WOMEN/MATERNAL Priority Need 1: Ensure women in California are healthy before, during, and after pregnancy.

 

The Maternal, Child, and Adolescent Health Division of the California Department of Public Health (CDPH/MCAH) monitored select quantifiable characteristics to track the health of California’s women and mothers as part of its routine surveillance efforts. The select indicators and measures listed in the table below are continuously and systematically collected, analyzed, and interpreted to guide program planning, implementation, and evaluation of interventions. CDPH/MCAH will continue to analyze by state and, when possible, county, race/ethnicity, maternal age, and other sub-state levels given the specific measure and the data constraints to identify specific improvement opportunities.

 

These indicators and measures serve as an early warning system to identify emerging issues, target program interventions, track progress toward specified objectives in the Five-Year Action Plan, allow priorities to be re-evaluated, and inform public health policy and strategies. Information gleaned from health surveillance data provides in-depth understanding of the health status of women and mothers, uncovers health disparities, and guides how CDPH/MCAH leads, funds, partners, and supports efforts at the state and local levels to improve efforts that will lead to desired outcomes.

 

 

As part of California’s Title V State Action Plan, focus areas were identified in each population domain to help guide the work. Each year, the 61 Local Health Jurisdictions (LHJs) in California develop annual Scopes of Work (SOW) that contain activities that align with the state’s Title V Action Plan and these focus areas.

 

The following graph shows the number of LHJs and the related focus areas in the Women/Maternal Health Domain that had activities the LHJs planned to implement in their 2021-2022 SOWs.

 

 

 

• 20 LHJs (33%) worked on Women/Maternal Focus Area 1: Reduce the impact of chronic conditions related to maternal mortality, in FY 2021-2022
• 26 LHJs (43%) worked on Women/Maternal Focus Area 2: Reduce the impact of chronic conditions related to maternal morbidity, in FY 2021-2022
• 48 LHJs (80%) worked on Women/Maternal Focus Area 3: Improve mental health for all mothers in California, in FY 2021-2022
• 32 LHJs (53%) worked on Women/Maternal Focus Area 4: Ensure optimal health before pregnancy and improve pregnancy planning and birth spacing, in FY 2021-2022

 

The following graph shows the number of activities in each focus area in which the LHJs conducted efforts to address these areas in their 2021-2022 SOWs.

 

 

 

• 24 SOW activities supported Women/Maternal Focus Area 1: Reduce the impact of chronic conditions related to maternal mortality were implemented by 20 LHJs (33%) in FY 2021-2022
• 56 SOW activities supported Women/Maternal Focus Area 2: Reduce the impact of chronic conditions related to maternal morbidity were implemented by 26 LHJs (43%) in FY 2021-2022
• 106 SOW activities supported Women/Maternal Focus Area 3: Improve mental health for all mothers in California were implemented by 48 LHJs (80%) in FY 2021-2022
• 58 SOW activities supported Women/Maternal Focus Area 4: Ensure optimal health before pregnancy and improve pregnancy planning and birth spacing were implemented by 32 LHJs (53%) in FY 2021-2022
• 44 SOW activities supported Women/Maternal Focus Area 5: Reduce maternal substance use were implemented by 28 LHJs (47%) in FY 2021-2022

 

Women/Maternal Focus Area 1: Reduce the impact of chronic conditions related to maternal mortality.

 

Women/Maternal Objective 1 (2021-2022 Application)[1]

By 2025, reduce the rate of pregnancy-related deaths (up to one year after the end of pregnancy) from 11.3 deaths per 100,000 live births (2013 CA-PMSS) to 10.8 deaths per 100,000 live births.

 

Women/Maternal Objective 1[2]

By 2025, reduce the rate of pregnancy-related deaths (up to one year after the end of pregnancy) from 12.3 deaths per 100,000 live births (2019 CA-PMSS) to 12.2 deaths per 100,000 live births.

 

Story Behind the Curve:

California’s pregnancy-related mortality ratio was mostly stable from 2009 to 2019 and consistently lower than the U.S. pregnancy-related mortality ratio.[3] The latest pregnancy-related mortality ratio for the U.S. was 17.3 deaths per 100,000 live births in 2018 (CDC PMSS) while California’s pregnancy-related mortality ratio was 16.1 (CA-PMSS). The U.S. pregnancy-related mortality ratio may be an underestimate of the true burden due to the Center for Disease Control and Prevention’s (CDC)limitations for identifying and verifying pregnancy-related deaths compared with the California Pregnancy Mortality Surveillance System (CA-PMSS). In 2019, California's pregnancy-related mortality ratio decreased to 12.8 deaths per 100,000 live births.

 

Despite the lower overall pregnancy-related mortality ratios in California, racial and ethnic disparities persisted, aligning with national statistics. In 2017-2019, the pregnancy-related mortality ratio for Black women and birthing people was three-to-four times greater than the mortality ratios for Asian/Pacific Islander, Hispanic/Latino, and White women and birthing people.

 

Cardiovascular disease remained the leading cause of pregnancy-related mortality from 2009 to 2019. Other leading causes were hemorrhage, hypertensive disorders, sepsis/infection, thrombotic pulmonary embolism, and amniotic fluid embolism. Pregnancy-related mortality ratio for deaths due to hypertensive disorders declined significantly from 1.7 deaths per 100,000 live births in 2014-2016 to 0.4 in 2017-2019. As a result, in 2017-2019, hypertensive disorders were no longer among the leading causes of pregnancy-related mortality.

 

Characteristics that trended with higher pregnancy-related mortality ratios for all racial/ethnic groups were older age, obesity, public health insurance coverage (Medi-Cal), and living in less advantaged communities. Geographic variations in pregnancy-related mortality ratios were also noted.[4]

 

California has made progress to reduce pregnancy-related mortality through investment in maternal health programs, strong leadership and engagement of the maternity care community, and targeted hospital quality improvement. California has longstanding (Black Infant Health program) and newer (Senate Bill 65, also called California’s Momnibus legislation) interventions targeting racial disparities in birth outcomes, but more needs to be done to narrow racial and ethnic disparities. A thorough public health investigation is needed to understand how systems and community-level characteristics interplay with patient, provider, and facility-level factors in contributing to pregnancy-related mortality and related disparities. Comprehensive case reviews to identify contributing factors (including discrimination and structural racism), improvement opportunities, and preventability are underway via CA-PAMR.

 

Women/Maternal Objective 1: Strategy 1:

Lead surveillance and research associated with pregnancy-related deaths (up to one year after the end of pregnancy) in California.

 

Activity:

CDPH/MCAH will lead and fund pregnancy-related mortality surveillance and public health investigation activities.

 

Narrative:

CDPH/MCAH’s California Pregnancy Mortality Surveillance System (CA-PMSS) aims to provide timely and accurate statewide surveillance of pregnancy-related mortality (up to one year after the end of pregnancy) through rapid-cycle case reviews by an expert committee. Meanwhile, CDPH/MCAH’s California Pregnancy-Associated Mortality Review (CA-PAMR) aims to identify contributing factors, clinical quality improvement and public health strategies, and preventability through in-depth case reviews by one or more committees of clinical and community experts. Findings from CA-PAMR inform actionable recommendations for preventing pregnancy-related deaths and reducing health inequities. In October 2020, CDPH/MCAH convened two CA-PAMR expert committees to review (1) all deaths due to obstetric hemorrhage in 2014-2018 (a topic-specific, statewide review) and (2) all-cause deaths in a four-county Southern California region beginning in 2019 and onward (a population-based, regional review). The Southern California region includes the counties of Los Angeles, Orange, Riverside, and San Bernardino. In June 2022, CDPH/MCAH convened a new CA-PAMR expert committee to review all suspected pregnancy-related deaths from COVID-19 in California. Deaths reviewed by a CA-PAMR expert committee are not also reviewed by a CA-PMSS expert committee. All deaths, whether reviewed in CA-PMSS or CA-PAMR, are included in the CA-PMSS surveillance data.

 

As of June 30, 2022, the CA-PMSS expert committee completed rapid reviews of all suspected pregnancy-related deaths in 2020 (47 deaths) and 86% of deaths in 2021 (37 of 43 deaths). The CA-PAMR Hemorrhage Review Committee completed in-depth reviews of 49 deaths from obstetric hemorrhage (100% reviews completed). The CA-PAMR Southern California Committee expert committee completed in-depth reviews of all suspected pregnancy-related deaths in the four-county region (31 deaths) and 84% of deaths in 2020 (27 of 32 deaths), except for COVID-19 deaths. The newly appointed CA-PAMR COVID Expert Committee will review all COVID-19 deaths suspected to be pregnancy-related. To date, CA-PMSS has identified 17 deaths from COVID-19 in 2020 and at least 39 deaths in 2021 (number not final).

