Massachusetts has four priorities for Women’s and Maternal Health for 2015-2020.

1. Promote equitable access to preventive health care including sexual and reproductive health services.
2. Promote equitable access to dental care and preventive measures for pregnant women and children.
3. Address substance use among women of reproductive age to improve individual and family functioning.
4. Promote emotional wellness and social connectedness across the lifespan.

 

Priority: Promote equitable access to preventive health care including sexual and reproductive health services.

Progress towards this priority is measured by the percent of women with a past year preventive visit. Key MDPH programs that contribute to improving this measure include Sexual and Reproductive Health Program, Early Intervention Parenting Partnerships Program, Massachusetts Maternal, Infant and Early Childhood Home Visiting, Welcome Family, and FOR Families. Additional activities to promote equitable access to preventive health care are discussed below.

 

NPM 1: Percent of women with a past year preventive visit

According to the most recent Behavioral Risk Factor Surveillance System survey (BRFSS), in 2017, 70.7% of women had a preventive visit in the past year, a statistically non-significant decline from the prior year’s measure of 76.8%. This has prompted MDPH to reevaluate its projections; the objective is now to reach 77.5% in 2020 (instead of 78.1%).

 

Through Title X (federal family planning funding) family planning clinics and MDPH’s Sexual and Reproductive Health Program (SRHP), Massachusetts promotes the 2014 Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs (QFP). These recommendations expand family planning to include preconception and other preventive health services, including screening for obesity, smoking, diabetes, violence, mental health, and reproductive life planning, including screening for and treating sexually transmitted infections (STIs). Additional preventive health services include breast and cervical cancer screening, immunizations, and other services based on nationally recognized standards of care. Women entering Title X clinics or other family planning service centers seeking contraceptive services often do not have another source of primary health care. Family planning services visits are opportunities for clinicians to offer broad preventive health services beneficial to overall health as well as to reproductive health.

 

Implementing broad preventive health services in family planning visits is an evidence-based strategy supported by CDC findings.[1] The ESM for this NPM has been the percent of visits at a Title X clinic, by women younger than 25 years old, when screened for chlamydia. Chlamydia screening is a component of CDC’s QFP because untreated chlamydia contributes to tubal infertility. In 2018, MDPH added new providers to its Title X network, some entirely new to the Title X program. The FY18 percent of women under age 25 screened for chlamydia is a new baseline, and an opportunity to reach more women with appropriate screening. In FY18, 62% of clients were tested; the objective is to reach 65% by 2021.

 

Sexual and Reproductive Health Program

Through the SRHP, providers offer comprehensive family planning services to decrease unintended pregnancy and STIs. Vendors operate in communities with higher rates of teen births and STIs and with low-income, uninsured, adolescent, refugee and immigrant populations. Vendors must provide clinical family planning services on site or by referral, and may provide education on family planning, outreach to promote family planning services, and/or supportive services to assist priority populations to access clinical family planning services.

 

SRHP funds 10 agencies statewide to provide clinical family planning services at over 90 sites. Clients eligible for these services include:

1. Uninsured residents living at or below 300% Federal Poverty Level (FPL).
2. Clients with MassHealth Limited (no other MassHealth plan).
3. Insured clients whose insurance does not cover contraceptives at the time of service, and also meet residency and income criteria. This includes plans that never cover contraceptives as well as plans with annual spending caps on prescriptions and/or medical devices (e.g., IUD). For this group, MDPH serves as secondary coverage to cover the cost of the contraceptives only.
4. Insured clients with a need for confidential family planning care and cannot be assured that using their insurance will not violate their confidentiality, and also meet residency criteria. Clients who may require confidential care include clients under 26 years of age who are covered under a parent/guardian plan and survivors of domestic violence (DV). Clients with insurance products that assure confidentiality are expected to utilize those products regardless of need for confidential care.

 

Agencies bill MDPH for clinical services for eligible clients by using Medicaid billing codes; six of these codes are for preventive health visits. This billing information provides data for the Title V Block Grant. Of all preventive health visits MDPH funded in family planning services in FY18, 94.5% were made by females. MDPH has refined this measurement since last reporting, when the denominator included all visits, regardless of reason, at Title X clinics. Using our refined measure, which includes in the denominator all preventive health visits (n=2,139), 95.5% (n=2,042) of preventive health visits were by females in FY17.

 

Early Intervention Parenting Partnerships Program

The Early Intervention Parenting Partnerships (EIPP) Program is a home visiting program for expectant parents and families with infants who experience barriers such as low financial resources, or housing instability, emotional and/or behavioral health challenges such as depression, substance use, or other stressors such as immigration-related stress. EIPP provides home visiting and group services to over 300 families annually in Lowell, Springfield, Fall River, and Cambridge/ Somerville by a team that includes an MCH nurse, a mental health clinical professional, and a community health worker. EIPP has demonstrated capacity for early identification of maternal and infant risk factors and linkages to services to prevent or mitigate poor health and/or developmental outcomes. EIPP provides maternal and infant health assessment and monitoring, health education and guidance, screening and appropriate referrals and linkage with WIC and other resources. Through strategies to foster continuity of care, EIPP addresses the complex physical, emotional, and environmental health needs of pregnant and postpartum women.

 

EIPP supported participants to attend preventive care visits by helping the participant contact the health care provider to schedule visits, arranging for transportation for the participant, and providing reminder phone calls and texts. In FY18, 21 participants were referred to a primary care provider.

 

Among the 321 pregnant and postpartum participants enrolled in EIPP in FY18, 61.7% self-identified as White, 37.1% Hispanic/Latino/Spanish, 19.0% Black and 13.7% Asian. Successful EIPP programs ensure their MCH team members reflect the cultural, linguistic, racial, and ethnic diversity of the population served. Annual cultural competence training and pay differentials for bilingual staff have been successfully implemented in several EIPP sites. However, staff turnover, particularly within the community health worker position, has been a challenge for those sites where the annual salary is low and a pay differential for bilingual staff is not offered.

 

Maternal, Infant, and Early Childhood Home Visiting Initiative

The Massachusetts Maternal, Infant, and Early Childhood Home Visiting Initiative (MA MIECHV), funded by HRSA/MCHB, provides evidence-based home visiting services to help pregnant and parenting families attain and sustain optimal health and well-being for all family members. MA MIECHV prioritizes services to families who qualify as high need according to statute and the state MA MIECHV Needs Assessment. The MA MIECHV 2016 Needs Assessment confirmed that families experiencing homelessness, with parental substance use disorders, who recently immigrated to the United States, and who are affected by mental health stresses and social isolation have substantial challenges and could benefit from home visiting. MA MIECHV serves pregnant and parenting families in 17 communities. Through regular, planned, voluntary home visits, parents learn how to improve their family’s health and provide better opportunities for their children.

