III.E.2.c Annual Report: Women/Maternal Health (Preconception, Pregnancy, Postpartum Health):

The Title V program refers to Women/Maternal health as the Preconception, Pregnancy, and Postpartum Health section. This section refers to the health of womxn of child-bearing age, usually 15-44, although demographics show that this age range has been widening. Maternal health is the health of womxn during pregnancy, childbirth, and the postpartum period. It encompasses the health care dimensions of family planning, preconception, prenatal, and postnatal care. The Title V Program recognizes the importance of addressing each of these stages and has renamed this area as the Preconception, Pregnancy, and Postpartum domain. Preconception health is an area that focuses on womxn’s health before she becomes pregnant, health during pregnancy focuses on womxn’s health beginning with conception up to the pregnancy outcome, and postpartum health is the area that focuses on womxn’s health after the pregnancy outcome and up to 6 months. Preconception care is important because it reduces unwanted and mistimed pregnancies and teen pregnancies. It also has been linked with better prenatal care engagement and birth outcomes.

 

The following priorities for preconception, pregnancy and postpartum health emerged from Rhode Island’s 2019 Needs Assessment:

1. Address prenatal health disparities
2. Reduce maternal morbidity/mortality

 

Priority: Address Prenatal Health Disparities

The RIDOH believes that all pregnant individuals should have access to comprehensive and timely prenatal services across the healthcare continuum. Overall, public health research and data show that social, economic, and environmental inequities have resulted in adverse health outcomes and have a greater impact than individual choices. Reducing prenatal health inequities through policy and systems change can help improve opportunities for every Rhode Islander.

 

Through the needs assessment process, stakeholders expressed a range of strategies that were broadly classified as “Prenatal Health” such as prenatal care, family planning, family home visiting, oral health care, and group prenatal care. There was also an overarching expressed desire to improve the social, environmental, and economic factors in communities where disparate perinatal outcomes are most prevalent.

 

While trends have been improving for all racial/ethnic populations, disparities remain in the following areas:

 

Reported unintended pregnancies: In 2016-2020, there were 37.8% of unintended pregnancies in Rhode Island.  Among racial/ethnic groups, 30.0% of Non-Hispanic Whites compared to Hispanics 43.3%, and 51.0% Non-Hispanic Blacks reported unintended pregnancies. 

 

Prenatal Care in First Trimester: In 2021, 84.1% of pregnant women who gave birth received prenatal care beginning in the first trimester, which is nearly similar to 84.3% in 2020.  Non-Hispanic White women (86.9%) were more likely to start prenatal care in the first trimester than Non-Hispanic Black women (79.1%).

 

Smoking During Pregnancy: Although the overall trend of cigarette smoking during the last 3 months of pregnancy has decreased from 4.0% in 2019 to 3.4% in 2020, pregnant women with disabilities had a statistically significant higher percentage (10.8%) of smoking during pregnancy than pregnant women with no disabilities (4.4%) in 2016-2020. Although the decreasing trend in cigarette smoking during pregnancy may not account electronic cigarette use, there was also a slight decline with this indicator from 7.1% in 2019 to 5.2% in 2020.

 

Preterm Births: The preterm birth (< 37 weeks gestation) rate in Rhode Island is 9.5% in 2021. This represents a decrease from the preterm birth rate of 9.1% in 2020. Non-Hispanic Black infants continue to have higher preterm birth rates (11.3%) than Non-Hispanic White infants (8.7%). Vital Records data show that 2.8% of women who gave birth in 2020 reported having a previous preterm birth.  Among RI-resident women who gave birth in 2020, 8.3% had gestational diabetes (compared to 7.6% in 2018) and 8.9% had gestational hypertension/preeclampsia (compared to 8.1% in 2018).

 

Low Birth Weight: In 2021, there were 806 infants who were born with low birth weight (< 2,500 grams), representing 7.7% of all RI-resident infants born.  In the same year, 95.1% of all very low birth weight (< 1,500 grams) infants were born in a Rhode Island Level III NICU hospital. Racial disparities are also observed among low-birth-weight babies (Non-Hispanic Black infants: 11.1%; Non-Hispanic White infants: 6.8%) for 2021.

 

Infant Mortality: The infant mortality rate in RI is 3.7 deaths per 1,000 live births in 2021, a decrease from 4.7 per 1,000 in 2020. There is a large disparity between the Non-Hispanic Black IMR (9.1 per 1,000 live births) and the Non-Hispanic White IMR (2.9 per 1,000).

 

Oral health: The statewide percent of women who had their teeth cleaned during pregnancy was 50.3% in 2020, a significant decrease from 57.6% in 2019. In 2016-2020, Non-Hispanic Black women (42.2%) and Hispanic women (51.8%) were significantly lower in reporting to have their teeth cleaned by a dentist or dental hygienist compared to Non-Hispanic White women (61.3%).

 

In addition, SISTA FIRE’s key learnings from Women & Infants Hospital (WIH) found several overarching issues that womxn of color (WOC) wanted birthing hospitals to address in order to decrease disparities in delivery and postpartum care: 1) Translation & Interpretation, 2) Trauma Informed Care/Consent, 3) Cultural Bias, 4) Community Resources, and 5) Workforce Diversity.

 

Translation and Interpretation: During triage, inpatient services, and discharge, WOC, especially non-English speaking WOC, felt that they were not properly communicated to, especially in their preferred language or dialect, about their condition, treatment, or about postpartum community resources and services.

 

Trauma Informed Care/Consent: Even without a language barrier many WOC felt that their needs, pain, and suffering was not properly acknowledged, empathized with, and treated during their hospital stay. For instance, one respondent felt ignored when she questioned her repeated examinations. She viewed the experience as violating and invasive. She wasn’t asked permission if doctors could use her as a practice patient and bring in multiple medical students at the teaching hospital. This story underlines the need for birthing hospitals to adequately communicate with their womxn of color patients in a culturally and linguistically responsive manner about their condition.

