Required HRSA Performance Measures Selected for the California Women/Maternal Health Domain:

The Maternal, Child, and Adolescent Health Division of the California Department of Public Health (CDPH/MCAH) is including these measures at the beginning of each population health domain annual report to provide reviewers a quick reference to the following required HRSA Performance Measures: National Performance Measure (NPM), National Outcome Measure (NOM), and Evidence-based/informed Strategy Measure (ESM).

 

• NPM: Selected by CDPH/MCAH for each domain from the HRSA MCH Block Grant Performance Measure Framework.
• NOM: Designated automatically by HRSA to correspond to the selected NPM.
• ESM: Developed by CDPH/MCAH to track and drive improved outcomes for the Women/Maternal domain.

 

Women/Maternal Health Measures:

 

NPM 1: Well-woman visit – Percent of women, ages 18 through 44 with a preventive medical visit.

 

National Outcome Measures:

NOM 2.	Rate of severe maternal morbidity per 10,000 delivery hospitalizations
NOM 3.	Maternal mortality rate per 100,000 live births
NOM 4.	Percent of low birth weight deliveries (<2,500 grams)
NOM 5.	Percent of preterm births (<37 weeks)
NOM 6.	Percent of early term births (37, 38 weeks)
NOM 8.	Perinatal mortality rate per 1,000 live births plus fetal deaths
NOM 9.1.	Infant mortality rate per 1,000 live births
NOM 9.2.	Neonatal mortality rate per 1,000 live births
NOM 9.3.	Post neonatal mortality rate per 1,000 live births
NOM 9.4.	Preterm-related mortality rate per 100,000 live births
NOM 10.	Percent of women who drink alcohol in the last 3 months of pregnancy
NOM 11.	Rate of neonatal abstinence syndrome per 1,000 birth hospitalizations
NOM 23.	Teen birth rate, ages 15 19, per 1,000 females
NOM 24.	Percent of women who experience postpartum depressive symptoms following a recent live birth

CDPH/MCAH developed the below ESM to track and drive improved outcomes for the Women/Maternal Health Domain.

 

ESM 1.1.: Percent of Local Health Jurisdictions that have adopted a protocol to ensure that all persons in MCAH Programs are referred for enrollment in health insurance and complete a preventive visit.

Surveillance:

CDPH/MCAH monitored select quantifiable characteristics to track the health of California’s women and mothers as part of its routine surveillance efforts. The select indicators and measures listed in the table below are continuously and systematically collected, analyzed, and interpreted to guide program planning, implementation, and evaluation of interventions. CDPH/MCAH will continue to analyze by state and, when possible, county, race/ethnicity, maternal age, and other sub-state levels given the specific measure and the data constraints to identify specific improvement opportunities.

 

These indicators and measures serve to identify emerging issues, target program interventions, track progress toward specified objectives in the Five-Year Action Plan, allow priorities to be re-evaluated, and inform public health policy and strategies. Information gleaned from health surveillance data provides in-depth understanding of the health status of women and mothers, uncovers health disparities, and guides how CDPH/MCAH leads, funds, partners, and supports efforts at the state and local levels to improve efforts that will lead to desired outcomes.

 

 

As part of California’s Title V State Action Plan, focus areas were identified in each population domain to help guide the work. Each year, the 61 Local Health Jurisdictions (LHJs) in California develop annual Scopes of Work (SOW) that contain activities that align with the state’s Title V Action Plan and these focus areas.

 

The following graph shows the number of LHJs and the related focus areas in the Women/Maternal Health Domain that had activities the LHJs planned to implement in their 2022-2023 SOWs.

 

 

• 18 LHJs (30%) worked on Women/Maternal Focus Area 1: Reduce the impact of chronic conditions related to maternal mortality via 25 SOW activities in FY 2022-23.
• 30 LHJs (49%) worked on Women/Maternal Focus Area 2: Reduce the impact of chronic conditions related to maternal morbidity via 56 SOW activities in FY 2022-23.
• 53 LHJs (87%) worked on Women/Maternal Focus Area 3: Improve mental health for all mothers in California via 106 SOW activities in FY 2022-23.
• 29 LHJs (48%) worked on Women/Maternal Focus Area 4: Ensure optimal health before pregnancy and improve pregnancy planning and birth spacing via 59 SOW activities in FY 2022-23.
• 32 LHJs (52%) worked on Women/Maternal Focus Area 5: Reduce maternal substance use via 54 activities in FY 2022-23.

