Women/Maternal Health, Annual Report FY 22 

 

The annual report is organized by three priorities to address maternal morbidity, mental health, and risk factors for preterm birth. 

 

Priority: Decrease risk factors contributing to maternal morbidity 

 

Measures 

Severe maternal morbidity is more than 100 times as common as pregnancy-related mortality—affecting about 52,000 women annually and it is estimated to have increased by 75 percent over the past decade. Rises in chronic conditions, including obesity, diabetes, hypertension, and cardiovascular disease, are likely to have contributed to this increase. Minority women, particularly non-Hispanic Black women, have higher rates of severe maternal morbidity. To address the priority of maternal morbidity, efforts include improving the health outcomes for women before, during, and after pregnancy. The selected NPM relates to leveraging women’s well visits as key opportunities for health intervention and referrals. The SOM was established to measure the disparity in maternal morbidity outcomes. The ESM relates to the priority and efforts to improve safety related to maternal morbidity by standardizing assessment and responses for hypertension, which will contribute to addressing disparate outcomes. 

 

•       NOM 2: Rate of severe maternal morbidity per 10,000 delivery hospitalizations 

•      According to data from the Health Care Utilization Project – State Inpatient Database, as analyzed by HRSA in the Federally Available Data (FAD), the rate of severe maternal morbidity per 10,000 delivery hospitalizations was 84.9 in 2020. This is an increase from the SMM rate in 2019 (78.4). 

 

•       SOM: Disparity- Non-Hispanic Black rate of severe maternal morbidity per 10,000 delivery hospitalizations 

•      According to data from the Health Care Utilization Project – State Inpatient Database, as analyzed by HRSA in the Federally Available Data (FAD), the rate of severe maternal morbidity per 10,000 delivery hospitalizations among Black women was 136 in 2020, about 60% higher than SMM rate overall.  

 

•       NPM 1: Percent of women (18-44) with a preventive medical visit in past year 

•      According to the Behavioral Risk Factor Surveillance System, 74.0% of reproductive-aged women in 2020 had a preventive medical visit within the previous year. This is consistent with years past. 

 

•       ESM: Percent of uninsured women 18 and older served in Title X Reproductive Health and Wellness clinics who were referred for enrollment or enrolled in health insurance. 

•      36.5% of the 7,102 uninsured women served in Title X clinics were referred for enrollment in health insurance in FY 2022, an increase from FY 2021 (30.9%). 

 

Objective 1: By 2025, increase percent of women with a preventative medical visit by 5%. 

Strategies: 

1. Provide well-woman visits within Title X clinics following ACOG guidelines. 

2. Community needs assessment on barriers to pre- and inter-conception care through MP subgrant. 

3. Implement culturally relevant community, clinical, or community-based services to address unique pre- and inter-conception issues for women 18-44 through Maternal and Child Health Program (MP) subgrant. 

4. Implement education and awareness for pre-conception and reproductive health targeting high-risk women through MP subgrant. 

5. Find and review data on quality and comprehensiveness of preventive medical visits as well as feasibility and evidence-based practices for promoting standards (including mental health, health behaviors, dental, social determinants, and referrals). 

6.   Work with partners to develop plan to increase coordination, referral, access, and uptake of high-quality services for at-risk women 18-44. 

7. Distribute guidelines on managing oral health care during pregnancy to perinatal and dental care providers. 

8. Integrate oral health education, assessment, and referrals for dental care into community-based health care systems that serve women of reproductive age (e.g., FQHCs, WIC, Home Visiting). 

 

The ODH Reproductive Health and Wellness Program (RHWP) is the umbrella agency that currently holds the Title X family planning grant. This grant funds 42 subrecipient agencies providing services at over 85 sites located in 58 counties in Ohio, with clinics in the northeast, northwest, southeast, southwest, and central regions of the state. The current subrecipient agencies are comprised of a diverse group of local health districts, non-profit agencies, Federally Qualified Health Centers, and Community Action Agencies. They provide services not only in traditional clinical settings but also in non-traditional settings, such as substance abuse treatment facilities, homeless and domestic violence shelters, and rehabilitation facilities. From January 1, 2021, through December 31, 2021 (CY21), the RHWP provided 60,682 clinic visits to 35,954 unduplicated clients including 27,283 women and 8,671 men. Ninety-three percent of these unduplicated clients live at or below 250% federal poverty level. Sixty-one percent of these unduplicated clients live at or below 100% of the federal poverty level.  

  

ODH is currently one of two funded Title X grantees in Ohio and has been a Title X Grantee since the inception of the grant in 1970. ODH celebrated its 50th anniversary in 2020 as a Title X grantee and was recognized along with five other grantees for their continued efforts and commitment to ensure quality family planning services accessible to women, men, and adolescents. Additionally, in 2021, RHWP was the Grantee Spotlight for improving internal and external financial monitoring practices.   

    

Existing gaps in the availability or accessibility of services are addressed annually by the program. According to Power to Decide, in Ohio, there are 729,630 women in need living in contraceptive deserts, and 66,260 women in need live in counties without access to a single health center that provides the full range of contraceptive methods.  

  

The RHWP has Title X clinics in 58 of the 88 counties in Ohio. The Title X clinics provide direct healthcare services. In addition, the Title X clinics also provide enabling services by offering referrals and outreach. One of the RHWP grant deliverables requires that 100% of subrecipients provide and implement an outreach plan describing at least two outreach activities focused on hard-to-reach and high-need populations, as reflected in the needs assessment. Identified populations are women in need of publicly funded contraceptive services, including, but not limited to, Appalachian, Latina, and Non-Hispanic Black or African American women of childbearing age and those with disabilities. Subrecipients are required to use the Social Vulnerability Index to help determine where to focus outreach efforts. Examples of outreach events include group or school presentations, community information events and festivals, educational programming, social media, health fairs, and advertising via billboards, posters, commercials, and flyers. Several of the RHWP subrecipients have mobile units that offer direct reproductive healthcare services at a variety of high-need locations (i.e., homeless, and domestic violence shelters, substance abuse clinics, recovery housing, resource centers, LBGTQ youth centers) on a rotating basis.  

  

The RHWP values the input of families, youth, and those with lived experience. All RHWP Title X clinics are required to have an advisory committee and are encouraged to have clients, including adolescent clients, as some of the members. Additionally, the clinics have patient satisfaction surveys which are used to learn from the patients and make changes when needed.   

  

A major anticipated barrier in providing family planning services consists of the continuance in the COVID-19 variants and hesitancy to return to the clinics. The RHWP quickly responded to the initial pandemic by educating staff and implementing telehealth services in the clinic sites. RHWP provided additional funding, training, and one-on-one technical assistance to subrecipients to assist with the implementation of telehealth services. RHWP sites held drive-through vaccination clinics; offered curbside medication, lab supplies, and specimen pick-ups and drop-offs; and mailed medication. Once in-person visits resumed, subrecipients contacted clients to reschedule missed or canceled appointments. The RHWP continues to work with subrecipients to continue and improve in providing these alternative methods of service. RHWP partnered with Ohio State University’s Clinical Skill Education and Assessment Center to design educational training and technical assistance to build capacity for understanding telehealth rules and regulations, billing, and coding. The training was specifically geared toward Title X clinical providers and administrative staff.  

  

The anticipated next steps are to expand the RHWP telehealth services to ensure access to high-quality and equitable care. The RHWP allowed the use of incentives to increase access to care. The RHWP will continue to offer educational webinars and clinical newsletters to provide providers with current ACOG clinical guidelines. Title X clinics will continue to track the number of clients referred for mental health or substance use treatment and insurance enrollment assistance.   

    

The RHWP has worked toward accomplishing providing well-woman visits within the Title X clinics following the American College of Obstetricians and Gynecologists (ACOG) guidelines. This strategy is designed to meet the objective of increasing the percentage of women with a preventative medical visit by 5% by 2025 and falls under the priority of decreasing the risk factors contributing to maternal mortality. Following ACOG recommendations, from October 1, 2021, to September 30, 2022 (SFY22), the RHWP Title X clinics provided women annual exams (5,606); mental health screenings, counseling (4,495), and referrals (802); nutrition referrals (3,476); primary care referrals (1,454); blood pressure testing (37,934); dental referrals (409); STI prevention counseling (39,040); screenings for gonorrhea (16,625), chlamydia (16,702), Hepatitis B (807), Hepatitis C (3,234), and HIV (7,414); breast (6,666), cervical (5,176), and colorectal (56) cancer screenings; and Medicaid/insurance enrollment assistance (3,617).   

  

Ensuring women receive high-quality reproductive health care that adheres to ACOG guidelines is important in Ohio because reducing health disparities and increasing health equity are of critical importance. According to the Guttmacher Institute, 524,810 non-Hispanic White women, 146,910 non-Hispanic Black women, and 38,110 Hispanic women in Ohio were likely in need of public support for contraceptive services and supplies in 2016.  There were 394,490 non-Hispanic White women, 120,720 non-Hispanic Black women, and 30,480 Hispanic women aged 20-44 and below 250% of the federal poverty level who likely need public support for contraceptive services and supplies.  

 

During SFY22, the RHWP has conducted many activities to help meet this goal. Quarterly newsletters were created and sent to Title X clinic physicians, nurse practitioners, and nurses containing clinical updates and recommendations by national organizations such as ACOG. The RHWP Title X Clinical Services and Protocol Manual was updated in 2020, 2021, and 2022. Once fully approved, it will be sent to all Title X clinics. This book of clinical policies and procedures is based on national standards of care set forth by medical organizations such as ACOG. The RHWP medical consultant provided a lecture on the ACOG well-woman and postpartum exam recommendations, Fourth Trimester Project, and data from Pregnancy-Associated Mortality Review during the July 2022 planning call with the Title X clinics. Over 100 healthcare providers attended this learning session. Lastly, RHWP program consultants review encounter level data to ensure patient visits are following Title X and ACOG standards of care. At Ohio Title X clinics, there has been a steady rate of well-woman annual comprehensive exams in SFY21 and SFY22. However, over the same time, there has been an 8.4% decrease in the number of pap smears conducted at annual comprehensive well-woman exams. According to the National Cancer Institute and the Centers for Disease Control and Prevention (CDC) cervical cancer screening rates are declining across the country, so the RHWP is planning to launch a media campaign to increase awareness of Title X clinics and telehealth services.   

