For reporting year 2022, the Bureau of Family Health (BFH) conducted activities in the Women/Maternal Health domain through Title V funding with additional federal funds from the Centers for Disease Control and Prevention (CDC) for support of maternal mortality prevention initiatives. Taking into consideration the overall population needs, the BFH has developed strategies that do not duplicate other funding sources, and that fill gaps not addressed by the existing system of care and current partners.

 

In 2021, there were 2.8 million persons of reproductive age (15-49 years old) who identified as female living in Pennsylvania (Pa.). The racial composition of this population is 78% white, 14% Black/African American, five percent Asian/Pacific Islander and three percent multi-race. Ten percent of women living in Pa. identify as Hispanic/Latinx. Several factors contribute to poor maternal outcomes and particularly disparate outcomes for Black/African American birthing people and babies. These factors include systemic racism, substandard housing, unsafe neighborhoods, stress, mental health issues, tobacco, and other substance use as well as intimate partner violence (IPV). Poor mental health, substance use (including substance use during pregnancy), and IPV have particularly negative consequences on a family.

 

In the United States, about 1.5 million women report being victims of some form of IPV every year. Of these reported cases, approximately 325,000 are pregnant during the acts of violence. The reason for this spike in IPV during pregnancy is unknown but could be due to relationship dynamic changes between partners, or that the frequency of prenatal visits yields more positive screens simply because patients are being screened more often. What is known is that IPV affects pregnancy more than any other common pregnancy complication. Experiencing IPV during pregnancy is associated with higher rates of depression, suicide attempts, and behavioral risk factors including the use of tobacco, alcohol, and drugs. Additionally, research has shown that birthing people abused during pregnancy are twice as likely to miss prenatal care appointments or initiate prenatal care later than recommended, supporting an association between insufficient prenatal care and adverse birth outcomes, including preterm delivery and low birth weight. Nationally, about five percent of pregnant people use illicit substances and one in seven birthing people experience symptoms of peripartum depression. Available data suggests a higher rate of IPV in some Black, Indigenous, and other People of Color (BIPOC) communities. However, the broader context of those statistics, including social determinants of health, systemic racism, and policing of these communities must be taken into consideration. What is known is that the harm caused by IPV is compounded by the inequities survivors face in accessing health care and other social supports they need to improve the health and lives for themselves and their families.

 

People who are pregnant or recently pregnant are more likely to get very sick from COVID-19 compared to people who are not pregnant. Further, people who have COVID-19 during pregnancy are at an increased risk for complications such as delivering preterm and/or a stillborn infant. Preliminary data from Pa.’s 2021 pregnancy associated deaths, defined as deaths during or within 365 days of the end of the pregnancy regardless of outcome, shows that the number of deaths due to natural causes doubled from 2020. The most common immediate cause of death for natural deaths was cardiac-related, followed by COVID-19-related deaths. The COVID-19 pandemic has resulted in a host of additional challenges for birthing people in Pa. and has disproportionately harmed the health and economic well-being of BIPOC communities, who have suffered a higher risk of hospitalization and death due to the disease. An important driver of these inequities is that BIPOC are more likely to be essential workers in industries that are not amenable to working from home, putting them at greater risk of contracting COVID-19. Moreover, communities of color are more likely to face food insecurity, unstable housing, and loss of income and health insurance.

 

An additional and critical note on this section, and throughout this report and application, the BFH acknowledges that the state of being pregnant, the act of giving birth or otherwise ending a pregnancy, and the act of parenting and caregiving are inclusive of all genders while also recognizing that data sources may not be.

 

Priority: Reduce or improve maternal morbidity and mortality, especially where there is inequity

 

The preconception and interconception periods are times when having access to a trusted health care practitioner is valuable, and that present opportunities for important conversations to occur. Data analyzed through Pregnancy Risk Assessment Monitoring System (PRAMS) surveys suggest that when birthing people have a health care practitioner talk to them about health issues, there is recognition and value in those conversations as preventative measures or interventions. Pregnancy and the postpartum period present a window of opportunity for home visitors, obstetricians, pediatricians, and other providers to assess and take steps to improve both the physical and mental health of birthing people and families, if the providers can connect with and gain the trust of the birthing people they are serving.

 

In 2020, 73.7% of all birthing people in Pa. received prenatal care in the first trimester. 77.2% of white, 64.8% of Black/African American, and 65.3% of Hispanic/Latinx birthing people receiving prenatal care in the first trimester. Racial disparities are evident and continue to persist with 1.1% of white birthing people, 4% of Black/African American birthing people and 3% of Hispanic/Latinx birthing people receiving no prenatal care.

 

Unhealthy birth outcomes, such as low birth weight and preterm birth, are influenced by many factors before, during, and in between pregnancies. Preconception care allows birthing people to talk to their provider about steps to take to promote a healthy pregnancy before conception or implement strategies to delay pregnancy. It also opens the door for early entry into prenatal care. Prenatal care continues to be a crucial method in identifying health issues throughout pregnancy, allowing for early intervention and healthier birth outcomes.