 

Activity:

CDPH/MCAH will lead surveillance and reporting of pregnancy-related mortality as mandated by Senate Bill (SB) 464 – California Dignity in Pregnancy and Childbirth Act.

 

Narrative:

CA-PMSS satisfies the surveillance and reporting of pregnancy-related mortality as mandated by SB 464. In September 2021, CDPH/MCAH published the first CA-PMSS surveillance report describing pregnancy-related deaths among Californians from 2008-2016. In May 2022, CDPH/MCAH’s CA-PMSS released data on pregnancy-related deaths from 2011-2019 with an accompanying teaching slide deck available at the CA-PMSS webpage and on the Pregnancy-Related Mortality Data Dashboard.

 

Activity:

CDPH/MCAH will focus surveillance and reporting on disparities to inform MCAH programs and promote health equity in California.

 

Narrative:

Findings from CA-PMSS and CA-PAMR data collection and case reviews are disaggregated by demographic and socioeconomic characteristics, such as race/ethnicity and delivery payer source, to identify which characteristics correlate with higher or lower pregnancy-related mortality ratios. Disparities in pregnancy-related mortality are also examined by geographic region and by community conditions defined using the Healthy Places Index, a validated measure that captures information on social determinants of health at the census tract level. Additionally, CA-PAMR’s case reviews include deliberations of system- and community-level contributing factors and the contributions of discrimination and structural racism to pregnancy-related deaths and associated health inequities. For reviews of 2020 and 2021 deaths, CA-PMSS and CA-PAMR data collection and case review materials were modified to capture the impact of the COVID-19 pandemic on pregnancy-related mortality.

 

Activity:

CDPH/MCAH will lead, fund, and disseminate data findings and data products related to pregnancy-related mortality and morbidity.

 

Narrative:

CDPH/MCAH and its partners presented on pregnancy-related mortality at two national scientific conferences and five meetings/webinars with key stakeholders in California and published a CA-PMSS surveillance report and CA-PMSS data update. Presentations at scientific conferences included (1) a poster titled, “Assessing subpopulation contributions to the rise in Black pregnancy-related mortality in California, 2011-2013 and 2014-2016,” presented at the 2021 American Public Health Association Annual Meeting and (2) an oral presentation titled, “Maternal Mortality Surveillance: Different Methods Inform Different Actions,” presented at the 2022 Association of Maternal & Child Health Programs Annual). Both CA-PMSS and CA-PAMR methodologies were featured in the presentation. CDPH/MCAH and its partners presented on various maternal mortality/morbidity topics to key clinical, public health, and community stakeholder groups in California: (1) Patient-Centered Outcomes Research Institute’s Birth-Centered Outcomes Research Engagement (B-CORE) Co-Learning Session participants, (2) the CA-PAMR Southern California Review Committee (3) the California Conference of Local Health Officers Maternal, Child and Adolescent Health Committee, (4) CDPH/MCAH’s Perinatal Equity Initiative Community Advisory Board, and (5) University of California, San Francisco Family Health Outcomes Project)’s webinar series participants CA-PMSS published reports as described above.

 

Activity:

CDPH/MCAH will lead the dissemination of data findings from CA-PMSS and CA-PAMR case reviews to raise awareness about pregnancy-related deaths and to improve clinical best practices in maternity care.

 

Narrative:

CDPH/MCAH updated the CA-PAMR webpage and created a new CA-PMSS webpage to promote the new CA-PMSS surveillance report released in September 2021 and subsequent CA-PMSS data update released in May 2022. Communications/media packages – including promotional messaging, fact sheets and social media content – routinely accompany CA-PMSS and CA-PAMR data releases. Additionally, in May 2022, CDPH/MCAH published a Pregnancy-Related Mortality Dashboard featuring data from CA-PMSS, as part of its new Data Dashboards series launch. CDPH/MCAH creates indicator-specific dashboards for California, all designed to serve the data needs of our partners and stakeholders. State-, county- and/or regional-level indicator data are shown by various stratifications or subgroups and by year. Each dashboard also includes a link to download the data. The dashboards are organized by the five Title V health domains.

 

Success(es):

CDPH/MCAH initiated CA-PMSS to conduct timely and accurate surveillance of pregnancy-related mortality in California. CDPH/MCAH set a target to review all pregnancy-related deaths within two years of the date of death. By June 2022, identification, verification, and review of pregnancy-related deaths in 2020 was mostly completed, despite a significant spike in pregnancy-related deaths due to direct and indirect effects of the COVID-19 pandemic. CDPH/MCAH also convened a special CA-PAMR committee of clinical and community experts in COVID-19 mitigation, response, and treatment to identify clinical and public health strategies to reduce pregnancy-related deaths in future pandemics. In-depth case reviews of COVID-19 deaths suspected to be pregnancy-related will begin in July 2022.

 

Challenge(s):

Disruptions in filling vacant administrative and scientific staff positions due to COVID-19-related redirections and shifting priorities have limited CDPH/MCAH’s capacity to produce customized data products to reach wider audiences and support communications and outreach activities to engage key stakeholder groups to translate maternal mortality/morbidity data to action.

 

Women/Maternal Objective 1: Strategy 2:

Partner to translate findings from pregnancy-related mortality surveillance and research into recommendations for action to improve maternal health and perinatal population health interventions.

 

Activity:

CDPH/MCAH will lead the development of recommendations for prevention of pregnancy-related deaths.

 

Narrative:

Data analyses of quantitative and qualitative data, prioritization of recommendations, and plans for dissemination of findings from the CA-PAMR Southern California and the CA-PAMR Hemorrhage committees are underway.

 

Activity:

CDPH/MCAH will partner with community stakeholders to disseminate best practices related to improving maternal health and support systems based on data findings.

 

Narrative:

With dissemination and translation of findings in mind, CDPH/MCAH and partners convened CA-PAMR and CA-PMSS committees that include clinical and community experts with ties to provision of care, support services, and advocacy for pregnant and birthing people. Plans are also underway to expand communications outreach in collaboration with MCAH’s Communications and Outreach team and MCAH programs directly or indirectly serving pregnant and birthing people.

 

Success(es):

CDPH/MCAH and its partners maintained two CA-PAMR committees – one focused on reviews of deaths from obstetric hemorrhage and one focused on reviews of all-cause deaths in a four-county region of Southern California – and convened a third CA-PAMR committee to review deaths from COVID-19. In-depth case reviews of pregnancy-related deaths are time and resource intensive, but all CA-PAMR activities remained on track despite increased challenges during the COVID-19 pandemic. In September 2021, the CA-PAMR Southern California Committee completed reviews of all pregnancy-related deaths in 2019 in the four-county region. In May 2022, the CA-PAMR Hemorrhage Committee completed reviews of all obstetric hemorrhage deaths in 2014-2018. Plans for data analysis and dissemination of findings from both CA-PAMR committees are underway. Findings from CA-PAMR committee reviews will yield information on contributing factors, improvement opportunities, preventability, and data-driven recommendations for prevention.

 

Challenge(s):

Pregnancy-related deaths spiked during the COVID-19 pandemic and strained the capacity of CDPH/MCAH staff and its partners. Several CA-PAMR committee members and nurse-abstractors resigned due to increased workplace demands, and finding replacements proved difficult during the pandemic. Consequently, CDPH/MCAH and its partners had little bandwidth to disseminate data findings and engage key stakeholder groups to translate maternal mortality/morbidity data to action.

 

Women/Maternal Focus Area 2: Reduce the impact of chronic conditions related to maternal morbidity.

 

Women/Maternal Objective 2 (2021-22 Application) [5]

By 2025, reduce the rate of severe maternal morbidity from 91.0 per 10,000 delivery hospitalizations (2018 PDD) to 86.5 per 10,000 delivery hospitalizations.

 

By 2025, reduce the rate of severe maternal morbidity from 93.5 per 10,000 delivery hospitalizations (2018 PDD) to 88.8 per 10,000 delivery hospitalizations[6]

 

Story Behind the Curve:

Maternal chronic health conditions such as diabetes, hypertension, and asthma are major contributors to poor maternal and infant health outcomes. The rates of these conditions at the time of delivery continue to rise. One of the priorities identified in the 2021-2025 needs assessment is to reduce chronic conditions related to maternal morbidity. Addressing the burden of chronic conditions among reproductive-aged women is a goal of preconception health efforts, with screening and management occurring during a preventive medical visit (National Performance Measure (NPM) 1). As chronic conditions impact maternal morbidity at childbirth, severe maternal morbidity (SMM) was selected as an objective to monitor for this focus area. SMM is a Healthy People 2030 objective and National Outcome Measure (NOM 2). SMM has been steadily increasing with persistent racial/ethnic, geographic, and socioeconomic disparities. In addition to increasing rates of chronic conditions at delivery, SMM may be increasing due to increases in maternal age, pre-pregnancy obesity, and cesarean delivery. Tracking and understanding patterns of SMM, along with developing and carrying out interventions to improve the quality of maternal care are essential to reducing SMM.[7]

 

Women/Maternal Objective 2: Strategy 1:

Lead surveillance and research related to maternal morbidity in California.