  

During SFY22, the RHWP has worked to increase the percentage of uninsured women who were given a referral for Medicaid/insurance enrollment. Technical assistance and resources were given on several occasions. As a result, there was a 6% increase in uninsured women being referred or assisted with insurance enrollment in SYF22. The RHWP will continue to encourage the importance of proper documentation of this assistance.   

 

 Concerning promoting standards and evidence-based practices, next year, the Title X subrecipients will adopt and implement a local policy/practice change that will address a social determinant of health that impacts inequities in reproductive health. All subrecipients will provide a written summary of the policy/practice change. Additionally, each year, the RHWP produces a clinical protocol manual for use by Title X subrecipients. It contains clinical updates and references national standards of care.   

 

The RHWP requires Title X clinics to provide preventative medical visits and many of the Preconception and Inter-conception Care subrecipients coordinate and increase access to high-quality services. Examples of women preventative medical services provided by Title X clinics include Pap smears (5,183), breast exams (6,716), colorectal cancer screening (56), blood pressure checks (37,967), and weight checks (37,521). Additionally, the Title X clinics provide counseling services on contraceptives (32,236), healthy relationships (21,085), family involvement (6,719), sexual coercion (9,386), sexual risk avoidance/abstinence (23,398), reproductive life planning (29,107), and sexually transmitted infections (29,077). 

 

All Title X clinics provide referrals and have extended hours outside of normal business operations. Additionally, all Title X clinics promote the provision of comprehensive primary health care services to make it easier for individuals to receive both primary health care and family planning services preferably in the same location, or through nearby referral providers. The RHWP used telehealth to increase the accessibility of reproductive health visits (2,644). 

 

The Maternal and Child Health Program (MP Program) funds Preconception and Inter-conception Care for Women’s Health provides funding to subrecipients to support the health and well-being of women ages 18-44 before they get pregnant and between pregnancies. The goals of this strategy are to (1) Reduce maternal morbidity and mortality by increasing equitable access to women well visits and preventative health services to women ages 18-44; (2) Increase the value of preconception health through education and awareness to women ages 18-44; and (3) Increase the capacity of local public health systems to support partnerships that address social determinants impacting preconception health services.    

  

The Preconception and Inter-conception Care objective of the MP Program started in FY21, funded 18 entities across 18 counties in Ohio to increase the percent of women with a preventative medical visit through FY24, and utilized Title V Block Grant funding. In FY21, each entity conducted a health and environmental scan to explore gaps, opportunities, and challenges for clinical and social service providers who support preconception and inter-conception health for women ages 18-44. These health and environmental scans were tailored to each community and therefore incorporate the voices of those living within those communities.   

  

In FY22, the Preconception and Inter-Conception Health initiative interventions focused on improving obesity rates and healthy eating, managing chronic conditions such as hypertension, providing mental health screenings for non-pregnant women 18-44, enhancing non-traditional partnerships to address social determinants of health, and improving awareness of preconception health.     

  

Since improving preconception health and awareness is a major component of this grant program, many agencies developed preconception education sessions for women 18-44 which resulted in serving 7,921 women at outreach events.  These events were held in various locations including jails, homeless shelters, WIC programs, non-profits, job and family service agencies, and health clinics.  The events were also held in conjunction with social media campaigns in some counties such as the “Dear Stark Women Campaign” to improve women’s wellness, the “Birth Spacing Initiative of Dayton-Montgomery Public Health” to address maternal and infant mortality, and “Walk with a Doc Initiative” in Belmont County to increase access to primary care services.    

  

For interventions focused on obesity and managing chronic illnesses, a total of 913 women were served.  The obesity and chronic disease interventions were implemented in settings such as clinics and health departments and included BMI screenings, physical activity classes, walking groups, cooking courses, and yoga.  For women with hypertension, this also included providing at home monitoring kits. To improve mental health awareness among women of reproductive age, some agencies provided education sessions in the community on topics related to managing anxiety and depression which resulted in 622 women being served.  Some agencies not only provide mental health education but also build clinical and community partnerships to provide access to mental health screenings and referrals to counseling services.  For agencies that increased clinical and community linkages, 6,105 women were screened, and 107 women were referred for mental health services.  Some health departments also focused on enhancing partnerships with non-profit agencies by using tools such as the Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences (PREPAR) tool to address the social determinants of health.  This year a total of 1,036 women were successfully screened to address issues related to financial barriers, housing insecurity, food insecurity, and transportation issues.    

  

Overall agencies and counties funded across Ohio for preconception and inter-conception health included populations for urban, suburban, and rural communities.  In total, 78% of women served with White, 3% African American or Black, 2% were Hispanic, Native Hawaiian or Pacific Islander, and 17% did not report their race/ethnicity.  

  

Related to preventative health visits and collaboration with providers, the Ohio Department of Health Oral Health Program (OHP) oversees statewide efforts to improve oral health and access to dental care for all Ohioans. The Program oversees and funds prevention and treatment activities statewide through community efforts including but not limited to community water fluoridation, safety net dental clinics, integration of oral health into early childhood health and education programs and school-based oral health programs.   

   

Managing oral health care during pregnancy is important because poor oral health can lead to poor health outcomes for the mother and her baby. Up to 75% of women develop gingivitis during pregnancy due primarily to hormonal changes. Left unchecked, gingivitis can progress to periodontal disease which affects up to 40% of all pregnant women. Women are also at risk for tooth decay during pregnancy due to changes in eating habits, frequent bouts of morning sickness and possibly less attention being paid to their oral hygiene practices.   

   

The OHP continues to work to integrate oral health education, assessment, and referrals for dental care into community-based health care systems that serve women of reproductive age (e.g., FQHCs, WIC, Home Visiting) through the Integration of Oral Health into Prenatal Care grant and the Oral Health Care and Primary Care Learning Collaborative. Integrating oral health education, assessment, and referrals for dental care into community-based health care systems that serve women of reproductive age is important because maternal oral health can affect infant oral health. Babies are not born with the bacteria that cause tooth decay. These bacteria are transmitted, usually by the mother, through saliva-sharing activities such as kissing, the use of shared utensils or other common behaviors. Oral health interventions targeting women before, during and after pregnancy can help prevent or reduce the risk of dental caries in their children.     

   

One way the OHP integrates oral health into prenatal care is through the Integration of Oral Health into Prenatal Care grant which is funded by Title V MCH Block Grant funding. The program began on April 1, 2021, and currently funds three subrecipients in the second-year grant period. Two agencies, Nationwide Children’s Hospital, and Columbus Neighborhood Health Centers, both located in Columbus, are in their second year of the program and are funded under continuation grants. The third agency, Third Street Family Health Services, located in Mansfield, is in its first year of the program. Guidelines for prenatal and dental care providers on managing oral health during pregnancy have been integrated into this grant. During the first grant period, April 1, 2021, through September 30, 2022, the first two subrecipients, Nationwide Children’s Hospital and Columbus Neighborhood Health Centers provided prenatal health services to 3,354 unduplicated patients. During this initial grant period, 3,214 oral health assessments were provided by prenatal care providers, and oral health education was provided during 3,021 visits. Additionally, 1,788 pregnant women with dental needs were referred for dental care and 660 completed dental care.  

   

The second program the OHP integrates oral health into prenatal care is the Oral Health Care and Primary Care Learning Collaborative: A State and Local Partnership project. Ohio is one of nine states selected to participate in the project. The focus of the project is to integrate oral health risk assessment and evaluation, education, and navigation for oral health care into primary care practice in a community health center (CHC). The project is being led by the National Maternal and Child Oral Health Resource Center, in collaboration with the Association of State and Territorial Dental Directors and the Dental Quality Alliance. In addition, experts from the National Network for Oral Health Access provide technical assistance to the CHC. The project started in January 2022 and goes through March 2024. Through the project, the OHP’s role focuses on assessing and improving systems-level capacity for integrating oral health care and primary care for pregnant women, infants, children, and adolescents, including those with special health care needs. The role of Ohio’s local partner, Lorain County Health and Dentistry, is to integrate oral health care and primary care for pregnant women into their OB/GYN clinic.   

   

In addition, Title V Block Grant funds have been awarded to four agencies/health care systems to provide oral health services to uninsured MCH population from low-income families, which will help to impact this strategy. Funded agencies are Cincinnati Health Department, Columbus Neighborhood Health Centers, Mercy Health Youngstown, and Third Street Family Health Services. During the fiscal year 2022, 2,108 unduplicated MCH clients were served through this program.   

   

A continuing education module for nurses and nutritionists titled, Help Me Smile – Ensuring the Oral Health of Young Children, was developed on oral health and pregnancy and is available to MCH programs, such as WIC and Home Visiting. Since the course was made available in late August 2022, 23 nurses, nutritionists, and home visiting staff have completed the training. The training is approved for 1.6 Continuing Nursing Education contact hours and is pending approval for registered dietitian continuing education units.

  

Objective 2: By 2025, reduce the rate of severe maternal morbidity by 12%. 

Strategies: 

1. Increase use of AIM safety bundles in healthcare systems for at-risk pregnant women. 

2. Increase women’s health screenings during pediatric well visits. 

3. Develop a statewide strategic maternal health plan through the Ohio Council to Address Maternal Health (OH-CAMH). 

4. Increase the percent of pregnant and postpartum women who receive urgent maternal warning signs education in WIC, Home Visiting, and Healthy Start programs. 

5. Train emergency department providers to recognize, triage, and treat obstetric emergencies. 

 

 

Maternal death marks a tragedy for families and communities and is associated with poor outcomes for infants and children, including a higher risk of infant mortality. While maternal deaths in the United States plummeted during the twentieth century, they began to rise again in the late 1990s. In response, the Ohio Department of Health (ODH) established a maternal mortality review committee called the Ohio Pregnancy-Associated Mortality Review (PAMR) in 2010. PAMR exists to comprehensively assess the causes and factors that contribute to maternal deaths so that recommendations can be made to prevent future deaths.  

 

To "catch up" to more recent deaths, Ohio PAMR decided to skip the committee review for 2019 deaths. Data from vital statistics for 2019 deaths is still available for analysis. Due to historical vacancies in the PAMR coordinator position, we have fallen perpetually behind in meeting the timely review of deaths. As of November 2022, ODH PAMR increased its capacity by hiring 2 part-time RN abstractors (~16 hours s per week), 1 full-time RN abstractor, and 1 full-time PAMR Coordinator RN. As a result, we finished the 2018 case reviews and initiated the 2020 case reviews in early 2022. We have decided to bypass 2019 reviews to start reviewing 2020 deaths in 2022 to have more timely data and have begun reviewing 2020 deaths during this reporting period.  