 

MA MIECHV home visitors support preventive health and prenatal practices for women by facilitating connections with the health care system, including connecting families to preventive care services when needed. Home visitors also discuss family reproductive life plans with participants and facilitate access to reproductive health services as needed. During federal FY18, MA MIECHV served 2,114 families and conducted 26,111 home visits.

 

Welcome Family

Welcome Family is a universal short-term postpartum nurse home visiting program funded by MA MIECHV. It offers a one-time nurse home visit and follow-up phone call to all mothers and caregivers with newborns in Boston, Fall River, Lowell, Holyoke and Springfield. The goal of Welcome Family is to promote optimal maternal and infant physical and mental well-being and provide an entry point into a system of care for families with newborns. The visit is conducted up to eight weeks postpartum. Nurses identify and respond to family needs by providing brief intervention, education, support, and referrals to community services and resources.

 

Universal home visiting programs, like Welcome Family, serve all families regardless of risk, income, age or other criteria. They can reach a broader range of families than programs with traditional risk-based eligibility, thereby identifying needs that might otherwise go undetected. Universal programs can reduce stigma associated with participation in eligibility-based programs, allowing home visitors to triage families with varying levels of need and connect them to services.

 

During the Welcome Family visit, nurses screen participants for access to health care providers, assess barriers, and facilitate connection to providers. In FY18, 87% of Welcome Family participants (n=1,946) had a health care provider after giving birth, consistent with the 88% reported in FY17. A majority (85%) of women with a health care provider reported that it was “easy” to access health care services. Among those who reported difficulty in accessing services, transportation (70%) was the main barrier.

 

FOR Families

FOR Families (Follow-up, Outreach and Referral) is a home visiting program managed jointly by MDPH and the Department of Housing and Community Development that helps families transition from homelessness to stable permanent housing. Services are provided to families who are temporarily housed in shelters in the Western, Northeast and Boston regions of the state. FOR Families home visitors, human service professionals with extensive public health, community health and child welfare experience, work intensively with families experiencing complex challenges. Home visitors assess family needs, make appropriate referrals, and coordinate services with primary health care, WIC, Early Intervention (EI), DV and substance use treatment. FOR Families collaborates with Housing Assistance Programs, the Department of Children and Families (DCF), the Department of Transitional Assistance, and the Department of Mental Health (DMH) to coordinate care. Home visitors identify local volunteer groups and faith-based organizations to provide families with transportation, activities for children, meal programs, and other necessities.

 

Total Massachusetts Emergency Assistance (EA) shelter/hotel entries during FY18 were two percent fewer than in FY17. During FY18 families at risk of homelessness were provided a benefit of up to $4,000 to assist securing housing. FY18 ended with a total EA caseload of 3,581 families with only one percent of these families placed in overflow hotels/motels.

 

FOR Families assessed 206 families in FY18 and 11% reported a pregnant woman in their household, up from 6% in FY17. Families were asked about the frequency of visits with their primary care doctor; in FY18, 35% reported annually, 19% more than three times per year, 21% one to three times per year, and 3% reported never. Families were assessed for contraceptive use; 44% reported not using a form of contraception, 27% use a form always and 2% use it sometimes. This information guides conversations about and referrals to reproductive health services.

 

FOR Families’ funding decreased in FY18, resulting in the loss of one home visitor position.

 

Additional activities to promote equitable access to preventive health care including sexual and reproductive health services

Sexual and Reproductive Health Program

In FY18, MDPH completed its third full year as a Title X grantee with three sub-recipients in four counties in western Massachusetts. SRHP provided technical assistance to the sites and increased Title X users. MDPH provided consultation to providers that focused on program and fiscal sustainability and completed four comprehensive program reviews of contracted agencies. MDPH is on target to complete program reviews of all contracted agencies within a three-year cycle. State and Federal funding increased slightly in FY18.

 

MDPH also offered education and training sessions on topics in family planning to community-based agency staff including Issues in Perinatal Opioid Misuse, Substance Abuse Services: Programs, Eligibility, and Enrollment, and Mapping Racial Equity.

 

During FY18, there were several state-wide initiatives to improve family planning service delivery. Starting in the summer of 2017, MDPH convened a series of meetings with all five Title X grantees in Massachusetts to explore where economies of scale and reduction of duplicated efforts could be achieved.

 

SRHP clients using long acting reversible contraception (LARC) increased 15.3% in FY18. In FY18, Massachusetts concluded its participation in the Association of State and Territorial Health Officials (ASTHO) LARC Learning Community as the Learning Community ended. The goal was to improve access to LARC, especially postpartum LARC insertion in hospitals prior to discharge, reducing the risk of rapid repeat pregnancies. In FY18, SRHP continued to work with MDPH staff, MassHealth staff, and practicing OB/GYNs to influence MassHealth to explore alternative reimbursement options that would fully reimburse hospitals for immediate postpartum LARC insertion. Challenges to increased LARC provision remain, including upfront stocking costs and reimbursement challenges for providers, lack of patient awareness of availability and effectiveness, and provider training and acceptance of LARC use with adolescents.

 

SRHP funds a highly successful Access Program to reduce barriers to care by providing pregnancy options counseling and case management services to women who are at least 18 weeks, six days pregnant by ultrasound, or are experiencing serious/complex medical or social issues that make it difficult to be seen in a clinic. In FY18, the Access Program provided case management services to 343 women, representing a 1% increase over FY17. The program expanded to include insurance enrollment services and served an additional 95 pregnant women.

 

Early Intervention Parenting Partnerships Program

In FY18, 84.1% of EIPP participants had a documented reproductive life plan that included family planning counseling and an identified method of contraception at two months postpartum. This percentage surpasses the EIPP performance measure goal of 80% and represents an increase from 74.2% in FY17. Twenty-seven participants were also referred to family planning services. Supporting EIPP participants in accessing LARC is a priority. Training and strengthening community linkages to local family planning clinics are two strategies that support this effort.

 

Challenges identified by EIPP providers include multiple and complex needs experienced by participants, such as mental health issues, opioid use and violence in the home, which take precedence in women’s lives over accessing health care services. For example, in FY18 participants identified the following needs, which established their eligibility at enrollment: 53.3% had a history of depression, including postpartum depression; 61.1% had inadequate food or clothing; 39.6% were homeless or experiencing housing instability; 11.5% reported tobacco use; 6.5% reported substance abuse in the home; and 2.5% reported violence in the home.

 

MA MIECHV

MA MIECHV requires home visitors to receive training on preconception and interconception care education, including how to support families with developing a reproductive life plan. Home visitors discuss family planning with participants and make referrals to family planning or primary care when appropriate.

 

Priority: Promote equitable access to dental care and preventive measures for pregnant women and children.