 

Activity:

CDPH/MCAH will lead surveillance and reporting of maternal morbidity including measurement of trends and disparities, and review of scientific literature to maintain currency with respect to both scientific methods and emerging issues.

 

Narrative:

CDPH/MCAH reviewed the definition of severe maternal morbidity as described in HRSA’s Federally Available Resource Document (FAD) version April 1, 2022. There were no changes from the previous definition used to report data (version April 13, 2021). The rate of SMM increased from 93.5 per 10,000 delivery hospitalizations in 2018 to 104.4 per 10,000 delivery hospitalizations in 2020. In 2020, Black women were more likely than all other racial/ethnic groups to have at least one severe maternal complication (168.7 per 10,000 delivery hospitalizations). Pacific Islander women were the next most likely to experience SMM (136.9), followed by Asian (118.8), Hispanic (103.8), AIAN (102.2), Multi-Race (87.5), and White women (87.1). CDPH/MCAH continues to review scientific literature to maintain currency with respect to both scientific methods and emerging issues related to maternal mortality and morbidity. Special focus was given to any reference discussing the coding change from ICD-9-CM to ICD-10-CM. Based on current findings, CDPH/MCAH has tentative ICD-10-CM coding definitions for hypertension, diabetes, asthma, substance use, and mental health disorders for women hospitalized at time of delivery. Morbidity definitions and data continue to be refined or updated based on ongoing literature review and evolving subject matter experts’ knowledge.

 

Activity:

CDPH/MCAH will lead surveillance and reporting of severe maternal morbidity as mandated by Senate Bill (SB) 464 – California Dignity in Pregnancy and Childbirth Act. Mandated reporting will occur at least once every three years and will include, but is not limited to, data on the conditions listed in SB 464 aggregated by state regions and race/ethnicity.

 

Narrative:

CDPH/MCAH is in the planning and development phase for reporting conditions as mandated by SB 464. The first mandated publication is not required until June 2023.

 

Activity:

CDPH/MCAH will identify and partner with an academic subject matter expert to conduct complex population-based data analyses, to inform decision-making for implementation of Levels of Maternal Care. This expert will develop a risk profile of women to look at the distribution of medically complex pregnancies throughout the state and identify where they give birth.

 

Narrative:

CDPH/MCAH continued to work with the Maternal Quality Indicators (MQI) Workgroup, based out of the UCLA Department of Obstetrics, to conduct complex population-based data analyses to inform decision-making for implementation of a system of levels of maternal care. To date, the following main goals of this project have been completed: (1) the identification of patient characteristics present before birth that are associated with SMM during delivery and calculation of the number of women affected in California hospitals; (2) the identification of hospitals where (a) the expected SMM risk is high indicating a hospital may be serving a medically complicated birthing population and (b) the observed to expected ratio is high, indicating a hospital may lack the resources needed to handle SMM patients; and (3) the conducting of analyses on SMM rates and hospital rankings, as described in the second goal above, but also while considering conditions reported as present on admission (POA).

 

Success(es):

CDPH/MCAH and MQI continue to disseminate findings on using SMM as a hospital performance measure. One manuscript, “Severe Maternal Morbidity in California Hospitals: Performance Based on a Validated Multivariable Prediction Model,” was published in November 2021. Another manuscript to evaluate California hospital performance based on a standardized SMM measure, this time considering only SMM conditions that would have been POA, was prepared and under review for publication (in Joint Commission Journal on Quality and Patient Safety), as of June 2022.

 

Women/Maternal Objective 2: Strategy 2:

Lead statewide regionalization of maternal care to ensure women receive appropriate care for childbirth.

 

Activity:

CDPH/MCAH will fund the RPPC Directors to focus on quality improvement in participating labor and delivery hospitals through the state and to coordinate and support a regionalized perinatal system.

 

Narrative:

Regionalization activities were focused on the development, evaluation, and procurement of the Regional Perinatal Programs of California (RPPC) Request for Application (RFA). RPPC’s goal is to improve access to risk-appropriate perinatal care for pregnant women and their infants and conduct quality improvement activities that promote an integrated regional perinatal system between public health, health care institutions, local communities, and state organizations. The 2022 -2025 RPPC RFA was formulated by a multidisciplinary team and culminated in the awarding of contracts to five agencies throughout California serving nine RPPC regions. The suddenness of the COVID pandemic revealed a need for agile and timely local emergency response for pregnant and birthing populations. The RPPC scope of work was updated to incorporate assisting with statewide and local response to disasters and emergency situations by supporting labor and delivery hospitals, local health jurisdictions, and other emergency responders as requested by CDPH/MCAH.

 

The RPPC Directors conducted annual site visits to labor and delivery hospitals in their regions with the exception of Kaiser Permanente hospitals. 86% of labor and delivery hospitals in California had a virtual site visit despite hospital staff being redirected or consumed with COVID-19 efforts.

 

Activity:

CDPH/MCAH will fund CMQCC to coordinate a collaborative of perinatal experts to consider clinical medicine, population health, and systems of care to promote quality improvement efforts in maternal health.

 

Narrative:

MCAH/RPPC promotes California Maternal Quality Care Collaborative (CMQCC) toolkits aimed at improving the health care response to leading causes of death among pregnant and postpartum individuals, as well as reducing harm to infants and birthing people from overuse of obstetric procedures. Toolkits released and promoted in this reporting year were Improving Diagnosis and Treatment of Maternal Sepsis, Mother & Baby Substance Exposure Initiative, and an updated Hypertensive Disorders of Pregnancy. CMQCC also operates the Maternal Data Center (MDC), an online web tool that generates near real-time data and performance metrics on maternity care services for hospital participants. The 2021-2022 RPPC SOW emphasized building data fluency and using the MDC for quality improvement. RPPC annual reporting demonstrates that RPPC regional staff effectively used the MDC RPPC Profile Report in preparation for 98% of site visits and to inform discussions about the facilities metrics during site visits.

 

The CDPH/MCAH Nutrition and Physical Activity (NUPA) Coordinator worked with RPPC contractor Perinatal Advisory Council/Leadership, Advocacy, and Consultation (PAC/LAC) and WIC Regional Breastfeeding Liaisons to finalize the fourth edition of Providing Breastfeeding Support: Model Hospital Policy Recommendations. The recommendations give evidence-based information and guidance to birthing hospitals who wish to revise policies and practices known to support breastfeeding. They were released in March 2022. MCAH provided training on the recommendations to all Local MCAH Directors in the Spring.

 

Activity:

CDPH/MCAH will lead and fund data collection to measure hospital Levels of Maternal Care using the CDC LOCATe tool.

 

Narrative:

The 2022 CDC LOCATe survey was fielded beginning in December 2021. In March 2022, MCAH received new state government guidance that changed previously communicated data confidentiality conditions for survey participation. Accordingly, the project was paused to alert participating facilities and reconfirm survey participation. The project remained paused as of June 2022 but is expected to resume pending reconfirmation by participating facilities.

 

Activity:

CDPH/MCAH will lead and fund the convening of key partners, such as RPPC Directors, birthing hospitals, CMQCC, etc., to identify opportunities to establish a Levels of Maternal Care system.

 

Narrative:

RPPC Contractor Community Perinatal Network, in collaboration with the Maternal Risk-Appropriate Care Workgroup and CDPH/MCAH, developed and produced the maternal transport recommendations to streamline transports between referring and receiving hospitals within the state. The tool will be helpful to further efforts addressing maternal risk-appropriate care and transport throughout California.  

 

Activity:

CDPH/MCAH will partner with CPSP, WIC Regional Breastfeeding Liaisons, and local MCAH programs to ensure a coordinated delivery system for women during and after their pregnancy

 

Narrative:

RPPC coordinates engagement between regional collaboratives and state partners such as WIC, SIDS, and the Comprehensive Perinatal Services Program (CPSP). The RPPC Chair and RPPC Coordinators participate in monthly Perinatal Service Coordinator (PSC) Executive and local MCAH meetings.

 

Local MCAH Program Examples:

Many Local MCAH programs collaborated with their RPPC Coordinators and other partners to ensure women receive risk-appropriate care for childbirth.

 

• Humboldt County’s PSC and RPPC held two meetings to review local data and birthing statistics trends. They collaborated to brief birthing hospital managers on these trends and to discuss hospital models friendly to babies and quality improvement projects taking place at local birthing centers.
• In February, the Mendocino County Home Visiting program staff attended a joint RPPC/CPSP roundtable discussion on preeclampsia. CMQCC presentations addressing the uneven burden of maternal mortality and perinatal mood disorders were shared with the LHJ Health Officer to disseminate locally.
• San Diego County met at least quarterly with the RPPC Coordinator to discuss quality improvement efforts among CPSP providers. They also hosted a Preventive Medicine Resident from UC San Diego/San Diego State who was conducting a landscape analysis aimed at identifying gaps in the availability of CPSP providers in targeted ZIP Codes (those in the fourth quartile of the Healthy Places Index).
• Sonoma County and RPPC formed a collaborative link with Providence Hospital though a shared training on prenatal and postpartum sepsis.