 

The ODH PAMR program is in the process of publishing a report summarizing findings from deaths that occurred in 2017 and 2018. From 2008 to 2017 there were 731 pregnancy-associated deaths in Ohio; 30 percent were pregnant at time of death, 20 percent were pregnant within 42 days of death, and 50 percent were pregnant within 43 to 365 days of death. 

• 31% were determined to be pregnancy related. 
• 59% of pregnancy-related deaths were deemed preventable.  

 

In 2019, PAMR was competitively awarded the Preventing Maternal Deaths: Supporting Maternal Mortality Review Committees (CDC-RFA-DP19-1908) and the HRSA State Maternal Health Innovation Program (HRSA-19-107) through September 2024. The CDC grant will provide $450,000 annually for five years; the HRSA grant will provide $10,423,277 total over five years. Through these grant funds, the following activities continued during FY22: 

• Ohio Council to Advance Maternal Health (OH-CAMH). 
• ODH is working with the Government Resource Center (GRC) to implement the Alliance for Innovation on Maternal Health (AIM) hypertension patient safety bundle in all delivery hospitals across Ohio to reduce preventable hypertension-related maternal morbidity/mortality.  
• ODH is working with GRC and the Ohio chapter of the American Academy of Pediatrics (AAP) to implement this project based on a program developed by the Family Medicine Education Consortium IMPLICIT Network (Interventions to Minimize Preterm and Low birth weight Infants using Continuous Quality Improvement Techniques). IMPLICIT Network is a framework that focuses on maternal health screenings at well-child visits to enhance access to a health care provider, especially for women who may not otherwise seek care.  
• ODH subcontracted with The Ohio State University College of Medicine Clinical Skills Education and Assessment Center (CSEAC) to provide virtual obstetric emergency simulation training to emergency department staff and first responders to increase their ability to identify, recognize, and treat leading causes of pregnancy-related deaths. 
• ODH subcontracted with The Ohio State University College of Medicine Clinical Skills Education and Assessment Center (CSEAC) to provide virtual telehealth delivery simulation training to women’s health providers to increase their ability to deliver high-quality, culturally appropriate care to pregnant and post-partum patients.  
• ODH has implemented statewide implicit bias training for public health and healthcare providers to increase their ability to recognize the influence of bias on health disparities. 
• ODH is focusing implementation of strategies aimed at addressing disparities in populations experiencing the greatest disparities through the Disparities in Maternal Health Community Grant Program. The goal of this grant program is to fund solutions identified by communities and address unmet needs through a disparities-focused, equity-driven lens. 

 

Title V Block Grant funding partially funds the PAMR program staff that manage and evaluate these federally funded initiatives. 

  

Mothers experience substantial health and safety issues, throughout the duration of their pregnancy and after childbirth, including severe maternal morbidity and pregnancy-related death. There were 186 pregnancy-related deaths in Ohio from 2008-2016. The top underlying causes of pregnancy-related death in Ohio include cardiovascular and coronary conditions, infections, hemorrhage, preeclampsia and eclampsia, and cardiomyopathy (Ohio Department of Health, 2019). A review of all pregnancy-related deaths in Ohio from 2012-2016 found that over half of all deaths during this time were potentially preventable (Ohio Department of Health, 2019). Among the pregnancy-related deaths due to preeclampsia or eclampsia, 85% were found to be preventable and 68% were found to occur in the postpartum period (the first 42 days) (Ohio Department of Health, 2019). Preeclampsia is a condition in pregnancy that is characterized by persistent high blood pressure and is a leading cause of maternal and infant illness and death in the US (Preeclampsia Foundation, 2019). In addition, hypertensive diseases of pregnancy, specifically preeclampsia, are leading causes of inpatient severe cardiovascular morbidity and mortality (Hitti, Sienas, Walker, Beneditti, & Easterling, 2018). Black women are disproportionately affected by preeclampsia, display signs of preeclampsia earlier in pregnancy, and are at higher risk of developing preeclampsia related morbidity than white women (Shahul, Tung, Minhaj, Nizamuddin, & Wenger, 2015). To reduce the preventable deaths due to hypertensive diseases of pregnancy, specifically preeclampsia in Ohio, continued targeted interventions at the provider, facilities/hospital level, and system level are needed. The ODH PAMR program has partnered with The Ohio Colleges of Medicine Government Resource Center (GRC), The Ohio State University, MetroHealth Medical Center, The Cleveland Clinic Foundation, University Hospitals, Ohio Hospital Association, Ohio Perinatal Quality Collaborative (OPQC), reduce the rate of maternal mortality in Ohio by September 2024 through increasing use of AIM safety bundles in healthcare systems for at-risk pregnant women.

 

During FY22, the second phase of implementation focused on application and spread of the Maternal Safety: Severe Hypertension in Pregnancy toolkit in the 53 delivery hospitals throughout Ohio that participated in Waves 1 and 2. Action Period (AP) calls have focused on reviewing each of the five domains in the hypertension patient safety bundle (Readiness, Recognition, Response, Reporting, and Respectful Care) and relating them to potential interventions on the project Key Driver Diagram (KDD). Participating delivery hospitals have been engaged in QI coaching calls to examine the current state of their organization’s implementation of the hypertension patient safety bundle, establishing specific goals for each organization in the project based on the identified project SMART aims. 

 

GRC and the subject matter experts (SMEs) utilized the AP calls to train participating sites on best practices for implementing the AIM HTN bundle. In addition to the monthly AP calls, a series of educational modules were developed by a subcommittee of clinical advisors. These modules serve as supplemental material intended to expand upon subjects addressed during the AP calls. Data is collected from participating sites in real time via the secure REDCap form on pregnant and postpartum women who present with a severe hypertensive event and analyzed monthly at the site and aggregate level. The data dashboard is updated every week and is accessible to sites in real time. GRC and the AIM HTN QIP Project Team continue to use a set of processes, outcome, and balancing measures to measure project success. Thirty hospitals participated in Wave 1 of the project with improvements noted for the timely delivery of acute antihypertensive therapy within 60 minutes for sustained severe hypertension; follow-up appointment scheduling after hospital discharge; and the provision of blood pressure cuffs for home monitoring. Data from 29 of the Wave 1 hospitals in aggregate showed a 19.3% increase in the primary process measure of timely and appropriate treatment with secondary process measures demonstrating significant increases ranging from 26.1% to 166.8%. These improvements were achieved and sustained throughout the multiple peaks in the COVID-19 pandemic, indicating participating hospitals were able to implement this program and sustain successes during the challenges of the pandemic.  Other aggregate process and outcome data including from hospitals participating in Wave 2 is pending review for this QIP and will be available at a later date.  

 

Additionally, GRC considered the health equity gap, specifically focusing on the disproportionate effect of maternal mortality on Black women and has identified ways to stratify measures to track disparities. The AIM HTN QIP continues to convene the Health Equity Subcommittee which meets monthly to plan and implement interventions related to reducing disparities in maternal morbidity and mortality with hypertension. The Health Equity Subcommittee created and implemented a second iteration of the Staff Equity Survey across all Wave 1 and 2 participating sites from early September 2021 through December 2021. The topics covered in the survey included: 1) Health Outcome Knowledge 2) Discussions with patients on socioeconomic/racial disparities 3) Implicit bias or anti-racism training 4) Health Equity challenges 5) Shared Decision-making Approach and 6) General Demographics. The vast majority of respondents were White (78.5%), with other responses including Asian (1.3%), Black (1.2%), Other (2.8%), or unknown/no response (15.7%). Similarly, most respondents reported being non-Hispanic (99.5%). Based on the results from the various sections of the Staff Equity Survey, the Health Equity Subcommittee found similar significant results that highlight the continued importance of providing Implicit Bias/Anti-Racism training to all participating hospitals. 

 

GRC has worked to identify each participating site’s current state of implementation of the AIM HTN patient safety bundle and established specific goals for each site based on the identified project measures and SMART aims. In FY22, GRC administered a survey to assess knowledge/awareness, skill in treating women who present during pregnancy or postpartum with a hypertensive event, self-efficacy in treating the target patient population, and behaviors/ practices that led to improvement. This survey will subsequently be repeated during the sustainment period in future funding cycles.  

 

Currently, GRC has continued conversations with ODH and SMEs in planning for statewide spread. Spread activities were built on lessons learned from Wave 1 and considered geographic location of hospital in Ohio, levels of care, and unique patient population challenges. The spread plan incorporates a focus on equity and includes the number of target sites for recruitment, a recruitment timeline, a finalized scope of work for spread activities, and two additional unique waves of site engagement. Additionally, the project team will refine the project SMART aims, Key Driver Diagram, and refine measures specific to spread activities that can be used for real time rapid cycle data feedback and spread sites for the third and final Wave of the QIP for HTN. 

 

GRC will also develop a plan to implement and spread the AIM Obstetric Hemorrhage (HEM) Bundle QIP over 3 Waves of delivery hospitals. GRC will continue coordinating the team of clinical experts and leadership teams from each site to contribute to the implementation of the AIM HEM Bundle, as they have done for the HTN bundle. Like HTN, HEM Wave sites will need early site engagement to ensure the success of the spread activities.  

 

The next steps for the Health Equity Subcommittee include the administration of a Patient Equity Survey that will return results from all participating hospitals from the patient's perspective. Based on the results of this survey with the staff survey results and OPAS data, the subcommittee will make recommendations to the QIP for disparity-focused action-oriented interventions to implement alongside current testing taking place at the participating sites. 

 

Risk factors among 2018 infant deaths in Ohio revealed that 42% of infants were conceived less than 18 months after a prior birth; 20% of mothers smoked during their first trimester of pregnancy; and 40% of mothers did not have first-trimester prenatal care2. Among women with Medicaid, 26% and 36% reported pre-pregnancy depression and anxiety, respectively.   The effect of these high-risk health behaviors and access to care on future pregnancies urges the need to provide medical care for women of childbearing age during the interconception period. By the time a woman begins prenatal care, it is often too late to modify many of the high-risk health behaviors associated with poor birth outcomes. Studies have shown that mothers regularly attend their child’s health care visits and are highly receptive to health advice at well-child visits. Through focusing on interconception health through screenings and interventions for birth mothers during well-child visits 0-18 months, this QIP aims to address health behaviors and access to care that affect maternal and infant health in Ohio. 