 

Additionally, pregnancy intention is associated with several health outcomes. Studies indicate that unintended pregnancies are associated with a plethora of adverse physical health, psychological, economic, and social outcomes which impact birthing people, their families, and society.

The BFH focuses on preconception, pregnancy, postpartum, and interconception care and uses programming to provide tools and resources to the birthing people and families served by Title V.

 

NPM 1: Percent of women, ages 18 through 44, with a preventive medical visit in the past year

 

Strategy: Increase the percent of women or birthing people who successfully complete evidence-based or informed home visiting programs 

 

Objective: Increase the percent of women or birthing people who successfully complete an evidence-based or informed home visiting program by 2% each year

 

ESM: Percent of women or birthing people who successfully complete evidence-based or informed home visiting programs

 

The BFH continued its partnership with the county and municipal health departments (CMHDs) to provide local services to residents in their communities. The eleven CMHDs are in Allegheny County, Allentown City, Bethlehem City, Bucks County, Chester County, Delaware County, Erie County, Montgomery County, Philadelphia County, Wilkes-Barre City, and York City. Delaware County Health Department was newly established in 2022 and is building their infrastructure. Each of these locations is affected by poverty, racial and health inequities and greatly benefit from the maternal and child health (MCH) services provided. The CMHDs have been longstanding partners for numerous reasons, one of which is direct access to Title V eligible participants at the local level. The CMHDs serve this population in many different capacities, and it is beneficial to the CMHDs as well as to the families to provide services across a wide range of physical health, mental health, and social services to improve and enrich the lives of families.

 

Various evidence-informed programs and best practices have been implemented to improve health outcomes and to reduce health inequities among disproportionally affected populations served by the CMHDs. In 2022, 1,374 pregnant and birthing people were served through CMHD home visiting programs. In 2022, the CMHDs returned to providing in-person home visits with 45% of enrolled participants successfully completing home visiting programs, exceeding the original goal of 24%. If the increased percentage continues in future years, BFH staff will consider revising the goals for this measure. Home visitors have regular contact with families, which facilitates comprehensive, family-centered care. This care puts home visitors in an ideal position to identify and address physical, mental, or emotional challenges pregnant and birthing people may be experiencing, as well as issues within the home, such as IPV, substance use, and social or financial problems.

 

Ten of the eleven CMHDs serve prenatal and postpartum birthing people and their infants through home visiting programs. Evidence-based or evidence-informed programming and curriculums, such as Parents as Teachers and Partners for a Healthy Baby, provide primary and preventative maternal and infant health services and education on a variety of health topics, such as substance use, healthy homes, safe sleep, fetal development, healthy nutrition for pregnancy, immunizations, birth control and family planning, parenting techniques, and breastfeeding.

 

Beginning in July 2020, the Department of Human Services (DHS) expanded home visiting services for all first-time parents, parents of children with additional risk factors, and families who wish to be enrolled, covered by Medicaid. These services are provided in collaboration with the physical health Medicaid managed care organizations (MA MCOs). Numerous CMHDs are contracting with MA MCOs to provide these services and others are considering this option. The MA MCOs or other referral sources refer the expectant or parenting person to an evidence-based or evidence-informed home visiting program that completes an assessment and determine the needs of the family.

 

In Pa., the Office of Child Development and Early Learning (OCDEL) is the lead agency for the Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV). OCDEL is a collaborative effort between the Pennsylvania Departments of Education and Human Services focused on improving systems so all children can reach their full potential. Many of the home visiting models offered through MIECHV have specific requirements beyond poverty level and need, such as prenatal enrollment and first pregnancy, unlike the flexible enrollment requirements of the CMHDs. Many of the CMHDs have MIECHV home visiting programs administered out of the same office, which allows for collaboration and referral. The BFH requires the CMHDs collect five outcome measures also collected by the MIECHV Program to better understand the effectiveness of the CMHDs home visiting programs as compared to the MIECHV Program. The outcomes for 2022 reported by the CMHDs are as follows: 8.1% of infants were born preterm following program enrollment; 93.9% of primary caregivers enrolled in home visiting were screened for depression; caregivers were asked if they had concerns with their child’s development, behavior, and learning at 98.2% of home visits; 84.9% of caregivers were screened for IPV; and 85.7% of caregivers with positive screens for IPV received referral information. While the data has limitations due to the small number of families served, when compared to MIECHV data, the outcome measures for the CMHDs scored higher for all five measures. The CMHDs will continue to collect the five outcome measures, reporting them on a yearly basis.

 

Due to the implementation of the MA MCO home visiting program, and the continuation of MIECHV, BFH continues to monitor the home visiting services provided by the CMHDs to avoid the duplication of services.