 

Challenge(s):

The RPPC Program lead promoted to a new position as the 2022-2025 RFA was being finalized, delaying the release of the RFA and the awarding of contracts.

 

Women/Maternal Objective 2: Strategy 3:

Partner to strengthen knowledge and skill among public health practitioners, health care providers, and families on chronic conditions exacerbated during pregnancy.

 

Activity:

CDPH/MCAH will fund the CDAPP Sweet Success Resource Center to train providers, develop educational materials, and produce a revised Guidelines for Care to improve and expand quality services for women with diabetes and during pregnancy.

 

Narrative:

The California Diabetes and Pregnancy Program (CDAPP) Sweet Success Training and Resource Center offered eight new training modules in 2021-2022 for a total of 23 Training Modules that affiliates and non-affiliates across the U.S. could utilize and learn from free of charge. All training modules are based on the fundamental components of diabetes management before, during, and after pregnancy in accordance with the CDAPP Guidelines for Care.

 

Activity:

CDPH/MCAH will lead the development and dissemination of culturally appropriate materials to address chronic disease in disparate populations such as overweight and obesity brief, preconception My Plate, and heart disease fact sheet.

 

Narrative:

CDPH/MCAH developed four new MyPlate Resources to help individuals achieve and maintain a healthy weight. Tools and handouts encourage pregnant or breastfeeding individuals and their families to include a variety of fruits, vegetables, whole grains, lean proteins, and dairy on their plates every day, and be physically active. The four new MyPlate Handouts include Preconception, For Pregnant and New Parents, For People with Gestational Diabetes, and For Children Ages 2-12. All four MyPlate resources are available in English and Spanish.

 

Activity:

CDPH/MCAH will lead the maintenance and implementation of tools and resources to reduce the rate of diabetes in pregnancy and overweight/obesity in childbearing parents.

 

Narrative:

The MCAH/CDAPP work plan encouraged the Resource Center to send out email blasts with website links to all Affiliates and those interested in CDAPP offerings to increase utilization of the CDAPP website and educational materials. The Resource Center engaged organizations through invitation and involvement in Stakeholder Groups, website links, and collaborative efforts to reduce the rate of diabetes in pregnancy and for overweight/obese parents. The CDAPP Training and Resource Center also updated numerous materials in the last fiscal year. There has been an immense push to update CDAPP patient and provider resources not just clinically, but graphically before the end of the contract period which ends June 30, 2022.

 

Activity:

CDPH/MCAH will offer technical resources such as the Diabetes Self-Management Education and Support (DSMES) Toolkit and aided with the implementation of evidence-based lifestyle change programs, such as CDAPP, to improve continuity of care.

 

Narrative:

The CDAPP Training and Resource Center has been funded by Title V through a Request for Application (RFA) process, with the outside vendor’s contract ending June 30, 2022. CDPH/MCAH decided not to continue funding the CDAPP Training and Resource Center due to the extensive focus on the medical management of pregnant individuals with gestational diabetes. During this next year, CDPH/MCAH is exploring interventions, strategies, and resources to reduce prevalence of gestational diabetes and prevention of Type 2 diabetes. At the beginning of this transitional phase, CDPH/MCAH developed and disseminated communications to the Stakeholders and Affiliates through an interactive forum to understand and address concerns and gather input on needs to support CDAPP SS beneficiaries and all individuals with gestational diabetes. CDPH/MCAH realizes the CDAPP Training and Resource Center not only provided training and resources for the affiliate but attracted other states beyond California who used the Training and Resource Center as part of their public health gestational diabetes program. CDPH/MCAH sees a continued need for national resources on gestational diabetes and postpartum care considering the interest and use of the CDAPP Training and Resources Center provided.

 

Activity:

CDPH/MCAH will develop and disseminate a social media campaign to share information from the maternal overweight and obesity brief to women.

 

Narrative:

This activity was paused during this report period and will be reassessed.

 

Activity:

CDPH/MCAH will fund local Black Infant Health (BIH) sites to develop a statewide media campaign to inform Black women about chronic health conditions and the BIH program.

 

Narrative:

MCAH/BIH led the development and dissemination of culturally appropriate materials that increase awareness of chronic health conditions affecting Black women during pregnancy. BIH created and disseminated the first issue of “Hey Black Infant Health” that shared events, resources, and program highlights. Social media content celebrating Black Maternal Health Week was developed in April 2022 and shared with BIH counties and on the CDPH/MCAH social media channels. The campaign centered the values of the Birth Justice movement and featured affirming guidance such as how to create a birthing music playlist.

 

 

Local MCAH Program Examples:

Local MCAH programs partnered to strengthen knowledge and skill among health care providers and individuals on chronic health conditions exacerbated during pregnancy.

 

• The City of Pasadena hosted two community conversations to increase COVID-19 vaccine confidence among at-risk communities. Project staff invited medical providers, community representatives, and community health workers. In December, staff held “Melanated and Vaccinated: Real People, Real Stories,” an outreach event for the Blackcommunity to share experiences and answer each other’s questions about the vaccine. “Unidos en CommuUNITY” similarly focused on the Pasadena Latino community and aimed to increase awareness and knowledge about the types of COVID-19 vaccines, the sequence/series and efficacy, and to motivate participants to stay safe post vaccination. This event provided on-site COVID-19 vaccinations.
• Riverside County partnered with CDPH/MCAH to pilot educational materials with pregnant clients with hypertension and other health conditions on how to test, track, and report elevated blood pressures in the home. The educational flyer was shared with OB providers. Training on using the “Pregnancy, Postpartum and Cardiovascular Disease” pamphlet was provided for all MCAH staff working with pregnant and postpartum women in all MCAH and home visiting programs. These efforts resulted in clients being empowered to assess and report their symptoms timelier.
• Sonoma County MCAH staff redesigned the MCAH pages and debuted an MCAH Facebook and Instagram placing the MCAH program on high display and positioning MCAH as a respected community leader in the provision of the latest MCAH health information, toolkits, resources, and linkages to Medi-Cal services. MCAH’s capacity to inform, educate, and disseminate educational materials addressing chronic health conditions during pregnancy expanded as demonstrated by a significant increase in site traffic and extremely positive feedback from MCAH partners.

 

Women/Maternal Focus Area 3: Improve mental health for all mothers in California.

 

Women/Maternal Objective 3:

By 2025, increase the receipt of mental health services among women who reported needing help for emotional well-being or mental health concerns during the perinatal period from 49.6% to 52.1%.

 

Story Behind the Curve:

It is estimated that approximately 20% of women will experience a perinatal mental health problem (PMHP). Mental health problems can range from mild depression and anxiety to mania and psychosis. In California, approximately half of birthing individuals who reported needing help for emotional well-being or mental health concerns during the perinatal period received mental health services. Promoting mental health and healthy behaviors during pregnancy is important to optimize maternal and infant health outcomes. Therefore, one of the priorities identified in the 2021-2025 needs assessment is to increase access to mental health services among women and birthing people who reported needing help for emotional well-being or mental health concerns.

 

Women/Maternal Objective 3: Strategy 1:

Partner with state and local programs to disseminate information and resources to reduce mental health conditions in the perinatal period. Create a cross-sector collaboration to consider the social, economic, and environmental origins of mental health problems among women that manifest during the perinatal period.

 

Activities:

CDPH/MCAH will partner, collaborate, and share resources with local health jurisdictions and state departments and commissions responsible for the provision of mental health services.

 

CDPH/MCAH will partner at the state and local levels to identify and promote best practices to address mental health, including stigma and discrimination due to mental health diagnosis.

 

CDPH/MCAH will support state and local workforce development to address mental health with the populations we serve.

 

Narrative:

CDPH/MCAH facilitated Maternal/Infant Health (MIH) Collaborative Meetings on mental health where CDPH/MCAH programs shared who they partnered with, what mental health topics their programs addressed, interventions and resources used, screening tools and referral linkages, and how education and outreach was used to improve mental health throughout the state. MIH Collaboratives demonstrated that MCAH programs and initiatives normalize accessing support and reduce stigma through universal screening and referring, and by braiding mental health topics throughout activities and interventions. For example, mental health may be addressed in counties with Perinatal Equity Initiative (PEI) programs during Group Prenatal Care, Preconception/Interconception Care, Doula programs, Fatherhood sessions, home visitation, and Community Advisory Board meetings. CDPH/MCAH programs will continue to work on improving cross-sector collaboration to consider the social, economic, and environmental origins of mental health problems among women that manifest during the perinatal period.

