, tobacco, marijuana and opioids, among youth and pregnant people.
- Reduce rates of and eliminate inequities in maternal morbidity and mortality.
Priority: Strengthen the capacity of the health system to promote mental health and emotional well-being.
Findings from the COVID-19 Community Impact Survey (CCIS), conducted between September-November 2020, underscore the continued importance of this Title V priority due to the pandemic. According to the 2019 Behavioral Risk Factor Surveillance System (BRFSS), reports of poor mental health among CCIS respondents were three times higher than in 2019, with one third of adults currently reporting poor mental health. People experiencing persistent poor mental health were 2-3 times more likely to experience barriers to accessing care, such as appointment delays/cancellations, concerns about contracting COVID-19, not having a private place for a telehealth appointment, cost/insurance coverage and lack of safe transportation. Requests for suicide prevention and crisis management resources were as high as 11% among certain subpopulations, and highest among transgender people, non-binary people, and people questioning their gender identity.
People experiencing poor mental health are more likely to report having had a change in their work status because of childcare. They are also more likely to report being worried about basic needs like getting medication and paying bills. While there has been an increase in people reporting poor mental health across all demographic groups, some populations are still significantly more likely to report poor mental health: transgender people, non-binary people and those questioning their gender identity; people with disabilities; American Indian/Alaska Natives; Hispanic/Latinx community; people who identify as multi-racial; people between the ages of 25-44; people with lower income; and caregivers of adults with special needs.
In 2018, 89.5% of birthing people reported that they have moderate or high social support, which decreased slightly to 83.4% in 2019 and 81.8% in 2020; the latter most likely due to the COVID-19 pandemic. Because the PRAMS survey is typically administered between two and four months postpartum, some of the 2019 respondents and all of the 2020 respondents would have completed the survey after the onset of the COVID-19 pandemic in March 2020.
Perinatal Mental Health Data Analysis Plan
During FY20, MDPH was awarded a budget earmark that instructed MDPH to expend funds to produce a report, in consultation with other state agencies and hospital systems, to define a set of measures to track the annual perinatal mental health outcomes for all deliveries in MA and to outline a process for the collection and reporting of said measures. MDPH completed the Perinatal Mental Health Data Analysis Plan in FY21. It proposes a statewide, population-based data tracking system, recommends an ongoing linkage of three existing state perinatal databases, and contains specific aims, process and outcome measures, data sources, feasibility, costs, and timeline. The plan seeks to collaborate further with the MA Child Psychiatry Access Program (MCPAP) for Moms to investigate the effects of perinatal mental health care provider training, care coordination, and resource referrals on the health of birthing parents and infants in MA, as well as their access to and costs of health care.
Perinatal Mental Health Training and Technical Assistance
MDPH continued to provide training and technical assistance on perinatal mental health (including maternal mental health and co-morbidities such as substance use and interpersonal violence) to state agencies (such as the Department of Children and Families and the Department of Early Education and Care), providers (including home visiting programs and community health centers), and health plans. The training and technical assistance will contribute to increasing awareness and reducing stigma about perinatal mental health issues and will support continued implementation of the MA Postpartum Depression regulations.
Early Intervention Parenting Partnerships Program (EIPP)
EIPP is a home visiting program that uses a team approach to engage with and support families during pregnancy, continuing through the child’s first birthday. Maternal mental health is a key topic of discussion, education, support, and referral. In FY21, 156 (55.5%) participants reported a history of depression, including postpartum depression (PPD), at enrollment. At the initial visit, all 281 participants were screened for PPD using the Edinburgh Postnatal Depression Scale (EPDS) with 22 (7.8%) screening positive for mild depressive symptoms and 28 (10%) screening positive for moderate or severe depressive symptoms. Of the 42 participants referred to individual counseling, 23 (54.8%) were enrolled in services, and 16 (38.1%) were placed on a waiting list.
EIPP participants are assessed on a three-question social connectedness screening tool at key prenatal and postpartum stages. At the initial visit, 281 participants were screened, with 30 (10.7%) reporting that they do not have the support they need from others to care for themselves and their infant. Each EIPP site facilitates one 10-week support group annually for its participants. Topics include maternal mental health, mother/infant attachment, self-care, parenting skills and others. Transportation, childcare, and food are provided to facilitate attendance.
MA Maternal, Infant, and Early Childhood Home Visiting Initiative (MA MIECHV)
MA MIECHV, funded by HRSA/MCHB, provides evidence-based home visiting services to pregnant and parenting families in 18 communities. MA MIECHV aims to improve the lives of children and families by supporting parenting, improving maternal and child health, and promoting child development and school readiness. MA MIECHV promotes emotional wellness and social connectedness among program participants in several ways.
MA MIECHV home visitors and supervisors attend training on common mental health concerns, strategies for supporting parents who experience mental health challenges, and mindful self-regulation skills to support home visitors when working with parents experiencing mental health challenges. The training incorporates reflective conversations and engages participants in help-seeking in response to episodes of mental distress, illness, or crisis. A three-day Facilitating Attuned Interactions (FAN) training further supports staff to engage in reflective practice.