 

Patient Discrimination: WOC often felt judged and nervous by staff asking personal questions and feared that hospital staff held negative stereotypes and biases about womxn of color, particularly about their competence as a parent. Patients expressed a real fear that child welfare would be contacted and that mothers would be separated from their children, and they often did not want home visiting services. “This was my first pregnancy, so I didn't really know.... I’m asking the nurses, and they are like ‘Yeah, she’s fine, it is kind of weird that her eyes are open, but she’s good.’.... Then the doctors start asking me questions, ‘Oh do you have any kind of infection or disease that we don't know about?’ ...They kind of made it seem like I was hiding something, and this is why my daughter is not showing the typical behavior for a newborn. So, I felt like they were blaming me.” This quote underlines the need for birthing hospitals and home visiting programs to address cultural bias among staff.

 

Community Resources: Finally, many WOC felt that they were not made aware of community resources.

 

Workforce Diversity and Community Representation: The Needs Assessment also highlighted the lack of diversity in the pregnancy, prenatal and postpartum workforce including family home visiting, family planning, birthing hospitals, and prenatal care providers. In addition, SISTA FIRE noted that there is a lack of representation of WOC as medical providers employed at Women and Infants and a general lack of hiring within the surrounding community or greater Providence area.

 

To respond to these disparities and support this new priority, RIDOH will resume, continue and add strategies as follows:

 

Continue to Address Prenatal Health Disparities within Prenatal Health Programs: Title V is continuing to grow its partnerships with community stakeholders, cultural groups, and networks, such as HEZ and SISTA FIRE, to address perinatal and birthing disparities within the birthing parent system of care. Through these partnerships, RIDOH administered programs, including family home visiting, family planning, oral health, and other preventative care, are seeking guidance on 1) Translation & Interpretation, 2) Trauma Informed Care/Consent, 3) Cultural Bias, 4) Community Resources, and 5) Workforce Diversity. This includes soliciting solutions to challenges from the community.

 

For example, RIDOH’s MCH program supported efforts of community stakeholders to increase the availability of doula services and support to womxn in RI. From October 2021 to April 30th, 2022, One Neighborhood Builders, RI Department of Health Maternal Child Health Program, and Journ3i LLC. collaborated to increase perinatal workforce capacity to address the multi-cultural and multi-lingual needs of birthing people within RI. Over this seven-month period, 26 community members of color were trained, mentored, and received free one-year memberships to RI Birth Workers Cooperative, Doulas of Color Network, and RI Perinatal Doula Agency. Cohort members also received doula bags and had their required CPR/AED, food handling safety, and HIPPA Compliance courses covered. So far, 11 initiative participants have become certified perinatal doulas through the Rhode Island Certifying Board (RICB). Please reference the appendix for a complete write up of the project. Through Preschool Development Grant funding, the above project has been extended by six months. Journ3i LLC. Is currently mentoring program participants and implementing workshops covering the following topics:

• How to set up your doula business,
• How to sign up with insurance and submit claims,
• How to build your clientele base,
• How to balance work and life responsibilities, and
• How to troubleshoot common job issues.

In addition, Quatia Osorio, RIDOH’s perinatal community consultant, continued to serve as an advisor and thought partner to inform racial equity initiatives and assist in the development and implementation of the MCH racial equity action plan. This includes her supporting MCH leadership in the development and implementation of racial equity organizational initiatives, objectives, and strategies related to the advancement of racial equity. For example, Quatia is collaborating with our disparities specialist to complete an infant health and mortality workplan. The idea was to catalogue pressing infant health issues that lead to poor outcomes and develop strategies to address this. WIC increasing outreach and sustaining client involvement was a strategy to address child malnutrition and promote newborn overall development. As a part of WIC trying to increase outreach to diverse communities, they are currently working on contracting with a videography and marketing company in order to create a video campaign to be shared on social media sites.

 

In 2021, SISTA Fire, a womxn of color network advocating for change within RI, continued its collaboration (funded by the MCH TA Grant) with Women and Infants Hospital to increase perinatal workforce diversity and address disparities of care present for pregnant people of color. SISTA Fire presented their birth justice demands to Women and Infants Hospital (WIH) based on their participatory action research findings showcased above. Over the course of the TA Grant, SISTA Fire repeatedly met with WIH to present and explore implementation avenues of their demands. There main demands are to be completed in the following areas:

• Culture and Approach,
• Translation and Interpretation,
• Workforce,
• Doula Engagement,
• Independent Community Review Board, and
• Community Resource Space.

WIH accepted a majority of the below demands and SISTA Fire has currently switched into monitoring WIH implementation progress. In the area of culture and approach, SISTA Fire demanded the following steps be taken by WIH:

• Adopt a culture of care philosophy
• Contract with expert consultants/coaches that can help guide these critical processes of culture and practice change
• Ensure a welcoming and safe environment in the Emergency Department by hiring and training community liaisons/greeters who shall be paid, dedicated local staff who will greet every patient who enters the emergency department, identify needs and preferred language, and help them access translation and interpretation. There shall be sufficient liaisons/greeters to cover every shift.
• Make affirmative acknowledgement of an explanation of the Patient’s Bill of Rights a standard part of the admissions process and posted more visibly, including in the Emergency Department.
• Require and report annual assessments of intake, wait times, and health outcomes in the Emergency Department to the Independent Community Review Board.
• Require training for all health providers around plain language communication.
• All medical professionals must obtain informed consent by ensuring that patients understand the reasons behind exams and procedures, as well as alternatives, before they happen.
• Require all employees to participate in anti-oppression cultural and historical training that shifts practices from the individualistic nature of “cultural competency” to the systemic and institutional analysis of “structural competency” or “equity competency” that is needed to ensure the health and safety of Black women.
• Integrate and guarantee trauma informed principles. This includes standards and protocols for physical exams, including providers must introduce themselves and state their role in the hospital, providers must explain everything before it is done, and only one provider can do pelvic exams unless clear consent is given in the patient's native language.