Progress towards the oral health priority is measured by a) the percent of women who had a dental cleaning during pregnancy and b) the percent of infants and children, ages 1 through 17, who had a preventive dental visit in the last year. The latter measure is discussed in the Child Health domain.

 

NPM 13A: Percent of women who had a dental visit during pregnancy

In 2016, PRAMS began using the phase 8 survey which asks similar, but not identical, questions on dental visits during the 12 months before and during pregnancy than those asked during previous years. During 2017, 54.1% of mothers had a dental cleaning in the year prior to pregnancy compared with 52.4% in 2016, and 56.2% of mothers had a cleaning during pregnancy, compared with 54.9% in 2016. The percentage of mothers receiving oral health care during pregnancy increased modestly among Asian mothers, from 46.0% to 46.9%, and among Black mothers, from 41.0% to 49.1%. Hispanic and White mothers both showed slight declines from 52.1% and 62.1% to 49.0% and 61.5% respectively between 2016 and 2017. Among women with a college degree, 67.6% had their teeth cleaned during pregnancy in 2017, up from 64.9% in 2016, while among women with a high school degree, only 37.9% had their teeth cleaned during pregnancy in 2017, a decline from 40.6% in 2016.

 

Office of Oral Health

With funding from HRSA’s Perinatal and Infant Oral Health Quality Improvement (PIOHQI) Project, in 2016 MDPH began piloting implementation of the MA Perinatal Oral Health Practice Guidelines (the Guidelines) in three community health centers (CHCs) to integrate oral health care into primary care, address the inequities in access to dental care, and reduce the prevalence of oral disease in pregnant women and infants. Increasing the number of infants who have a dental visit by age one year increases the likelihood they receive dental care as part of their regular health care. MDPH and the Perinatal Oral Health Advisory Committee supported the pilot sites to implement the Guidelines and establish best practices that can be replicated statewide.

 

In FY18 the three pilot CHCs tested medical-to-dental referral procedures to establish a mechanism by which all pregnant women and infants are referred for dental screening and treatments, and to establish a dental home. At each of the three sites, obstetricians, midwives, family practitioners, and pediatricians have been implementing referral procedures to ensure that all pregnant women and infants receive a referral to the dental department.

 

Data collected from South Cove Community Health Center, one of the pilot sites, showed a baseline of 45% (FY18) of pregnant patients seen in the dental department. As of December 1st, 2018, approximately 47% of pregnant patients who were seen in the medical department were also seen in the dental department during their pregnancy as a direct result of the referral process. At baseline, 0% of infants between 6-36 months of age who were seen in the South Cove pediatric clinic were being seen in the dental clinic. As of January 1, 2019, this increased to 43%. Monthly performance reports were shared across sites to build relationships and foster coaching among teams.

Promotion and implementation of the Guidelines are recognized by the National Maternal and Child Oral Health Policy Center[2] and cited by Mills and Moses (2002)[3] as evidence-based strategies to improve maternal and child oral health by 1) supporting the development of state perinatal oral health guidelines, 2) encouraging medical and dental providers to work together to ensure that pregnant women have access to accurate information and dental care, and 3) educating about the importance and safety of dental care for women of all ages, including pregnant women.

 

The Office of Oral Health and the Massachusetts League of CHCs tracked this ESM by surveying the state’s 49 CHCs for information on Guideline adoption/implementation. There was no increase in the percent of CHCs (6%) that implemented the Guidelines between 2016 and 2017, but the project added two additional CHCs in 2018. The PIOHQI grant will end in May 2019 and there are no current plans to continue tracking Guideline implementation after that time. Therefore, MDPH will replace this ESM (see WIC below).

 

WIC

Among infants born in-state to resident mothers in 2017, nearly 40% participated in MA WIC, with the majority of the infants’ mothers joining WIC prenatally. WIC nutrition staff regularly screen women and children for dental care, offer oral health nutrition education, online nutrition education, and provide dental referrals as needed. Several WIC programs collaborated with community-based dental practices to offer screening and fluoride varnish in the WIC clinic setting. The WIC program distributed educational materials to WIC local programs during National Dental Health Month in February. To better measure the impact of the Guidelines, in FY19 we will measure the percentage of pregnant women enrolled in WIC who receive oral health education as a new ESM.

 

Priority: Address substance use among women of reproductive age to improve individual and family functioning.

Substance use negatively affects maternal and child health and requires a multi-faceted approach to improving care. The 2015 Title V needs assessment yielded suggestions for program improvement including more services for families, education for service providers and parents, earlier identification of mothers and infants needing services, and better integration of care. These suggestions continue to guide the Title V substance use priority. Neonatal Abstinence Syndrome (NAS) is addressed in the maternal health section for several reasons: in Massachusetts, there is a focus on the dyadic relationship because promoting attachment and bonding helps mitigate the severity of NAS, strengthen the parent’s recovery, and lead to better outcomes for parent and child. There are maternal-focused activities and infant-focused activities, but with no dyad domain, it makes most sense to ground activities related to NAS in our focus on maternal support. For this priority, the SPM is the percent of infants diagnosed with NAS in Massachusetts hospitals who receive EI services. This measure was selected because these data are more readily accessible, the measure reflects both a more integrated system of care and potentially better family engagement, and because in Massachusetts, a diagnosis of NAS confers automatic eligibility for EI for the infant through 12 months of age. The Bureau of Family Health and Nutrition (BFHN) partners closely with the Bureau of Substance Addiction Services (BSAS), other MDPH stakeholders, birth hospitals, and community-based organizations to address this priority.

 

Perinatal opioid use continues to be a significant concern. The NAS rate in Massachusetts is almost three times the national average. Related activities in FY18 included increasing access to medication assisted treatment (MAT) for pregnant women and improving care of the opioid exposed newborn, along with increasing family supports, and at the policy level, developing a state response to the federal mandate for Plans of Safe Care.

 

An emerging, related issue is the legalization of marijuana. Nationally, prenatal marijuana use is increasing, likely due to decreased perception of risk and increased access. Based on emerging research on the possible effects of marijuana use in pregnant and breastfeeding women, BFHN is collaborating with BSAS to provide guidance and recommendations to health care providers.

 

SPM 1: Percent of infants diagnosed with neonatal abstinence syndrome in Massachusetts hospitals who are receiving Early Intervention services.

