Women/Maternal Health Progress Report (October 1, 2021-September 30, 2022)

The 2020 comprehensive Title V needs assessment process led to the development of the

Priority Need: To improve utilization of preventive health visits to promote women’s health before, during and after pregnancy.  Several strategies were identified and incorporated into the state action plan to impact the following performance measures:

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

As SC Behavioral Risk Factor Surveillance System (BRFSS) data from 2021 indicate 72.5% of women 18-44 years of age had a routine checkup within the past year, much work is needed to meet the 2025 objective of 85%. SC’s state action plan includes a focus on utilization of health care visits to improve women’s health throughout the life course—before pregnancy to ensure the woman is healthy prior to conception and manage chronic conditions; early in the pregnancy for appropriate monitoring, screenings and education; and postpartum to ensure mom is recovering from delivery and any risks can be identified and managed (e.g., maternal mortality, postpartum depression).

The MCH Bureau’s Family Planning/Title X/Preventive Health program provides contraceptive services, pregnancy testing and counseling, and other preconception health services such as screening for smoking, depression, domestic violence, and substance use disorder (SUD). Services are provided through a network of 57 Preventive Health clinics located throughout the state. Most DHEC Preventive Health sites supply prenatal multivitamins and dispense to women seeking pregnancy or who are currently pregnant. When indicated, referrals and linkages to needed support services were provided by the clinics. Each clinic has a community resource list available to provide to clients that encompass a multitude of resources including local Medicaid offices, local Federally Qualified Health Centers (FQHCs), other free and low-cost clinics, mental health, substance use, and dental service providers.

During this reporting period, DHEC Preventive Health sites provided 27,469 women between the ages of 18-44 with a preventive medical visit, which was a slight increase when compared to the prior reporting period. Additionally, 2,517 women who received family planning and preventive health counseling had a positive pregnancy test.  In an effort to expand preventive health services, the University of South Carolina opened DHEC’s first satellite clinic on their Lancaster County campus. This clinic provided the same preventive health services as the local health department and served the student body and public. DHEC continued their partnership with FQHCs Regenesis Health Care in Union County and added CareSouth Carolina in Dillon County. Partnering with these FQHCs help improve the quality and access of reproductive health services in underserved communities.

Increasing awareness and providing education to women, children and families around available resources is an identified strategy to increase service utilization. DHEC is required by law to provide a Family Services Directory that lists services for women and children by provider and by county. These resources include adoption, child care, clothing assistance, counseling, emergency services, employment, family planning, financial support, health care, hospitals, housing, legal aid, substance abuse treatment programs, transportation, and services to help victims of domestic violence and sexual assault, addressing barriers faced by women throughout the state. The MCH Bureau is responsible for maintaining and updating the directory, and efforts to update the service list and explore more interactive access to the information continued. During FFY2022, there were 605 downloads of the Family Services Directory. Similarly, the MCH Bureau partners with The Care Line, which serves as the state’s Title V information and referral hotline and provides support to women and their families by making it easier to get the services they need. From October 1, 2021 to September 30, 2022 a total of 103,656 calls were made to the Care Line. Of this number, 26,218 were specific to the COVID-19 response.

MCH Bureau staff also participate in outreach activities. Promotional material/items were also disseminated throughout the state at conferences, health fairs and community events. During FFY2022, we were able to attend more in-person events as Covid-19 restrictions were lifted. DHEC and partners were able to distribute educational and promotional material in person and through home-visit drop offs; answer questions and make referrals at the outreach events; and also partner with Palmetto Healthy Start and Family Solutions of the Low Country to provide educational and resource materials for their clients during their breastfeeding classes, birthing sessions, car seat safety classes, family planning classes and nutrition classes.

Another strategy to increase utilization of services is to strengthen the referral network for women who screen positive for substance misuse and abuse. On May 2, 2022 the Medical University of South Carolina (MUSC) launched SC’s Perinatal Psychiatry Access Program, called Moms IMPACTT (IMProving Access to Perinatal Mental Health and Substance Use Disorder Care Through Telehealth and Tele-mentoring), with SC’s Title V program serving as a member of the Project IMPACTT Advisory Committee.  Moms IMPACTT provides pregnant and postpartum people, with immediate access to evidence-based perinatal mental health (PMH) and Perinatal Substance use Disorder (PSUD) treatment, including care coordination, to address the specific medical, psychiatric, social and family needs of PPW via phone and telehealth modalities. 

A Care Coordinator (CC) employs a Brief Intervention (BI) using Motivational Interviewing (MI) techniques to support positive health behaviors and a shared decision-making process to provide patient-centered referrals to an appropriate level of care and/or Social Determinants of Health (SDoH) resources. IMPACTT also promotes effective and efficient coordination and delivery of services across multiple systems and providers (e.g., behavioral health, obstetrics, pediatrics, primary care, child and family services, community organizations) by offering training and provider-to-provider consultation to build provider capacity to identify and manage PSUD/PMH concerns.