 

In the area of translation and interpretation, SISTA Fire demanded the following steps be taken by WIH:

• All patients shall be asked at any and all registrations what their preferred language is, and what language is spoken most often at home.
• Ensure that all text including signs, discharge intake, patient education materials, and resource guide documents are in plain written language in both English and Spanish, vetted by a community advisory group.
• How to access interpretation services should be explained via clearly marked signs in the hospital in multiple relevant languages, as well as by affiliated providers who need to tell their patients at prenatal visits, “You have the right to an interpreter!” (notwithstanding the new “opt out” standard.) Translation services need to be available from prenatal through postpartum.
• Invest in translation infrastructure including on-call in-person colloquial interpreters, iPad for when in-person translation is not available (including in triage), and fortifying pipelines with CCRI, RIC and other local organizations who already specialize in medical interpretation, to support expanding your infrastructure.

 

In the area of workforce, SISTA Fire demanded the following steps be taken by WIH:

• Hire providers and leadership of color, specifically nurses, physicians, midwives, board of directors, and corporate leadership so that hospital decision-makers are reflective of the communities in Providence. Within 2-years 20% of all new RN hires must be BIPOC, and within 5 years all healthcare workers in each individual classification must be BIPOC. This is based on the current percentage of RI residents who are BIPOC. After the respective 2 and 5 year marks the hospital shall deposit an amount equal to the FTE short fall in hires into an independent training and education fund, with the explicit purpose of providing adequate tuition and loan reimbursement for staff to meet the goals.
• Report hiring and workforce demographic data on an annual basis to the community review board.
• Create a workforce pipeline (CCRI, RIC, etc.) for local medical professionals of color. This includes accepting Rhode Islanders with two-year nursing degrees with the commitment of completing a four year degree after they are hired/while they are employed.

 

In the area of doula engagement, SISTA Fire demanded the following steps be taken by WIH:

• Shift institutional practices at WIH to better integrate doulas of color within hospital health teams for the quality prenatal, natal, and postpartum care they provide women of color who choose to deliver at WIH.
• This includes making sure staff know what doulas do during the prenatal period and referring patients to community-doulas.
• Hire a management level full-time Doula Liaison. Guarantee that all doulas who are asked to advise or consult with the hospital are paid for their time.
• Ensure that patients are always allowed to have a support person as well as an advocate in the room (such as a family member and a doula), regardless of provider preference throughout their care. This must hold even in an emergency situation.

 

In the area of Independent Community Review, SISTA Fire demanded the following steps be taken by WIH:

• In consultation with SISTA Fire, Women and Infants will establish an independent review board made up of impacted community members who evaluate Women & Infants Hospital’s efforts to meet these demands.
•  Introduce and adopt a community-created Patient Bill of Rights.
•  In consultation with SISTA Fire, WIH will establish a third-party system for discrimination reporting for community members.
• Report patient satisfaction data disaggregated by race and community investment data on an annual basis to the community.
• Additionally, complainants that go through the HR and Compliance reporting structure for alleged discrimination, harassment, and other DEI related policy violations shall be informed of their right to appeal HR and Compliance outcomes to the Independent Community Review Board which shall be empowered to hold hearings and determine corrective action.

 

In the area of community resource space, SISTA Fire demanded the following steps be taken by WIH:

• Create an on-site staffed space where interpreters, translated patient-education materials, and information about community resources (i.e. WIC, housing, legal services, food pantry) are available. Ensure that patients know about the space, that it is in an accessible location, and is consistently staffed by a community health worker or resource navigator.

 

Continue to Support the Development of a Doula Infrastructure: MCHP partnered with Journ3i LLC. and the Early Childhood Comprehensive Systems (ECCS) Grant in order to implement an asset and gap analysis of the doula workforce. For instance, doulas gaining access to insurance reimbursement is an asset. However, the lack of provider knowledge of reimbursement processes and general provider confusion and frustration in navigating this landscape are ongoing gaps. Doulas, such as Journ3i LLC., are working with private and public insurances to troubleshoot and fix reimbursement technical issues. The RI Birth Worker’s Cooperative, an administrative doula billing organization, has been holding technical assistance sessions with members who need support with signing up with insurance, submitting claims, and receiving reimbursements. Other doula workforce gaps included:

•  a lack of in-state trainings available to community members interested in becoming doulas,
• a lack of diverse doulas serving diverse populations,
• a plethora of unaddressed financial barriers blocking individuals from entering the workforce, and
• a lack of connection and collaboration between doulas and other young family serving agencies.

The report also explored the established and emerging assets of the workforce which included:

• a newly established Birth workers Cooperative, a cooperative supporting doulas in signing up with insurance and billing them. The organization provides HIPAA compliant software so doulas can store client information. They also supply billing support services that help doulas check client insurance eligibility, send in claims, and do claim denial/error follow up,
• a newly established Doulas of Color Network, a network that brings doulas of color together from across the state to connect, learn, and collaborate with each other,
• an established doula association, since 2011, named Doulas of Rhode Island (DoRI),
• new community and state collaborative efforts to bring national doula trainings to Rhode Island, and
• sustained perinatal population demand of doula services.

The next phase of the grant will be creating a workplan to address the gaps mentioned above.

 

Preconception, Pregnancy, and Postpartum and Health Equity Zones

Bolster HEZ activities for the prenatal population:

• Central Providence HEZ: As mentioned in the above sections, One Neighborhood Builders partnered with Journ3i LLC. And RIDOH to implement a  doula workforce pilot initiative. The program aimed at improving BIPOC maternal health outcomes by training and mentoring 26 community members of color interested in entering the doula workforce. Thus far, 12 program participants have become certified perinatal doulas through the RI Certifying Board.

 

• Newport HEZ: The Newport HEZ also focused intensively on racial equity and racial justice. One of the Newport HEZ’s leading priorities was to eliminate disparities in Black maternal and child health outcomes. In efforts to improve racial equity, the HEZ participated in and hosted several racial equity trainings throughout the reporting year, reaching hundreds of attendees in the Newport community and beyond. The Newport HEZ conducted all their work through a resident-centered, racial justice lens.