The MA EI system is increasing its capacity to serve infants with NAS and their families. In 2016, 71.1% of infants with NAS were referred to EI within six months of birth, and 41.4% of infants with NAS were enrolled in EI within 12 months; the goal is to reach 75% and 50%, respectively, by 2020. In FY18, an engagement pilot was implemented with 10 EI programs and birth hospital partners. The goals of the pilot were to increase the enrollment of families of infants with NAS in EI by providing a non-reimbursable engagement visit in the hospital before discharge, decrease stigma experienced by parents of infants with NAS, ease the transition of families into a professionally-supported home environment, and familiarize hospitals with the benefits of EI. Fewer referrals were seen than expected but much groundwork was laid, and the pilot revealed a larger need to improve all referrals to EI from birth hospitals. Challenges included hospital reluctance to have outside personnel providing hospital visits and staff turnover at hospitals. Persistence was the primary means of overcoming this challenge. At the end of FY18, the pilot was re-procured with six programs due to a significant cut in funding.

 

The EI/NAS workgroup continued to meet monthly to discuss eligibility, programming, collaboration and marketing. This group developed a widely disseminated EI/NAS resource document for community providers. In order to reduce stigma, it promoted the successful language change of the psychosocial eligibility factors from “At Risk Factors” to “Child & Family Eligibility Factors.” An EI/NAS video developed for the pilot and information on EI were included in BSAS’s Journey Recovery Project, a web-based resource for pregnant women affected by substance use. These activities all increase the visibility of EI as an important resource for families of infants with NAS.

 

This SPM continues to fluctuate because the diagnosis and treatment of infants with NAS is evolving. As more non-pharmacologic care is provided, fewer infants are receiving an NAS diagnosis. As more infants are being cared for outside of neonatal intensive care units, referrals to EI are more challenging. There are more providers, often a less controlled discharge system, less awareness of EI, and perhaps less perceived need for EI if infants have shorter hospital stays. These challenges are being addressed through quality improvement (QI) projects and provider education in hospitals.

 

Additional activities to address substance use among women of reproductive age to improve individual and family functioning

Massachusetts Perinatal Neonatal Quality Improvement Network  

The Massachusetts Perinatal Neonatal Quality Improvement Network (PNQIN) is an umbrella collaborative that unites the efforts of MDPH, the Neonatal Quality Improvement Collaborative (NeoQIC), the Massachusetts Perinatal Quality Collaborative (MPQC) and the Massachusetts chapter of March of Dimes. The need for such cooperation in Massachusetts has never been clearer than when responding to the current opioid epidemic.

 

BFHN provided financial and leadership support to MPQC and to NeoQIC. In FY18, MDPH sponsored the PNQIN semi-annual perinatal opioid summit. The goals of the summit were to identify how statewide efforts to address opioid use improve the clinical care of mothers and newborns, learn about recent data trends and innovations in non-pharmacologic techniques in the care of newborns at risk for NAS and mothers with opioid use disorder, and determine potentially sustainable peer recovery coach service delivery models to support pregnant and parenting women with substance use disorders. The summit brought together over 30 hospitals that participate in data collection and QI work, community and advocacy groups, the Department of Children and Families, the Health Policy Commission, the Department of Mental Health, and the Attorney General’s Office. Through BFHN’s guidance, there has been increased focus on the parents, the dyad/triad, providing care both upstream and downstream of the hospital stay, and extending care postpartum. Part of PNQIN’s three pronged approach to addressing perinatal opioid use included a QI component to increase hospital referrals to EI for NAS. In FY18, work began with two participating hospitals submitting data to link NAS births with EI referral and enrollment data and expanded in FY19 to five hospitals.

 

Moms Do Care

In FY18 the Moms Do Care Project, funded by SAMHSA and the Health Policy Commission and implemented in collaboration with MDPH and other state and community agencies, provided services to 318 pregnant and postpartum women with opioid use disorder at four sites in Massachusetts. This model of peer-guided care integration assisted women to gain access to MAT, behavioral health and obstetrical care as well as navigate complex insurance, housing, pediatric, and child welfare systems. Moms Do Care assisted in the expansion of the perinatal peer recovery coach workforce, as well as the number of buprenorphine-waivered obstetricians. An Action Learning Collaborative for hospitals and community-based organizations using peer mothers in recovery to support perinatal women with substance use disorders continued to meet monthly and was a resource for workforce development. MDPH’s commitment to the perinatal peer recovery coach workforce is an example of strong family engagement in MCH programming. One successful means of engaging and supporting families affected by perinatal substance use is to provide a venue for women in recovery to share their experience, strength, and hope.

Perinatal Substance Use Collaboratives

A statewide meeting was held in FY18 to share lessons learned from the perinatal substance use collaboratives. A new collaborative was created in the most western, and second most rural, county in the state with a very high rate of opioid use, opioid overdose, and NAS. This collaborative was very well attended by a cross-section of community providers, with consumers sharing their experiences with the service systems.

 

Plans of Safe Care

In FY18, the SAMHSA-funded Massachusetts “Policy Academy for Improving Outcomes for Pregnant and Postpartum Women with Opioid Use Disorders and Their Infants, Families, and Caregivers” met to determine the implementation of the Child Abuse and Prevention Treatment Act’s mandate for a Plan of Safe Care for every substance affected newborn, as well as to define “substance affected newborns.” MDPH drafted relevant materials and guidance that were finalized and disseminated in FY19. The CDC-funded Essentials for Childhood also worked directly with one community to develop a brief on their approach to addressing perinatal opioid use in their community. This was finalized in FY19 and serves as one community’s response to developing a Plan of Safe Care.

 

Women Recover Conference

Three hundred participants attended a statewide conference on gender responsive treatment services for addiction treatment professionals, medical professionals and policy makers, with a focus on the history of gender responsive services in the state.

 

Safe Sleep and Substance Use

In FY18, a workgroup was convened to address infant safe sleep among women affected by substance use. This workgroup resulted in a regional training series for safe sleep in family residential and pregnancy enhanced treatment programs. An application was also successfully submitted to fund a safe sleep ad campaign focused on families at greater risk including those using nicotine and sedating medications.

 

Fetal Alcohol Spectrum Disorders (FASD)

BSAS and BFHN co-led the state FASD Task Force that convened families, state agencies, academic institutions and community agencies to address FASD at the policy, state and community levels. The Task Force has worked to reduce stigma and raise awareness of strategies for prevention and support for families of children with FASD. Prevention strategies include addressing barriers that substance using women encounter in trying to access services. The Task Force has developed strategies for supporting parents and their children with FASD, working with early childhood systems including EI, and working with school departments.

 

Early Intervention Parenting Partnerships Program

EIPP screened participants for tobacco, unhealthy alcohol, and drug use at enrollment and during postpartum. Substance abuse is a key topic of discussion, education, support and referral. Many EIPP staff report that participants use tobacco to manage anxiety. In FY18, 11.5% of EIPP participants reported tobacco use at enrollment, 6.5% reported substance abuse in the home, and 12.1% reported smoking during the last three months of pregnancy. Of the 37 participants who reported tobacco use, 16.2% were supported in maintaining connections with smoking cessation services they were already receiving, and 62.2% were referred to smoking cessation services. No one declined the referral. In addition, 22 participants were supported in maintaining connections with substance abuse services they were already receiving while seven participants were referred to substance abuse services.  