All MA MIECHV programs hold parent support groups and group series to facilitate connections among families. Programs identify topics based on the needs and interests of their participants and the larger community.
MA MIECHV home visitors screen for depression and social connectedness according to evidence-based model requirements and make referrals to services as needed. Depression screens are conducted using the EPDS or Center for Epidemiologic Studies Depression Scale (CES-D) within three months of delivery (for those enrolled prenatally) or within three months of enrollment (for those not enrolled prenatally). In FY21, 90% of MA MIECHV participants were screened for depression within the required time frame, a slight decrease from 93% in FY20. In FY21, 45% of caregivers referred to services for a positive screen for depression were documented to have received one or more service contacts, a decrease from 53% in FY20. MA MIECHV programs continue to report limited language and cultural capacity among mental health services in many MA communities as barriers to successful access to treatment. The long waitlists for mental health supports have been exacerbated by the
COVID-19 pandemic.
Welcome Family
Welcome Family, funded by MA MIECHV, is a universal one-time nurse home visiting program for families with newborns in five communities. The Welcome Family Learning Collaborative is a forum for the five contracted agencies to plan and implement quality improvement projects and share best practices and lessons learned. From July-December 2020, the Learning Collaborative focused on depression screening, a topic chosen in collaboration between MDPH and local Welcome Family staff due in large part to the growing mental health concerns and social isolation resulting from the COVID-19 pandemic. Specifically, local programs tested use of the EPDS for caregivers who screen positive on the Patient Health Questionnaire-2 (PHQ-2), the tool currently used in Welcome Family. This project focused on improving an existing process to identify mental health concerns and connect parents to services if needed.
The primary process measure was to increase the number of caregivers who pre-screen positive on the PHQ-2 to then be administered the EPDS. From August-December 2020, this measure increased from 40% to 75%. Contracted agencies tested changes such as developing scripts to introduce the EPDS, reviewing the EPDS verbally and in writing, and offering the EPDS to all caregivers with a history of depression regardless of PHQ-2 score. The secondary measure was increasing referral acceptance to mental health services for caregivers for whom a concern is identified on the PHQ-2 or EPDS. There was no noted improvement on this measure.
Following the Learning Collaborative, the programs agreed that the PHQ-2 screen is just as effective in identifying symptoms of depression when coupled with the expertise of the Welcome Family nurses. Therefore, it was decided not to integrate the EPDS into standard program practice. The program will apply lessons learned through this project, such as the understanding that no screening tool is diagnostic, the ability for Welcome Family nurses to offer mental health support without a diagnosis, and the importance of a family-driven and culturally appropriate approach to the types of referrals offered.
F.O.R. Families (Follow-Up Outreach Referral)
The F.O.R Families program serves families experiencing homelessness with complex medical needs, substance use disorder, safety concerns, and high levels of depressive symptoms. The program is a joint initiative between BFHN and the MA Department of Housing and Community Development (DHCD). During the intake assessment, and as needed in subsequent visits, home visitors assess participants for symptoms of depression, identify any potential risks to the parent and baby, and make referrals to mental health services. Mental health is a key topic of discussion, education, and support with families.
This priority focuses on primary prevention of substance use as well as overdose prevention, prevention of subsequent substance exposed newborns, prevention of substance use in the next generation, and prevention of more significant use or negative sequelae.
Findings from the CCIS indicated that two out of five people who reported using substances in the last 30 days had increased substance use since the onset of the pandemic. Respondents with a cognitive disability and parents and caretakers of persons/children with special needs were more likely to report increased substance use. Nearly half of respondents reported alcohol use, and of those, 38% reported increased use during the pandemic. Over half of those who reported using tobacco in the past 30 days reported increased use since prior to February 2020. People using substances were more likely to report poor mental health but delayed seeking mental health care. Respondents – particularly those using cocaine, heroin, or other opioids – reported interest in accessing health services related to counseling, tobacco cessation, peer and recovery support.
Objective 1 (NPM 14). By 2025, reduce the percentage of people who report smoking during pregnancy from the baseline of 4.3% in 2018 (PRAMS) to 3.0%.
Title V plays an important role in preventing substance use during pregnancy, a critical period of development in the life course. Smoking during pregnancy increases the risk of complications, such as preterm birth, and increases an infant’s risk for low birth weight and congenital heart defects. NPM 14 tracks progress on reducing tobacco use during pregnancy to mitigate the high mortality, morbidity, and economic costs attributed to tobacco use. The percentage of people who report smoking during pregnancy decreased to 3.5% in 2020, meeting the original 2025 objective. MDPH therefore revised the 2025 objective to 3.0%.