 

 

Priority: Reduce Maternal Morbidity & Mortality

The maternal morbidity and mortality trends have been increasing for all racial/ethnic populations in the following areas:

 

Maternal Morbidity Rate: The 2021 severe maternal morbidity rate was 85.4 per 10,000 delivery hospitalizations, which is nearly similar to 85.2 per 10,000 in 2020. Racial disparities continue to be seen between Black women (112.0 per 10,000 delivery hospitalizations) than White women (77.6 per 10,000) in 2017-2021. These disparities can also be seen among delivery hospitalizations regarding postpartum hemorrhages (Hispanic women: 1,039.7 per 10,000 delivery hospitalizations; Black women: 1,033.3 per 10,000; White women: 780.0 per 10,000) and severe hypertension (Black women: 638.8 per 10,000; Hispanic women: 477.3 per 10,000; White women: 356.2 per 10,000). According to Pregnancy Mortality Surveillance System data, there were less than 10 pregnancy-associated deaths in 2014-2018.

 

Postpartum Depression: The percentage of women reporting symptoms of postpartum depression was 12.7% in 2020, an increase from 11.5% in 2019. In 2016-2020, women who identified as Other reported 17.6% reporting postpartum depressive symptoms compared to Non-Hispanic White women with 11.4%, a statistically significant difference. An even larger and significant disparity in postpartum depression exists between women with disabilities (32.8%) and women with no disabilities (10.7%).

 

Low-Risk Cesarean Deliveries: In 2021, 28.3% of women had cesarean delivery with a low risk first birth.

 

To respond to these disparities and support this new priority, RIDOH currently implements the following strategies as follows:

 

Strategies supporting efforts to reduce maternal morbidity and mortality that will continue:

 

• Continue supporting the Rhode Island Pregnancy & Postpartum Death Review Committee (PPDRC): PPDRC is a newly established multidisciplinary committee that reviews deaths that have occurred during pregnancy or within one year of the end of pregnancy (this replaces the Maternal Mortality Review Committee). PPDRC reviews these deaths to identify factors contributing to the deaths, to recommend public health and clinical interventions that may prevent future deaths, and to improve systems of care. To date, there is a 50-member committee that has been oriented by the Center for Disease Control and Prevention (CDC), established a meeting schedule, developed a data sharing relationship with the CDC, and contracted with a logistics coordinator for abstractions and recording purposes.

 

The Pregnancy and Postpartum Death review is conducted pursuant to RIGL §23-4-3 and Department of Public Health rules and regulations pertaining to the reporting of selected causes of mortality in Rhode Island. RI’s legislation informs the composition of the PPDRC members that are appointed by the Director of Health. Per the legislation, the committee shall include:

• an obstetric provider from each hospital that delivers obstetrical care
• a neonatal specialist
• state agencies
• a perinatal pathologist
• a maternal fetal medicine specialist
• individuals or organizations that represent the populations that are most affected by pregnancy-related deaths or pregnancy-associated deaths and lack of access to maternal health care services.

Since the committee’s inception, they have reviewed eight cases and have published a 2021 report on their first year of findings and recommendations. Some of their recommendations underlined the need for:

• universal substance use screening,
• pregnant people and new families to be connected to and prioritized for stable housing resources,
• RI birthing facilities to implement diversity, equity, and inclusion initiatives
• increased provider education and system collaboration on substance use disorder,
• emergency care protocols and procedures for perinatal patients,
• improved continuity and coordination of postpartum care, and
• increased utilization of family visiting services to support perinatal patients.

Protocols for integrating community participation include designating our MCH Disparities specialist, Aidea Downie, as a community member liaison. She helps the committee receive reimbursement for their time and tries to answer and/or resolve any questions or concerns the committee members may have. In all, she is there throughout the process, including submitting paperwork to the committee, reviewing orientation and case review materials, and accessing meeting links and agendas. Currently, they have 10 committee members representing the community that are being supported by the liaison.

 

RI Title V has fully engaged the perspectives expressed through the needs assessment from SISTA FIRE and Health Equity Zones to ensure systemic racism, discrimination, unaddressed language barriers, and a lack of culturally responsive providers are wholly incorporated in committee recommendations. It is important to note that Rhode Island acknowledges the breadth of gender identity of individuals who may become pregnant (e.g., transgender, non-binary, and intersex) and named our committee the Pregnancy and Post-Partum Death Review Committee.

 

• Continue to implement a Perinatal Quality Collaborative with diverse representation from the community: Until recently, Rhode Island was the only state in the nation without an active Perinatal Quality Collaborative (PQC). In early 2020, hospital professionals, the Hospital Association of Rhode Island, and RIDOH partnered to initiate a PQC in the state to improve health outcomes for womxn and newborns using quality improvement (QI) methods. In February 2020, the Rhode Island Prematurity Task Force leadership helped to spearhead the development of a PQC through monthly meetings and by coordinating with the Alliance for Innovation in Maternal Health Program to identify immediate needs. The RI AIM program began in 2020 with the focus on decreasing postpartum hemorrhage by implementing their AIM bundle. In November 2020, the Perinatal Neonatal Quality Collaborative of Rhode Island (PNQCRI) was launched during a Grand Rounds at the Women and Infants Hospital of Rhode Island. Since that time, RIDOH has worked with the National Perinatal Information Center to 1) support grant writing activities related to committee funding, 2) advocate for diverse representation from the community to reduce racial/ethnic disparities in the hospital setting, and 3) coordinate efforts with the PPDRC and the AIM program in addressing maternal morbidities and mortality. Most recently, the RIDOH supported the PNQCRI in applying for CDC grant funding. Additionally, RIDOH is currently supplying stipends for the four community members that sit on the committee. The community member liaison is supporting this aspect of the PNQCRI initiative.

 

• Promulgate birth center regulations: The Birth Centers Regulatory Advisory Committee (BCRAC) was established in 2018 as a collaborative effort between the RIDOH MCH program and Health Facilities Regulations program. In response to requests for further discussion on revisions to the regulations, RIDOH established and convened the BCRAC, including representatives from the obstetrics/gynecology, midwifery, community health worker, and doula professions among its membership. The goal of the BCRAC was to draw together these various interested party groups, review/discuss the regulations, receive detailed input on possible revisions to the regulations, and produce a report on the BCRAC’s findings for presentation to the Director of RIDOH. The BCRAC met 6 times during a period of 5 months. The recommendations will then be implemented at the discretion of the RIDOH Director and the department’s facilities regulations team.