 

MA MIECHV

MA MIECHV home visitors screened participants for tobacco, unhealthy alcohol, and drug use. Screening provides opportunities for intervention with substance users before more severe consequences occur. All MA MIECHV participants are screened for substance use routinely. Home visitors discuss substance use with participants and make referrals to services when appropriate.

 

MA MIECHV requires home visitors to attend a full-day training on substance use. The training curriculum includes an overview of addiction and substance use, including tobacco, a review of the different categories of drugs and tobacco products, and effects of substance use, including the impact exposure can have prenatally and on the ability to parent. The training also teaches home visitors how to recognize symptoms, behavior patterns, and family dynamics that may indicate substance use, and strategies to support participants affected by substance use. MA MIECHV and EI also partnered with the Department of Early Education and Care, specifically the Head Start State Collaboration Office (HSSCO) to encourage providers to attend HSSCO-held focus groups to gather additional information on needs of family support providers around the opioid crisis. Focus groups were developed with the assistance of MA MIECHV staff. The focus groups involved providers from EI, Head Start, home visiting, and early education providers, and feedback informed the development of a cross-program training opportunity. The training, Supporting Families and Young Children Affected by Opioid and Substance Use: Bridging Systems and Services, was delivered by the Forever Hope Training Center in the spring/summer of 2018. The training, developed with the assistance of MA MIECHV staff, was tailored to the needs of Massachusetts and was offered and hosted by HSSCO in six regions across the state to all interested Head Start/Early Head Start, Early Education programs, Home Visitors, EI, and Family Engagement networks staff.

 

During federal FY18, 10% of the households enrolled in evidence-based home visiting services reported a history of substance use or need for treatment. This is likely an under-report of the number of households affected by substance use. During the same time, 18% of households reported that someone in the household used tobacco products in the home, up from 16% in federal FY17. In federal FY18, 54.2% of primary caregivers enrolled in home visiting who reported using tobacco or cigarettes were referred by a home visitor to tobacco cessation counseling or services within three months of enrollment, an increase from 37.5% in federal FY17.

 

The Early Head Start program that was intended to focus on serving opioid affected newborns through hospital collaboration was not successful due to a lack of referrals from the hospital, and a service system that was not adequately collaborative. However, this program still served many opioid affected families and developed a strong referral mechanism with the area child welfare office.

 

In FY18, MA MIECHV began to develop a pilot that would provide cross-training and enhanced supervision for a ‘Parents as Teachers’ parent educator with personal experience with substance use and recovery. This pilot came to fruition in FY19.

 

Welcome Family

Welcome Family nurse home visitors screen women for substance and tobacco use, provide brief intervention and education, and refer women to substance use and smoking cessation resources. In FY18, nurses provided 217 brief interventions and offered 21 referrals to participants in response to concerns identified during screening.

 

A common challenge the Welcome Family nurses face is that the substance use screen infrequently yields disclosures due to the sensitive nature of this topic and the difficulty of developing a relationship with the mother during a one-time visit. MDPH will leverage the universality of Welcome Family to de-stigmatize the topic.

 

Welcome Family nurses stay apprised of research, resources, and trainings on counseling families on marijuana use during pregnancy and breastfeeding. They sought to improve collaborations with local substance use service agencies in their communities by emphasizing the importance of providing parenting support, which home visiting can offer, in addition to recovery support.

 

FOR Families

In FY18, 17% of clients reported an issue with drugs or alcohol; of these clients, 12% had an issue with drugs, 3% with alcohol, and 1% with both. Among those who reported having an issue with drugs and/or alcohol, 36% reported being in treatment. Furthermore, 30% of clients reported smoking cigarettes. Assessing substance use at the time of intake is a challenge because the relationship with the client is not well established and the client may not disclose sensitive information. However, this is the only opportunity in the electronic record where data regarding substance use are specifically captured. After intake assessment, the program relies on case notes.

 

WIC

WIC staff screen women for substance use both in the perinatal and postpartum periods during the certification process. State WIC staff disseminated a mandatory substance use training module to all local agency staff. The substance use assessment questions in the WIC Eos system were updated to improve screening, counseling, and referrals, especially related to marijuana use.

 

Priority: Promote emotional wellness and social connectedness across the lifespan.

Emotional wellness affects the development of individuals, especially children, during key times in their lives. It is a cumulative outcome of heredity, experiences, support, education, and environment. Progress on this priority is measured by the percent of women who reported discussing what to do if they feel depressed during pregnancy or after delivery at any prenatal care visit with a health care worker. The EIPP Program, MA MIECHV, FOR Families, PRAMS and MA Postpartum Regulations are addressing this performance measure.

 

Other initiatives at MDPH, focused on improving emotional wellness and social connectedness in early childhood and adolescence, will be discussed in the Child and Adolescent Health domains.

 

SPM 5: Percent of women who report being screened for depression by a health care worker during any prenatal or postpartum visit.

In years 2012-2016, PRAMS asked if a health care provider had discussed only at a prenatal visit with women what to do if they felt depressed during the pregnancy or after birth. Massachusetts is revising this SPM to reflect the importance of screening all women for depression both during prenatal care and after pregnancy at a postpartum visit. The new SPM will now report the Percent of women who report being screened for depression by a health care worker during any prenatal or postpartum visit.

 

Based on the most recent MA PRAMS data (2017), 95.6% of women reported being asked by a health care worker if they feel depressed during either a prenatal visit or a postpartum visit. This is a slight increase from 94.8% in 2016. Women who were born in the US (95.4%) or who were unmarried (97.1%) reported being asked if they feel depressed more frequently than women who were not born in the US (96.0%) and those who were married (94.9%); however, these differences were not statistically significant. Differences in screening by race, education, insurance, federal poverty level and WIC participation were also non-significant. FY18 activities, accomplishments and challenges to address this measure are described below.

 

Early Intervention Parenting Partnerships Program

Maternal mental health is a key topic of discussion, education, support and referral with EIPP families. In FY18, 53.3% of participants reported a history of depression, including postpartum depression (PPD) at enrollment. At two months postpartum, 198 participants were screened for PPD using the Edinburgh Postnatal Depression Screen (EPDS) with 6.1% screening positive for mild depressive symptoms and 7.6% screening positive for moderate or severe depressive symptoms. Fifty-six EIPP participants were supported in maintaining a connection with their individual counselor and 81 participants were referred to individual counseling; of those referred, 24.7% were enrolled in services and 54.3% were placed on a waiting list. In addition, 3.7% were denied services. Anecdotal data indicate that these women were denied mental health services due to insurance issues.