 

Strategy: Increase the percent of adolescents, women and birthing people enrolled in centering pregnancy programs who talk with a health care professional about birth spacing or birth control methods

 

Objective: Annually increase the percent of adolescents, women and birthing people who talked with a health care professional about birth spacing or birth control methods by 1%

 

ESM: Percent of adolescents, women and birthing people enrolled in Centering Pregnancy Programs who talked with a health care professional about birth spacing and birth control methods

 

In 2022, the BFH continued its partnership with Lancaster General Hospital (LGH) in Lancaster City to provide the Centering Pregnancy Program (CPP). The CPP aims to improve birth outcomes as well as improve the knowledge base of the participants related to pregnancy and parenting.

 

LGH also administers a group specifically for pregnant people with substance use disorder (SUD). Sessions are facilitated by a Licensed Social Worker certified in addictions counseling. The group follows the traditional CPP model of prenatal care but incorporates education specifically related to SUD and pregnancy, such as how to calm an infant going through withdrawal, stress management, and what to expect if your infant must stay in the Neonatal Intensive Care Unit. In 2022, 57 pregnant people enrolled in the SUD CPP group. Challenges to participation included fear of stigma and Children and Youth Services involvement, transportation issues, and scheduling conflicts with counseling and medication dosing appointments. However, despite challenges, the program continues to be successful with 91% of participants reporting satisfaction with their care. Due to increased SUD screenings in LGH’s medical practices, the SUD CPP group continued to have an increase in referrals. The program sessions remained virtual in 2022. The virtual format was more successful for the SUD group by eliminating barriers such as transportation and childcare, allowing participants to attend more frequently, and fostering stronger connections within the group.

 

Combined, LGH’s program served 111 families with a continued emphasis on improving birth outcomes and reducing inequities among this disproportionately affected population in Lancaster City. Of those served, 59.5% were white, and 15% were Black/African American, with 36% of participants identifying as Hispanic/Latinx. Program outcomes were positive. LGH saw higher than expected rates for full-term births with 93% of their participants delivering at full term. Breastfeeding/chestfeeding rates were also positively affected with 91% of participants breastfeeding/chestfeeding at birth versus 79% of birthing people receiving traditional prenatal care in the same practice. CPP participants were screened for depression and referrals were made to mental health professionals as necessary. The CPP had high patient satisfaction rates, with LGH reporting that 95% of birthing people that completed either the traditional CPP or SUD program were satisfied with the experience. This will be the last year for the CPP with LGH as their grant agreement will end on June 30, 2023.

 

Additionally, Albert Einstein Health Network (AEHN), located in Philadelphia and WellSpan York continued their expanded CPPs. Combined, in 2022, AEHN and WellSpan York served 110 birthing persons. WellSpan York continued to serve their Spanish-speaking population with the Centering sessions being led by a Spanish-speaking coordinator and the inclusion of Spanish-speaking healthcare providers. After over a year of providing CPP virtually, the sessions returned to in-person with both healthy food options and transportation, which had been a major barrier, being provided to participants.

 

The CPPs submitted data related to family planning and birth spacing, specifically how many adolescents and women talked with a healthcare professional about birth spacing and birth control methods. Eighty-nine percent of participants enrolled in CPPs talked with a health care professional about birth spacing and birth control methods, exceeding the goal of 85%. Delaying pregnancy allows birthing people in Pa. the opportunity to choose when they are ready to begin or expand their families. It also affords them the opportunity to improve their own health and habits prior to becoming pregnant.

 

Strategy: Implement care models that include preconception and interconception care

 

Objective: Increase the percent of women and birthing people enrolled in IMPLICIT ICC program screened for risk factors during well-child visits (WCV) by 1.5% each year

 

ESM: Percent of women and birthing people served through the IMPLICIT ICC program that are screened for the 4 risk factors during a minimum of one WCV 

 

Interconception care (ICC) is the use of medical and psychological interventions to address individuals’ risk factors between pregnancies, with the aim of improving future maternal and infant health outcomes. ICC has the capacity to reduce the persistent racial disparities in maternal and infant birth outcomes. The leading underlying causes of infant mortality, particularly among Black/African American babies, are low birth weight and preterm birth (factors which are often connected). By offering biomedical, psychosocial, and behavioral interventions prior to pregnancy, the influence of risk factors for adverse pregnancy outcomes, such as preterm birth, can be minimized.

 

The setting of ICC has taken multiple forms, with most birthing people being provided this care only during annual well-woman visits or at their postpartum checkup(s). However, in a system where most people do not routinely receive early postpartum care, birthing people may not see their maternal care provider until at least 6 weeks postpartum, if at all; many do not, or cannot, attend the six-week postpartum visit, due to time, childcare, work, and transportation constraints. Often, the first appointment a birthing person has with a provider after their baby’s birth is with their infant’s doctor – not their own, when they take their newborn or child to their routine WCV.

 

Family physicians are ideally positioned to lead health care system change related to ICC; even parents that lack providers of their own are likely to take their infants to their WCV. WCVs in the first two years of life occur frequently (at one and two weeks and at one, two, four, six, nine, 12, 15, 18 and 24 months), presenting family health providers with regular opportunities to screen for and address maternal risk factors. Working within the WCV framework provides an opportunity for family health providers to address maternal health during the interconception period.