The ESM for this NPM is the percentage of people using the statewide smoking quit-line who are pregnant, with a goal of increasing to 6.2% by 2025 (from 0.8% [13/1,537] in FY21). 1-800-QUIT-NOW provides free and confidential services in English and Spanish, and translation for other languages, by a trained quit coach to stop smoking. Quit coaches connect callers with quit-smoking resources through the caller’s community programs, and callers may be able to receive free nicotine replacement therapy. According to the Surgeon General’s report, “…the evidence is sufficient to infer that proactive quit-line counseling, when provided alone or in combination with cessation medications, increases smoking cessation…and the evidence is sufficient to infer that tobacco quit-lines are an effective population-based approach to motivate quit attempts and increase smoking cessation.”[1]
MA PRAMS updated a study to assess agreement of the reporting of cigarette smoking between PRAMS and birth certificate (BC) during the last three months of pregnancy among a population-based sample of people who gave birth to a live born infant from 2012 to 2020. People reported higher smoking prevalence in PRAMS than in BC for maternal smoking during the last three months of pregnancy, but both PRAMS and BC had significantly decreasing trends in the smoking prevalence from 2012 to 2020 (7.8% in 2007 to 3.4% in 2020 according to PRAMS; 4.4% in 2007 to 1.9% in 2020 according to BC). The overall percent agreement between PRAMS and BC was high (97.8%) and the Kappa statistics showed a moderate level of agreement (0.63) between PRAMS and BC. However, the Kappa statistics for subgroups including people who were Black non-Hispanic, Hispanic, younger than 20 years of age, had less than a high school education and a preterm birth showed a lower level of agreement for reporting smoking between PRAMS and BC, even after adjusting for bias and prevalence. MA PRAMS is developing a fact sheet and manuscript based on the updated findings from this analysis, which will be finalized in FY23. MDPH will continue to track the trends and level of agreement in smoking prevalence reported by PRAMS and BC and plan to share findings with the Registry of Vital Records and Statistics to support their quality improvement efforts around data collection on the BC Parent Worksheet.
MA Tobacco Cessation and Prevention Program (MTCP)
MTCP engaged with Tufts Interdisciplinary Evaluation Research (TIER) to conduct a mixed methods evaluation aimed at better tailoring smoking cessation efforts to meet the unique needs of pregnant and parenting people in the state. The evaluation is aimed at increasing access to nicotine/tobacco cessation supports among pregnant and parenting people, with the goal of promoting quit success. A combination of survey data and interviews with key stakeholders was used to learn about: existing tobacco/nicotine cessation services; the ways in which pregnant and parenting subpopulations (e.g., MassHealth users, families with mental health and substance use disorder concerns) access these services; and how these services might be adapted to be more effective with these populations. MTCP and the Bureau of Substance Addiction Services (BSAS) worked with TIER to engage family support programs, such as WIC, MIECHV, and BSAS regional programs that manage substance use treatment facilities that support pregnant and parenting people, to develop the survey questions and disseminate the survey. Given the limitations that COVID-19 presented for gathering in person, TIER was unable to conduct Community Evaluator-run focus groups (including one with fathers) as originally planned. In FY23, MTCP will analyze the data, disseminate findings among people impacted, and engage impacted communities in next steps. MTCP hopes these findings will increase the quality of existing programs, develop harm reduction messaging that includes vaping, and more effectively promote quitting resources.
MA MIECHV
MA MIECHV provides training on substance use and trauma-informed practice, and all home visitors routinely screen participants for substance use. During federal FY21, 10% of the households enrolled in evidence-based home visiting services reported a history of substance use or need for substance use treatment, which is likely an under-report. During the same time, 12.1% of households reported that someone in the household used tobacco products in the home, down from 13.8% in federal FY20.
In FY21, 50% of primary caregivers enrolled in home visiting who reported using tobacco or cigarettes at enrollment were referred to tobacco cessation counseling or services within three months of enrollment. This represented a decrease from 57% in FY20. MA MIECHV developed a Tobacco Cessation Toolkit to support home visitors with resources on tobacco cessation and strategies for having conversations with participants about tobacco use. MA MIECHV will disseminate the Toolkit in FY22.
Objective 2. By 2022, improve measurement of marijuana use/consumption among pregnant people by adding specific questions to the PRAMS survey.
PRAMS
In 2020, 2.3% of people reported any use of marijuana during pregnancy (2.5% for White non-Hispanic people, 4.2% for Black non-Hispanic people, 1.7% for Hispanic people, and 0.6% for Asian non-Hispanic people). People with lower SES were more likely to use marijuana during pregnancy; among those with Medicaid, 6.0% used marijuana during pregnancy, compared to 0.1% with private insurance, and among people ≤100% federal poverty level vs. >100%, rates were 5.3% and 1.7%, respectively. MA PRAMS will continue to use the current opioid supplement to collect marijuana use during pregnancy with funding support from BSAS. PRAMS data collection for 2021 is ongoing and will be completed by July 31, 2022.