 

This is the first advisory committee of its kind at the RIDOH focused on regulations. The regulations were worked on by the RIDOH team and presented back to the BCRAC in the Fall of 2019. The MCH program was instrumental in recruiting a diverse cross-section of participants from the community to serve on the committee, which is a testament to its partnerships and collaborations in the community. The regulations received extensive public input and should have been finalized in late 2020. However, due to RI’s COVID-19 Response, the regulations have yet to be finalized. In April 2021, RIDOH re-engaged with the RI Governor’s Office of Regulatory Review to promulgate the regulations. ORR has requested and received a cost benefit analysis of the regulations as well as further scholarly article analysis. It is anticipated to be final early Fall 2022.

 

Preconception, Pregnancy, and Postpartum and Health Equity Zones

• Convene the MCH/HEZ Learning Classroom: Convene the MCH/HEZ Learning Classroom: The HEZ MCH Learning Classroom is an interactive educational space created to educate Health Equity Zones on Maternal Child Health issues across all six domains. The Maternal Child Health Program has put together a list of speakers from both the community and RIDOH to attend our bi-monthly meetings and educate the group on the initiatives they implement. Each HEZ must send a representative to consistently attend the learning classroom meetings. The learning classroom will move into its 2nd year of programming in October 2022.

 

Other Programs/Projects Related to Women/Maternal Health

Improve Access to Oral Health Services: The Oral Health Program (OHP) works to achieve optimal oral health for all by eliminating oral health disparities in RI while also integrating oral health with overall health. The OHP focuses on prevention of oral disease through assurance of state-level oral health and public health leadership and enhancement of community efforts to prevent, control, and reduce oral diseases across the lifespan. In addition, the OHP works with dental providers, health professionals, community partners, and the RI Oral Health Commission to build and sustain community capacity for high-quality, culturally sensitive oral health services. Highlights of effective ongoing interventions include:

• Advanced Education in General Dentistry Residency Program which expands services for underserved adults
• Continued implementation of the school-based sealant program, Seal RI!
• Education to families and providers on the importance of the age one dental visit through TeethFirst!
• Provision of mobile dental programs serving Medicaid elders in nursing homes
• Licensure of public health hygienists
• Training of providers through an annual dentistry mini residency
• Academic detailing visits
• Medicaid adult dental learning collaborative.

Two years ago, the MCH priority of improving Access to Oral Health Services was moved from the cross-cutting domain to the women/maternal health domain and the following strategies were developed:

 

Provide guidelines and professional development for healthcare (infant and perinatal medical providers), dental, and service (MCHB, HRSA, and HHS funded programs) providers on the importance of oral health for pregnant womxn and infants: Due to the onset of the COVID-19 Pandemic, the Oral Health Program was entirely activated to the response and much of the work of the Program was put on hold. Meeting with providers and engaging in educational events also proved difficult, especially from February-June 2020 as everyone worked to develop alternatives to in person meetings. Unfortunately, because of these difficulties, the Oral Health Program was unable to continue its oral health promotion for pregnant womxn.

 

Pilot an electronic dental referral and data collection system between dental and medical providers: Unfortunately, the pilot created from previous years did not move to the next phase as it was found that the United Way 2-1-1 database needed extensive updating. Fortunately, the State of RI released a Request for Proposal for a company to build a statewide referral system. The organization (Unite Us) was chosen, and the Oral Health Program began to discuss the incorporation of dental referrals in this new system.

 

Maintain and promote oral health related resources (bilingual brochures, patient education flipbooks, toothbrushes, etc.) and prompts (Efforts to Outcomes Family Visiting case management system) within Family Visiting programs, WIC program sites, medical providers, and dentists: The Oral Health Program started the second year of a partnership with the Providence Bruins hockey team in the Winter of 2019/2020. The partnership included advertising around the arena, visuals on e-newsletters and the Bruins website as well as announcements during games about the importance of the first dental visit and preventive dental visits in general. The biggest component was tabling at the games and because of the timing of the COVID-19 pandemic, the Providence Bruins were unable to finish their season and the Program was not able to attend the games.

 

The Oral Health Program also continued to partner with the Family Visiting Program at the RI Department of Health (RIDOH). During this time, the two programs worked to add additional questions for family visitors to ask their families about their oral health (including frequency of going to the dentist, consumption of tap water, etc.). The Family Visiting Program also adapted to the Pandemic by having Hasbro Children’s Hospital medical residents attend a Zoom informational session about RIDOH’s different program where the event used to be in person. The RI Dental Director attended multiple sessions to discuss the importance of the age one dental visit and starting healthy oral health habits early.

 

Support family planning at Title X agencies: RIDOH’s Family Planning Program supports twenty-six family planning services sites, including twenty-two federally qualified community health center sites, three school-based health centers, and services at the RI Women’s Division of Corrections. The family planning service sites provide comprehensive, accessible, affordable, and confidential Title X family planning services to culturally diverse, primarily low-income womxn, men, and adolescents. Family planning services include contraceptive services, preconception care, reproductive life planning, reproductive health counseling, HIV screening and referral, STI testing and treatment, and related preventive health services. The confidentiality and affordability of Title X services provide a critical safety net, particularly for low-income, uninsured individuals and minors. Family planning services are often an entry point into the healthcare system. Title X family planning clinics provide referrals to other clinical specialties and community-based supports, including prenatal care and home visiting, as appropriate. In CY2020, Title X agencies provided family planning services to over 19,000 women, men, and adolescents. Among unduplicated Title X clients served in CY2020: 12% were less than 20 years of age; 19% were male; and 10% were uninsured.

 

To further support preconception care, the Family Planning Program partners with the Center for Health Data & Analysis (CHDA) to provide multivitamins with folic acid to womxn of reproductive age at Title X family planning clinics. Folic acid supplementation reduces the likelihood of neural tube birth defects. Title X family planning agencies adapted to continue to provide critical services during the COVID-19 pandemic, including implementation of telehealth visits, adjustments to scheduling and waiting room protocols, and prioritizing access to family planning services.