 

In 2022, the BFH continued to partner with the University of Pennsylvania and the IMPLICIT Network to strengthen and expand the Title V-funded IMPLICIT ICC Program, wherein maternal screenings are conducted at WCVs. The IMPLICIT Network developed, piloted, and implemented a model for ICC in Pennsylvania in 2012. Since that time, the IMPLICIT ICC model of care has been successfully implemented in a variety of sites in several states and is showing promising results in reducing unintended pregnancies and improving preconception health.

 

The IMPLICIT ICC model promotes utilizing scheduled WCVs to improve the health of birthing people between pregnancies. At each WCV, birthing people are screened for four behavioral risk factors to assess their health (smoking status, depression, contraception use, and multivitamin with folic acid use), and counseled and referred for services as necessary. The ICC program is focused on increasing the number of birthing people who see their medical providers in the interconception period as well as changing maternal behaviors to improve overall health and birth outcomes in subsequent pregnancies.

 

The effectiveness of the ICC model of care is measured by how many birthing people are screened for modifiable maternal risk behaviors, and how many of those with positive screens receive either an intervention or a referral to services. In 2022, the IMPLICIT Network reached 3,587 unique parent-baby dyads who may not have received care otherwise. Of the individuals that received ICC screening, 15% screened positive for tobacco use, 11.7% for depression, 20.2% for lack of contraception use, and 41.3%for lack of multivitamin with folic acid use. Approximately 27% of the individuals who were served last year identify as Black/African American; continued efforts to expand the reach of this model is critical if it is to significantly impact statewide maternal racial health disparities.

 

The IMPLICIT Network experienced staffing challenges that impeded its ability to meet all grant goals regarding screening and intervention rates for 2022. ICC screening was performed at 8,551 well-child visits, resulting in an overall screening rate of 80.3%; this is lower than the target of 82.4%. The Network met grant goals for smoking, depression, and multivitamin interventions, but fell shy of meeting the targeted intervention rate for contraception. Interventions for positive screens were documented at the following rates: 88.8% for tobacco use, 96.2% for depression, 70% for contraception use, and 63.1% for multivitamin with folic acid use. Maternal behavioral change after intervention for each of the four behavioral risk factors continues to be tracked; a cohort of 700 people who gave birth in 2020 are being followed longitudinally to evaluate the effectiveness of the IMPLICIT ICC model of care.

 

In 2022, the IMPLICIT Network established a Health Equity Committee (HEC) to improve the quality of care for all through a more inclusive health equity lens. The HEC’s priority focus in 2022 was creating opportunities to collect feedback from, and collaborate with, the communities the Network serves.

 

Strategy: Implement community-based, culturally relevant maternal care models

 

Objective: Increase the number of community-based doulas providing services in priority neighborhoods

 

ESM: Number of community-based doulas trained in communities served by the program

 

Doulas are trained to provide non-clinical emotional, physical, and informational support, education, and advocacy during pregnancy, labor, and in the early postpartum period. In addition, doulas help empower pregnant people to establish and maintain positive communications with care providers, resulting in increased engagement in healthcare decision-making. Doulas spend up to 11 times longer with clients than other health care providers and encourage pregnant or postpartum people experiencing warning signs to seek medical attention prior to experiencing a life-threatening emergency. Doula care also improves maternal health outcomes by reducing unnecessary medical procedures that can result in serious short- and long-term complications.

 

Community-based doulas provide pregnant people and their partners with low-cost or free education, support, and counseling during pregnancy, birth, and the postpartum period; focus on eliminating health barriers and disparities; and promote healthy bonding between pregnant people and their babies. In contrast to conventional doulas, community-based doulas share the same background, culture, and language as the pregnant people they support. They also have additional training in social determinants of health, trauma, and racial equity that supplements the traditional doula education curriculum.

 

The Philadelphia Department of Public Health (PDPH) provides care through the Doula Support Program (DSP) to Philadelphia residents. The DSP focuses on prenatal and postpartum people with a history of a SUD, including opioid use disorder (OUD). The program utilizes a community-based doula model to offer support to enrolled individuals up until one year postpartum. Due to a rise in cases of infants born with neonatal abstinence syndrome (NAS), PDPH saw a need to design this program to specifically serve pregnant or parenting people with substance use issues. The doulas also help address social determinants of health by discussing housing, employment, and mental health. In 2022, the program served 52 pregnant or parenting people. Of these participants, 86% identified as Black/African American, and almost six percent identified as Hispanic/Latinx. Almost 90% of program participants were covered by Medicaid. To foster a sense of community among program participants, the DSP started a virtual parent group that meets twice a month to offer support and facilitate connections among program participants. 

 

In 2022, through the RFA process, the BFH awarded a grant to Pittsburgh’s Healthy Start program, to implement a community-based doula program using the HealthConnect One (HC One) model. Healthy Start operates in Allegheny and Westmoreland counties, in areas with high rates of racial disparities in preterm birth and infant mortality.