Center for Birth Defects Research and Prevention
The Center for Birth Defects Research and Prevention (CBDRP) collects data on marijuana use during pregnancy through the Birth Defects Study To Evaluate Pregnancy ExposureS (BD-STEPS) telephone interview, a population-based case-control study aimed at understanding the causes of birth defects and identifying potential risks for having a baby with a birth defect. As part of the study, individuals participate in an hour-long telephone interview on a range of topics, such as sociodemographic, medications used during pregnancy, illnesses in pregnancy, chronic medical conditions, treatments for infertility, physical activity, smoking and alcohol use in pregnancy, and occupational exposure. The interview includes questions on marijuana use in the month prior to pregnancy through the third month of pregnancy, the route of marijuana use (e.g., smoke, vape, eat), the frequency of use, and the reason for use (e.g., relieve nausea/vomiting, relieve stress/anxiety). Participants include control mothers who had a liveborn infant with no birth defect and case mothers who had an infant with one of the 23 eligible birth defects. Control participants are randomly selected from the birth population and their responses reflect marijuana exposures in the MA birth population.
The Stillbirth Study was incorporated into BD-STEPS to leverage the existing study design to understand risk factors and interventions to reduce the occurrence of stillbirths. As part of this study, people whose pregnancies ended in a stillbirth and were not affected by a birth defect are recruited into the study and participate in the main interview, as well as a follow-up interview focused on risk factors for stillbirth. People who participate in this study include 1) control participants who had a liveborn infant with no birth defect and 2) case participants who had a pregnancy that ended in a stillbirth (includes stillbirths with and without a birth defect). People in this study are asked the same questions on marijuana use as above. Given this is a population-based study, responses represent those in the general population.
Both the BD-STEPS and Stillbirth Study have been conducting interviews since 2014, with a one month pause during the pandemic while the interviewers shifted to teleworking. After the pause, the interviewing and data collection have resumed and are underway. The questions related to marijuana use and consumption were added in 2019 and the data will become available in early 2023.
PRAMS
PRAMS does not currently have data on alcohol consumption during pregnancy. CDC has postponed the Phase 9 survey revision to 2023 and MDPH decided not to implement a state-specific supplement with questions that include alcohol consumption in all three trimesters of pregnancy due to survey space constraints and concerns about response rates. The current Phase 8 survey asks about alcohol consumption in the past two years and during the three months before pregnancy. MDPH will include the alcohol consumption during pregnancy questions on MA PRAMS Phase 9 survey in April 2023 starting with January 2023 births.
Center for Birth Defects Research and Prevention
Interim findings from BD-STEPS show that between 2014 and 2018, 44% of respondents reported consuming alcohol during the first month of their pregnancy. This proportion decreased to 7% and 5% during the second and third months of pregnancy, respectively. Alcohol use during the first month of pregnancy was reported slightly more frequently among those who had not intended to become pregnant compared to those who did (46% vs. 43%). These figures represent alcohol use among respondents who gave birth to liveborn infants without a birth defect whose patterns of substance use are meant to reflect those in the general population.
Fetal Alcohol Spectrum Disorders Task Force
Fetal Alcohol Spectrum Disorders (FASD) is an invisible disability. The goal of the state FASD Task Force, co-chaired by the Title V MCH Director, is to highlight this developmental disability and strategies to prevent FASD, support families with children diagnosed with an FASD and support children, youth, and young adults living with FASD. In response to the 2020 Title V needs assessment, the FASD Task Force has been reframed to explicitly focus on prevention efforts. The Task Force convenes families, state agencies, academic institutions, and community agencies to address FASD at the policy, state, and community levels.
In FY21, the Task Force worked to reduce stigma and raise awareness of strategies for prevention and support for families of children with FASD. Prevention strategies include addressing barriers that people with substance use disorder encounter in trying to access services. The Task Force developed strategies for supporting parents and their children with FASD, working with early childhood systems, including Early Intervention, and with school departments. In FY21 families with children with FASD met through a virtual support group with the support of the MA FASD State Coordinator. Virtual FASD trainings were held for staff from health care, addiction/clinical/social service groups, and criminal justice sectors and were offered to addiction provider treatment agencies on universal strategies for working with adults who may have cognitive impacts from prenatal alcohol exposure.
A new brochure was completed in FY21 by BSAS that specifically addresses alcohol and tobacco, two commonly used drugs that are particularly dangerous during pregnancy. The brochure will be helpful during pregnancy and after birth, so parents can be alerted to possible child health impacts from prenatal alcohol and drug use.
Additional activities to prevent the use of substances among youth and pregnant people
PNQIN
PNQIN, the state PQC (Perinatal Quality Collaborative), is the joint union of the MA Perinatal Quality Collaborative (MPQC) and the Neonatal Quality Collaborative (NeoQIC). PNQIN is dedicated to improving health outcomes of birthing people, newborns, and families through a quality improvement collaborative of providers and stakeholders. PNQIN aims to achieve collaborative learning through sharing of data and best practices and use of real-time data to drive improvement, while targeting health inequities in all its projects. PNQIN receives financial and leadership support from MDPH. Since 2017, PNQIN has focused on addressing perinatal opioid use during three key time periods: during pregnancy, focusing on increasing the percent of mothers with opioid use disorder who are in medication assisted treatment during pregnancy; at delivery, focusing on improving breastfeeding rates among birthing parents of infants with NAS; and during the first year of life, focusing on increasing the enrollment of infants with NAS in Early Intervention (EI) services.