 

Healthy Mom, Healthy Family is a QIP designed to impact maternal and infant health and is sponsored by the ODH and administered by GRC in partnership with Ohio Chapter-American Academy of Pediatrics (OhioAAP) and March of Dimes. Healthy Mom, Healthy Family is based on the national network model: Interventions to Minimize Preterm and Low Birth Weight through Continuous Improvement Techniques (IMPLICIT) Interconception Care (ICC).

 

Nine pediatric and family medicine practices were actively engaged in Wave 1 and 18 practices were actively engaged in Wave 2 with the QIP in FY22. QI and data/research progress included analyzing submitted data collection forms by practice and aggregate, data collection form submissions, finalization of change package, education materials, patient materials in Arabic, Somali, Mandarin, and Spanish, provider quick reference guide, practice cover sheet, final evaluation outline, data collection form, training video on completing data collection form, REDCap portal, pre/baseline data survey, data linkage manual, data dictionary, data variables, data measures sampling frame, workflow, recruitment materials, pre-implementation survey, patient screening note, recruitment registry, and registration survey. Recruitment for Wave 3 has been initiated and will continue through FY23. Regular meetings with project partners and sponsors occurred bi-weekly and with project clinicians- monthly.  In FY22, nine practices completed Wave 1 from March 2021 to January 2022 with over 1,500 total screens completed.  At baseline, 12.5% of these sites did not frequently (never or rarely) screen for tobacco use. Twenty-five percent of patients were not frequently screened for family planning and multivitamin use and all sites frequently screened for postpartum depression (Always, often, sometimes). Of 1,536 total screens completed in wave 1, 91.2% received screening for postpartum depression or anxiety, 92.5% received screening for tobacco use, 92.2% received screening for multivitamin use and 91.6% received screening for family planning. At the end of Wave 1, the percent of women self-reporting having symptoms of postpartum depression/anxiety decreased from 17.1% to 9.2% with referrals for mental health services increasing from 57.1% to 66.7%. The percent of women who received a referral for tobacco use increased from 87.5% to 100%, the percent of women who reported not currently taking a multivitamin, prenatal vitamin or folic acid decreased from 50% to 37.8% and the percent of women who received education on 18-month healthy birth spacing increased from 64.1% to 72.7% at the end of wave 1. Wave 2 will conclude in FY23 with results available at a later date.  

 

Site engagement in FY22 was slightly improved from the previous year though some sites struggled with not submitting regular monthly data and/or participating in the monthly AP calls. Sites have been contacted individually following absences at AP calls to explain absences and receive the educational recordings. The engagement has been discussed with sites during quarterly coaching calls. Sites have been polled on availability to attend future AP calls. A monthly newsletter highlighting data including reminders to submit data is being sent to sites. 

 

In FY23, GRC will continue to analyze collected data from Waves 2 and 3 and use data to work with practices on PDSA cycles and implement the plan for recruitment of Wave 3 sites. The online resource and participant dashboard will continue to be updated with final materials and Action Period call recordings. The Ohio AAP and clinical lead will continue to join bi-weekly calls to review materials, report on progress toward full practice participation, and provide feedback. The clinical team will meet via webinar for further discussion and feedback on project activities, data collection, PDSAs, and Action Period training webinars. Wave 3 recruitment will be continued, including distribution of marketing materials, and following the actions of the marketing plan. 

 

The Ohio Council to Advance Maternal Health (OH-CAMH) was established as Ohio’s Maternal Health Task Force to fulfill the requirements of the Health Resources Services Administration (HRSA) State Maternal Health Innovation (MHI) Program grant, which was awarded to ODH in 2019.

 

Over FY22, two general OH-CAMH membership meetings were held: one on February 22, 2022, and one on June 22, 2022. During the February meeting, team leads from each of the implementation teams shared their team’s progress with the rest of OH-CAMH. Two presentations were also given during this meeting. The first presentation was focused on the Ohio Infant Mortality State Task Force while the second presentation was focused on how federal maternal health efforts overlap with OH-CAMH activities/strategies. During the June meeting, implementation team leads were asked to generate questions their teams would like to pose to the larger OH-CAMH membership regarding their team’s objectives/plans. OH-CAMH members were invited to take part in an interactive discussion with the team leads to provide answers to their questions and provide feedback/advice utilizing online polling software. Team leads were then provided with the polling answers they received during the meeting and tasked with taking those answers and comments back to their respective teams to assist them with creating a work plan to implement their strategy’s activities by the end of 2022. Planning and implementation will continue throughout the duration of FY23 with TA provided by ODH PAMR staff as needed. 

  

To reduce the preventable deaths due to hypertensive diseases of pregnancy, specifically preeclampsia in Ohio, targeted interventions at the provider, facilities/hospital level, and system level are needed. ODH is using HRSA MHI funds to increase the percent of pregnant and postpartum women who receive urgent maternal warning signs (UMWS) education in WIC and Home Visiting programs through this QIP. Sponsored by ODH and administered by the GRC, the UMWS QIP aims to increase knowledge of and improve health outcomes among women at risk for an adverse event related to hypertensive events in the prenatal and postpartum period. 

 

Forty-Six out of 74 WIC sites in Ohio participated in Wave 2 of the UMWS QIP in FY22, with a total of 72 out of the 74 WIC clinics participating over the 2 waves. Over 7,900 data forms were collected on WIC participants during Wave 1. 97.5% of WIC participants received the educational handout on the UMWS, 96.3% received verbal education from WIC employees, and 94.7% received both the handout and verbal education. Wave 2 implementation focused on education dissemination with pre-/post-test knowledge surveys for project evaluation, including qualitative data collection administered to WIC employees to measure change over time. Results from Wave 2 will be available in FY23. Ohio WIC clinics will continue to supply the UMWS verbal education and corresponding handout to all postpartum and pregnant women during the next five-year grant cycle as a required SMART objective. The Ohio WIC grant cycle is currently five years and begins October 1, 2022. Local clinics will be tracking the women that receive the education, by race and ethnicity, and report it to state WIC in their Quarterly Activity Reports. 

 

During FY23, GRC continues to distribute education materials throughout Wave 1 and 2 sites and begin onboarding ODH evidence-based Home Visiting sites for Wave 3. Project evaluation will also continue, and pre-/post-test knowledge surveys administered to Home Visiting providers and will be used to measure change over time. 

 

Emergency medicine staff and first responders are often the experts’ women turn to when they are experiencing acute distress during and after pregnancy. Data from the ODH Pregnancy-Associated Mortality Review program revealed that 23% of pregnancy-related deaths in Ohio from 2008-2016 occurred in an emergency department or in an outpatient setting and 41% of pregnancy-related deaths in Ohio from 2010-2016 involved maternal transport. Despite this data, a needs assessment of Ohio's delivery hospitals found that only 30% of obstetric emergency simulations involve emergency department staff. ODH has partnered with the Clinical Skills Education and Assessment Center (CSEAC) at The Ohio State University’s (OSU) College of Medicine to develop and deliver simulation trainings for emergency medicine physicians, physician assistants, nurse practitioners, nurses, and first responders to recognize, triage, and treat obstetric emergencies. Training content includes but is not limited to the identification, treatment, and management of hemorrhage, hypertension, and cardiac conditions in pregnant and postpartum patients. The CSEAC has also developed Train-the-Trainer sessions offered to emergency medicine physicians and nurse educators throughout Ohio to teach them how to facilitate low-cost, low-fidelity obstetric emergency simulation scenarios at their home hospitals. Participants can win a MamaNatalie Birthing Simulator for their home hospitals to train their emergency department staff on obstetric emergencies. 

 

In FY22, CSEAC focused on the continued delivery of trainings as well as the evaluation and dissemination of data. During this time frame, CSEAC delivered a total of 6 training sessions for this project (5 direct training sessions and 1 train-the-trainer training session). Two of the direct trainings were provided to emergency medicine residents, two were provided to the Ohio Chapter of the Emergency Nurses Association (ENA), and the remaining trainings were open to all emergency medicine providers throughout the state. Across all 6 sessions, a total of 131 attendees participated in the trainings.  

 

Direct training outcomes among past participants to date include a significant increase in knowledge related to the identification, treatment, and management of postpartum hemorrhage, hypertensive emergencies, peripartum cardiomyopathy, and resuscitation on a pregnant patient. Evaluations also showed a significant increase in self-efficacy in managing/caring for obstetrical cases and in participants' confidence in their ability to perform life-saving clinical skills, including how to ​​​quantify blood loss, perform CPR on a pregnant patient, and use of intrauterine tamponade balloon. Additionally, participants reported that they highly intended to use what they learned in the training. As a result of the train-the-trainer session, evaluations showed a significant increase in the participants’ self-efficacy in developing, conducting, and evaluating simulations. When asked what they felt was most beneficial, participants highlighted the content, the small group simulations, and the opportunity to role play as a learner, facilitator, and debriefer during the training. Participants of the train the trainer session also reported that they highly intended to use what they learned in the training back at their job. 

 

Dissemination of this evaluation data became a large focus for OSU CSEAC throughout FY22. Thus far, 2 posters and 2 presentations related to this project have been accepted. Posters were accepted for the 2022 Emergency Nursing Association Conference and the 2022 Association of Maternal & Child Health Programs (AMCHP) Annual Conference. Presentations were accepted for the 2022 Society for Academic Emergency Medicine Conference and the 2022 Human Factors and Ergonomics in Health Care Society’s International Symposium. 

 

The COVID-19 pandemic continued to impact these trainings throughout FY22 with staffing shortages and capacity remaining an issue among emergency medicine providers. Additionally, training attendance attrition has become a reoccurring problem. However, OSU CSEAC has pivoted to address these problems by increasing registration numbers, continuing to offer all trainings in a virtual setting, and by adjusting marketing tactics. Despite pandemic restraints, interest in these trainings has remained high with multiple waitlists for almost every training. 

 

In FY23, CSEAC will continue delivering training sessions, collecting attendee evaluation responses, and analyzing aggregate data. Dissemination on a local, state, and national level will also continue to remain a focus of OSU CSEAC as their team begins to write manuscripts for possible journal submissions. Due to high interest and demand in this project, funds from OSU CSEAC’s telehealth training project have been shifted over to this project for FY23 and on. These additional funds will be used to increase training offerings, increase dissemination opportunities, and explore OSU CSEAC’s ability to target new audiences, such as first responders. 