 

The HC One training curriculum and program model has been identified as an AMCHP “best practice”. HC One community-based doula programs provide no-cost, culturally concordant perinatal services to individuals at high risk for poor birth outcomes. Services are generally provided from the 24th week of pregnancy until three months postpartum and are intended to enhance infant health, strengthen families, and establish family supports.

 

The HC One model has been shown to decrease medical interventions during labor and delivery, improve birth experiences, and increase breastfeeding rates, among other positive outcomes. HC One community-based doula programs have the potential to reduce racial disparities and promote equity in health outcomes, mitigate risk factors, and promote the development of protective factors. In areas where an HC One community-based doula program has already been implemented, the program has been demonstrated to reduce medical interventions during labor and birth, improve bonding between parent and baby, improve rates of breastfeeding/chestfeeding, and support infant care.

 

No new doulas were trained through these initiatives during the reporting year. The PDPH doula program was staffed at maximum capacity and did not need to hire or train new doulas to provide doula care to the program’s service population. The start date for the Healthy Start HC One doula program was July 1, 2022. Due to the intensive, extensive, and comprehensive nature of the HC One 20-session doula training, no doulas completed the HC One training in the 2022 reporting year. The Grantee anticipates having their doulas fully trained by early 2023. The BFH looks forward to providing an update regarding implementation and progress of the Healthy Start community-based doula program in the 2023 Title V Report.

 

Objective: Increase the number of behavioral health providers trained in pregnancy intention assessment

 

ESM: Number of behavioral health providers trained in pregnancy intention

 

The unintended pregnancy rate for birthing people with OUD is 84.9%, significantly more than the national average of 45%. Further, according to the DOH’s “Neonatal Abstinence Syndrome: 2020 Report”, 1,825 newborns were diagnosed with opioid-related NAS, compared to 1,608 the year before. The incidence of NAS per 1,000 live births in 2020 was 14.0, an increase from the rate of 11.9 in 2019.

 

In 2022, the BFH continued and completed its partnership with the Alliance of Pennsylvania Councils, Inc. (Alliance) in an initiative to reduce the rate of unplanned pregnancies, increase access to family planning care, and improve detection and treatment access for women and birthing people with OUD. This multifaceted initiative built linkages between family planning organizations and behavioral health/substance use treatment centers between 2018 and 2022.

 

At the beginning of this project, each family planning council belonging to the Alliance was tasked with developing a pilot program to identify and address the specific needs of their region. Projects selected for implementation included training behavioral health providers on assessing their clients’ pregnancy intention and contraceptive needs; facilitating access to family planning services for people in treatment facilities; conducting screenings in schools to identify youth in need of services; and educating communities about SUDs, including OUD.

 

In 2022, the Alliance trained seven behavioral health providers to assess for pregnancy intention as part of their routine intake and counseling. Albeit this is higher than the number of providers trained in 2021 (two), it did not meet the objective to increase the number of behavioral health providers trained in pregnancy intention assessment. The low number of provider trainings and the absence of new partnerships with SUD treatment facilities was due to the natural project trajectory, as 2022 was the final year of the grant and the Alliance’s focus was instead on maintaining and strengthening existing partnerships.

 

In 2022, the Alliance provided services to improve the preconception health of and reduce unintended pregnancy rates for 5,243 individuals, including 3,804 people with an SUD, 3,076 individuals with OUD, 1,477 women with OUD, and 12 youth. Due to the subsiding of COVID-19 pandemic-related barriers and restrictions in 2022, the Alliance was able to refer more individuals to contraceptive care and conduct more counseling and group education sessions than in 2021. In 2022, 704 individuals participated in 86 group education sessions on sexual and reproductive health.

 

It is critical that initiatives intended to improve birth outcomes prioritize groups that have been historically economically and socially marginalized, such as populations of color. Although efforts have been made throughout this initiative to better engage individuals that identify as BIPOC, the majority (73.9%) of individuals served by this program in 2022 were white; however, the percentage of white clients varies between the pilot projects, depending in part on the demographics of the geographic area served. Overall, the population served by the program was slightly less majority-white than the state of Pa. (73.9% compared to 81%). The program also served more Hispanic/Latinx clients than the state population (17.2% compared to 7.8%). The overall racial and ethnic composition of the clients served did not shift substantially from 2021 to 2022, despite the continued disproportionate burden on people of color and the agencies that serve them.

 

This grant initiative ended in 2022. By increasing access to integrated sexual and reproductive health services for groups that are disproportionately affected by SUD, the BFH hoped to reduce the incidence of unintended pregnancy and improve health outcomes for birthing people with OUD and their babies. If the BFH selects to replicate elements of the pilot projects in future partnerships, a focus on serving communities of color will be key to addressing racial maternal and infant health disparities through this work.