 

Local MCAH Program Examples:

Examples from the Local MCAH annual reports to reduce mental health conditions in the perinatal period include the following:

• Butte County’s MCAH Director partnered with local First 5 and attended the Mothers Strong coalition quarterly meetings. Mother’s Strong is dedicated to bringing vital mental health information to moms and families in California’s north state region. Meeting participation has remained consistent over the last year.
• El Dorado County MCAH distributed an electronic referral form and provided education to all key providers, community-based organizations, and WIC. Continued partnership with El Dorado County Child Protective Services led to the rotating participation of MCAH Public Health Nurses (PHNs) during daily evaluation of child abuse reports. In this role, PHNs can assess perinatal mental health in these meetings and during urgent response home visits. PHNs intervened on several occasions to develop a safety and support plan for postpartum clients. PHN care reduced wait times for mental health treatment.
• In Humboldt County, the Licensed Clinical Social Worker worked with the Nurse Family Partnership (NFP) program, case managers, and other mental health programs to provide ongoing education and guidance to nursing case managers and other mental health programs to improve well-being of first-time families in Humboldt County. They attended trainings on Sexual Orientation & Gender Identity (SOGI), Dialectical Behavior Therapy (DBT) skills Certification, Infant Massage, Serving Neurodivergent Survivors, Tribal Opioid Response Training, Domestic Violence Training, and completed the Parent-Child Relationship Programs Workshop Certificate Promoting Maternal Mental Health. Staff also presented on Maternal Mental Health to the Humboldt County Perinatal Community Coalition (HCPCC) composed of key local stakeholders including WIC, and obstetric, behavioral health, and oral health providers.
• Sonoma County piloted a coordinated Perinatal Mood and Anxiety Disorder (PMAD) and Adverse Childhood Experience (ACEs) referral, closed-looped, case management system with a “no wrong door” entry approach which will share data and referral information between all partners in the system.
• The Perinatal Equity Initiative in Santa Clara County screened a documentary titled “From the Ashes,” and held a discussion on Black Maternal Mental Health. Resources on this topic were disseminated to attendees and shared statewide through the Preconception Health Council of California (PHCC).

 

Success(es):

• A maternal mental health dashboard was in the planning and development stage this reporting period.
• The PHCC, led by CDPH/MCAH, held a meeting to share work on mental health within member organizations. They identified barriers to advancing mental health and potential solutions and shared best practices and resources with one another. This information was disseminated throughout the state by PHCC member organizations and through statewide channels of communication.
• Two CDPH/MCAH staff were selected for the 2022-23 cohort of the 2020 Mom Government Agency Maternal Mental Health Fellows Program. In that role the Fellows will gain knowledge regarding federal and state best practices to address maternal mental health issues and to recognize racial disparities.

 

Women/Maternal Objective 3: Strategy 2:

Partner to strengthen knowledge and skill among health care providers, individuals, and families to identify signs of maternal mental health-related needs.

 

Activities:

CDPH/MCAH will partner with existing MCAH programs (BIH, Indian Health, AFLP, CHVP, CPSP) to raise mental health awareness and promote resources.

 

CDPH/MCAH will partner with mental health programs to identify materials, training (such as Mental Health First Aid), and other resources to educate and inform individuals and families about maternal mental health signs, symptoms, and services.

 

Narrative:

Resources were shared through collaborative/council meetings, eblasts, newsletters, and across networks statewide. CDPH/MCAH led in promoting and disseminating mental health messages through coordination of social media platforms and education materials to educate women and families to recognize mental health symptoms as well as behaviors and abilities that reflect well-being as via the Maternal Mental Health webpage. MCAH programs and initiatives strive to mitigate the effects of stress and trauma and increase self-efficacy over time through strengths-based, relationship-centered activities.

 

Adolescent Family Life Program (AFLP) partnered with Dignity Health and affiliates to present a Youth Mental Health First Aid webinar for all AFLP, CA Personal Responsibility Education Program, and Information & Education staff. The training taught participants how to identify, understand, and respond to signs of mental illness and substance use disorders in youth. AFLP established a mental well-being youth ambassador program to amplify youth voice in the 18- month Adolescent and Young Adult Behavioral Health Collaborative Innovation and Improvement Network (CoIIN). The CoIIN aims to strengthen depression screening rates and follow-up through primary care quality improvement and public health strategies. Two Mental Well-Being Ambassadors participated in monthly public health meetings and developed a survey to collect information about priority areas of focus from youth across the state.

 

Activity:

CDPH/MCAH will collaborate with local BIH sites to promote the use of the Edinburgh Postnatal Depression Scale during the prenatal and postpartum period with BIH Participants.

 

Narrative:

Black Infant Health participants are assessed by mental health professionals when they enter the program. BIH mental health professionals are exploring validated screening tools that are more relevant and accurate for Black parents.

 

Activity:

CDPH/MCAH will lead in promoting and disseminating mental health promotion messages through social media platforms and education materials to educate women and families to recognize early signs and symptoms of mental health disorders.

 

Narrative:

The Preconception Health Council of California (PHCC) shared resources from CDC HEAR Her Campaign, 2020 Moms and the Shades of Blue Project, and coordinated social media messaging for mental health with organizations represented on the council. These resources were shared statewide through the PHCC member organizations reaching providers, individuals, and families.

 

Activity:

CDPH/MCAH partnered with local Perinatal Service Coordinators to support new requirements for provider screening of mental health at least once during pregnancy and postpartum and ensure CPSP providers receive training on mental health.

 

Narrative and Local MCAH Program Examples:

• Shasta County provided information on legislation requiring screening for maternal mental health to CPSP providers. By informing providers of this requirement and sharing resources for mental health care referrals, MCAH helped the community to better understand the importance of screening pregnant and postpartum people for mental health issues and referring them to get the help they need.

• Sonoma Country called their partnership to disseminate mental health messages “a tremendous success. The increase in our web traffic doubled and is still growing.”

 

 

Success(es):

• American Indian Maternal Support Services (AIMSS) completed a Mental Health Module currently being piloted by the National Institutes of Health that addresses Indigenous preventive approaches, related treatment options, and challenges.
• The Orange County PMAD Collaborative Toolkit developed in 2020 was a celebrated presentation during April’s 2022 Annual PSC Education Day. The Toolkit orients to local resources, walks providers and community organizations through screening and referring. It includes the validated screening tools, decision trees and flow charts, online resources for additional training, guidance on Medi-Cal reimbursement and billing codes, and lots of client-facing educational materials to meet the unique demands of their clients specific to their county. The Toolkit was adapted and implemented by Sonoma County in 2021-2022.

 

Women/Maternal Objective 3: Strategy 3:

Partner to ensure pregnant and parenting women are screened and referred to mental health services during the perinatal period.

 

Activity:

CDPH/MCAH will partner with MCAH programs (CPSP, BIH, CHVP, AIMSS, ALFP, LHJs) to utilize validated mental health screening tools.

 

Narrative:

Some of the screening tools include PHQ-9, Edinburgh Postpartum Depression Screening (EPDS), IPV Relationship Assessment Tool, and 4 Ps Tool. Mental health professionals and LHJs work within their specific counties to enhance referrals and linkages to mental health services.

 

Black Infant Health participants are screened by mental health professionals when they enter the program. In addition to direct linkages to mental health services, participants are also supported through community events, workshops, speaker presentations, and groups that address topics such as anxiety and depression, stress management, and anti-Black racism.

 

SIDS Coordinators offer grief and bereavement services following a presumed SIDS/SUID death, making referrals to counseling, SIDS Parent Support Groups, and maintaining contact with the family/caregiver over time to ensure families are cared for.

 

Activities

CDPH/MCAH will partner with Department of Health Care Services Mental Health Branch and the Mental Health Services Act Oversight & Accountability Commission to identify validated tools for mental health screening in the perinatal period.

 

CDPH/MCAH will partner with Department of Health Care Services Mental Health Branch the Mental Health Services Act Oversight & Accountability Commission to ensure adequate and appropriate access to perinatal mental health services are made available at the local level.

 

Narrative:

CDPH/MCAH did not partner with DHCS/MHS and the Mental Health Services Act Oversight & Accountability Commission.