 

The ODH PAMR program has identified disparities, poor access to care, and sub-optimal care coordination as key contributors to maternal mortality in Ohio. We also know that while more than 90% of Ohio women live within 50 miles of an obstetric critical care hospital, women living in areas of southeast, Appalachian, Ohio lack this access. Additionally, the COVID-19 pandemic has proven that telehealth is a needed service for all patient populations. This holds true especially when considering access to vital peripartum services for women in Ohio. Telehealth is a valuable strategy for addressing these issues. ODH has partnered with the Upper Midwest Telehealth Resource Center (UMTRC) and OSU CSEAC to develop free, interactive, virtual simulation training opportunities aimed at training maternal health care providers on how to conduct effective telehealth encounters. 

 

In FY22, OSU CSEAC and UMTRC delivered a total of 9 simulation-based telehealth trainings. Across these 9 trainings, there was a total of 253 attendees. Like FY21, the COVID-19 pandemic continued to be a tremendous stressor on OSU CSEAC and UMTRC’s telehealth trainings in FY22, especially throughout the beginning half of the year. Learning from the project’s accomplishments amid COVID-19 in the previous years, in FY22, the project team created and offered more tailored trainings for specific target audiences to garner increased training registration and attendance. All 9 trainings conducted in FY22 were tailored for Title X clinical providers and Title X administrative staff. Each training offered a different pathway for the two audiences. Administrative attendees were provided with live presentations focused on telehealth billing and administrative details, while clinical attendees participated in interactive, virtual telehealth simulation experiences. 

 

Outcomes among FY22 training participants include a significant increase in: 

• Self-efficacy scores related to confidence in conducting telehealth visits. 
• Perceived skills in conducting telehealth tasks such as figuring out why technology doesn’t work, protecting the privacy of patients, checking tech equipment, etc. 

 

Additionally, results suggest that trainees highly valued the training, intended to use what they learned in the training back at their job, learned and retained knowledge, and improved their confidence. Some have reported positive impacts on their jobs. 

 

As the pandemic begins to wane, telehealth has unfortunately become a less sought after learning topic among providers. Providers and health care staff have been saturated with a multitude of telehealth training opportunities and webinars over the past three years. As mentioned above, OSU CSEAC has tried to address this waning interest through trainings for tailored audiences. However, identifying new audiences still interested in learning about telehealth towards the end of FY22 became increasingly difficult, and, as a result, ODH decided to bring this project to a close at the end of FY22. Funds from this project have been shifted over to the Obstetric Simulation project.  Looking towards FY23, the final point of focus for this project will be to seek out opportunities to present and/or publish our work at local, state, and national levels. 

 

As stated in our FY21 application, the Ohio Gestational Diabetes Mellitus (GDM) Collaborative ended in FY22. The Ohio GDM Collaborative aimed to prevent, delay, or diagnose earlier, type 2 diabetes among women with a history of gestational diabetes mellitus by increasing the number of women who receive postpartum testing and education for T2DM, so health risks are addressed early and effectively. The Office of Health Improvement and Wellness and the Bureau of Health Promotion formed the Ohio Department of Health's (ODH) Ohio (GDM) Collaborative. Ohio Medicaid is an additional partner. The group was a unique collaboration between chronic disease and maternal child health with the overarching goal of preventing or delaying the onset of T2DM in women who have a history of GDM. 

 

At participating OB/GYN sites, several clinical interventions were measured to show the positive impact on health outcomes for women diagnosed with GDM. These interventions included identifying women at high risk for GDM and conducting early T2DM screening before their second prenatal visit, postpartum visit rates, and family planning education measured by LARC utilization. 

 

Primary care practice sites participated in project activities including providing education on the risk of developing T2DM, recommended re-screening time for T2DM, and health and Wellness. All education measures improved with special causes or variations caused by non-random circumstances. For women who had a prior pregnancy impacted by GDM or had two or more risk factors associated with increased T2DM risk, screening rates increased by 19.4% (from 61.9% to 81.3%) with the control chart showing special cause. 

 

The mother infant dyad program combined well child visits with postpartum Primary Health care visits resulting in greater postpartum visit attendance and diabetes screening. Women who participated in the program were, on average, more likely to complete postpartum visits and receive T2DM screenings than women who did not participate, and these differences were statistically significant. Medicaid claims data were used to identify outcomes for the comparison group. 

 

Home visiting sites throughout the state monitored women with GDM to provide education and resources to improve health outcomes. The preliminary results of a comparison between group participants and matched comparison group show that participants were more likely to complete a postpartum visit. The data obtained through this pilot program will be used to inform the expansion of the Ohio Comprehensive Home Visiting Integrated Data System (OCHIDS) to better track and provide education and resources to women with a history of GDM. The data collection forms were compared with OCHIDS and Medicaid claims to ensure data quality. 

 

Objective 3: By 2025, develop expanded maternal health surveillance to allow for adequate monitoring and tracking to inform programmatic interventions. 

Strategies: 

1. Expand data collections for COVID-19 for maternal population (SOARS, OPAS, ODRS linking to birth certificate). 

2. Enhance surveillance for maternal morbidity through PAMR program. 

3. Develop protocols for systematic data into action. 

4. Implement Women’s Behavioral Health Learning Collaborative within family medicine practices to improve postpartum visits.  

 

Both the Bureau of Child and Family Health as well as the Bureau of Maternal and Infant Vitality have a Data and Surveillance section to support data, evaluation, surveillance, and monitoring needs of programs within the bureaus. Data and Surveillance are composed of epidemiologists, researchers, and health policy analysts. The following programs sit within the Data and Surveillance section: 

 

Bureau of Child and Family Health: 

•       Child Fatality Review (CFR)  

•       Fetal Infant Mortality Review (FIMR)   
•       Ohio Medicaid Assessment Survey (OMAS) 
•       Shaken Baby Syndrome Education Program (SBS) 
•       Sudden Infant Death Syndrome (SIDS) Program  
•       Youth Risk Behavior Survey/Youth Tobacco Survey (YRBS/YTS) 

Bureau of Maternal and Infant Vitality 

•       Ohio Pregnancy Assessment Survey (OPAS)  
•       Ohio Study of Associated Risks of Stillbirth (SOARS)  
•       Ohio Fatherhood Survey (OFS) 
•       Pregnancy-Associated Mortality Review (PAMR)  

 

These programs serve as valuable data sources that inform programmatic work throughout the Bureau and Department as a whole. These data sources and the Title V Block Grant funded staff that work within Data and Surveillance are working to develop expanded maternal health surveillance to allow for adequate monitoring and tracking to inform programmatic interventions, including COVID-19 in Maternal Populations Surveillance, Maternal Morbidity Surveillance, Maternal Substance Use Disorder Surveillance and Developing Protocols for Systematic Data into Action. 

 

According to the CDC, people with COVID-19 during pregnancy are more likely to experience preterm birth (delivering the baby earlier than 37 weeks) and stillbirth and might be more likely to have other pregnancy complications compared to people without COVID-19 during pregnancy. In FY22, Data and Surveillance staff continued to leverage current related surveillance activities to expand data collections for the COVID-19 maternal population to collect additional data on how COVID-19 is impacting Ohio’s MCH population. They continued doing so by utilizing the amended 2021 Ohio Pregnancy Assessment Survey (OPAS) and the 2021 Ohio Study of Associated Risks of Stillbirth (SOARS) questionnaires that include supplemental questions related to COVID-19. By adding questions about the diagnosis and impact of COVID-19 on pregnant women, additional analyses will be conducted on the prevalence of pandemic-induced financial difficulty, healthcare access issues, social issues, anxiety, or depression, etc. among mothers who either recently delivered a live birth or experienced a stillbirth. 

 

Additionally, the Data and Surveillance section utilized the CDC pregnancy module for the COVID-19 case report form (CRF) which is comprised of a Pregnant Case Form and a Neonate Form. The module includes surveillance questions for the mother on the clinical course of disease, adverse fetal and birth outcomes of infants born to mothers with SARS-CoV-2 infection, and frequency and risk factors for neonates testing positive for SARS-CoV-2 infection. ODH utilized modified fields within the Ohio Disease Reporting System (ODRS) to capture information within the pregnancy module. 

 

Staff continued performing a monthly retrospective data linkage using the ODRS and Vital Statistics (VS) data, including birth and death certificates, Using the linked ODRS and VS data, epidemiology staff examined outcomes of pregnancies with confirmed SARS-CoV-2 infection. In addition to the ODRS data on infection, the birth and fetal death certificate data provide information such as birth weight, gestational age, abnormal conditions of the newborn, and characteristics of labor and delivery. Medical record abstraction is performed on a sample of pregnant cases from 2020.  This data was sent to CDC’s Surveillance of Emerging Threats to Mothers and Babies (SET-NET).  We will continue to perform medical record abstraction on a sample of 2021 pregnant women and share with CDC’s SET NET. 

 

Data and Surveillance staff used these enhanced data collection activities to assess health-related outcomes of mothers and infants among COVID-19 affected pregnancies. 

 

Severe maternal morbidities (SMM) are unexpected outcomes of labor and delivery that result in significant short- or long-term consequences to a woman’s health (Kilpatrick 2016). In FY22, ODH’s PAMR program staff successfully executed a Data Use Agreement (DUA) with the Ohio Hospital Association (OHA) to analyze Severe Maternal Morbidity (SMM) incidence in Ohio from 2020-2021 and perform enhanced surveillance of maternal morbidity. These data represent approximately 98% of hospital-based births in Ohio and exclude non-hospital births and births occurring in military facilities or other states. Births to out-of-state residents are also excluded from the SMM estimates. Over the next year, ODH PAMR staff will work to analyze and publish a report that summarizes severe maternal morbidity in Ohio from 2020-2021. The ODH PAMR program will develop a plan to share this data with key stakeholders throughout Ohio and encourage programming to target populations and drivers of SMM. Additionally, since OHA is the agency that collects maternal morbidity data from Ohio hospitals that is used for enhanced surveillance of maternal morbidity, ODH will continue to foster a collaborative relationship with OHA.  