The Moms IMPACTT access program has been combined with a monitoring program, Listening to Women and Pregnant and Postpartum People (LTWP), so that women’s PSUD, PMH and/or SDoH needs are met throughout pregnancy and the postpartum year. Women accessing IMPACTT are enrolled in LTWP, in a text/phone-based screening and remote care coordinating system. LTWP includes brief text-based mental health and substance use screenings with immediate access to CC (role described in Moms IMPACTT), during each trimester in pregnancy, one month postpartum and every three months from delivery until 12 months postpartum. 

Both IMPACTT and LTWP have demonstrated benefit in creating better access to care for women with PSUDs, PMH and SDoH and supporting frontline health providers that care for them. In the past year, the IMPACTT program provided access to care for 585 perinatal women (65% White, 28.4% Back, 9.5% Hispanic, 2% Native American), of which 52% are insured by Medicaid, 91.3% reside in counties designed as fully Medically Underserved Areas, and 32.2% reside in counties designed as fully rural.

Further, an evaluation of LTWP, which included 3,535 PPW receiving prenatal care in a large outpatient obstetric practice, demonstrated that women enrolled in LTWP were significantly more likely to be screened for PMH, PSUDs and Intimate Partner Violence (IPV) [RR:1.10, 95%CI 1.03-1.16], screen positive [RR:1.91, 95%CI 1.72-2.10], be referred to treatment [RR:1.55, 95%CI 1.43-1.69], and attend treatment [RR:4.95, 95%CI 3.93-6.23], compared to women who received in‐person Screening, Brief Intervention and Referral to Treatment (SBIRT). Importantly, LTWP demonstrated a significant reduction in racial disparities; Black women enrolled in LTWP were significantly more likely to screen positive [54.1% vs. 32.9%; RR: 1.65, 95% CI 1.35-2.01], and attend treatment for mental health conditions [83.0% vs. 14.6%; RR: 5.49, 95% CI 3.69-8.17], compared to Black women receiving in-person SBIRT.

Additional strategies related to substance use screening and referrals are outlined in the Perinatal/Infant domain.

Community Health Workers are excellent resources that can greatly enhance utilization of services, especially in the MCH arena. One Title V strategy is to partner with the Center for Community Health Alignment at the University of South Carolina (USC) Arnold School of Public Health to increase utilization of CHW in communities of greatest need. During FFY2022, CCHA continued to channel investment in CHWs and the organizations that employ them, incorporating evaluation and sustainability plans. Some examples include:

• CCHA was successfully funded for another year for the “CHWs Changing Outcomes in SC” (CCOSC) statewide project. Funded by the SC Department of Health and Human Services, this year the program provides funding for 23 CHWs at 14 clinical settings and community-based organizations, reaching all 46 counties in the state. Priority areas include Type 2 Diabetes, high-need / high-cost service use, immunizations, pediatric asthma, sickle cell disease, and perinatal health. Five of these CHWs are explicitly focused on perinatal health. The USC Center for Rural and Primary Healthcare (CRPH) is conducting an evaluation of this program that includes quantitative and qualitative data.
• Collaborating with Diabetes Free SC to fund, train, and support CHWs at five community health centers across the state for the second of three years. In addition, CHWs support pregnant people with diabetes as part of the Management of Maternal (MOMs) Programs at three sites across the state. CRPH is also evaluating this program.
• CCHA’s EACH Mom & Baby Collaborative has funded three projects to expand access to perinatal CHWs in South Carolina, with a fourth one starting in the fall of 2023.
  • A PASOs-trained CHW has been integrated into the Shifa free prenatal care clinic in Charleston.
  • Five Certified Peer Support Specialists (CPSS), who are in recovery from substance use and work with others in their recovery journey, cross-trained as community-based doulas with BirthMatters. One CHW is now working with the Medical University of SC’s Women’s Reproductive Behavioral Health division as a CPSS-Certified Doula. The other four are integrating doula work into their roles at women’s residential treatment centers, area drug and alcohol centers, and correctional facilities.
  • Two CHWs working in rural counties with SC’s Department of Health and Environmental Control in the Midlands have expanded their services to include Family Solutions’ perinatal curriculum and structure.
• CCHA created video case studies of CHWs and the work they do at various sites across the state – available online.

Building and enhancing the skills of the CHW workforce was deemed a priority in FFY22. CCHA has two CHW Core Competency training courses – one in English (delivered by the CHW Institute) and one in Spanish (delivered by PASOs) – that are approved training courses by the SC CHW Credentialing Council. There is currently one specialty track that is credentialed to provide CHW continuing education credits (perinatal), and four more have applied for credentialing.

• Since 2020, CCHA has trained 224 people in CHW Core Competency who then went on to receive CHW certification from the SC CHW Credentialing Council - 168 people in English and 56 in Spanish.
• The training team has also held several cohorts of specialty workshops, covering MCH topics such as perinatal health, diabetes prevention and management, opioid misuse prevention and care and STIs.