 

Local MCAH Program Examples:

• Public Health Nurse case managers in El Dorado County made frequent perinatal mental health referrals. They advocated for urgent mental health services for high-risk mothers and linked people to counseling, medical care, and inpatient treatment services using their EPDS score as criteria. They found that universal use of the EPDS created a common language between MCAH and providers.
• Although no client in Lassen County scored 10 or greater on the EPDS, staff used the screener as an opportunity to have a conversation about postpartum depression and let clients know to pay special attention to their own or their partner’s mental health for the full year after birth and to share resources and contacts.
• A first-time pregnant mother in San Mateo’s county-funded Black Infant Health program screened positive on the EPDS and was immediately referred for mental health services and enrolled in the NFP program. Before the client started with BIH/NFP, the client had relationship issues, was deeply depressed, and did not know which direction her life would go or where she could get support. Things started changing for her. She connected with a faith-based organization that gave her additional support and set a goal to provide a good life for herself and for her baby. The support she received from BIH/NFP helped change the direction of her life.
• One Perinatal Equity Initiative (PEI) site regularly programs a community event called “Shifting Power” that is designed to address stigma clients might experience when needing mental health treatment.
• A Healthy Babies home visitor in Nevada County witnessed the many successes of the Moving Beyond Depression (MBD) Program. A recently enrolled mother reported difficulty sleeping, feeling tired even after sleeping, and a lingering lack of motivation. Some past trauma and grief were mixed in with her feelings of depression. She agreed to try out MBD. After meeting with her MBD therapist, she felt better about herself, was able to sleep, get up in the morning, and reframe her negative thought patterns. She said a tremendous weight was lifted from her shoulders because of the tools she learned through MBD. She completed the MBD program and was referred to another program that is helping with her past trauma and grief. This mom said that if it wasn’t for the MBD program she would have never been able to move forward and was so grateful her home visitor connected her with MBD.

 

Challenge(s):

• San Mateo offers a county-funded Black Infant Health program and continued to provide services virtually, though the pandemic continues to be a challenge when scheduling visits with clients. Scheduled assessments are sometimes postponed or cancelled during a visit to address more critical issues that the clients are currently facing (e.g., homelessness).

 

Women/Maternal Focus Area 4: Ensure optimal health before pregnancy and improve pregnancy planning and birth spacing.

 

Women/Maternal Objective 4:

By 2025, increase the percentage of women who had an optimal interpregnancy interval of at least 18 months from 73.6% (2017 CCMBF) to 76.4%.

 

Story Behind the Curve:

Pregnancies that occur less than 18 months after a live birth are associated with delayed prenatal care and increased risk for adverse birth outcomes. Access to services that promote appropriate birth spacing can reduce the risk for poor birth outcomes such as preterm birth and low birthweight. Access to family planning counseling and contraception plays a key role in birth spacing and reduced risk for poor birth outcomes.

 

Women/Maternal Objective 4: Strategy 1:

Partner with local health jurisdictions and other State agencies to increase knowledge and skill to improve health and health care before and between pregnancies.

 

Activity:

CDPH/MCAH will lead the Preconception Health Council of California (PHCC) to guide and inform statewide preconception efforts.

 

Narrative:

CDPH/MCAH continues to lead the PHCC to guide and inform statewide preconception efforts that focus on improving health and health care before and between pregnancies.

 

Activity:

CDPH/MCAH will lead a refresh of Every Woman California website to re-establish a platform for sharing preconception health information for the public ad health professionals.

 

Narrative:

The refreshed website was launched in February 2022.

 

 

Activity:

CDPH/MCAH will support disseminating and promoting best-public health and health care practices, resources, and education from key preconception initiatives (Preconception COIIN and National Preconception Health & Health Care Initiative).

 

Narrative:

Interconception Care Guidelines developed in 2020-2021 were published on the PHCC Every Woman California webpage. These guidelines were disseminated statewide through PHCC meetings, presentations, CDPH newsletters, and eblasts.

 

CDPH/MCAH coordinated a learning session where DHCS trained PHCC members on the American Rescue Plan Act (ARPA) Postpartum Care Extension. The PHCC then convened and developed recommendations for best practices to support the implementation of the ARPA Postpartum Care Extension. CDPH/MCAH also coordinated a learning session where UC Davis Perinatal Origins of Disparities Center presented at PHCC on ACEs Aware and its implementation in Yolo County. Connections were made within the PHCC networks to advance this work. PHCC shared work on mental health within member organizations. They identified barriers to advancing mental health and potential solutions, and shared best practices and resources with one another.

 

Activity:

CDPH/MCAH will collaborate with local MCAH programs to develop and adopt protocols to ensure that all clients in local MCAH programs have health insurance, are linked to a provider, and complete a preventive visit(s).

 

Narrative:

Local MCAH programs facilitated access to care and appropriate use of services including, but not be limited to, oversight of CPSP, patient/client outreach, services for children and youth with special health care needs, education, community awareness, referral, transportation, childcare, translation services, and care coordination. They continued to develop and revise policies in response to COVID-19 in areas such as telehealth. In July, MCAH promoted and disseminated CDPH guidance regarding COVID-19 vaccination for pregnant and lactating individuals to improve COVID-19 vaccination rates in people of reproductive age.

 

PEI’s Preconception/Interconception Intervention provided patient-centered support, education, information, and referral. PEI funding allowed participating counties to contract with community-based organizations to offer to their program participants a variety of services and educational opportunities, including opportunities for participants to get fit, learn healthy eating practices, have group-based discussions with their peers, and learn how to protect themselves from sexually transmitted infections (STI).

The BIH Program continued to provide education and resources related to birth spacing and pregnancy planning during weekly group sessions and individual case management. The program promoted the importance of optimal physical and mental health between pregnancies via regular exercise, good nutrition, and self-care.

 

Activity:

CDPH/MCAH will lead efforts to improve girls and women’s understanding of constructs of healthy relationships, the use of agency, and communication skills in an effort to prevent intimate partner violence.

 

Narrative:

CDPH/MCAH hosted a live virtual training for local AFLP agencies on healthy relationships. The presentation built applied knowledge in identifying and supporting crucial conversations around healthy and unhealthy aspects of relationships and youth experience. AFLP’s Basic Training incorporates information on family planning and safer sex. Some AFLP agencies educate program participants on the importance of immunizations during and after pregnancy.

 

Activity:

CDPH/MCAH will partner with CDPH/CID to improve vaccination rates in people of reproductive age and to reduce rates of STIs through barrier protection.

 

Narrative:

The partnership with CDPH/CID was paused during this report period and will be reassessed.

 

Activity:

CDPH/MCAH will partner with the CDPH Office of Oral Health to disseminate the Perinatal Oral Health Quality Improvement Project findings and promote best practices, resources, and education on oral health during, before, and after pregnancy.

 

Narrative:

CDPH/MCAH paused monthly collaborative meetings with the Office of Oral Health and continued to participate on the Office of Oral Health Advisory Committee Workgroups. Our continued relationship also identified a Dental Consultant who was recruited to be on the PHCC. The Dental Consultant assisted in the review of the Interconception Guidelines related to oral health.

 

Local MCAH Program Examples:

• Santa Clara County PEI provided information sessions on ovulation and family planning. The sessions focused on taking an active role in deciding if or when to become pregnant.
• Los Angeles County PEI offered a provider training series that focused on teaching the importance of respectful, culturally attuned care and communication with Black patients. This focus on language discipline ensured that providers have the tools to hold reproductive conversations with Black patients that are empowering, informed, and effectively support them on their sexual and reproductive health journeys.
• Los Angeles’s BIH Program hosted a Nutrition and Pregnancy Workshop to educate participants about nutritional needs for a healthy pregnancy, the benefits of being physically active while pregnant, and easy meal-planning tips. Participants received grocery bags of food that included chicken, ground turkey, fresh produce, and shelf stable food.
• To mitigate the limited access to providers and clinics because of the pandemic, Alameda County developed a greater social media-based outreach approach to increase knowledge and referrals to MPCAH/Starting Out Strong. MPCAH/Starting Out Strong provides one-to-one parenting support for new and expectant CalWORKs parents. Facebook and Instagram pages detail information about Maternal Child Health-related themes, MPCAH programs and services, and how to enroll through a variety of digital methods such as live chats and groups. One virtual outreach effort held consistently during this reporting period was a live monthly virtual resource space called Mommy Chat where Facebook/Instagram followers heard about and engaged with MPCAH programs, staff, and resources in real time.
• Glenn County developed and disseminated a preconception and interconception health flyer, and faxed Preconception/Interconception guidelines to 25 local provider offices with a cover letter expressing the importance of preconception health care. They coordinated with California Health & Wellness and Anthem Blue Cross to mass distribute the letter and guidelines to their contracted providers.

• San Bernardino sent two preconception best practice and resources mass emails to 45 OB offices. CDPH/MCAH preconception messages for families were shared on social media. San Bernardino’s best performing social media post was titled “#FolicAcid daily BEFORE pregnancy?” and reached 1,998 people.

• Sonoma County promoted CDPH/MCAH social media posts and linked to the Every Woman California website to educate women of reproductive age regarding healthy inter-birth intervals. A weekly newsletter was developed to promote the release of the Interconception Care Project.

 

Challenge(s):

• San Bernardino County reported there was not a lot of content that was social media-ready and the process of making them social media-ready and tailoring them for each platform was too time-consuming given staff was limited on time and resources.