 

Strategy: Implement care models that include maternal behavioral health screenings and referral to services

 

Objective: Increase the percent of women and birthing people enrolled in Title V home visiting, Centering Pregnancy, and IMPLICIT programs that are referred for services by 1% annually, following a positive screening

 

ESM: Percent of women and birthing people enrolled in home visiting, Centering Pregnancy and IMPLICIT that are referred for behavioral health services, following a positive screening 

 

The BFH understands the strong connection between physical and behavioral health and has worked to ensure that birthing people are screened for behavioral health issues when receiving care through Title V funded programs. The BFH requires all Title V funded CMHD home visiting programs to utilize evidence-based/informed screening tools to assess behavioral health issues during the perinatal period. By doing so, the BFH aims to identify and address potentially risky behaviors or circumstances to improve pregnancy outcomes, as well as improve health for children and families in the same household. Many of the CMHDs and the CPPs use the Edinburgh Depression Scale, a validated tool comprised of ten questions that can be used in both the prenatal and postpartum periods. In 2020, the BFH made the decision to no longer require the use of the 5Ps tool, a quick, non-threatening tool that assesses risk for alcohol dependency, substance misuse, interpersonal violence, and depression based on five domains (Parents, Peers, Partner, Pregnancy, and Past). To remain consistent, BFH staff have allowed the CMHDs to discontinue use of the 5Ps if it was not working for their organization. Going forward, as new grant agreements are executed, the BFH is asking partners to utilize evidence-based tools for depression screenings in lieu of the 5Ps tool which is not considered an evidence-based tool as it lacks published, peer-reviewed research studies.

 

The IMPLICIT ICC Program, mentioned earlier in this report, includes maternal depression screenings at WCVs. Birthing people are counseled and referred for services as necessary. This initiative is focused on increasing the number of birthing people who see their medical providers in the interconception period and changing maternal behaviors to improve overall health and birth outcomes in subsequent pregnancies. In 2022, 2,331 birthing people received a depression screening at their child’s WCV; of these, 471 had positive screenings, and interventions were documented for 453, or 96.2% of these individuals.

 

Given the importance of providing follow-up services for behavioral health issues, the BFH chose to measure the percent of women enrolled in home visiting, CPP, or IMPLICIT programs that are referred for behavioral health services, following a positive screening. Warm handoff referrals, where the home visitor or healthcare provider assists the participant in setting up a behavioral health appointment, help to increase the likelihood that the participant will follow through with the appointment. In 2022, 90.4.3% of pregnant and birthing people enrolled in the home visiting, CPP, or IMPLICIT programs were referred for behavioral health issues, following a positive screening. The focus on providing referrals for behavioral health services following a positive screen helped to exceed the first-year goal of 80% of participants that received referrals. Reasons pregnant and postpartum people may not be screened include refusal or early withdrawal from the program. Additionally, with many programs still holding virtual sessions due to COVID-19, participants are not always comfortable discussing mental health issues through a virtual platform.

 

Pa., through the Pennsylvania Partnership for Children, was awarded the Pritzker Children’s Initiative Prenatal-to-Age-Three Implementation grant. The overall goal of the project is to increase the number of children and families receiving high-quality services by 25% by 2023, and by 50% by 2025. BFH staff sit on the Maternal Health Subgroup, which focused on extending Medicaid access to postpartum services; advancing behavioral health screenings for prenatal and postpartum people; ensuring that those with a positive screen receive needed services; and advancing reimbursement for doulas in the Medicaid program.

 

Strategy: Implement care models that encourage women and birthing people to receive care in the early postpartum period

 

Objective: Increase the percent of women and birthing people that receive early postpartum care through a 4th trimester pilot program, compared to the year 1 baseline data, by at least 3% annually, starting with reporting year 2022

 

ESM: Percent of women and birthing people who attend a postpartum visit within 28 days of delivery, through the 4th trimester pilot program

 

Maternal mortality (MM) and morbidity, and the pervasive disparities between racial and ethnic groups, continues to be a strong area of focus. According to the CDC, there was a 40% increase in MM nationwide in 2021, with a rate of 32.9 deaths per 100,000 live births, compared with a rate of 23.8 in 2020 and 20.1 in 2019. In 2021, 1,205 individuals died of maternal causes in the U.S., compared to 861 in 2020 and 754 in 2019.

 

Racial disparities in health outcomes persist. In 2021, non-Hispanic Black/African American birthing people experienced a MM rate 2.6 times higher than that of white birthing people; 69.9 Black/African American women and birthing people per 100,000 died from maternal causes in 2021, versus 26.6 of their white counterparts. The MM rate continued to climb for Black/African American individuals; the rate for this population was 55.3 per 1000,000 live births in 2020, 44.0 in 2019 and 37.3 in 2018.  

 

In addition to racial disparities in MM rates, birthing people continue to experience disparities in MM based on age. In 2021, MM rates for individuals aged 40 and older were 6.8 times higher than the rate for women under 25. There were 20.4 deaths per 100,000 live births for birthing people under age 25, versus 31.3 for people aged 25-39, and 138.5 for individuals aged 40 and older.

