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WOMEN/MATERNAL HEALTH DOMAIN 

SUMMARY/OVERVIEW

FY20 ANNUAL REPORT

 

2016-2020 MCH Priority Needs Addressed in this Domain

Women’s/Maternal Health:  Support the physical and emotional well-being of women and their children

Oral Health:  Increase access to oral health services for pregnant women and children

 

NOTE:  The FY20 Annual Report represents the final year of priorities, strategies and activities aligned with the 2016-2020 needs assessment and state action plan for the Women/Maternal Health Domain. 

 

DOMAIN CONTRIBUTORS:

Maternal and Infant Health (MIH) Coordinator – Division of Child and Family Health

Reproductive Health Unit – Division of Child and Family Health

Division of Death Prevention – Office of the Chief Medical Examiner (OCME)

Dental Health Program – Division of Prevention and Health Promotion

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DOMAIN OVERVIEW

 

MATERNAL AND INFANT HEALTH (MIH) COORDINATOR: The MIH Coordinator serves as subject matter expert housed at VDH’s Central Office who partners closely with an array of state and local partners, including the Virginia Neonatal Perinatal Collaborative (VNPC), the Maternal Mortality Review Team, and the recently-formed maternal mental health workgroup and Pathway to Coordinated Care for Infants and Families (PCC) workgroup. 

• Virginia Neonatal Perinatal Collaborative (VNPC):  As of February 2020, the Virginia Neonatal Perinatal Collaborative (VNPC) moved to Virginia Commonwealth University through a contract with VDH.  VDH continues to provide contract administration, epidemiological support, and is represented on all VNPC committees. VNPC selected three initial quality improvement (QI) projects to focus on based on the Alliance for Innovation on Maternal Health (AIM) patient safety bundles : (1) reduce the use of inpatient intravenous antibiotics at hospital nurseries/NICUs; (2) decrease the rate of severe maternal morbidity attributable to obstetric hemorrhage; and in FY21, (3) care coordination from delivery to the post-partum visit and then transition to annual women’s health, also known as the fourth trimester, where Virginia will be one of three states to pilot this bundle.  Virginia’s statewide perinatal quality collaborative is committed to including each of the 54 birth hospitals across the Commonwealth in these quality improvement projects.

 

REPRODUCTIVE HEALTH: This units led by the Reproductive Health Unit Supervisor, and includes the following programs and funding streams:

• Title X Family Planning (Title X): Clinical family planning programs consistent with Title X requirements and Quality Family Planning Services as defined by the CDC
• Contraceptive Access Initiative (TANF, Title V): Clinical contraceptive care for low-income patients without insurance
• Doula Certification Program and Task Force (Unfunded): State Program offering doulas the opportunity to earn state certification and to work together to promote doula services across the Commonwealth
• State Funding for Certain Abortions (General Funds): Abortion services for Medicaid members in cases of rape, incest, or incapacitating fetal anomaly
• Adolescent Health Program (Sexual Risk Avoidance Education, Title V): Positive youth development programs that build protective factors among participants that will make them less likely to initiate sexual activity
• Resource Mothers (TANF, Title V): Adolescent health program providing support services to pregnant and parenting teens and their families (Of note, the Adolescent Health Program and Resource Mothers Program are detailed in the Adolescent Health Domain)
• This unit works closely with the 35 LHDs to provide over $3.5 million in annual funds to support their local maternal and infant health programs and initiatives, providing quarterly recorded meetings via webinar platform for technical assistance and allow LHDs to share lessons learned across LHDs and programs. 

 

MATERNAL MORTALITY REVIEW TEAM:  The MMRT is a multidisciplinary group with representatives from academic institutions, behavioral health agencies, hospital associations, state chapters of professional associations, state medical societies, and violence prevention agencies.  The MMRT collects data on and reviews the deaths of all Virginia residents who were pregnant within a year of their deaths regardless of the outcome of the pregnancy or the cause of death.  These deaths are termed “pregnancy-associated deaths”.  The MMRT is dedicated to the identification of all pregnancy-associated deaths in the Commonwealth and the development of recommendations for interventions in order to reduce preventable deaths.  Each case is reviewed by the MMRT to determine the community-related, patient-related, healthcare facility-related and/or healthcare provider-related factors that contributed to the woman’s death.  The MMRT also assesses and recommends needed changes in the care received that may have led to better outcomes.  Consensus decision-making is used to determine whether the death was preventable and/or related to the pregnancy.