 

Women/Maternal Objective 4: Strategy 2:

Lead a population-based assessment of mothers in California, the Maternal and Infant Health Assessment Survey (MIHA), to provide data to guide programs and services.

 

Activity:

CDPH/MCAH will collaborate with UCSF Center for Health Equity (CHE) to create a survey and to revise the sampling plan to ensure representative data at the state, regional, and county levels.

 

Narrative:

Revisions were made to include Sutter and Yuba as individually sampled counties due to their increasing birthing population. This change increased the number of counties individually sampled from 35 to 37. The total sample remained the same at around 10,000 to allow for representative stable data at the state, region, and county levels. Survey development for MIHA 2022 occurred from August 2021 through March 2022 and involved collaboration between MCAH subject matter experts, leadership, and UCSF CHE, as well as input from other CDPH programs, the CDC, and key MCAH/MIHA stakeholders. New topics added in MIHA 2022 included hospital practices that support breastfeeding, workplace breastfeeding support, and postpartum leave.

 

CDPH/MCAH supported the UCSF CHE in MIHA data collection to maximize participation among individuals selected to participate in the survey. Data collection for MIHA 2021 began in May 2021 was completed in January 2022; and data collection for MIHA 2022 began in May 2022. MIHA 2021 had an overall response rate of 61.0% (6,093 participants), a slight increase from previous years.

 

CDPH/MCAH reviewed the MIHA weighting procedures and supported UCSF in creating final weights to complete the MIHA 2020 dataset and in creating provisional weights for MIHA 2021 data. Using the Vital Records Business Intelligence System, final weights will be calculated when the final California Comprehensive Master Birth File is available for 2021. MCAH collaborated with UCSF in validating constructed variables for raw MIHA 2021 data from May to June 2022 and updated the MIHA variable database.

 

Activity:

CDPH/MCAH will partner with the UCSF Center for Health Equity to conduct analyses of CDPH/MCAH priority topics, develop surveillance products, and design and implement scientific research studies.

 

Narrative:

CDPH/MCAH collaborated with UCSF on finalizing two sets of MIHA data snapshots using 2016-2018 MIHA data. These surveillance products contain many key MCAH indicators by different maternal demographics for the overall birthing population and for the prenatal WIC participant population at the state, regional, and county levels. The 2016-2018 MIHA data snapshots for the overall birthing population were released in February 2022, and the Snapshots for the prenatal WIC participant population will be released next year.

 

Activity:

CDPH/MCAH will lead the dissemination of findings in a variety of MIHA data products.

 

Narrative:

CDPH/MCAH also collaborated with UCSF on the development of a comprehensive report focused on the health of Black birthing individuals and their infants, and a series of data briefs that focus on secondary impacts of the COVID-19 pandemic on birthing individuals and their families.

 

Women/Maternal Objective 4: Strategy 3:

Lead the implementation of the Comprehensive Perinatal Service Provider (CPSP) program to ensure access to comprehensive prenatal care for Medi-Cal Fee-for-Service clients.

 

Activities:

CDPH/MCAH will coordinate with DHCS to improve access to high quality prenatal care.

 

CDPH/MCAH will continue to establish standards for an applicant to become a CPSP provider, review applications, and notify the applicant if their application is accepted.

 

Narrative:

In January 2022, CDPH/MCAH developed a new Enrollment Application Form (4448) that streamlined the application process for providers while providing guidance to the Perinatal Services Coordinators (PSCs) for reviewing the application to ensure a successful provider enrollment. Local MCAH Programs Policies and Procedures (P&Ps) were revised to reflect these new changes. CDPH/MCAH continued reviews and approved or denied CPSP Provider applications according to established standards.

 

 

Activities:

CDPH/MCAH will support local Perinatal Service Coordinators to identify and recruit providers in medically underserved areas to increase access to perinatal care.

CDPH/MCAH will support locals by providing technical assistance and training on the CPSP provision of services, and quality of care.

 

CDPH/MCAH will fund CPSP Provider Orientations to ensure CPSP providers understand the role and responsibilities of becoming a CPSP provider in addition to provision of services.

 

Narrative:

CDPH/MCAH supported the efforts of the PSCs to lead community outreach that identified and encouraged recruitment of providers into CPSP. For the first time in two years, CDPH/MCAH conducted the PSC Annual Meeting on April 27 and 28, 2022. The first day was an education day in which speakers presented a variety of topics including New Interconception Guidelines for Care, Maternal Mental Health, Sexually Transmitted Diseases, and Adverse Childhood Events. Presentations on the second day addressed PSC roles and responsibilities for Provider Enrollment, the new CPSP Provider Application, monitoring and oversight, chart and administrative reviews, telehealth, virtual chart reviews, virtual visits, and provider recruitment and recruiting techniques.

 

Activity:

CDPH/MCAH will lead in monitoring and providing oversight of CPSP, including quality improvement efforts to monitor providers and ensure quality of care for CPSP.

 

Narrative:

PSCs continued to provide technical assistance and training on the CPSP provisions of services to CPSP providers and provided monitoring and overview of the CPSP program through informal roundtable discussion, doing on-site and virtual visits, and conducting chart and administrative reviews.

 

Activity:

CDPH/MCAH will partner with the Office of Oral Health to provide education on the importance of oral health during pregnancy.

 

Narrative:

MCAH paused monthly collaborative meetings with the Office of Oral Health.

 

Local MCAH Program Examples:

• Monterey County PSCs conducted outreach to local clinics including Cypress Health Care Partners, Monterey Birth and Wellness Center, and Taylor Farms Family Health and Wellness Center highlighting the CPSP program objectives of improving perinatal health to pregnant people.
• 95% of San Bernardino County’s visits were conducted using the CPSP QA form and 19/20 providers who completed the QA form scored 80% or above. One office is beginning to conduct services after pausing CPSP services for the past two years.

 

Success(es):

The PSCs continued to recruit CPSP providers despite the pandemic, 49 CPSP provider applications were approved, a 32% increase from 37 approved provider applications in FY 20-21. Many CPSP providers reported to their PSCs that clients were satisfied and felt they had their obstetrical, nutritional, psychosocial, and health educational needs met with both on-site and virtual visits. To find the best fit for their clients’ participation in the CPSP program, CPSP providers stated they will continue to offer both face-to-face and virtual office visits to promote successful completion of the CPSP program.

 

Challenge(s):

• Serving medically underserved regions through California continued to be challenging. Not all counties have CPSP providers or PSCs. While more CPSP applications were approved in FY 2021-2022 than FY 2020-2021, the overall enrollment and participation of Fee-For-Service (FFS) providers has decreased. MCAH worked with the PSCs in counties with few or no CPSP providers to encourage recruitment into the CPSP program.

 

Women/Maternal Objective 4: Strategy 4:

Fund the DHCS Indian Health Program (IHP) to administer the American Indian Maternal Support Services (AIMSS) to provide case management and home visitation program services for American Indian women during and after pregnancy.

 

Activities:

CDPH/MCAH will fund DHCS IHP to conduct perinatal case management and care coordination to support pregnant American Indian individuals to receive health care, education, emotional support, and referrals to social, health and community services.

 

CDPH/MCAH will fund DHCS IHP to provide maternal health training for AIMSS grantees and Indian health clinics through meetings, webinars, or conferences.

 

CDPH/MCAH will support DHCS IHP to screen and refer American Indian pregnant individuals for mental health and substance use disorder services.

CDPH/MCAH will support DHCS IHP to educate women and families to recognize early signs and symptoms of mental health and substance use disorders through health promotion messages.

 

Narrative:

The IHP provided grant support and oversight to the American Indian Maternal Support Services (AIMSS) programs who provided case management and home visitation to pregnant American Indian clients and their infants until one year of age. Based on individual client needs, comprehensive care was coordinated with other clinical services such as primary care, behavioral health, psychiatry, dental care, and diabetes program services including appointments with clinic nutritionist and/or lifestyle coaches as available at clinics. Follow up with these referrals were tracked and monitored. The AIMSS program served 233 American Indian women from four tribal programs.

 

Activity:

CDPH/MCAH will fund DHCS IHP to collect and monitor program data to include in Title V reporting.

 

Narrative:

DHCS data was not yet available as of reporting time.

 

Success(es):

A first-time 25-year-old mother delivered her two pound, two-ounce baby preterm at 28 weeks by cesarean due to HELLP Syndrome. The mother recovered well and was discharged, but the baby transferred to a higher-level children’s hospital a few days later. The mother did not have transportation. She became depressed not seeing her baby for a few days and considered discontinuing pumping her breastmilk because she was uncertain that she could get the milk to her baby. The Family Spirit Home Visiting Program arranged transportation to the hospital for her. They helped her enroll in Temporary Assistance for Needy Families (TANF) and CalFresh. She continued using the transportation services offered to attend her postpartum appointment, drop off her application for pandemic tribal assistance, and to obtain a copy of her infant’s birth certificate to facilitate program eligibility requirements.