 

EIPP participants are assessed on a three-question social connectedness screening tool at key prenatal and postpartum stages. At the initial visit, 321 women were screened, with 14.6% reporting that they do not have the support they need from others to care for themselves and their infant.

 

Each EIPP site facilitates a 10-week support group annually for its participants. Topics include maternal mental health, mother/infant attachment, self-care, parenting skills and others. Transportation, child care and food are provided to facilitate attendance.  

 

MA MIECHV

MA MIECHV promotes emotional wellness and social connectedness among program participants in several ways. All MA MIECHV home visitors and supervisors are required to attend a day-long mental health training focused on common mental health concerns, strategies for supporting parents who struggle with mental health challenges, and mindful self-regulation skills to support home visitors when working with parents facing mental health challenges. The training incorporates reflective conversations and engages participants in help-seeking in response to episodes of mental distress, illness or crisis. A three-day Facilitating Attuned Interactions (FAN) training, also required for all MA MIECHV staff, further supports staff to engage in reflective practice.

 

MA MIECHV home visitors screen for both depression and social connectedness according to evidence-based model requirements, document the results of those screens, and make referrals to services as needed. Depression screens are conducted within three months of enrollment (for those not enrolled prenatally) or within three months of delivery (for those enrolled prenatally) using the Center for Epidemiologic Studies Depression Scale (CES-D) or EPDS. Data on completed depression screens are collected and analyzed to assess progress on a MIECHV performance measure assessing the percent of primary caregivers enrolled in home visiting who are screened for depression using a validated tool. During FY18, 82.5% of MA MIECHV participants were screened for depression within the required time frame, unchanged from FY17 (83.0%). An outcome performance measure assesses the percent of primary caregivers referred to services for a positive screen for depression who receive one or more service contacts. During FY18, 50.9% of caregivers were documented to have received one or more service contacts, a slight increase from 48.3% in FY17. MA MIECHV programs have reported limited service, language, and cultural capacity among mental health services in many Massachusetts communities as a barrier to successful access to treatment.

 

Research suggests that social isolation contributes to stress and emotional fragility, particularly in populations served by MA MIECHV. All participants are screened for social connectedness at six month intervals throughout the duration of program enrollment. Each model uses different tools to assess the extent to which the participant is connected with social networks. All MA MIECHV programs hold a six-week group series to support their service population and to facilitate connections among families. MA MIECHV provides flexibility on topics for the group series to allow programs to better meet the needs of their participants and the larger community.

 

FOR Families

FOR Families serves homeless families with complex medical needs, substance use, safety concerns, and high levels of depressive symptoms. During the intake assessment, and as needed in subsequent visits, home visitors assess women for symptoms of depression, identify any potential risks to the mother and baby, and make referrals to mental health services. The intake assessment does not capture data specifically for women during pregnancy or after delivery.

 

Of the 206 families assessed in FY18, 50% reported that someone in the household had been diagnosed with depression, and 20% reported that a household member had ever been hospitalized for a mental health crisis. Home visitors provide support through reflective listening during their home visits and refer clients to mental health treatment in their community. Families are encouraged to maintain connections with their natural supports as a source of assistance when facing housing instability.

 

Pregnancy Risk Assessment Monitoring System (PRAMS)

MDPH began administering PRAMS Phase 8 survey with two new questions on social connectedness and father’s involvement in April 2016. Data from 2017 show that many mothers have someone to loan them money (77.0%), help them if sick in bed (87.4%), talk with about problems (88.3%), help if feeling frustrated with new baby (89.0%), and help with transport to doctor’s office (90.4%). The majority of women report that the father of their new baby always/often contributes to providing for the baby’s basic needs (87.9%) and that their husband or partner is always/often a source of encouragement and emotional support (81.0%).

 

While support overall is high for all five social support measures, Black non-Hispanic, Hispanic and Asian non-Hispanic women were significantly less likely to report supports compared with White non-Hispanic women. Black non-Hispanic, Hispanic and Asian women were significantly less likely to report having someone to loan them $50 (67.0%, 61.7%, and 41.7%, respectively), to help if sick in bed (80.4%, 78.1%, and 80.6%, respectively) or to have someone to talk with about problems (79.6%, 79.3%, and 75.6%, respectively) compared with White non-Hispanic women (86.4%, 92.6%, and 94.0% respectively). Black non-Hispanic, Hispanic and Asian women were significantly less likely to report having someone to help if tired and feeling frustrated with the new baby (81.9%, 77.7%, and 84.2%, respectively) and to have someone to transport her and her baby to the doctor’s office if she had no other way of getting there (82.4%, 82.1%, and 80.7%, respectively) compared with White non-Hispanic women (93.8% and 95.5%, respectively).

 

Black non-Hispanic and Hispanic women were less likely to report that their baby’s father always/often contributed to the baby’s basic needs (75.4% and 80.4%, respectively) and were less likely to report receiving encouragement and emotional support from their husband or partner (66.4% and 75.1%, respectively) compared with White non-Hispanic women (91.9% for contributing to basic needs and 84.4% for encouragement and emotional support).

 

Postpartum Depression Regulations

The Postpartum Depression regulations, promulgated in FY15, require health care providers to report their data to MDPH annually if they conduct a PPD screen during a clinical encounter with a postpartum woman. A single service code is used as a mechanism for reporting PPD screening by providers. Understanding statewide PPD screening patterns and outcomes through relevant data will improve detection and facilitate treatment for mothers in need of help.

 

Through an IRB, MDPH receives data from the Center for Health Information and Analysis to monitor PPD screening patterns. From July 2015 through June 2016, the most recent data available, there were 70,005 unique deliveries identified from the birth certificate, of which 56,080 (80.1%) were linked to an All-Payer Claims Database (APCD) claim. The numbers of women screened for PPD within six months after delivery ranged from 374 to 500 monthly. From July 2015 through June 2016, 5,822 (10%) out of 56,080 deliveries were screened for PPD and 577 (10%) of them had a positive screen. The proportion of women screened for PPD was higher among White non-Hispanic (12%) and American Indian (11%) compared to 9%, 8% and 6% among Asian, Black non-Hispanic and Hispanic, respectively. The proportion of PPD screening was lower among women who were covered by Medicaid compared to others (7% vs. 13%). A higher proportion of screening was seen among women with higher levels of education and the percentage of screening increased with increasing education level.

 

Among those screened, Hispanic women (13%) had a higher proportion of positive screens compared to White non-Hispanic (10%), Black non-Hispanic (9%), and Asian (9%). The proportion of positive screens was higher among women who were covered by Medicaid compared to those on private insurance (13% vs. 9%). Of concern is the finding that women who were more likely to screen positive for PPD (Hispanic women and those with Medicaid) also had lower percentages of screening, suggesting that women in greater need of support are less likely to be identified.