 

DENTAL HEALTH PROGRAM: The DHP performs many duties including the provision of the following:  Educational activities and resources to a wide variety of partner groups to promote proper oral hygiene and support prevention services and access to dental care; direct clinical preventive services and assistance with establishing a dental home; quality assurance review to assure a competent public health oral health workforce; and, surveillance and evaluation activities to monitor and track dental disease rate and trends as part of program assessment for effectiveness and planning. 

 

STATE ACTION PLAN UPDATES

 

M/WH DOMAIN PRIORITY 2016-2020			Women’s/Maternal Health: Support the physical and emotional well-being of women and their children
STRATEGY			Develop and mobilize strong interagency, multisector, and community partnerships to address disparities in maternal and infant mortality rates
OBJECTIVE			Eliminate the racial and ethnic disparities in Virginia’s maternal mortality rates.   By December 2025, decrease the disparity in black-white maternal mortality disparity ratio from 2.1 (2017) to 1.23 (2025).
OUTCOME MEASURE			(2021-2025) SOM 2:  Maternal Mortality Disparity: Black/White Maternal Mortality Ratio
2016-2020 SUMMARY
Data Source:  National Vital Statistics System (NVSS) – NOM 3
2016	2017	2018		2019	2020
		1.9		2.2	2.7
GOAL FOR 2021-2025 SAP:		By December 2025, decrease the disparity in black-white maternal mortality disparity ratio from 2.1 (2017) to 1.23 (2025).

 

Maternal Mortality Review Team:  Activities of the Maternal Mortality Programs included the coordination and facilitation of the bi-monthly Maternal Mortality Review Team meetings.  These activities included case selection for each meeting, requesting records from health, social and community based agencies that were used in the review, review of those records, and determination of inclusion or exclusion in the review, as well as scanning the record for additional information that could be collected from other providers for use.  Due to COVID-19 restrictions, the MMRT successfully implemented virtual review team meetings.  After each review team meeting, the data was entered into the MMRIA system by the Maternal Mortality Programs Manager and Maternal Mortality Research Associate.  The Programs Manager also maintained and reviewed the recommendations from each review meeting for the applicability and appropriateness based on the review topic and current data trends.

 

Additionally, in an effort to disseminate the findings and recommendations of the MMRT, Dr. Melanie Rouse (Maternal Mortality Programs Manager) participated in several dissemination activities.  These activities included the following:

• Dr. Rouse was invited to submit a written statement to the U.S. Commission on Civil Rights briefing regarding “Maternal Health Disparities”, September 2020.
• Dr. Rouse was an invited speaker at the following events:
  • Virginia Neonatal Perinatal Collaborative Perinatal Mortality Summit regarding maternal mortality and racial disparities in Virginia, February 2020.
  • Virginia Neonatal Perinatal Collaborative Monthly Webinar regarding the Maternal Mortality Review Team process and recommendations, March 2020.

 

MMRT Data Capacity:  Using data from Maternal Mortality Surveillance Program, the OCME provided data to the Division of Population Health Data (DPHD) related to maternal health and health disparities for use in data briefs and other materials when requested.  The Maternal Mortality Surveillance Program is the hallmark data program for maternal mortality, which not only includes data collection, but also data analysis and subject matter expert input.  The OCME also serves as a subject matter expert and will review data briefs and other materials as requested by the DPHD once developed and before dissemination of materials. 