 

Promote routine pregnancy intention screening with the One Key Question® (OKQ) model: To promote reproductive health counseling that encourages planning and empowers individuals to clarify reproductive health needs and intentions, RIDOH Family Planning has provided training and technical assistance on pregnancy intention screening. The One Key Question® (OKQ) model (“Would you/and your partner like to become pregnant in the next year?”) encourages routine pregnancy intention screening. In preparation of OKQ implementation, all Title X family planning agencies received training on the OKQ model, as well as preconception care and reproductive life planning. All Title X agencies have implemented routine pregnancy intention screening with the OKQ model. RIDOH Home Visiting programs have also integrated pregnancy intention screening into their intake forms and developed protocols for routine screening.

 

RIDOH Family Planning has also engaged partners throughout the state and across sectors and specialties, including primary care, Head Start, Early Intervention, and substance use treatment providers, to consider integration of routine pregnancy intention screening in their practices. To support community-based partners providing sexual/reproductive health counseling/education, RIDOH Family Planning has drafted a toolkit for non-clinical professionals with counseling recommendations, training resources, and job aids.

 

Coordinate Preconception Health social marketing campaign: During the reporting period, RIDOH developed social marketing materials to promote preconception care, including print ads, webpage banners, vinyl banners, and radio PSAs that include messaging related to “Thinking about having a baby? Be Healthy. Be ready.” Social marketing materials were shared via Pawtucket Red Sox program book and game day radio announcements, Providence Bruins game day communications, RI Pride website and RI PrideFest activities, and at community outreach events throughout the state. RIDOH Family Planning and the Center for HIV, Hepatitis, STD, and TB Epidemiology developed and released the RIght Time app to provide sexual/reproductive health information, including where to find free condoms, family planning services, HIV/STI testing, and an “Ask the Expert” feature. The app and associated services were actively promoted up until the COVID shutdown in March of 2020. Communications activities included outreach at Providence Bruins hockey games, tv commercials, and partnerships with community-based agencies to promote the app. RIDOH Family Planning also developed, recorded and released television commercials on ABC6 to advertise the RightTime app, as well as messaging on preconception health.  To date, this campaign has not resumed.

 

Improve coordination of transition from OBGYN to primary care: Medicaid coverage for pregnant women is terminated at 60-days postpartum, however RI’s Medicaid 1115 waiver provides additional coverage via the “Extended Family Planning Benefit” (EFP). For women with a Medicaid covered birth, the EFP provides coverage of family planning services for two years postpartum. Access to health insurance is critical to ensure continuity of care. Although the ACA requires all individuals to have health insurance and RI has expanded Medicaid, maintaining continuity of coverage can be a challenge and many people experience instability with gaps in coverage. The EFP provides a safety net for family planning services, particularly for women the eligibility threshold for Medicaid coverage of 138% FPL and the prenatal Medicaid eligibility of 250% FPL. RIDOH academic detailing activities with OB-GYN practices included questions regarding protocols for insurance enrollment services and referrals. RIDOH worked in collaboration with RI Prematurity Task Force to review communications sent by insurers to their pregnant members regarding continuity of insurance coverage and transition to primary care.

 

Integrate preconception care into undergrad/graduate/continuing education and training for clinical providers and allied health professionals: RIDOH partnered with the RI HIV & STI Prevention Coalition and the RI Prematurity Task Force to provide preconception health focused professional development opportunities with continuing education credits for physicians, nurses, social workers, and certified health education specialists.

 

Adult Immunization Registry: During the 2019 legislative session, the Rhode Island general assembly approved a bill expanding the State’s childhood immunization registry to include adults. With passage of the bill, the Immunization Program and KIDSNET moved ahead to begin development of the Rhode Island Child and Adult Immunization Registry. The system was modified to accommodate data for adult immunizations and began accepting electronic immunization data for people over age 18 starting in October 2020 for dates of vaccine administration on or after 08/15/2020. The system went live for users to view adult immunization data shortly thereafter. Many adults receive vaccines at non-primary care sites such as pharmacies, workplace and community clinics. A vaccine registry facilitates the secure sharing of this information with the primary care and specialty care doctors who are coordinating care. A lifelong registry will help eliminate unnecessary re-vaccination that both saves health care costs and reduces inconvenience to patients.

 

A registry is also a source of information for the public to easily obtain comprehensive immunization records that they may need for employment, education, travel, etc. A lifelong registry will further assist with the rapid collection of vaccination status and dissemination of that data and is critical to disease prevention and containment during an outbreak, such as COVID-19. Having the registry equipped to capture adult immunizations in time for the COVID-19 vaccine response, which started in early December 2020, was crucial. The lifelong registry allowed RIDOH to monitor adults and adolescents at the population level to identify communities/sub-populations at risk for spread of disease to target education and outreach to less well vaccinated populations and individuals. Additional modifications to facilitate interstate data sharing, connection with the state health information exchange, and likely COVID-19 booster doses are planned for the 10/1/2021-9/30/2022 project period. The process of onboarding practices to send electronic records for adults will continue until all practices are sending data.

 

Disparities in Infant Mortality (DIM) Advisory Board: When undertaking the IM CoIIN project, RIDOH sought to convene a diversity of stakeholders in order to thoroughly assess the nuances of why certain gains made in supporting pregnancy and the perinatal period were not being felt by all segments of the population in the state. For the Disparities in Infant Mortality Advisory Board, RIDOH prioritized identifying womxn of color active in the perinatal health community at the community-level, as well as diverse stakeholders in perinatal health. Community-level stakeholders represented doula work and a parenting support and education agency. Other stakeholders included health care providers and public health. RIDOH invited public health representatives from the Center for Health Data and Analysis (CHDA), the Family Home Visiting Program (FHV), the Maternal and Child Health (MCH) program leadership, as well as the Health Equity Institute (HEI). In its first year the DIM group brought together 12 individuals representing 4 diverse stakeholder groups. Heading into the second year of the group, stakeholders representing policy and advocacy, as well as community organizing were added, and membership increased to 16 individuals.