Moms Do Care (MDC)
Moms Do Care is an opioid addiction program in seven project sites that offers pregnant and postpartum people recovery treatment. In FY21, the MDC technical assistance (TA) team provided extensive TA and training in building the program model and assisted the MDC health care systems to plan for ways to sustain the regional, integrated systems of support established by the program. MDC advanced the perinatal peer mentor workforce by assisting the health care systems to hire, develop and sustain this workforce through: identification and training of peer mentor candidates and supervisors; consulting on HR policies and procedures; assisting health care systems to understand and value the roles and competencies of peer mentors; implementation of statewide learning collaborative calls; and continued collaboration with BSAS to assist peer mentors through the recovery coach credentialing process. The MDC training and TA teams expanded their trainings to include the staff and leaders of multiple hospital and health care center departments and community partners. Trainings focused on ways to develop trauma informed, family-focused and recovery-oriented systems of care. MDPH continued to share its lessons learned with MassHealth as the Commonwealth works to build a reimbursement structure for this program model. In FY21, 125 new participants were enrolled.
The Journey Recovery Project
The Journey Recovery Project, led by BSAS with support from BFHN Title V staff, is an interactive, web-based resource for pregnant and parenting people with questions or concerns about substance use, or who are in recovery. In FY21, new video and print content were developed, focused on the developmental stages of a young child, including tips for parents on how to balance parenting and recovery at each developmental stage. A new facilitator’s guide to using the Journey Project in group settings was disseminated. MDPH launched a mass media campaign between 7/15/20 and 10/4/20 to promote treatment for people of childbearing age and to direct traffic to the Journey Recovery Project website for information and encouragement. There were ads on Facebook, Instagram, YouTube and Google, and grocery/pharmacy chain hand sanitizer stations. The campaign delivered 36,434 total sessions to the landing page and 99.6% of users to the campaign were new users.
Plans of Safe Care (POSC)
The Child Abuse and Prevention Treatment Act mandates a POSC for every substance affected newborn. The purpose of the POSC is to support the prevention of ongoing substance use among pregnant people and new parents. POSC can also serve as a primary prevention strategy for a future generation of children by connecting children with developmental services and helping parents access recovery, parenting, and concrete supports. In FY21, BFHN and BSAS jointly designed and conducted trainings for substance use treatment providers, including family residential treatment programs and methadone programs, on how to support families in need of a POSC.
FIRST Steps Together
FIRST (Families in Recovery SupporT) Steps Together, funded by the State Opioid Response grant, is a home visiting initiative for opioid affected families, which provides parenting and recovery support by peer family recovery support specialists to prevent ongoing substance use and subsequent substance exposed newborns. Program services include integrated home-based peer recovery support, evidence-based individual and group parenting interventions, care coordination, Plans of Safe Care, mental health services, dyadic therapy, and systems advocacy. During FY21, 376 parents and 734 children were served. Almost all clients had open or past child welfare cases and half did not have custody of their children. In addition, 975 groups were held, with 4,146 duplicated participants.
FIRST Steps Together contributed to building the capacity of the peer recovery perinatal/parenting workforce through extensive curriculum development training and monthly learning collaboratives. All staff were trained in the use of the Ages and Stages Questionnaire and Ages and Stages-Social Emotional. The first didactic and clinical supervision training in Mothering from the Inside Out occurred, as well as a three-part webinar series on Trauma, Resilience, and Relationship in the Brains of Parents and Children.
MA MIECHV
MA MIECHV implemented a pilot to provide cross-training and enhanced supervision for a Parents as Teachers (PAT) home visitor with lived experience with substance use and recovery. The goals of the pilot are to: 1) fill a gap in cohesive parenting support for families in recovery, 2) build capacity of home visitor/recovery coaches to support pregnant and parenting families with substance use disorder and supervisors’ capacity to support home visitor/recovery coaches; and 3) engage in cross-systems collaboration to support reunification and promote family stability. In FY21, 19 families participated in the pilot.
MA MIECHV supports collaboration between home visiting and Department of Children and Families (DCF) offices at the state and local level to support services for families affected by substance use who are DCF-involved. Given racial inequities in the country’s child welfare system, policies that facilitate access to home visiting through transitions in custody arrangements promote more equitable access to home visiting. During custody disruptions, home visiting has the potential to support participants in their identities as parents, understand their children’s ongoing development, and allow for continuity of voluntary services through different stages of involvement with DCF. MA MIECHV programs identify strategies to enhance continuity of services for families who are working to regain custody of their children, including support and education for parents working toward reunification and support for families in which grandparents may have custody. To support families with varying custody arrangements, home visitors participate in supervised visitation at DCF offices and coordinate with DCF workers to support participants with their service plans.