 

Women/Maternal Focus Area 5: Reduce maternal substance use.

 

Women/Maternal Objective 5:

By 2025, reduce the rate of maternal substance use from 20.7 per 1,000 delivery hospitalizations (2018 PDD) to 19.7 per 1,000 delivery hospitalizations.

 

Story Behind the Curve:

Maternal substance use disorder (SUD) is widely recognized as a significant public health issue. SUD data is collected from hospital discharge diagnosis codes at delivery as defined by Agency for Healthcare Research and Quality (AHRQ). Substances included in this analysis are opioids, cocaine and other stimulants (including psychostimulants), alcohol, cannabis, sedative, hallucinogens, inhalants, psychoactive substances, and glyceride. The most recent Needs Assessment indicated a pattern of significant racial/ethnic disparity related to maternal substance use during pregnancy.

 

Women/Maternal Objective 5: Strategy 1:

Lead research and surveillance on maternal substance use in California.

 

Activity:

CDPH/MCAH will lead surveillance of maternal substance use, including measurement of trends or disparities, and review of scientific literature to maintain currency with respect to both scientific methods and emerging issues.

 

Narrative:

CDPH/MCAH continued to monitor maternal substance use at time of delivery using patient discharge data and before, during, and after pregnancy using the Maternal and Infant Health Assessment (MIHA) survey. Patient discharge data show that the rate of maternal substance use at delivery increased from 20.7 per 1,000 delivery hospitalizations in 2018 to 21.1 per 1,000 delivery hospitalizations in 2020. In 2020, American Indian and Alaska Native (AIAN) women were more likely than all other racial/ethnic groups to have a substance use diagnosis (80.9 per 1,000 delivery hospitalizations) at delivery. Black women were the next most likely to have a substance use diagnosis (60.8), followed by Multi-Race (31.6), White (28.3), Pacific Islander (17.3), Hispanic (16.9), and Asian women (3.1).

 

MIHA data on alcohol use before and during pregnancy, cigarette use before, during, and after pregnancy, and cannabis use during and after pregnancy collected in 2021 and 2022 showed that rates remained relatively stable, with no statistically significant increases or decreases. 2016-2018 MIHA data released in 2022 showed that there are disparities in prenatal substance use by age, education, income, and race/ethnicity.

 

Activity:

CDPH/MCAH will lead the dissemination of data findings (reports, presentations, etc.) to raise awareness about maternal substance use and provide data to guide programs and services.

 

Narrative:

CDPH/MCAH continued to review scientific literature to maintain currency with respect to both scientific methods and emerging issues related to maternal substance use. CDPH/MCAH is currently planning and developing data dashboards to disseminate surveillance findings, and maternal substance use is one of many key indicators to be highlighted. The related neonatal abstinence syndrome dashboard is already published and contains maps, bar charts, and trend charts using state and county-level data from 2008-2021.

 

Local MCAH Program Examples:

• Sonoma County MCAH staff partnered with the new Sonoma County Learning Collaborative, the Sonoma County Opioid Prevention Behavioral Team, Child Protective Services, Human Services, Social Services, Family Youth Services, Foster Families Services, Child Welfare System, the Court System, Probation Department, the Drug Court Judicial System, Birthing Hospitals, Clinics, and other Department of Health staff to examine this problem, collect the data, and disseminate the findings to the public and local partners.

 

Women/Maternal Objective 5: Strategy 2:

Partner at the state and local level to increase prevention and treatment of maternal opioid and other substance use.

 

Activity:

CDPH/MCAH will support local MCAH programs in identifying resources on treatment and best practices to address substance use and opportunities to collaborate and improve linkage to services at the state and local level.

 

Narrative:

CDPH/MCAH met with the CDPH Substance and Addiction Prevention Branch to expand our partnership through increased collaboration and data sharing. Plans are in development to update the opioid use and pregnancy toolkit.

 

AIMSS programs have integrated behavioral health services and universal screening and referral for SUD. Three of the four sites use Family Spirit home visiting curriculum that considers drug impacts on the community, the developing baby, and families and loved ones.

 

CPSP providers and practitioners such as social workers and health educators referred clients to appropriate treatment and resources during pregnancy, with increasing ability to focus on the postpartum period because of the ARPA Postpartum Extension. PSCs worked with CPSP providers to link clients to other MCAH programs, such as BIH and CHVP and appropriate state and local programs.

 

CHVP local agencies continued to collaborate with early childhood systems to improve substance use screening and linkage. However, lack of access to appropriate care for pregnant and parenting people who need SUD support and treatment continued to be an issue across the state. CHVP encouraged our local implementing agencies to include organizations that do work around SUD on their local Community Advisory Boards. In addition, the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Benchmark Performance Measure for tobacco cessation referrals requires LIAs to assess participants for tobacco use at intake and provide them with resources.

 

Substance use is compounded by homelessness and associated with increasing transmission of communicable diseases. MCAH partnered with the CDPH Sexually Transmitted Diseases Control Branch and Office of AIDS to present on how substance use, and other adverse social factors contributed to increasing rates of congenital syphilis, perinatal HIV, and perinatal HCV at our Annual Meeting for PSCs.

 

Activities:

CDPH/MCAH will support UCSF/FHOP in the local dissemination of the ASHTO Public Health Perinatal Opioid Toolkit, targeting dissemination to counties of greatest need.

 

CDPH/MCAH will lead in the development and dissemination of social media campaigns related to maternal opioid/substance use.

 

Narrative:

The Association of State and Territorial Health Officials (ASHTO) Public Health Perinatal Opioid Toolkit was not disseminated this year as in the prior year. MCAH also paused the development of a social media campaign related to maternal opioid/substance use to be resumed when new data becomes available.

 

Local MCAH Program Examples:

• A significant accomplishment for El Dorado County was leading the development of the El Dorado Perinatal Substance Use Treatment Collaborative. This collaborative includes Behavioral Health, county SUD services, Marshall Medical Center, Barton Health, El Dorado Community Health Centers (FQHC), Shingle Springs Health & Wellness (tribal health), El Dorado Child Abuse Prevention Council and several community-based organizations. MCAH established a guide for treatment services and a “no wrong door” approach of linking substance using or at-risk women to treatment and support services. The collaborative adopted the 4Ps Plus Screening Tool which MCAH purchased and coordinated the trainings on utilization. From this collaborative, MCAH received more referrals for case management and referrals from OB providers during early pregnancy. We are meeting women at a critical time and supporting their acceptance into treatment programs.
• Monterey County’s MCAH Home Visiting program screened 81 clients for substance use during their enrollment. All clients are given education on risks of substance use during pregnancy and risk of exposure to children. Clients were referred to community agencies for treatment, group support, and/or counseling. MCAH nurses referred to community programs such as Door to Hope, McStart, County Behavioral Health, and peer support groups.
• San Mateo County successfully partnered with the San Mateo County Behavioral Health & Recovery Services Division to provide the home visiting staff with the latest alcohol and other drug (AOD) education and knowledge on linkages and referrals to treatment programs. A training on “Substance Use Harm Reduction & IMAT approach” was provided to 50 Family Health Home Visiting staff. Staff now feel more confident to address issues on AOD/substance use because they have the latest resources and networks to assist them when dealing with these issues with their clients.
• Fresno County collaborates with the jail to allow Public Health Nurses to meet with inmates every week to provide health information, resources, and linkages to MCAH Programs.

 

Success(es):

• A 36-year-old woman pregnant with twins presented to Fresno’s BIH Program. She was using meth and experiencing homelessness. BIH referred her to an inpatient treatment program. She delivered her twins while in treatment. As of this report, she reached one year sobriety and remained active in BIH and outpatient services. She registered for community college and moved into her own apartment with her babies. Because of her success within the program, the father of her babies decided to enter an inpatient treatment program
• A Stanislaus County CHVP participant struggled to stop using during her pregnancy. She was able to maintain her pregnancy and graduate from the program and had a healthy baby girl. She became an advocate and community champion in mental health/substance use.

 

[1] Objective 1 reflecting 2013 CA-PMSS data submitted in 2021-22 Application

[2] Updated to reflect 2019 CA-PMSS data analyzed after the 2021-22 Application submission.

[3] Centers for Disease Control and Prevention Pregnancy Mortality Surveillance System (CDC PMSS) https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm.

[4] CA-PMSS. Data from 2009-2019 were published at www.cdph.ca.gov/pmss and MCAH’s Pregnancy-Related Mortality Data Dashboard

[5] Objective 2 submitted in 2021-22 Application

[6] Objective 2 based on the most current methodology for calculating SMM changed after submitting the 2021-22 Application.

[7] Severe Maternal Morbidity in the United States | Pregnancy | Reproductive Health |CDC