 

The DIM advisory board met throughout 2018- 2019 to discuss data, consider the perspectives of womxn of color in the community as shared by the advisory board members, and develop recommendations for the MCH leadership team. Seeking to follow in the footsteps of Oregon, Minnesota and most recently New York City, the DIM group considered how to put a strategy forward for doula reimbursement for Medicaid beneficiaries. Several members supported RI’s recently passed Doula Bill and the certification of the doula workforce. The DIM advisory board and the MCH program will work with community advocates over the next year and continue to advise on all aspects of bill implementation and doula workforce development. Currently, our MCH Perinatal Community Consultant Quatia Osorio, helps to review and assist in integrating maternal child health initiatives into the Health Equity Zone structure. For instance, she is currently working with RIDOH’s Health Equity Zone team to develop a structure for dispersing $125K in funding to community initiatives. She is also working on applying for funding to implement perinatal workforce development activities. The DOH also supported and collaborated on Mrs. Osorio’s application for the HRSA Emerging Issues grant, which laid out a structure for perinatal workforce development rooted in and led by the community.

 

AMCHP Infant Mortality Collaborative Improvement and Innovation Network (CoIIN): The AMCHP Infant Mortality CoIIN is a multi-year national initiative supported by the Maternal and Child Health Bureau (MCHB) of the Health Resources and Service Administration (HRSA). CoIINs are multidisciplinary teams of federal, state, and local leaders working together to tackle a common problem. Using technology to remove geographic barriers, participants with a collective vision share ideas, best practices, and lessons learned, and track their progress toward similar benchmarks and shared goals. CoIIN provides a way for participants to self-organize, forge partnerships, and take coordinated action to address complex issues through structured collaborative learning, quality improvement, and innovative activities. For the last two years, RI has participated in the Social Determinants of Health Workgroup which holds monthly technical assistance calls, webinars, and an annual in person meetings. The Disparities in Infant Mortality Advisory Committee was formed as a result of participating in this CoIIN. Two policy initiatives were pursued through this work: 1) increasing access to doulas and 2) revising the current birth center regulations.

 

Community Health Worker Legislation and Workforce Development: In the 2020-2021 RI General Assembly Legislative session, the Medicaid Reform Act for Community Health Workers was passed that authorizes RI’s Medicaid program to improve health outcomes, increase access to care, and reduce healthcare costs, by providing medical assistance coverage and reimbursement to community health workers. RIDOH MCH participates in a CHW Sustainability Strategy Team to ensure implementation of the CHW Workforce, viability of the CHW Association of RI, and adherence to the CHW Certification Standards. It is important to note that parents of children with special needs have become certified as CHWs and will benefit from this legislative approval.

 

In 2021-2022, RI received the federal grant, Community Health Workers for COVID Response and Resilient Communities (CCR) (CDC-RFA-DP21-2109), which funds 67 organizations across the United States. CCR is a 3-year grant that supports the training and deployment of CHWs to COVID-19 response efforts. The aim is to utilize CHWs as a tool to strengthen community resilience to fight COVID-19 by addressing health disparities. RIDOH recently hired full-time staff to oversee the project management and evaluation of the grant. Staff recently sent out a request for proposals (RFP) of community agencies interested in receiving financial and administrative support in hiring a CHW.  Fifteen applications were received and ultimately eleven community organizations and agencies had their RFPs awarded. Currently, staff are working with awarded agencies to support the hiring, integration, and evaluation of CCR funded CHWs.

 

Additionally, RIDOH MCHP applied for the Real Jobs Program through the Department of Labor and Training. Founded in 2015, Real Jobs RI is a business-led workforce development initiative. Working with a network of employers, training providers, and community organizations, Real Jobs RI partnerships build workforce solutions that address industries’ unique workforce challenges. RIDOH was awarded a planning grant in order to train CHWs in a MCH specific curriculum. The goal is to expand not only the competencies of CHWs but also their abilities to adequately support young families. The3 month planning grant will consist of a short needs assessment (surveys and focus groups) gauging the interest and needs of CHWs in this content area. The planning grant will allow for DOH to plan out how the implementation phase of this project will look like. At the end of our planning process, in October 2022, DOH will submit, to DLT, our needs assessment findings and MCH CHW training implementation plan. DLT will then review and decide on whether or not award our proposal.

 

Community Health Network (CHN): The Community Health Network is RI’s centralized referral system for all Evidence Based Lifestyle Change Programs (EBLPs) that was created in 2012 in response to data collected in 2011 through Rhode Island’s Patient Centered Medical Homes Needs Assessment Survey. Since its inception, the CHN has provided a strong foundation for RI primary care practices as a referral mechanism for their patients to be able to effectively manage their chronic diseases. Managed by the Rhode Island Parent Information Network (RIPIN), the CHN utilizes Patient Navigators (PNs) to receive the referrals, contact the patients, provide program information, and place interested individuals into classes that best meet their healthcare needs. In the calendar year 2020, 34 providers from 29 practice sites made 433 referrals to CHN. The programs currently housed under CHN are:

• Tools for Healthy Living - Chronic Disease Self-Management: This evidence-based education workshop teaches people how to manage symptoms and medications, communicate with family and doctors, relieve stress, eat well, exercise, and set attainable goals.
• Diabetes Prevention Program: This evidence-based education workshop teaches people how to lower their risk of getting Type 2 Diabetes by eating healthier, increasing physical activity and losing weight.
• Diabetes Self-Management: This evidence-based education workshop teaches people to deal with symptoms of diabetes, fatigue, pain, hyper/hypoglycemia, stress, and emotional problems such as depression, anger, fear, and frustration.
• Certified Diabetes Outpatient Education Program: CDOEs are Registered Nurses, Dietitians and Pharmacists who teach patients how to manage their glucose, blood pressure, cholesterol, medication, and nutrition.
• RI Smokers’ Helpline: This Program provides tobacco cessation educational training for physicians and other healthcare providers, training and support on the use of the fax-referral system to the Smokers’ Helpline for patients who desire to quit smoking and follow up reporting on patient progress with the Program.
• Walk with Ease: The Arthritis Foundation Walk with Ease program is designed to help people living with arthritis better manage their pain and is also ideal for people without arthritis who want to make walking a regular habit. Led by a certified leader, this program has been shown to reduce pain and increase balance and walking pace.
• Matter of Balance - Managing Concerns About Falls: Facilitated by Peer Leaders, these group workshops teach techniques to reduce fears of falling and increase activity levels among older adults.
• Chronic Pain Self-Management Program: This workshop provides you with the tools to manage medications, fatigue, frustration, proper nutrition, and communication skills, and teaches you to evaluate treatments and make an action plan.
• Powerful Tools for Caregivers: This workshop allows caregivers to develop a wealth of selfcare tolls to reduce personal stress, change negative self-talk, communicate their needs to family members and healthcare providers, communicate more effectively in challenging situations, recognize the messages in their emotions, deal with difficult feelings, and make tough care-giving decisions.
• Healthy Living for Your Brain and Body- Tips from the Latest Research: During this 90-minute workshop, participants learn about research in the areas of diet and nutrition, exercise, cognitive activity and social engagement, and use hands-on tools to help incorporate these recommendations into a plan for healthy aging.
• Know the 10 Signs- Early Detection Matters: During this 2-hour workshop, participants learn how to recognize common signs of Alzheimer’s disease; how to approach someone about memory concerns; the importance of early detection and benefits of a diagnosis; possible tests and assessments for the diagnostic process, and Alzheimer's Association resources.
• LIVESTRONG at the YMCA: An evidence-based strengthening and conditioning program to help cancer survivors reclaim their health and well-being by improving their fitness, diminishing therapy side effects, and receiving peer support.
• Pedaling for Parkinson’s: A form of “Forced Exercise” indoors on a stationary bicycle. Participants complete a 10-minute warm up, followed by 40 minutes of active cycling, and a 10-minute cool down. Participants must have a diagnosis of Parkinson’s Disease from a physician, as well as be able to safely hold themselves upright on a bicycle.
• Understanding Alzheimer’s and Dementia: Learn about the impact of Alzheimer's; the difference between Alzheimer's and dementia; stages and risk factors; current research and treatments available for some symptoms; and Alzheimer's Association resources.
• Asthma Services: Focuses on asthma at home, school, and healthcare centers. The program aims to lower asthma-related hospitalizations, emergency room visits, and missed days of work and school.

 

RI WISEWOMAN Program: The Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) Program focuses on reducing cardiovascular disease risk factors among high-risk womxn. Addressing risk factors such as high blood pressure, elevated cholesterol, obesity, inactivity, diabetes, and smoking greatly reduces a woman’s risk of CVD-related illness and death. The purpose of the WISEWOMAN program is to: 1) assure that cardiovascular screening is provided to womxn 30 and older who are eligible for the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) or RI Medicaid eligible between 30-64 years; 2) work with community-based organizations to provide evidence-based prevention services to those womxn in need (through individualized lifestyle coaching and/or agreements with organizations such as the YMCA, Weight Watchers, and those that provide Diabetes Primary Prevention Programs) ; 3) improve the management and control of hypertension by integrating innovative health system-based approaches and strengthening community-clinical linkages (such as team-based care, self-measured blood pressure monitoring, and pharmacy medication management programs) ; and 4) gather and reporting program related evaluation data, including impact measures. The RI WISEWOMAN Program is offered at Federally Qualified Health Centers and free clinics.

 

An eligible WISEWOMAN member is given a heart health assessment/screening to determine their risk factors and willingness to change. This assessment is completed with the member, health risk factors for CVD are reviewed. Screening questions responses, clinical measures, and risk reduction counseling is written into My Heart Health Booklet and given to the member. A referral(s) is made to the Community Health Network based on the members SMART Goals. The WISEWOMAN Program has enrolled 105 unique women from October 1, 2019 through September 30, 2020. Of the 105 women, 163 Screenings, Re-Screening, and Follow-Up Assessments have been completed from October 1, 2019 through September 30, 2020. The WISEWOMAN Programs continues to partner with community resources throughout RI and offer free memberships to our WISEWOMAN members through the CHN Referral Program. This referral system enables WISEWOMAN members to choose a health behavior support service with their health care team at the WISEWOMAN sites. From 105 unique women, 223 referrals were made through the CHN. Of the 223 referrals made to the CHN, 33 unique women were referred to LSP; 104 women were referred to gyms; and 73 women were referred to HCP.

 

Women’s Cancer Screening Program: The Women’s Cancer Screening Program (WCSP), RI Cancer Registry, and the Comprehensive Cancer Control Program implement a coordinated approach to inform policy, systems, and environmental change strategies to prevent and control cancer. The WCSP works to enhance the existing statewide infrastructure with health systems to provide breast and cervical cancer screening services to uninsured and underinsured womxn and to implement key evidenced-based strategies to reduce structural barriers to screening within health systems. The WCSP works collaboratively with other RIDOH programs and a network of community-based partnerships that provide services to underserved womxn and focus on health care systems that provide essential primary care services to the most vulnerable populations in RI.

 

The goal of the WCSP is to decrease breast and cervical cancer incidence, morbidity, and mortality by focusing on underserved populations in RI who have increased cancer risk. These outcomes are accomplished by implementing key evidence-based strategies to reduce structural barriers within health systems including increasing breast and cervical cancer screening services, eliminating barriers to accessing screening, and follow-up and referral for treatment. A large proportion of the work is spent partnering with the RI Federally Qualified Health Centers (FQHC) and Free Clinics to implement health systems change to drive and improve age-appropriate cancer screening.

 

Over the past 25 years, the WCSP has provided breast and cervical cancer screening services to approximately 41,200 program eligible women including over 37,000 and over 32,000 women screened for breast cancer and cervical cancer, respectively. As a result of this, over 540 invasive cancers have been identified. Over 2,500 women have been navigated and enrolled into Medicaid through the WCSP to cover the cost of treatment related to a precancerous breast and/or cervical condition or to cover the cost of treatment needed for women with a diagnosis of breast or cervical cancer. The WCSP staff are seasoned staff serving as the backbone of the program. The staff provide ongoing support to all providers, clinicians and their office staff ensuring provider compliance with program requirements and policies. June 2020 to July 2021, approximately 1090 women were served by the program. During this time, there was a marked reduction in program direct service utilization due to the impact of COVID-19.