 

Although the PPD screening data presented above are useful for monitoring trends over time, the estimation of PPD screening through claims data has been challenging and these screening rates are believe to be substantial underestimates. As noted above, CHIA data suggest that only 10% of eligible mothers were screened, while anecdotal data from birth hospitals participating in PNQIN indicate their PPD screening rates are as high as 80% and PRAMS data suggest that women are routinely being asked about depression during prenatal and postpartum visits. MDPH is exploring barriers to data collection (e.g., do all health plans accept the claims code and report this information to CHIA?) and working to identify opportunities to improve the completeness of reporting.

MassHealth continues to pay for the administration of standardized depression screening during pregnancy and postpartum. Perinatal care providers may submit claims for one prenatal and one postpartum depression screen for a pregnant or postpartum MassHealth member in a 12-month period. Pediatric providers may claim for the administration of one postpartum depression screen in conjunction with a well-child or episodic visit for a MassHealth member aged 0-6 months. Reimbursement for screening requires the use of a validated, MDPH-approved perinatal screening tool such as the Beck Depression Inventory, CES-D, EPDS, Postpartum Depression Screening Scale, or Patient Health Questionnaire-9. MDPH will continue to promote screening for all postpartum women by primary care and obstetric providers.

 

Additional activities to improve Women’s/Maternal Health

Other MDPH activities to improve women’s/maternal health that are not specific to the performance measures are discussed below.

 

Prenatal Care

MA MIECHV

MA MIECHV local agencies conduct community outreach to pregnant women to encourage early enrollment into programs. Among the 2,018 female participants served during FY18, 46% were pregnant at enrollment. MA MIECHV home visitors encourage prenatal participants to attend their scheduled prenatal care visits, and identify and mitigate maternal risk factors associated with late and inadequate prenatal care by screening mothers for substance use, intimate partner violence, and depression, and refer participants to appropriate resources.

 

WIC

WIC nutrition staff screen all pregnant and postpartum participants to assess utilization of prenatal care. Providing referrals to health care providers is a core WIC service. According to PRAMS 2017 data, 87.2% of WIC participants enrolled in prenatal care in the first trimester, compared to 95.7% of mothers not participating in WIC. In 2018, 41% of the pregnant women participating in WIC had enrolled in the first trimester. Local WIC agencies continually seek opportunities to improve this metric. Many WIC clinics are co-located in community health centers, enabling more timely referrals. WIC Community Coordinators routinely share the message that WIC services can be accessed prior to the first medical visit for the pregnancy. Outreach material provided annually to clinicians emphasizes a pregnant woman’s eligibility to enroll in WIC prior to her first obstetrics visit. Additionally, relationships between WIC and obstetric providers focused on breastfeeding have continued to strengthen, likely resulting in additional referrals for prenatal women.

 

Postpartum Visits

Early Intervention Parenting Partnerships Program

In FY18, 79.4% of EIPP participants had a postpartum visit (PPV) with their health care provider between 21 and 56 days after birth. This rate exceeds the EIPP performance measure goal of 60% and is an increase from last year’s performance of 74.7%. Successful strategies home visitors employed to support participants in attending their PPV included calling the health care provider together to schedule the visit, arranging for transportation for the participant, and providing reminder phone calls and text messages.

 

MA MIECHV

MA MIECHV home visitors promote completion of the PPV for all postpartum mothers they serve. In FY18, 43.6% of MA MIECHV participants who enrolled in home visiting prenatally or within 30 days after delivery received a postpartum visit with a health care provider within eight weeks of delivery, increased from 35.5% in FY17. This will be a continuing focus for MA MIECHV.

 

Maternal Mortality

Maternal Mortality Review

In 2015, there were 25 pregnancy-associated deaths, including one maternal death. A pregnancy-associated death is the death of a woman while pregnant or within one year of termination of pregnancy, irrespective of cause. Women who die from a cause related to pregnancy or childbirth either during pregnancy or up to 42 days after pregnancy termination are called maternal deaths and are a subset of pregnancy-associated deaths. The 2015 pregnancy-associated mortality ratio was 34.7 deaths per 100,000 live births and the maternal mortality ratio (maternal death) was 1.4 per 100,000 live births. More recent data entered into the Maternal Mortality Review Information Application (MMRIA) were lost when MMRIA data became corrupted. MMRIA is now up and running again and MA anticipates re-entering data during summer 2019 and will update reporting when data are available.

 

The Maternal Mortality and Morbidity Review Committee (MMMRC) reviews all maternal deaths, studies the incidence of pregnancy complications, and makes recommendations to improve maternal outcomes and eliminate preventable maternal death. The work of the MMMRC, protected under M.G.L. c. 111, section 24A and 24B, assures the confidentiality of all records and proceedings. Understanding the causes of maternal deaths provides insight into the factors that contributed to both maternal morbidity and mortality, which can inform strategies to reduce the incidence of these tragic events. The MMMRC consists of obstetricians, certified nurse midwives, maternal fetal medicine specialists, neonatologists, pathologists, perinatal psychiatrists, academics, critical care specialists and the state medical examiner or his designee. The MMMRC is coordinated by Title V staff and any meeting costs (copying files) are covered by the Title V Block Grant.

 

In FY18, the MMMRC published a white paper on opioid use and maternal mortality in Massachusetts which was disseminated widely. Results indicated there were 199 pregnancy-associated deaths identified in Massachusetts from 2005–2014. Approximately one in five pregnancy-associated deaths (20.6%; n=41) was related to substance use. An increasing trend in the proportion of substance use-related deaths was observed over the study period, from 8.7% in 2005 to 41.4% in 2014 (p-value for trend=0.008). This trend is consistent with the increase in opioid overdose deaths in Massachusetts overall during the same time.[4]

 

Opioids (heroin, fentanyl, morphine, codeine, hydrocodone, methadone, propoxyphene, oxycodone, opiates) were identified in the majority of substance use-related deaths (65.9%) and 13.6% of pregnancy-associated deaths over the study period. Heroin and morphine were present in 19.5% of substance use-related deaths (n=8) and fentanyl in 17.1% (n=7). Among substance use-related deaths, two or more specific drug types were indicated in 22.0% (n=9). A majority (90.2%) of the substance use-related deaths occurred in the postpartum period, between 42–364 days postpartum.

 

Sexual and Domestic Violence Prevention

During FY18, MDPH continued to improve collaboration between sexual and domestic violence (SDV) community-based programs and health care systems. MDPH assisted in the development and implementation of Jane Doe, Inc.’s Health Care Learning Forum in May 2018 through participation in the Healthcare Collaboration Advisory Group. In November 2018, MDPH also launched the online Chapter 260 training designed to meet the requirements outlined in the Mass General Law Chapter 260 on training and education in SDV Prevention (for nine different boards of registration). Approximately 3,500 nurses completed the training in FY18.