CCHA and CRPH partnered to develop and disseminate the CHW Prioritization Index (available online). This interactive database uses several indicators of community priorities and opportunities, to determine where CHWs are most needed in our state and can be filtered to focus on perinatal indicators.
 

SPM 1: Percent of women who receive a post-partum check up.

SC Pregnancy Risk Assessment Monitoring System (PRAMS) data show 90.6% of women who delivered a live birth in 2021 had a post-partum visit, an increase of 6.3% from the previous year. The Title V program has identified several strategies to increase utilization to 92% by the year 2025.

On April 22, 2022, SC DHHS extended Medicaid coverage from 60 days to 12 months postpartum for new and expecting mothers who qualify for Medicaid because they are pregnant. SCDHHS expects this targeted policy change to provide extended coverage for approximately 5,000 women per year.

This timeframe corresponds to the second year of the Postpartum Care Learning Collaborative Affinity Group. The group participates in monthly technical assistance calls and monthly calls with the eight other states. We participate in workshops that focus on implementing quality improvement projects to improve health outcomes during the postpartum period for Medicaid and CHIP beneficiaries. Plan Do Study Acts (PDSA) were done with two groups: BirthMatters, a doula program utilizing the Community Health Worker Model; and Listening to Women Program, a patient-and-provider-informed technology-enhanced intervention using text/phone-based screening and referral programs for pregnant and postpartum women experiencing mental health, substance use problems or intimate partner violence. The goal was to identify the best practices in each program.

Increasing awareness of post-partum danger signs for mothers at risk of maternal morbidity and mortality has been identified as a Title V strategy and is key to reducing adverse birth outcomes. The Title V program released a limited version of the CDC’s Hear Her Campaign during FFY2021 to educate new moms and family members of the danger signs in the postpartum period and also introduce strategies to empower new moms in advocating for their healthcare. Additionally, the CDC has resources/materials that address Urgent Maternal Warning signs, and these resources are being distributed in hospital discharge packets for birthing persons. The one-page fact sheet was also shared with the multidisciplinary SC MMRC for distribution among their facilities and office practices. DHEC plans to promote the Hear Her Campaign further through television and radio advertising, social media, and continuing to share printed educational materials.

NPM 2: Percent of cesarean deliveries among low-risk first births.

Percent of cesarean deliveries among low-risk first time births is one measure that has been a priority for Title V and the SC BOI. This indicator is associated with the longer outcome measures of severe maternal morbidity per 10,000 delivery hospitalizations and the maternal mortality rate per 100,000 live births. The strategies Title V has identified to reduce morbidity and mortality among our SC moms are outlined below.

Title V/MCH has collaborated with the SC Medicaid Agency, the Department of Health and Human Services, and BOI to support state-wide adoption of AIM safety bundles among birthing facilities. This is SC’s third year of involvement with the AIM initiative. AIM is a national data-driven maternal safety and quality improvement initiative promoting consistent and safe maternity care to reduce maternal mortality by aligning national, state and hospital-level quality improvement efforts. AIM Hospital Champions meet monthly during the SC BOI Quality and Patient Safety Workgroup meeting to discuss the implementation of patient safety bundles and improvement strategies. Every birthing facility in SC has an identified a hospital Champion who receives outreach regarding the implementation of the AIM maternal safety bundles.  As a state, we continue to work to engage those facilities that are late adopters through our clinical and OB educator networks.  

Since 2015, SC DHHS and Prisma Health-University of South Carolina School of Medicine Simulation Center have continued a multi-year partnership for the SimCOACH trainings. SimCOACH is a mobile simulation education unit, and annual team trainings are offered to each birthing hospital in SC. Trainings, led by a maternal-fetal medicine specialist, address obstetric and neonatal emergencies and best practices in maternal fetal health.  SC’s Title V program coordinates these efforts and more through a contract mechanism with each of the 4 Regional Perinatal Centers to ensure trainings and education are provided to all birthing facilities across the state.

Strengthening capacity and support of SC’s Maternal Morbidity and Mortality Review Committee is a key strategy to reduce adverse maternal outcomes. The SC MMRC, housed within DHEC’s MCH Bureau, collects, reviews and analyses data for pregnancy associated deaths and develops annual legislative briefs. Some of the topics addressed include pregnancy related deaths by the timing of the death in relation to pregnancy, pregnancy related determination of maternal deaths, leading causes of pregnancy related deaths, preventability of the death, and contributing factors to include discrimination and mental health conditions. The MMRC makes recommendations to prevent pregnancy related deaths. The legislative briefs have been presented and disseminated at the SC Birth Outcome Initiative (BOI) meetings, the SC OB Task Force and SC ACOG. These agencies are instrumental in the disseminating the SC MMRC’s recommendations. Strengthening the capacity and support of MMRC is a key strategy to improve maternal health outcomes. During FFY2022, a social worker was hired as part of the MMRC to include the family/patient voice; interviews are now being conducted with family members of the deceased mother to better assess circumstantial and contributing factors.

Table 1. Significance* Testing for Women/Maternal Health Measures

*p<0.05