MA MIECHV also addressed model-specific barriers to supporting families through custody disruptions. Historically, PAT has specified that a parent and child be present during visits, disincentivizing programs from working with families experiencing custody disruptions despite a gap in parenting support services for this population. PAT home visitors offer visits with parents and children during supervised visitation at DCF offices supplemented by visits with only the parent and report that these visits without children, although not historically counted, are central to reinforcing parenting topics and building parents’ confidence. In FY21, Tufts Interdisciplinary Evaluation Research (TIER), in partnership with MA MIECHV, initiated a mixed methods implementation study to understand these strategies and inform potential PAT policy changes and implementation guidance. Initial finding from the study informed the development of new data collection forms to be used by PAT parent educators.
Priority: Reduce rates of and eliminate inequities in maternal morbidity and mortality.
Since 1997, MDPH has convened the Maternal Mortality and Morbidity Review Committee (MMMRC) to review maternal deaths, study the incidence of pregnancy complications, and make recommendations to improve maternal outcomes and eliminate preventable maternal death. Understanding the causes of these deaths provides insight into the factors that contribute to maternal morbidity and mortality. The performance measure for this priority tracks efforts to improve the timeliness of the review process and the efficiency with which review findings can be translated into strategies to address inequities in maternal health outcomes.
Objective 2. By 2025, develop a structure for community input to the review process that is authentic and addresses the power dynamics between medical providers and community stakeholders.
Maternal Mortality and Morbidity Review Committee
MDPH aims to link birth and death files and other datasets (such as MassHealth) to identify pregnancy-associated and related deaths in a timely manner, strengthen and increase the number of memoranda of understanding and data sharing agreements with key state agencies to ensure timely access to data, improve the process and timing for data abstraction into the Maternal Mortality Review Information Application (MMRIA) and establish a process/mechanism for community engagement in the review process.
Investigations by the existing MMMRC are authorized by the MDPH Commissioner, pursuant to M.G.L. c. 111, s. 24A. This statute allows MDPH to request birth and death records but does not require relevant entities to provide access to requested records nor does it authorize the MMMRC to access other sources of relevant data. As a result, there are critical records not consistently available, including autopsy reports from the Office of the Chief Medical Examiner, prenatal care records, toxicology reports, outpatient and emergency department records, and Emergency Medical Services records. The lack of legal authority leads to a delay in acquiring relevant data.
Competing demands associated with the COVID-19 pandemic have also caused delays in progress on these objectives. In FY21, 0% of pregnancy-associated deaths were reviewed within two years. MDPH identified Title V funding to hire a Maternal Child Health Clinical Coordinator to ensure timely abstraction of pregnancy-associated deaths into MMRIA to support a review within two years of the death.
In FY21 and FY22, MDPH members of the MMMRC also completed a Lean Six Sigma quality improvement training that identified activities to improve the timeliness of identification and review and community contribution to the review process. The MMMR team used process mapping to examine steps in the MMMR process (identifying pregnancy-associated deaths, collecting and entering data, conducting multidisciplinary reviews, analyzing and summarizing data, disseminating findings and translating recommendations into action) and identify critical points, bottle necks, or problem areas in the process.
MDPH Vital Records is now sending linked birth and death certificates to the MMMRC electronically rather than in paper form which supports increased timeliness in the identification of pregnancy-associated deaths. MDPH established an MOU with the CDC so that the CDC now hosts the MA MMRIA and provides IT support. MDPH and CDC established a process for the electronic download of the Vital linked records directly into MMRIA and are conducting data quality checks to ensure accuracy and completeness.
Maternal Mortality and Morbidity Review Committee
The MMMRC has identified, among other factors, barriers to accessing care, racial inequities, and the absence of systemic coordination of care contributing to maternal deaths in MA. The MA Maternal Mortality Initiative released several data briefs outlining areas of concern in maternal mortality. MMMRC members, PNQIN leadership, legislators, and community stakeholders used the data briefs, as well as national data, to develop a workgroup charged with drafting legislation to make recommendations to address barriers resulting in racial inequities, including persons of color dying of pregnancy-related causes. As a result of this workgroup’s leadership, a Special Legislative Commission on Racial Inequities in Maternal Health was established by a legislative act signed by Governor Charlie Baker in January 2021, which was authorized in Chapter 348 of the Acts of 2020. The Commission was tasked with making recommendations to address barriers that result in racial inequities, including people of color dying of pregnancy-related causes. Specifically, the Commission was charged with gathering statewide data on maternal mortality and severe maternal morbidity (SMM) and making recommendations to eliminate racial barriers to accessing equitable maternal care. Representatives from MDPH and the MMMRC were appointed to this Commission and presented a summary of current activities and identified gaps in services, such as limited legislative authority and staff capacity to support further community engagement in the process. A final report, filed with the legislature in May 2022, included findings of the data and draft legislation necessary to carry out the Commission’s recommendations.