 

Nationwide, the leading underlying causes of maternal mortality are cardiovascular conditions (more than 33%), infection (12.5%), and obstetric hemorrhage (11.2%). Based on CDC Maternal Mortality Review Committee (MMRC) Data from 36 states, over 80% of all pregnancy-related deaths are preventable. The leading underlying causes of pregnancy-related death among Black/African American birthing people are cardiac and coronary conditions, and over 50% of postpartum strokes occur within 10 days of delivery. Early postpartum care decreases mortality risk for people with hypertensive disorders and other chronic conditions.

 

Pregnancy care has traditionally been organized into three trimesters, with a single postpartum visit at approximately six weeks postpartum. The timing of this visit contradicts the evidence that shows over 50% of pregnancy-related deaths occur after the birth of the infant, and 40% of these deaths occur by six weeks postpartum. In addition, as many of 40% of individuals do not see their maternity provider at all after discharge from the hospital or birth center, with rates even lower among Black/African American people.

 

The “fourth trimester (4TM)” generally refers to, at least, the first three months postpartum up to a year postpartum. The mainstream maternal health framework does not provide routine care for birthing people until six weeks after childbirth, halfway through this period. However, birthing people experience significant biological, psychological, and social changes during this period that that can lead to poor outcomes if not promptly and adequately addressed. In the weeks following childbirth, preexisting conditions and new health concerns that go unaddressed can result in the exacerbation of these health issues and, in some cases, maternal death. By ensuring individuals receive a postpartum visit in the early fourth trimester – before 28 days have elapsed – birthing people can be connected to the care they need, and rates of maternal mortality and morbidity will decrease.

 

In 2018, the American College of Obstetricians and Gynecologists (ACOG) called for a new paradigm for postpartum care that addresses the current needs for birthing people and protects against morbidity and mortality after pregnancy. As a result of the ACOG recommendations, the IMPLICIT Network, with support from BFH, developed and began implementation of an innovative 4TM model of care, to address gaps in postpartum care and decrease rates of maternal morbidity and mortality in the early postpartum period. This care model enables providers to identify birthing people who are at increased risk of postpartum health problems, develop tailored care recommendations for families, and increase the number of birthing people receiving maternal health care within 28 days of delivery.

 

The IMPLICIT 4TM model aims to identify high risk patients, who may have mood concerns, obesity or wound concerns, thyroid disorders, hypertensive disorders, endocrine disorders, renal disease, or substance use disorders. 4TM providers create a postpartum registry of anyone who received prenatal care at the practice, or delivered with providers in the practice, and prioritizes getting patients back into the office to see their providers between 7 and 21 days after delivery. Ideally, providers develop a plan for the early postpartum visit when the patient is between 28 weeks gestation and delivery.

 

4TM providers collect patient data from multiple encounters, including at prenatal visits, immediately after delivery, and during the early postpartum visit. At the early postpartum visit, 4TM connects patients with any needed psychosocial, biomedical, and other wraparound services or referrals. 4TM screening assesses for biomedical risk (hypertension, preeclampsia, cardiovascular, diabetes, and postpartum hemorrhage) and psychosocial risk (depression, tobacco use, and substance use). In order to reduce fragmentation of care across providers and settings, providers establish a care team, which may include a primary care provider, specialty physician, lactation consultant, mental and behavioral health providers, and a case manager. Initially, the IMPLICIT Network planned to use baseline data from eight 4TM pilot sites established in 2021. The goal of establishing baseline data was to demonstrate the efficacy of the model, while expanding to new sites in 2022. However, due to COVID-19-related staffing limitations, the pilot project experienced significant barriers to establishing timely, consistent, and accurate data collection, reporting, and analysis, resulting in an extension of the pilot period.

 

In 2022, the IMPLICIT Network completed the pilot stage and fully implemented the 4TM model at three sites (Lancaster General Family Medicine Residency (FMR), UPMC Williamsport FMR, and University of Pennsylvania Philadelphia-FMR). By the end of 2022, two of these sites were sharing early postpartum visit and 4TM questionnaire data, and the third site was sharing early postpartum visit data, while collecting questionnaire data. The baseline data for the ESM was established in 2022, with 58.2% (336) of 577 eligible birthing people among the three sites having received an early postpartum visit through the 4TM program. In addition, the two sites currently sharing 4TM screening questionnaire data indicated that of the 426 birthing people who were eligible for 4TM screening at their sites, 318 (74.6%) received any 4TM screening and 219 (57.5%) received the full 4TM screening.

 

The IMPLICIT Network has continued to experience challenges in collecting, sharing, and analyzing data from the 4TM project. The data sharing process has so far largely relied on manual data entry, a labor-intensive and time-consuming process. In addition, unforeseen complications with utilizing and updating electronic health records and creating common workflows delayed progress of this initiative. Additionally, initial baseline data revealed issues related to data validity and clarity within the 4TM questionnaires, which have since been updated. In 2023, the IMPLICIT Network will continue to support 4TM sites’ efforts to implement the new care model and standardize, collect, share, and analyze data.