 

Additionally, the Maternal Mortality Programs Manager collaborated with the Virginia Neonatal Perinatal Collaborative Director of Operations to develop a shared vision plan which aims to improve maternal and infant health across the Commonwealth through data-driven, evidence based collaborative initiatives.  The Programs Manager also engages in monthly VNPC-led Maternal & Infant Sister Agency Workgroup meetings to (1) identify shared goals, priorities and strategies, (2) eliminate silos across state sister agency maternal and infant leads, and (3) meaningfully collaborate on shared deliverables of interest to improve maternal and infant health outcomes in Virginia.

 

Doula Certification Program:  During the 2020 General Assembly Session, Virginia legislators tasked VDH with establishing a Doula Certification Program in order to make doula series more accessible to all people, but specifically to Black women, who experience the highest maternal mortality rate of any population in Virginia.  In order to accomplish this, VDH’s Reproductive Health Unit convened stakeholders to develop state regulations that will guide the program.  Stakeholders included doulas, clinicians, advocates and representatives from the Department of Medical Assistance Services (DMAS).  Similarly, Virginia legislators tasked DMAS with establishing a benefit for community-based doulas. VDH and DMAS work in concert so that when the doula certification program is launched in FY2022, certified doulas will then be able to apply to become a Medicaid provider.  Medicaid coverage for doulas will open access to low-income women and directly address the racial maternal mortality disparity in Virginia. An official Doula Task Force convened in FY21 to provide the opportunity for doulas, providers, clients, and payers to provide continuous feedback to the Doula Certification Program throughout program implementation.  

 

Maternal Health Collaborative (VDH, VNPC, VHHAF):  Kick-off for this Collaborative was January 2020.  However, due to COVID, the emphasis for this collaborative for its first 18 months was to build buy-in across Virginia’s hospital systems.  Beginning in July 2021, and through the use of cross-sector collaborations, The Collaborative’s aim, based on data, analytics and analysis, is for hospital systems to partner with community based organizations to improve health outcomes of Black maternal populations.  Each hospital system CBO goals and objectives will be unique to their own community. This is funded by a mix of general funds, Title V and Pew Charitable Trust Calling All Sectors Grant.   

The opportunity to partner with both VNPCH and VHHAF provides strong, strategic alignment.  The Virginia Hospital and Health Care Association (VHHAF) aims to improve maternal health quality, care and access across the state of Virginia. As a principal convener of hospitals and healthcare systems statewide, VHHAF is uniquely positioned to support our state in building a collaborative-community based framework that minimizes rework, siloes and duplication, and optimizes financial resources to ultimately improve care for birthing people, and the overall community.

 

M/WH DOMAIN PRIORITY  2016-2020	Women’s Maternal Health:  Support the emotional well-being of women and children
STRATEGIES	Increase capacity of youth-serving agencies to implement Aim 4 Teen Moms (AIM4TM), an evidence-based pregnancy prevention program designed for parenting teens. Work with community stakeholders to remove policy, financial, and training barriers to LARC utilization.
OBJECTIVE	By June 30, 2020, reduce the rate of unintended pregnancies for all women of child-bearing ages (ages 15-44) from 49.5% (PRAMS 2016) to 47%.
PERFORMANCE MEASURE	SPM 4 – Unintended pregnancy: Proportion of females ages 15-44 using Tier 1 (most effective) contraceptive methods
2016-2020 SUMMARY
Data Source:  Pregnancy Risk Assessment Monitoring System (PRAMS)
2016	2017	2018	2019	2020
	35.5%	31.0%	65.1%	70.1%
GOAL FOR 2021-2025 SAP:		Reduce the rate of mistimed pregnancies from 25.3% (PRAMS 2018) to 21.8% by 2025.

 

VDH Reproductive Health:  VDH’s Reproductive Health Unit includes several programs dedicated to the assurance, access and provision of quality, comprehensive family planning services.  These include:  Contraceptive Access Network (formerly known as the Long-Acting Reversible Contraceptives (LARC) Stakeholder Workgroup), the Virginia Contraceptive Access Initiative (formerly known at the Virginia LARC Initiative), the Title X Family Planning Program, Resource Mothers, and the Doula Certification Program and Task Force. 