PNQIN
PNQIN implements the Alliance for Innovation on Maternal Health (AIM), the goal of which is to reduce maternal mortality and SMM and reduce racial disparities by working with hospital teams to align hospital-level quality improvement efforts. In FY21, in partnership with MDPH and the Betsy Lehman Center for Patient Safety, PNQIN generated SMM reports stratified by race and ethnicity for eight pilot sites. These reports were shared with the participants sites and submitted to AIM. In FY21, PNQIN hosted 19 webinars to review the process and data reports. PNQIN met with the remaining 21 active birthing hospitals to review their SMM data in fall 2021.
In FY21, a collaborative effort between PNQIN AIM staff and the Coordinated Approach to Resilience and Empowerment (CARE) Clinic team at Brigham and Women’s Hospital produced a two-hour virtual stigma, bias, and trauma-informed care training for hospital teams. Fifteen teams from six MA regions attended 18 offerings of the training. Participants – primarily physician and nurses – reported high levels of acquired knowledge and confidence to perform skills related to trauma-informed care.
PNQIN also collaborated with the Institute for Perinatal Quality Improvement to provide equity training to Massachusetts providers (SPEAK UP Champions Implicit & Explicit Racial Bias Education). There were 70 participants at a SPEAK UP Kick-off introductory event in December 2020 and three trainings were held between January and May 2021.
PNQIN also leads MA’s efforts around Levels of Maternal Care. Staff from BFHN and the Betsy Lehman Center worked with the Level of Care Assessment Tool (LOCATe) Task Force to prepare for the dissemination of the LOCATe tool, a self-assessment of maternal level of care at all MA obstetric units to understand the maternal health resources available by hospital and region. In June 2020, state-specific questions related to racial equity and implicit bias were added to the LOCATe Version 9 survey. The survey included a series of questions designed to measure relevant facility and staffing capacities and asked the hospital to report its own self-assessed Level of Maternal Care. All 40 birthing hospitals in the state completed the survey in spring 2021. CDC analyzed the responses and reported back LOCATe-assessed levels for each hospital. Fifty percent of hospitals self-reported a higher level than their LOCATe-assessed level. Of the 20 hospitals that over-reported their Level of Maternal Care, most did so by only one level, but several hospitals over-reported by two levels. There were no discrepancies of more than two levels.
Surveillance for Emerging Threats to Mothers and Babies Network (SET-NET)
In FY21, the MA Center for Birth Defects Research and Prevention (CBDRP) began conducting surveillance for SARS-CoV-2 infection among pregnant people and their infants through their participation in CDC’s Surveillance for Emerging Threats to Mothers and Babies Network (SET-NET). The goals of MA SET-NET are to monitor the effects of COVID-19 on pregnant people and their infants, inform clinical guidance and practice, and ensure that MDPH is prepared to meet the needs of pregnant people and infants during public health emergencies.
In addition to constructing the database for MA SET-NET and refining case ascertainment methodology, mother-baby linked data were submitted monthly to CDC. These data contributed to two national-level studies, “Birth and Infant Outcomes Following Laboratory-Confirmed SARS-CoV-2 Infection in Pregnancy – SET-NET, 16 Jurisdictions, March 29—October14, 2020” and “Risk factors for illness severity among pregnant women with confirmed SARS-CoV-2 infection—Surveillance for Emerging Treats to Mothers and Babies Network, 22 state, local, and territorial health departments, March 29, 2020—March 5,2021” for which MA SET-NET team members were included as co-authors.
MA SET-NET also led analyses using state-level data, including a study comparing characteristics of pregnant people with and without SARS-CoV-2 infection during pregnancy. This analysis highlighted the elevated risk for COVID-19 during pregnancy that racially and ethnically minoritized pregnant people face due to socially mediated factors, such as structural racism, which drive differential risk for COVID-19 in communities of color. These findings were summarized in a manuscript accepted for publication in Public Health Reports, presented at national-level conferences, and shared in an infographic developed for National Public Health Week. Other analyses in progress include an examination of the risk of SARS-CoV-2 infection during pregnancy associated with maternal occupation and industry, an analysis of the risk of pre-term birth conferred by SARS-CoV-2 infection during pregnancy, and a multistate project investigating the risk of stillbirth associated with SARS-CoV-2 infection during pregnancy.
MA SET-NET applied a racial equity framework to its analyses by highlighting inequities among racially and ethnically minoritized people in not only risk for SARS-CoV-2 infection during pregnancy, but also adverse birth outcomes such as pre-term birth and stillbirth. Sharing data through presentations, publications, and infographics called attention to these inequities and helped to inform equitable COVID-19 prevention and mitigation efforts for pregnant people. Data were shared with numerous collaborators internal and external to MDPH.