 

ODH has numerous programs aimed at improving infant and maternal health outcomes. ODH leadership is working to encourage programs to use existing data sources to inform programmatic initiatives, establish protocols to make it easier for programs to access new data reports to inform programmatic initiatives, enhance staff understanding of using data to inform programming, and streamline data sharing and dissemination internally and externally. In FY21, a mall workgroup of individuals across various programs convened to being planning to develop protocols to use population and program data to inform programmatic activities. In FY22, the workgroup worked together to develop protocols that promote the use of equitable program and population data to inform program design, activities, administration, evaluation, data analysis, and dissemination to achieve equitable health outcomes among populations of interest. This included planning and delivering learning sessions across the department to increase staff awareness of existing data sources that can be used to inform program implementation. Over the next SFY, this workgroup will continue to develop and implement protocols to increase our capacity to put data into action. 

    

The Focus on ME (FOM), Mental Health is Essential Health Quality Improvement Project is funded by ODH and Ohio Department of Medicaid (ODM) and administered by the Ohio Colleges of Medicine Government Resource Center (GRC). The Project aims to 1) increase the percent of women of reproductive age screened for anxiety and depression, and 2) initiate a care plan for 80% of women who screen positive. The care plan is defined as a referral, medication, or both based on screener results of mild, moderate, or severe. The project worked with experts in women’s mental health and primary care and initiated project activities with 22 primary care sites. The project period is from 7/1/21-6/30/23. 

 

The Focus on ME, Mental Health is Essential Health Project started clinical activities with 22 participating sites on March 1, 2022. This statewide initiative serves as a pilot phase to determine challenges and best practices for implementing frequent anxiety and depression screeners for women of reproductive age and addressing their care within a primary care setting. The Focus on ME, Mental Health is Essential Health Project completed four major activities: 

•       Pre-Work Activities: Two pre-work webinars, held in January and February 2022, served as an introduction and onboarding activity.  
•       Action Period Calls: One-hour webinars provided sites with an opportunity to learn from subject matter experts on best practices related to the assessment, identification, treatment, and care for women with anxiety and/or depression. Each webinar included a relevant clinical topic, a quality improvement topic, and data review. 
•       Quality Improvement Activities: All participating sites were provided the opportunity to attend individualized coaching calls with a Quality Improvement coach. These calls included a discussion geared toward site-specific data and clinical and quality improvement resources that could be utilized to accelerate improvement. 
•       Data Collection for Implementing Change: Sites extracted data from electronic health records on a bi-weekly basis to support the quality improvement process and allow teams to use data in real-time to track performance and inform change in the PDSA process. Following extraction, the data was cleaned and formatted and entered onto a dashboard. The dashboard was available to sites for tracking their progress on the Project and examining specific aggregate measures. 

 

It was identified that sites had variable documentation practices for care plans. Care plan documentation has begun to improve with the implementation of project activities and will continue to improve throughout the project. Lessons learned in this phase of the project will help to inform the next steps for Phase 2, which will begin on April 1, 2023. 

 

Priority: Increase mental health support for women of reproductive age 

 

Measures 

The need to address mental health for women of reproductive age, pregnant, and postpartum is reflected in the selection of outcome and performance measures for both subsets of the population of women. 

•       NOM 24: Percent of women who experience postpartum depressive symptoms following recent live birth. 

•      According to the Ohio Pregnancy Assessment Survey, 15.8% of women with a recent live birth experienced postpartum depressive symptoms in 2020. This is relatively unchanged since 2016. 

•       SOM: Percent of women (18-44) with 14 or more mentally distressed days in past month (OMAS) 

•      According to the 2021 Ohio Medicaid Assessment Survey (OMAS), 12.6% of women of reproductive age experienced 14 or more mentally distressed days in the past month, an increase from 2019 (10.7%). 

•       SPM: Percent of women (18-44) with unmet mental health care or counseling services need in past year (OMAS) 

•      According to the 2021 OMAS, 14.7% of reproductive-aged women had unmet mental health or counseling needs. This is a decrease from 2019 (15.5%), but still higher than 2017 (9.7%). 
•      Note: The question from 2019 and prior was broken into two questions for clarity, but the data are still comparable. 

•       ESM: None developed at this time. 

 

The need to address mental health for women of reproductive age, pregnant and postpartum is reflected in the selection of outcome and performance measures for both subsets of the population of women. 

 

Objective 1: By 2022, develop plan to increase coordination, referral, and uptake of mental health services for women 18-44.  

Strategies: 

1. Develop plan in coordination with other state agencies to increase coordination, referral, and uptake of mental health services for women of reproductive age.  

2. Continue to build trauma informed care into interventions in community-based settings for mental health. 

3. Continue screenings for mental health/ substance abuse and provide referrals through Title X program. 

 

  

The OH-CAMH Strategic Plan consists of 11 draft strategies to improve maternal health outcomes in Ohio. Strategy 8 within the OH-CAMH Strategic Plan is focused on maternal mental and behavioral health in Ohio and is co-led by a BMIV staff member who is partially funded by the Title V Block Grant. In FY22, Strategy 8 worked as a team to finalize their strategy language and plan out first steps to implement the activities within their strategy. This strategy’s current objectives are to: 

1.   Work with Ohio stakeholders and those with lived experience to develop an effective and culturally sensitive maternal mental health screening protocol.  

2.   Work with Ohio stakeholders and those with lived experience to develop a training curriculum and rollout plan for maternal health providers.  

3.   Develop a work plan for increasing community-based maternal mental health programs to ensure access to specialized maternal mental health care and support. 

 

Throughout FY22, the Strategy 8 implementation team has been seeking collaboration with other projects working on maternal mental health as well. In FY23, Strategy 8 will become a part of the newly formed Ohio Perinatal Mental Health Task Force led by Mental Health America of Ohio through their Perinatal Outreach & Encouragement for Moms program. This task force seeks to increase communication, coordination, and collaboration efforts with the end goal of making Ohio one of the leading states in the country in perinatal mental health education, access to care, and treatment. 

  

The Sexual Assault and Domestic Violence Prevention Program (SADVPP) works to build trauma-informed care into interventions in community-based settings for mental health through a statewide integrated system of sexual violence prevention and intervention strategies that are relevant and culturally sensitive. The SADVPP supports efforts to respond to and prevent domestic violence and human trafficking and works to reduce and address adverse childhood experiences (ACEs) and trauma with a focus on the role of public health and healthcare systems. 

 

Being trauma responsive in the provision of health care is an important factor in both reducing ACES and mitigating the impact of ACES across the lifespan. The Health Policy Institute of Ohio has linked ACEs to poor health. Exposure to ACEs is a pervasive problem in Ohio, with nearly two-thirds of Ohioans having been exposed to ACEs. Ohioans of color and Ohioans with low incomes, disabilities, and/ or who are residents of urban and Appalachian counties are more likely to experience multiple ACEs. Preventing ACEs can improve health. For example, if exposure to ACEs were eliminated in Ohio, an estimated 36% of depression diagnoses could be prevented. Without a trauma approach, other efforts to reduce negative health outcomes are less effective.   

 

Health center staff are in a unique position to initiate conversations with their patients about healthy relationships and violence, offer universal education on the health impact of intimate partner violence (IPV), human trafficking (HT), and exploitation, and promote harm reduction strategies. Especially now during COVID-19 and increased isolation and experiences of abuse, health providers have a critical role to support their patients. Building local partnerships with domestic violence or community-based programs will help facilitate warm bi-directional referrals and promote the short- and long-term safety needs of patients for vulnerable populations. 

 

The work completed for this strategy supports the Public Health Services and System through workforce development, as well as supporting program planning and implementation of policies and procedures in health centers and advocacy organizations to ensure a trauma response to survivors and support meeting the health care needs of survivors.  In partnership with the Ohio Association of Community Health Centers and the Ohio Domestic Violence Network, and under the leadership of the national domestic violence technical assistance provider Futures Without Violence, the SADVP program provided trainings for community health centers and domestic violence and human trafficking advocates on trauma-informed care, intimate partner violence, and human trafficking. SADVPP staff members in positions partially funded through the MCH Block Grant were members of the leadership team for this project. All trainings were for three hours each, with a track for staff at community health centers and a track for domestic violence shelter staff or human trafficking advocacy staff.  A total of eight trainings were offered among the two cohorts of trainees. 

 

The first cohort of trainings was held in May and June of 2021 with 135 people trained.  The second cohort was held in July with 155 people trained. In addition to the trainings, in eight communities where representatives from both the community health centers and one or more victim service agencies participated in the training, a “debrief” meeting was held to facilitate discussion among the participants about working together going forward to meet victim needs.  

 

The development of the partnership among the state agencies was itself an important outcome of this project.  This project built and strengthened statewide connections which will support ongoing efforts in this area of need. Because the project was a component of a national initiative of Futures Without Violence, there was a nine-page evaluation provided for Ohio.  Summary from that evaluation including, provision of technical assistance for creation of models for Electronic Health Record integration of IPV and/or trafficking into health center workflow, state capacity created for routine related training, encouragement to all Community Health Centers to have a policy that every patient is seen alone for some part of the visit, participating sites implemented related policies and protocols, began offering related universal education to patients, increased related documentation of harm reduction strategies and referrals, provide sample wording or scripts about what to say when a patient discloses IPV or HT, including safety strategies, provide specific related support and referrals, and have memorandums of understanding with appropriate related local organizations. Sites have additionally addressed staff support and safety, including protocol for what to do if a staff person is experiencing IPV/HT/exploitation, responding to a perpetrator on-site, support for staff around related topics, provision of written information on site, and providing community or client education on related topics.  

 

As a result of relationships built through the Futures Without Violence Project, ODVN and OACHC have received additional funds through other sources and will be doing significant additional collaboration to better address healthcare needs of survivors of domestic violence in 2023.  

 

To continue to increase coordination, referral, and uptake of mental health services for women of reproductive age, SADVPP staff are leading an OH-CAMH strategy area to continue building relationships with organizations throughout the state of Ohio and synergize efforts. The work of this strategy team is ongoing, and more information will be available as the group continues to convene. OH-CAMH was previously referenced regarding strategy 8 which focuses on Maternal and Behavioral Health.  In 2022, the workgroup focused on this project finalized what is known as “OH-CAMH Strategy 7” with the work to:  
  

 Promote organizational shifts in culture that support a trauma responsive approach to clinical and public health services by:  

•       Addressing past experiences of trauma and current/ongoing trauma (racism and systemic oppression, pandemic) among providers of care and employees within select organizations serving pregnant people.  
•       Increasing the provision of appropriate health services to address client/patient experiences of trauma (including but not limited to domestic and intimate partner violence and human trafficking).  