VDH Reproductive Health Unit utilizes PRAMS data to promote contraceptive access in Virginia, and the CDC featured Virginia’s efforts on its webpage as a “data to Action” success story.  https://www.cdc.gov/prams/state-success-stories/virginia-contraception.html

 

Title X Family Planning Program: This program provides comprehensive family planning services at approximately 140 clinical sites across the Commonwealth, including 34 local health districts and 3 federally qualified health centers.  As the nation’s only federally funded family planning program, Title X provides structure, funding, and technical support to clinics providing family planning services according to CDC’s Quality Family Planning Services guidelines.  VDH is Virginia’s sole Title X grantee.  The Title X Family Planning Program is not directly supported by Title V funds, but Title X complements Title V by supporting comprehensive family planning services beyond those provided by Virginia Contraceptive Access Initiative.

 

Contraceptive Access Network – This group of agencies work to reduce unintended pregnancies among women of childbearing age and increase access to comprehensive, quality family planning services.  This group was originally developed to address infant mortality, recognizing the role of contraceptive access on maternal and infant healthy.  The group is facilitated by VDH, meets twice a year, and includes over 70 members from a variety of community-based health centers, governmental organizations, hospital systems, payers and  community members.  This group collaborated successfully advocate for the Virginia LARC Initiative.

 

Virginia Contraceptive Access Initiative – In 2018, VA PRAMS data showed that 49% of pregnancies resulting in a live birth in Virginia were unintended and had increased from 46% in 2014. High rates of unintended pregnancy present an economic burden to the state of Virginia and may be associated with negative maternal and child health outcomes.  To address this concern, the Virginia LARC Initiative began in 2018 as a two-year pilot program funded through federal TANF funds allocated by the Virginia General Assembly.  The LARC Initiative allowed VDH to contract with eighteen health providers to offer LARC insertions and removals to eligible patients.  During the two-year pilot period (October 2018 – July 2020), the LARC Initiative provided approximately 3,986 no-cost visits to eligible patients.  In July 2020, the Virginia Assembly expanded the scope of the program to cover all-FDA approved methods of contraception, and thus the program’s name changed to the Virginia Contraceptive Access Initiative.  As of June 30, 2021, the expanded program has provided over 5,000 no-cost visits to eligible patients, representing a significant increase in patients served.

 

 

M/WH DOMAIN PRIORITY  2016-2020	Oral Health:  Increase access to oral health services for pregnant women and children
STRATEGIES	Integrate targeted adolescent oral health messaging into existing MCH-focused dental education programs to improve oral health for individuals across the lifespan Continue to foster a network of 6 regional Oral Health Alliances to conduct regional needs assessments and implement systems change and data-sharing initiatives to improve the oral health of all Virginians, with emphasis on pregnant women, and children and adolescents ages 1-17 Convene statewide groups focused on targeted oral health issues and facilitate collaboration and work plan development, and provide leadership and oversight to guide initiatives
OBJECTIVE	By June 30, 2020, increase the percent of women who had a dental visit during pregnancy from 46.5% (PRAMS 2015) to 51.95)
PERFORMANCE MEASURE	NPM 13.1 – Percent of women who had a preventive dental visit during pregnancy
2016 -2020 Summary
Data Source:  Pregnancy Risk Assessment Monitoring System (PRAMS)
2016	2017	2018	2019	2020
	46.5	44.7	49.9	48.4
GOAL FOR 2021-2025 SAP: Moved to Cross-Cutting/Systems Building Domain		By June 30, 2025, increase the percent of women who had a dental visit during pregnancy from 50.8% (PRAMS 2018) to 52.9%.

 

The Dental Health Program (DHP) has many internal partners including other VDH MCH programs and the statewide oral health coalition now known as Virginia Health Catalyst (VHC).  VHC is a non-profit organization that serves as the only statewide oral health coalition in the Commonwealth.  It is a diverse group working to spark change so that all Virginians have equitable access to comprehensive health care that includes oral health, and to bring excellent oral health to all Virginians through policy change, public awareness and innovative programs.  The VHC works closely with VDH to implement grant objectives and has in-depth knowledge of the Virginia Oral Health Plan and the Virginia Oral Health Report Card, and other foundations that prioritize oral health activities statewide.   VHC has access to a diverse network of key, statewide stakeholders, and the unique ability to share oral health information with both key partners and the public.  VHC staff understand the need to continue promotion of oral health at the local level, support local initiatives to affect meaningful change, and to evaluate efforts to ensure ongoing, comprehensive support for structural sustainability. 