 

Strategy: Use Maternal Mortality Review Committee (MMRC) recommendations to inform programming

 

Objective: Implement a minimum of 1 MMRC recommendation annually

 

ESM: Number of MMRC recommendations implemented

 

To reduce risk factors associated with maternal deaths, particularly where there are racial/ethnic inequities, data regarding the incidence/causes of MM and prevention recommendations must be shared with health providers and the public. The Pennsylvania Maternal Mortality Review Committee (PA MMRC), a requirement of Pa.’s 2018 Maternal Mortality Review Act, serves as the formal process to investigate the causes of pregnancy-associated deaths and develop prevention strategies. Per legislative requirements, PA MMRC membership includes obstetricians, maternal fetal medicine specialists, certified nurse-midwives, addiction medicine specialists, specialized gynecologic psychiatrists, social workers, coroners, emergency medicine physicians, and community voices. In addition to clinical guidance, PA MMRC members consider the impacts of social determinants of health, with a goal of reducing racial bias and health inequity. This initiative is dually funded through the CDC and Title V.

 

The PA MMRC reviews all pregnancy-associated deaths, defined as a death during pregnancy or one year following the end of pregnancy regardless of outcome, in Pa. with the exception of pregnancy-associated deaths that occur in Philadelphia County. Philadelphia has administered a local MMRC for more than a decade. PA MMRC and Philadelphia MMRC collaborate to collectively review all deaths in Pa.

 

The PA MMRC’s first report highlighting maternal death cases from 2018, was published in January 2022. Recommendations were provided for system, provider, and community levels related to four primary themes: build infrastructure to identify and support pregnant and postpartum individuals with mental health concerns; build infrastructure to identify and support pregnant and postpartum individuals who use substances; build infrastructure to provide more comprehensive medical care for all pregnant and postpartum individuals; and build infrastructure to identify and support pregnant and postpartum individuals with history of intimate partner violence. These themes were presented to the Pennsylvania Perinatal Quality Collaborative (PA PQC), the action arm of the MMRC, for potential implementation of specific recommendations.

 

In 2022, the PA MMRC reviewed 2020 pregnancy-associated deaths. In 2020 there were 87 cases verified as pregnancy associated. During this time the committee reviewed a total of 54 of the 87 verified cases or 62% of cases. Of those reviewed, 32 deaths were accidental deaths, including poisoning/overdose, with 23 of the 32 related to substance use. There were seven homicides, two suicides, and 13 natural deaths. The committee determined that 15 of the cases reviewed were pregnancy-related, defined as a death during pregnancy or within one year of the end of pregnancy from a pregnancy complication, a chain of events initiated by pregnancy, or the aggravation of an unrelated condition by the physiologic effects of pregnancy.

 

Maternal Mortality Review Program (MMRP) staff continued to strengthen partnerships with internal and external stakeholders. Staff attended the Pennsylvania Coroner’s Association Annual Meeting to convey the critical role coroners’ and medical examiners’ records play in the work of the MMRC. Internally, staff met with the Bureau of Health Statistics and Registries as well as other program areas who review deaths to improve the quality of data acquired for the MMRP.

 

In 2021, Philadelphia MMRC implemented recommendations around four topic areas: Early Warning Signs Training Initiative, Obstetrics and Cardiology Taskforce, Transforming Philadelphia’s Response to Intimate Partner Violence in Acute Obstetrical Settings, and Community Investment. While no new recommendations were implemented in 2022, Philadelphia MMRC continues to work to implement programming and initiatives around these topics.

 

In 2022, the PA PQC worked with 55 hospitals representing 81% of live births in Pa. to implement the following initiatives: an expanded focus on maternal OUD (39 hospitals), NAS (43 hospitals), and contraceptive care, including access to immediate postpartum long-acting reversible contraception (LARC) (19 hospitals); Moving on Maternal Depression (MOMD) to improve prenatal and postpartum depression screening and follow-up rates and reduce associated racial/ethnic disparities (23 hospitals); and the PA AIM initiative to adopt the PA AIM Bundle to improve severe hypertension in pregnancy treatment and reduce associated racial/ethnic disparities (24 hospitals). Each of these initiatives have made considerable progress in improving the safety of pregnant and parenting people in Pa.

 

Strategy: Initiate regular meetings and collaboration between DOH, DHS, and MIECHV

 

Objective: Convene quarterly meetings between agencies that provide services related to maternal health

 

ESM: Number of meetings held between DOH, DHS and MIECHV annually (maternal health)

 

Effective collaboration and coordination are important to create a high-quality system of support for birthing people and families in Pa. Collaboration across agencies and programs ensures better coordinated services and reduces the duplication of services across agencies. BFH staff met the goal of convening with DHS and MIECHV quarterly in the 2022 calendar year. The intent of these meetings is collaboration among agencies to understand the programs and initiatives offered through the systems of care for the people in Pa. This knowledge and understanding aids in the development of gap filling programs offered through Title V.