  

In support of this strategy, the working group completed a project plan which will be implemented in 2023.  Steps to implement this plan will include:  

•       Create a resource document, already created, to house resources for this work including tools, training, organizational resources, protocols, and champions/consultants to support this work.  
•       Identifying and building our capacity as members of the workgroup to support partners.  
•       Reaching out to identify and engage with audiences ready to start this work.  

  

A final step for this component of the objective is internal work within ODH to address trauma informed care.  Within this reporting year, information about ACES, including several short virtual training options was shared in the agency wide newsletter, and a more in-depth training series on ACES and trauma was made available to ODH employees to review and share with their partners.  Discussion is scheduled for future related work for ODH employees.  

  

The RHWP continued screenings for mental health and substance abuse and provide referrals through the Title X program in FY22 and will continue working toward this strategy in FY23. According to Substance Abuse and Mental Health Services Administration, only 47% of adults with mental illness in Ohio receive any form of treatment from either the public system or private providers. The remaining 53% receive no mental health treatment. According to America’s Health Rankings, 22% of Adults in Ohio suffer from depression and 15.3% suffer from frequent mental distress.  In addition, there are 37.1 drug related deaths per 100,000, making Ohio the 47th worst state. Self-reported pre-pregnancy, gestational, and postpartum depression in Ohio have increased annually since 2016 (OPAS, 2016-2020) and pregnancy-related deaths related to mental health conditions and substance use disorder are prevalent (PAMR, 2019). Thus, increasing coordination, referral, and uptake of mental health services for women aged 18-44 and increasing mental health support for women of reproductive age is specifically important in the Ohio context.   

  

The RHWP continues to implement best practices regarding screening for mental health and/or addiction issues (e.g., Edinburgh Screening tool, Alcohol Screening Brief Intervention). Every client has a Reproductive Life Plan (RLP) and is screened for mental health needs. If necessary, clients are referred for appropriate care. A process and outcomes tracking system has been developed to document and ensure monitoring and oversight of screening and referrals to providers. Over FY22, Title X clinics increased care coordination and quality assurance of linkages of women to care by developing a network of providers that will accept referrals for un/underinsured clients and tracking those referrals.   

  

All RHWP clients are screened for mental well-being and substance use disorder. In terms of unduplicated female mental health counseling and referrals, Ohio Title X clinics reported a 3.5% increase in self-report of mental health risk factors SFY21 to SFY22 (1,824 vs 2,882) and a 0.4% referral decrease from SFY21 to SFY22 (729 vs 621) of those same clients. Ohio Title X clinics reported an 0.8% increase in positive self-report of substance use risk factors (1,843 vs 2,097) and an 8% decrease in referrals (321 vs 196) from SFY21 to SFY22. The data the RHWP collects is unable to determine if a positive self-report warrants a mental health or substance use referral. The number of RLP discussions increased by 5% (26,497 vs 29,097). While health relationship counseling is not equivalent to mental health screening or referral, relationships may cause stress in a woman’s life.  Ohio Title X clinics reported a 9% increase in relationship counseling at visits from SFY21 to SFY22 (16,501 vs 21,075).  

  

The RHWP has a deliverable within the grant application that provides additional funding to Title X clinics that wish to provide enhancements to services to special populations, including individuals with substance use disorder. From October 1, 2020, through September 30, 2021, there were 184 female visits provided to women with substance use disorder through this deliverable. In SFY22, the number of reproductive health visits to the substance use disorder special population increased to 651. Over 13% off these visits occurred at a treatment center and the remaining visits were at a Title X clinic (87 offsite, 564 onsite). These efforts will continue throughout FY23. Please see Priority 1, Objective 1 of this section of the report for more information about the RHWP.   

  

Objective 2: Increase access, referral, and coordination of mental health services for pregnant and postpartum women 18-44.  

Strategies: 

1. Implement culturally relevant peer support behavioral health services for high risk pregnant and postpartum women through MP subgrant. 

2. Implement programs and strategies to decrease alcohol use during pregnancy. 

3. Continue Practice and Policy Academy participation to inform implementations of plans of safe care. 

4. Increase women’s postpartum depression/anxiety screening during pediatric well visits. 

5. Implement Women’s Behavioral Health Support Learning Collaborative as a new strategy. 

6.   Implement the Women’s Behavioral Health Support Learning Collaborative,” as a new strategy ODH will utilize to, “Increase access, referral, and coordination of mental health services for pregnant and postpartum women 18-44. 

    

The Maternal and Child Health Program (MP Program) funds three main strategies focused on 1) Preconception and Inter-conception Care for Women’s Health, 2) Peer Support Person-Centered Wellness, and 3) Adolescent Health Evidence-Based Resiliency. The second strategy focused on Peer Support Person-Centered Wellness provides support for assessing, planning, and implementing peer support systems and screening tools (behavioral and/or physical health) available within a designated target area or region that support pregnant and/or post-partum women within one year of pregnancy. The goals of this strategy are to reduce maternal morbidity and mortality by increasing access, referral, and coordination of mental health services for pregnant and postpartum women 18-44 and increase the capacity of local public health systems to support partnerships that address social determinants impacting mental health services. 

  

Self-reported pre-pregnancy, gestational, and postpartum depression in Ohio have increased annually since 2016 (OPAS, 2016-2020) and pregnancy-related deaths related to mental health conditions and substance use disorder are prevalent (PAMR, 2019).  Additionally, data from the Ohio Pregnancy Assessment Survey (OPAS) has shown that self-reported social support during pregnancy among women with a live birth has decreased annually since 2016 (OPAS, 2016-2020). Additionally, pregnancy-related deaths associated with mental health conditions and substance use disorders are prevalent (PAMR, 2019). To decrease risk factors for maternal morbidity in Ohio, it is important to increase access, referral, and coordination of mental health services for pregnant and postpartum women Thus, the MP Peer Support Person-Centered Wellness strategy is using Title V Block Grant funds to support Public Health Services and System infrastructure to increase access and uptake of mental health services on a local level.  

In FY21, six subgrantees across 6 different counties in Ohio developed comprehensive plans to implement culturally relevant peer support behavioral health services for pregnant and postpartum women. In FY22, 3,212 women (pregnant or within 1 year postpartum) were screened for substance abuse and/or mental health. Of those screened, 2,362 women were referred for peer support services, of which 1,891 women attended at least one peer support session. Peer support sessions were offered in individual and group settings, both virtually and in person.  Planning is underway for FY23 to continue and expand the availability of peer support to address mental health and addiction issues among women (pregnant of within 1 year postpartum). There will continue to be a focus on:  

•                   Increasing the number of peer support personnel working with pregnant and postpartum women to improve their mental wellness.  

•                   Increasing the number of screenings for behavioral health to pregnant and postpartum women.  
•                   Increasing the number of referrals for pregnant and postpartum women to behavioral health services.  
•                   Increasing the behavioral health knowledge of personnel who work with pregnant and postpartum women by attending educational and training events. 

These interventions are to be implemented and evaluated through FY23.  

 

Fetal Alcohol Spectrum Disorder (FASD) is a term that describes a range of birth outcomes and potentially lifelong effects that could result if a mother drank alcohol during her pregnancy. The effects include physical, mental, behavioral, and/or learning disabilities. Per the CDC, up to 16 out of 1,000 children are estimated to be affected by FASD. FASD Steering Committee efforts are led by the Ohio Department of Mental Health and Addiction Services and the Ohio Department of Health. The FASD Steering Committee updates a strategic plan yearly, conducts trainings on FASD prevention, screening, and treatment, and holds an annual forum with the goal of decreasing alcohol use during pregnancy.  

 

The Sixth Annual FASD Forum took place on September 9, 2022. The agenda included a welcome and keynote address, with Dr. Robin Gurwitch, Ph.D., Clinical Psychologist, Professor in the Department of Psychiatry and Behavioral Sciences at Duke University Medical Center; Multiethnic Advocates for Cultural Competence presentation, luncheon, and eight breakout session workshops. Registration was 305, with 192 in attendance, 76 in-person, and 116 virtual audiences. The evaluation ranking for all sessions was 4.68, with the highest overall ranking of 4.8, for the Caring for the Superheroes workshop. Continuing education units were offered for counselors, social workers, CDP, DODD, and OPA through OhioMHAS; as well as certification for ECMH, and IECMH through OCCRRA. The Forum also hosted the annual FASD Hope Taft awards for a professional and a community member whose impact and work for awareness and prevention of FASD has made a significant impact on individuals and families with FASD.  

 

The 2022-2027 Ohio FASD steering committee strategic plan is currently being implemented. Feedback was solicited from community members and other stakeholders on the draft strategic plan, and it includes older adult education as they care for kin and integrates trauma-informed and health equity strategies.  

 

The Genetics Services Program at ODH funds a network of genetic centers in Ohio to provide educational events on a range of genetics topics to different types of audiences. A total of 75 events on FASD were conducted during the period 10/01/2021 – 09/30/2022. The audience included mainly middle and high school students. 

 

Starting in March 2022 Home Visiting participated in the planning and preparation of Wave 3 of the Ohio Maternal Safety – Urgent Maternal Warning Signs (UMWS) Quality Improvement Project, a collaboration between ODH Pregnancy-Associated Mortality Review and the OSU Wexner Medical Center, College of Social Work, and the Ohio Colleges of Medicine Government Resource Center (GRC). Wave 3 of this project is designed to increase home visitors’ knowledge of UMWS and their comfort level in sharing this information with pregnant home visiting participants. The goal is to see increased rates of UMWS information shared by home visitors during prenatal home visits. In June 2022 registration began and the GRC and ODH presented the voluntary project to home visiting providers during the monthly home visiting community of practice.  

 

The project kicked off in September 2022 and continues through September 2023. There are 23 participating home visiting providers (agencies) serving 41 counties, and 187 individual participants in this quality improvement project. 