 

Program activities aimed at increasing oral health care for pregnant women, infants, children and individuals with special healthcare needs (ISHCN) within the DHP are the Bright Smiles for Babies Fluoride Varnish Program, Dental Preventive Services Program, and Perinatal and Infant Oral Health Program. 

 

The Perinatal, Infant, and Adolescent Oral Health Program aims to improve access to oral health care for pregnant women, infants and adolescents who are most at risk for disease through integration of dental services and information into the primary care delivery system.  Additionally, this program allows for expansion of the existing Virginia Oral Health Surveillance System to include data collection, analysis, and reporting of indicators regarding pregnant women and infants.  In 2019, this program began focus on HPV prevention and oral cancer education, and vaping concerns for the adolescent population. 

 

Specific activities in FY20 (October 1, 2019 – September 30, 2020) include:

STRATEGY 1:  Integrate targeted adolescent oral health messaging into existing MCH-focused dental education programs to improve oral health for individuals across the lifespan
Recruit and hire an experienced oral health educator to focus on maternal, infant and adolescent oral health	Completed
Continue to provide education and trainings aimed at perinatal and infant oral health including education for home visitors and other family support workers	Ongoing
Review existing school-aged Oral Health Curriculum and revise as needed based on emerging issues (HPV, Vaping) and current standards of Learning (SOL) requirements	Completed
Using current information obtained through literature reviews regarding the need for oral health education for adolescents on emerging issues, assess the individual needs of schools in each of the 5 Health Planning Districts	Ongoing
Plan and implement educational initiatives and trainings including development of educational material and social media content related to adolescent oral health	Ongoing
Evaluate initiatives and trainings to ensure that goals are met	Ongoing
STRATEGY 2:  Continue to foster a network of 6 regional Oral Health Alliances to conduct regional needs assessments and implement systems change and data-sharing initiatives to improve the oral health of all Virginians, with emphasis on pregnant women, and children and adolescents ages 1-17
Continue to conduct regional oral health assessments	Completed
Determine community-led strategies to improve oral health in their regions	Ongoing
Support development and implementation of project work plans to support regionally identified projects	Completed
Disseminate information to state level partners and other regional alliance members to inform statewide activities and planning	Completed
Disseminate micro grants to support alliance efforts	Completed
STRATEGY 3:  Convene statewide groups focused on targeted oral health issues and facilitate collaboration and work plan development, and provide leadership and oversight to guide initiatives
Identify the appropriate statewide organizational and community partners to participate in a water equity workgroup	Completed
Convene a Water equality workgroup and host meetings at different localities across the state	Ongoing
Develop and implement a workplan to support identified goals around water equity in Virginia	Ongoing
Continue convening the EDH workgroup, including providing oversight regarding program direction, participating in discussions related to allocation and management of resources, and sharing responsibility for the identification and maximization of community ownership to sustain the EDH workgroup’s projects beyond the grant year	Ongoing
Identify existing groups working on HPV in Virginia and approach these groups about Virginia Health Catalyst participating as a collaborative member.	Ongoing
Ensure oral health initiatives are integrated into the workplans and projects conducted by existing HPV workgroups, with specific focus on dental visits and oral cancer education and screenings for children under 17, pregnant women, and their families	Ongoing
Convene the Virginia Oral Health Summit focused on community engagement to provide trauma-informed care, oral health and systemic health, and health equity to providers	Completed

 

 

 

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EMERGING ISSUES

 

Reproductive Health: The COVID-19 pandemic brought unprecedented challenges to Virginians, but it also challenged health systems to consider alternate approaches to providing care.  Health providers were forced to consider telehealth options when they may not have considered them before, and CMS relaxed federal policies to allow for Medicaid reimbursement of telehealth visits.  While telehealth services are not easy to navigate for all, telehealth can increase access to some populations, including young people and people with transportation barriers. 