Given the novelty of the COVID-19 pregnancy surveillance, MA SET-NET experienced initial challenges developing a mechanism for sharing data on COVID-19 during pregnancy with healthcare providers, MDPH programs serving pregnant people, and other interested parties. However, despite technical and capacity challenges, MDPH was able to use alternative channels for data dissemination including several tailored presentations and an infographic.
PRAMS
PRAMS is working with the CDC to collect data on how COVID-19 has affected pregnant and postpartum people and their infants, and about COVID-19 vaccination including receipt of COVID-19 vaccination before, during and shortly after pregnancy, and reasons for not obtaining COVID-19 vaccination. PRAMS collected seven months of COVID-19 data among pregnant people who gave birth in 2020 and data analysis is ongoing. MDPH does not have 2021 COVID-19 and COVID-19 vaccine data yet (data collection is ongoing until July 31, 2022). In addition, MDPH received funding through the CDC COVID-19 Disparities Grant to conduct a PRAMS for Dads project to collect data about fathers’ experience during pregnancy and the birth of their child, and their experiences with COVID-19 testing, vaccination, health status, social determinants of health, mental health, and racism during the COVID-19 pandemic. See more about PRAMS for Dads in the Crosscutting domain under the family engagement priority.
PNQIN
PNQIN is working with MDPH to improve COVID-19 vaccination among pregnant people. Vaccination is a foundational strategy to prevent illness, hospitalization, and death from SARS-CoV-2 infection for pregnant people, who are at increased risk for severe disease. Existing data do not demonstrate any safety concerns of vaccination against COVID-19 during pregnancy and lactation. However, data remain limited and guidelines at this point specify that pregnant and lactating people should discuss the risks and benefits of vaccination with their provider. In spring 2021, PNQIN identified the following strategies to promote COVID-19 vaccination among pregnant people: 1) increase provider capacity to educate pregnant and lactating people, particularly those with vaccine hesitancy, regarding the safety and efficacy of vaccination during and after pregnancy, 2) support birth facilities in protocol implementation to screen and institute provisions for SARS-CoV-2 vaccination of pregnant and lactating people and their families, and 3) expand clinical-community care linkages in response to the COVID-19 pandemic. Implementation of these strategies began in September 2021 and will be discussed next year in the FY22 report.
Vaccine Equity Initiative
The Vaccine Equity Initiative (VEI) launched in February 2021 and aims to 1) increase trust in the vaccine’s safety and efficacy, acknowledging that in many communities of color, mistrust and hesitancy can stem from a history of medical mistreatment, 2) identify and reduce barriers for accessing the vaccine, and 3) increase vaccine access for priority populations, through existing vaccination locations and mobile vaccination options. VEI focuses on the 20 cities and towns hardest hit by COVID-19 and priority populations disproportionately impacted by COVID-19, including but not limited to: Black, Indigenous, People of Color, individuals with disabilities; individuals with mental illness and/or substance use disorder; and individuals who identify as LGBTQ+. To date, 167 community- and faith-based organizations, Tribal and Indigenous People Serving Organizations, Community Health Centers, and other community-based healthcare organizations have been awarded over $46.5 million through the VEI. In addition, the VEI has provided over $4.7 million to municipalities and Local Boards of Health in the priority communities.
MDPH Title V staff have played a critical role in various components of the VEI. Through the VEI Community Liaison Program, a designated MDPH staff person works with each of the 20 communities to identify barriers to vaccine access and develop community tailored solutions. Ten BFHN staff have served as Community Liaisons. Their efforts included exploring specific outreach and education opportunities such as town halls or tabling events in commonly accessed locations and increasing availability and ease of accessing vaccine through community-based or mobile clinics in trusted spaces. MDPH staff (including 10 working on Title V programs) also served as COVID-19 Vaccine Ambassadors, attending community meetings upon request (e.g., with the Brazilian Women’s Group and JAHAN Women and Youth Intercultural) to provide clear, accurate, consistent information about the vaccine, build trust and confidence, dispel vaccine misinformation, and encourage vaccine uptake. From February – June 2021, Ambassadors presented at 60 community meetings with over 3,100 participants. One Title V staff person also served as a liaison to Federally Qualified Health Centers to support placing weekly vaccine orders, and another provided project management support to the MDPH COVID-19 vaccine communications efforts, such as translating scientific information and policy decisions about the COVID-19 vaccine into information for the public and standardizing guidance for COVID-19 vaccine providers.
Towards the end of FY21, VEI began to identify a need to include pregnant people, young children, and families as a priority population in its work, given the increased risk of serious illness from COVID-19 among pregnant people and stark racial inequities in vaccine uptake among this population, as well as slower rates of vaccination among children and youth compared to adults. VEI established a Pediatric and Family Vaccine Workgroup, led by Title V staff in BFHN, to develop and implement strategies to increase vaccination among young children and their families, including pregnant and breastfeeding people. See the FY23 application for more information.
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