 

Domestic Violence Services

There were six Domestic Violence Service models in FY18:

 Children Exposed to Domestic Violence (CEDV): provides clinical intervention and support services to children who have been adversely affected by exposure to DV and the parent who experiences DV. In FY18, 13 programs served 481 children and 760 non-offending adults. MDPH currently funds 12 CEDV programs across the state. On average, CEDV programs met with 63 children and 40 adults monthly.

 

Supervised Visitation Services: provides access to safe visitation services and locations as well as neutral exchange for non-custodial parents. In FY18, 12 agencies and 17 supervised visitation centers served 1,019 children and 874 adults. MDPH currently funds 12 agencies and 17 Supervised Visitation Centers across the state. On average, SVS programs provided services to 772 children and 278 adults monthly.

 

 General Community-Based Services (GCB): enables victims of DV and their families and community members to receive free and confidential support and advocacy, while also providing basic assistance to survivors and their children. A majority of GCB Programs also support survivors through providing flexible cash assistance to sustain survivor’s safety, stability and wellbeing. In FY18, 36 GCB Programs, and 38 Community Based Sites served 1,621 children and 11,052 adults, including support groups and counseling.

 

 Emergency Shelter: provides services to assist survivors and their children with temporary shelter when in imminent danger due to DV or sexual assault, with the primary objective of supporting and stabilizing survivors so that they are able successfully to transition into long-term safe and stable housing. In FY18, 26 shelters provided safety, stability, and advocacy services to 726 adults and 570 children.

 

Housing Stabilization: provides services that assist survivors and their children in establishing safe, stable housing. Survivors are able to address their needs over 12 to 18 months, improving outcomes for them and their children as they successfully transition into a safe and stable environment. In FY18, seven housing stabilization programs served 126 adults and 99 children. This represents a significant decrease in the number served compared to FY16, due to the loss of Housing and Urban Development funding. There was a decrease of 44 rooms statewide in FY18.

 

Substance Misuse & Trauma Services: assist survivors and their children who need to leave an unsafe situation due to domestic and/or sexual violence, and need longer-term recovery, advocacy, and support to address their needs with substance misuse and trauma. In FY18, one substance misuse and trauma shelter served 29 adults and zero children.

 

Sexual Assault Prevention and Survivor Services

In FY18, MDPH funded 16 comprehensive rape crisis centers, providing quality, culturally-relevant, trauma-informed, accessible services throughout the state. Each rape crisis center has an assigned service area, collectively providing services to all 351 cities and towns in Massachusetts. Services assisted survivors of both genders and provided free, confidential support by trained rape crisis counselors, including 24/7 hotlines with access for people who are deaf or hard-of hearing; short-term individual and group crisis support; individual client advocacy and supported referrals; 24/7 accompaniment to hospitals and police stations; advocacy and accompaniment to courts and to some educational institutions and human services agencies; outreach to primary and secondary survivors; and education and community mobilization focused on primary prevention of sexual violence.

 

Intimate Partner Abuse Education

All Certified Intimate Partner Abuse Education Program (IPAEP) staff continue to be trained by the Institute for Health and Recovery to use the Safety and Health through Alcohol and Drug Education (SHADE) curriculum. Data continue to be collected to evaluate the effects of the SHADE curriculum on referrals to substance use treatment. The IPAEPs function under a statutory set of standards and guidelines, considered best practices, which are promulgated by MDPH. IPAEPs work toward establishing privileged communication with the partners they contact by partnering with community-based DV agencies, which either conduct the contacts themselves, or provide supervision to IPAEP staff who conduct the contacts. Approximately 80% of IPAEP participants are court-ordered to the program as a condition of their probation. Data show that men of color are disproportionately represented in IPAEPs. All IPAEPs continue to increase their awareness of and skills to provide culturally-responsive services to African Americans. Through the intake processes and educational content in the weekly groups, programs acknowledge the role of structural oppression, and specifically racism, as it affects the lives of these men. Programs also respond to the known risk and protective factors that support and mitigate DV perpetration. One example is that programs now support participants to develop employment skills in lieu of traditional community service as a form of payment for the program. IPAEPs are strongly encouraged to hire more African American staff and to include African Americans among leadership and on Boards of Directors.

 

In FY18 IPAEP served over 4,000 individuals, having an impact on the safety of the current and future partners and children of these program participants.

 

Rural Domestic and Sexual Violence Project

Due to the loss of federal funding, the Rural Domestic and Sexual Violence Project formally closed January 2018. Prior to closure, the Project was a partnership between MDPH, four community-based sexual and DV programs, the Hilltown Community Health Centers Inc., Jane Doe Inc., and local District Attorney’s Offices. The Project was designed to address the disproportionate rates of domestic and sexual violence in rural Massachusetts by providing culturally relevant services and prevention initiatives in 79 rural municipalities in Berkshire, Franklin, Hampshire, Hampden and Worcester Counties.

 

In FY18 the Project engaged men in promoting domestic/dating and sexual violence prevention policies and practices through the White Ribbon Campaign in rural schools in Hampshire, Hampden, Franklin and Worcester Counties, and the Walk a Mile in Her Shoes initiative in Berkshire County. The Project also strengthened child sexual abuse prevention efforts by providing two child sexual abuse prevention workshops for 24 MCH professionals, victim advocates, and early childhood educators that focused on understanding and responding to the sexual behaviors of children, identifying risk and protective factors regarding child sexual abuse, and appropriate intervention.

 

Because of the lack of affordable stable housing, and high rates of poverty for rural survivors, the Project coordinated an economic security initiative that included facilitation of a taskforce to maximize resources for survivors and support local survivor-centered economic development initiatives, the expansion of an informational website that included an economic security resource guide (in English and Spanish) to assist programs in navigating the resources survivors need, and the implementation of two webinars and one half-day workshop to assist programs that support survivors in becoming economically self-sufficient. Additionally, the Project implemented a digital storytelling and expressive arts program for survivors of domestic and sexual violence

 

The Project also strengthened efforts to address domestic and sexual violence policies and systems in rural health settings, and reviewed screening and supportive referral procedures with community health centers in the region.

Finally, the Project hosted a two-hour workshop for 18 domestic and sexual violence advocates and MCH providers focused on understanding the concept of cultural humility and enhancing culturally-responsive practices in rural MA.

 

 

[1] http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6304a1.htm

[2] http://www.astdd.org/docs/improving-the-oral-health-of-pregnant-and-young-children-aug-2012.pdf

[3] Mills LW & Moses DT. (2002). Oral health during pregnancy. Am J Matern Child Nurs; 27(5):275-80.