 

Maternal Mortality Review Team:  In an effort to fulfill the requirements outlined in the Virginia State Code, the MMRT elected to skip the full Team Review of the 2015, 2016, and 2017 pregnancy-associated deaths.  This was done so that the Team could be more current in the cases that are being reviewed and in the reporting of maternal mortality data to State officials.  However, all data for 2015, 2016, and 2017 will be collected and entered into the MMRIA system.  Moving to more current case review, while necessary, has created a backlog of cases that need to be abstracted into the database.  As such, the MMRT Research Associate will complete data entry for the backlogged cases, as well as, assist the Team with other administrative items. 

 

Dental Health Program:  Families are worried about going to the doctor or dentist office because of possible exposure to COVID-19.  The dental office is especially concerning because many of the regular procedures produce aerosols, which can spread the virus.  Many patients already had fears about going to the dentist; COVID has added more concerns to an already stressful experience. Delayed dental care allows existing conditions to worsen and new issues to begin creating more extensive and pervasive disease.  As patients begin to re-enter dental care, providers lack the ability to keep up with the demand for those requiring greater amounts of care. 

 

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CHALLENGES/BARRIERS

 

Reproductive Health:  The COVID-19 pandemic challenged Resource Mothers staff and clients in unprecedented ways.  When a state moratorium on in-person home visits was issued for safety reasons, community health workers needed to consider alternate ways of delivering services to clients.  During FY20, VDH purchased licenses for doxy.me, a HIPAA-compliant video platform, to use during virtual encounters, and all Resource Mothers staff were given access.  During this project period, Resource Mothers staff learned that doxy.me was a difficult platform to use in areas of the Commonwealth with poor internet access.  Families without access to broadband and without unlimited cellular data were largely unable to use this platform.  As a result, VDH switched to Zoom for Health Professionals, another HIPAA-compliant platform, during the FY21 funding period.  VDH predicts that Zoom for Health Professionals will be easier for clients and staff to navigate in areas with limited connectivity.

 

Maternal Mortality Review Team:  As the focus on maternal mortality and infant/child mortality have increased, review teams across the U.S. have found significant racial and ethnic disparities in mortality ratios between Black and White populations.  This has led to an increase in focus on the social/environmental determinants that contribute to these deaths, including systemic racism, personally mediated racism and discrimination.  As such, the Maternal Mortality Projects Manager also facilitated a training for the MMRT that included training on the fatality review process, as well as health equity and implicit bias.

 

Dental Health Program:  

• The Virginia Governor’s budget for 2020 release in mid-December 2019 did not include funding dedicated to adding a comprehensive adult dental benefit in Medicaid.  
  • Partners worked to educate communities and state legislators about the importance of adding a comprehensive adult dental benefit in Medicaid.  With support from around the state, the comprehensive benefit was added to the final 2022 budget. 

• VDH and partners shifted roles and priorities because of COVD-19.  Many partners pivoted their activities to support the crisis response, and did not have the capacity or capabilities to work on dental projects.
  • VDH and Catalyst team members continued to work towards project goals and support partners vial teleworking.  Both VDH and Catalyst continued to be dedicated to supporting partners through the COVID-19 crisis.  VDH and Catalyst team members also continued to reevaluate programs, educate themselves regarding the COVID-19 crisis and impact on all stakeholders, and discuss alternatives for the future.
• The widespread use of new technologies for education, meetings and information gathering is a growing edge with multiple roadblocks including individual computer skills, internet access, overwhelmed networks, and limited or no access to technology.
  • VDH staff members are working toward expanding their technical knowledge and computer skills regarding online platforms for meetings and education.
• Families are worried about going to the dentist because of possible exposure to COVID-19.  The dental office is especially concerning because many of the regular procedures produce aerosols, which can spread the virus. 
  • VDH worked with the Governor’s office and partners on an educational campaign promoting the need for dental care and how dental offices have adapted care to ensure safety for all during services.