 

To increase referral and coordination of mental health services for pregnant and postpartum women 18-44, access to services and screening must first be established. Among women with Medicaid, 26% and 36% reported pre-pregnancy depression and anxiety, respectively. Only about 70% of Ohio women reported attending a health care visit in the 12 months prior to their pregnancy but mothers regularly attend their child’s health care visits and are highly receptive to health advice at well-child visits. Through focusing on interconception health through screenings and interventions for birth mothers during well child visits 0-18 months, the Healthy Mom, Healthy Family QIP aims to address increase women’s postpartum depression/anxiety screening during pediatric well visits.  

 

Throughout FY22, site engagement was low with several sites not submitting regular monthly data and/or participating in the monthly AP calls for Wave 1. Wave 2 saw improved engagement among participating sites, with a few still struggling with data submission and AP call attendance. Sites were contacted individually to discuss absences, engagement, and receive educational recordings. A monthly newsletter highlighting data, reminders to submit data, and to promote engagement was sent to sites. 

 

Recruitment for Wave 3 will continue over SFY 23 to increase the reach of women’s postpartum depression/anxiety screening during pediatric well visits. Please see Priority 1, Objective 2 of this section of the report for more information about the Healthy Mom, Healthy Family project. 

 

Priority: Decrease risk factors associated with preterm birth 

 

Measures 

Ohio continues to have high rates of infant mortality, with prematurity as the leading cause of infant death in Ohio. The risk factors associated with preterm birth include and extend beyond interventions for pregnant women. The selection of the SPM for smoking among reproductive age women aligns with the need to address smoking before women become pregnant to complement the existing efforts to identify and support pregnant women in quitting during pregnancy. Home visiting services targeted at high-risk pregnant women can improve birth outcomes and the ESM measures efforts contributing to addressing the priority. 

•       NOM 5: Percent of preterm births (<37 weeks) 

•      According to the Ohio Bureau of Vital Statistics resident birth files, 10.3% of births occurred prior to 37 weeks gestation in 2020. This is unchanged from years past. Black infants were more likely to be born preterm (14.2%) compared to white infants (9.4%).  

•       SPM: Percent of women (18-44) smoking in reproductive age 

•      According to the 2020 Behavioral Risk Factor Surveillance System, 21.9% of reproductive-aged women currently smoke. While down slightly from 24.7% in 2016, this prevalence has remained stable since 2018 (hovering around 22%). 

•       ESM: Percent increase in enrollment of high-risk populations in evidence-based home visiting programs 

 

The risk factors associated with preterm birth include and extend beyond interventions for pregnant women. The selection of the SPM for smoking among reproductive age women aligns with the need to address smoking before women become pregnant to complement the existing efforts to identify and support pregnant women in quitting during pregnancy. Home visiting services targeted at high-risk pregnant women can improve birth outcomes and the ESM will measure efforts contributing to addressing the priority. 

 

Objective 1: By 2025, reduce the proportion of women of reproductive age smoking by 15%.  

Strategies: 

1. Develop plan to re-engage partnerships and identify strategies for addressing smoking use among women of reproductive age (including 5 A’s strategies and provider training through RHWP, WIC, HV, TUPCP). 

2. Improve cross-referrals among programs addressing tobacco use (e.g., Quit Line refer to Baby and Me Tobacco Free). 

3. Identify and leverage cross promotional/marketing opportunities (media, partner, collaborations. 

4. Continue to provide supports for pregnant women to quit smoking through Moms Quit for Two program. 

 

In FY22, the Tobacco Use Prevention and Cessation Program and BCFH initiated a bi-monthly meeting series to re-engage this partnership and identify strategies for addressing nicotine use in women of reproductive age. The following programs worked together: Asthma Program, Home Visiting Program, Oral Health, Mom’s Quit for Two, RHWP, FASD, MP, Tobacco, WIC, and Safe Sleep/Cribs for Kids. 

 

The RHWP began collecting data regarding the tobacco status of all clients. For unduplicated women clients, 21% reported being a current every day smoker, 4.7% indicated being a current someday smoker, 8.5% stated being a former smoker, and 56% reported never smoking. The RHWP does not currently collect data regarding tobacco cessation counseling, but Title X clinics provide it as part of preconception and prenatal health education.   

 

The Perinatal Smoking Cessation Program aims to reduce smoking among Ohio women before, during, and after pregnancy and to reduce exposure to second-hand smoke by increasing the adoption, reach, and impact of evidence-based behavioral cessation programs. According to the American College of Obstetricians and Gynecologists, pregnant women should be advised of the significant perinatal risks associated with tobacco use, preterm pre labor rupture of membranes, low birth weight, increased perinatal mortality, ectopic pregnancy, and decreased maternal thyroid function. Women who quit before or during pregnancy can reduce or eliminate these risks. According to the America’s Health Ranking of 2020, 13.2% of mothers reported smoking while pregnant. Data collected from the Ohio Pregnancy Assessment Survey, focusing on 2016-2019 indicated that 20% of pregnant women smoked cigarettes at least three months before becoming pregnant. Further, the survey produced results that at least 10% of women were smoking within the last three months of pregnancy. The Perinatal Smoking Cessation Program seeks to serve high-risk women, and the children that live with them, in counties with the highest incidence of infant mortality and/or prenatal smoking rates to reduce the proportion of women of reproductive age smoking in Ohio. 

 

The Perinatal Smoking Cessation Program funds the implementation of the evidence-based model Baby & Me Tobacco Free through the Moms Quit for Two subgrant program. The subgrant currently funds 24 entities throughout Ohio to provide in-person and telehealth support and resources for pregnant women to quit smoking. In addition to funding traditional sites through the 24 entities, the program expanded through telehealth to make the Perinatal Smoking Cessation program available in all of Ohio’s 88 counties. The Moms Quit for Two program recruits program participants through cross-referrals among programs, such as WIC and Home Visiting, as well as through OBGYN offices, local shelters, birthing centers, community centers, fairs/festivals, local probation offices, and billboards. 

 

In FY22, the Moms Quit for Two program had a total of 687 referrals to the program with 575 clients enrolled. Of that, 87% of babies born to program participants were not lower than the goal birth weight of 5.5 pounds. Eighty-seven percent (87%) of the babies were born at the term of 37 weeks and 80% were at the combination of the goal weight and term of delivery. Though the COVID-19 pandemic continued to impact recruitment retention rates for all 24 agencies, grantees utilized a range of methods to reach their clients, such as using social media, including Facebook and Twitter, phone calls, and e-mails. Additionally, outreach, which included personal visits, was conducted to potential partners, such as OBGYNs and various clinics, to increase awareness and referrals.  

  

This grant program will continue throughout SFY23. Grantees and program staff will receive additional training on the Baby & Me, Tobacco Free curriculum in FY23. ODH Perinatal Smoking Cessation will continue to partner with programs such as Tobacco Use and Cessation, infant safe sleep, Ohio Equity Initiative, and WIC to improve cross-program referrals.  

   

Ohioans of all ages are eligible for free tobacco cessation services through the Ohio Tobacco Quit Line. After several years of limited eligibility, Ohio made changes to eligibility in July 2019 that open participation for all Ohioans regardless of insurance status or income. Eight weeks of nicotine replacement therapy (NRT) is available; one two-week dose is shipped after each call (up to four times). Participants have their choice of patches, gum, or lozenges (NRT is not provided to participants under 18). Consumers of any tobacco or nicotine products may enroll. The Tobacco Use Prevention and Cessation Program (TUPCP) has been engaged in the fight to address the causal association of maternal smoking to infant mortality for many years. A specialized Pregnancy Protocol through the Ohio Tobacco Quit Line is promoted throughout the state. The program is offered by coaches trained to work with pregnant women through the postpartum period. TUPCP is funded through a CDC grant and also works with other partners addressing maternal smoking, such as the Baby and Me Tobacco Free Program. Program grantees are required to work with health care providers to ensure pregnant women are being screened and referred to available services. Mass media campaigns are also part of regular program activities.   

 

Objective 2: By 2025, increase enrollment of high-risk populations in evidence-based home visiting programs by 10% each year.  

Strategies: 

1. Implement home visiting services for at risk pregnant and post-partum women. 

 

The Ohio Department of Health supports the implementation of four home visiting models: Healthy Families America (HFA), Moms & Babies First (MBF), Nurse Family Partnership (NFP), and Parents as Teachers (PAT).  All models serve at-risk pregnant and post-partum women. In FY22 ODH Home Visiting exceeded the goal of enrolling 10% more families in FY22 than in FY21. 

 

ODH continues to work with home visiting providers to expand services to meet the needs of families in their communities, focusing attention on where there are waitlists and/or many unserved, eligible women/infants. The following initiatives have resulted in further expansion of home visiting services for at risk pregnant and post-partum women in FY 22: 

• Revision of the OAC Home Visiting rule expanded eligibility and allowed more women and families to be served. Rules became effective 1.31.22 and allowed additional families to qualify for home visiting services. Home visiting rule now aligns eligibility policies with the home visiting models, allowing families to enroll later in Healthy Families America (HFA) Child Welfare Protocol and Parents as Teachers (PAT), and remain in services longer in HFA and PAT programs. 
• Ohio Department of Health continues to work with the Ohio Department of Job and Family Services to strengthen and streamline the referral process from Child Protective Services to Home Visiting, allowing more high-risk families to be referred. In December 2021, ODH began a Continuous Quality Improvement (CQI) project with five local Public Children Services agencies (PCSAs) to improve the success of referrals for home visiting services. The results have been mixed and successful referrals from local PCSAs continue to be challenging. 
• Nurse Family Partnership (NFP) expanded eligibility in some programs to allow multiparous (more than one pregnancy) women and women beyond the 28th week of pregnancy to enroll (traditional NFP enrolls first time pregnant women up through the 28th week). In June 2022, NFP was implemented in 24 counties, 13 with traditional eligibility, and 11 with expanded eligibility. 
• PAT continues to expand in Ohio to meet the need for increased home visiting capacity. In Ohio PAT families/children can enroll up to age 2. 
  In June 2022, PAT was implemented in 19 counties. In 3 of those counties, more than one model was implemented, providing more eligibility options for families and programs. 
• In FY22 the eligibility criteria for Moms & Babies First expanded to include pregnant Black women of all incomes in the communities with high infant and maternal mortality rates. MBF programs also came under the Home Visiting rule and fee for service reimbursement rates for home visits completed. MBF is now able to set and expand its capacity. 

 

Please see Objective 4 of the Infant section of the report for more information about the Home Visiting Program and how it has worked to improve access to home visiting services for at-risk pregnant and postpartum women throughout Ohio.