 

Women/Maternal Priority Need 1:  

Ensure women in California are healthy before, during, and after pregnancy.

 

Women/Maternal Focus Area 1: Reduce the impact of chronic conditions related to maternal mortality.

 

Women/Maternal Objective 1:

By 2025, reduce the pregnancy-related mortality ratio (up to one year after the end of pregnancy) from 12.8 deaths per 100,000 live births (2019 CA-PMSS) to 12.2 deaths per 100,000 live births.

 

Story Behind the Curve:

California’s pregnancy-related mortality ratio was mostly stable from 2009 to 2019 and consistently lower than the U.S. pregnancy-related mortality ratio. The latest pregnancy-related mortality ratio for the U.S. was 17.6 deaths per 100,000 live births in 2019[1] while California’s pregnancy-related mortality ratio was 12.8.[2] The U.S. pregnancy-related mortality ratio may be an underestimate of the true burden due to limitations for identifying and verifying pregnancy-related deaths compared with the California Pregnancy Mortality Surveillance System (CA-PMSS). Due to the impact of the COVID-19 pandemic, California's pregnancy-related mortality ratio increased to 18.6 deaths per 100,000 live births in 2020.

 

Despite the lower overall pregnancy-related mortality ratios in California, racial and ethnic disparities persisted, aligning with national statistics. In 2018-2020, the pregnancy-related mortality ratio for Black women and birthing people was 3.1 to 3.6 times greater than the mortality ratios for Asian/Pacific Islander, Hispanic/Latina, and White women and birthing people.

 

Cardiovascular disease remained the leading cause of pregnancy-related mortality in 2018-2020. Other leading causes were hemorrhage, sepsis/infection, thrombotic pulmonary embolism, and amniotic fluid embolism. Pregnancy-related mortality ratio for deaths due to hypertensive disorders declined significantly from 1.4 deaths per 100,000 live births in 2015-2017 to 0.8 in 2018-2020. As a result, in 2018-2020 hypertensive disorders were no longer among the leading causes of pregnancy-related mortality.

 

Characteristics that trended with higher pregnancy-related mortality ratios for all racial/ethnic groups were older age, obesity, public health insurance coverage (Medi-Cal), and living in less advantaged communities. Geographic variations in pregnancy-related mortality ratios were also noted and ranged from 11.6 deaths per 100,000 live births in the Orange – San Diego – Imperial Region to 19.5 in the Northeastern and Northern Central Valley Region.[3]

California has made progress to reduce pregnancy-related mortality through investment in maternal health programs, strong leadership and engagement of the maternity care community, and targeted hospital quality improvement. California has longstanding (e.g., the Black Infant Health program) and newer (e.g., Senate Bill 65,[4] also called California’s Momnibus Act) interventions targeting racial disparities in birth outcomes, but more needs to be done to narrow racial and ethnic disparities. A thorough public health investigation is needed to understand how systems and community-level characteristics interact with patient, provider, and facility-level factors in contributing to pregnancy-related mortality and related disparities. Comprehensive case reviews to identify contributing factors (including discrimination and structural racism), improvement opportunities, and preventability are underway via the California Pregnancy-Associated Review Committee (CA-PARC).[5]

 

Women/Maternal Objective 1: Strategy 1:

Lead surveillance and investigations of pregnancy-related deaths (up to one year after the end of pregnancy) in California.

 

Activity:

CDPH/MCAH will lead and fund pregnancy-related mortality surveillance and public health investigation activities.

 

Narrative:

The California Momnibus Act (Chapter 449, Statutes of 2021) requires CDPH to establish the California Pregnancy-Associated Review Committee (PARC) effective August 1, 2022, to conduct in-depth reviews of all pregnancy-related deaths. CA-PARC now serves as the umbrella framework for long-standing California Pregnancy-Associated Mortality Review (CA-PAMR) subcommittees.

 

CDPH/MCAH’s California Pregnancy Mortality Surveillance System (CA-PMSS) aims to provide timely and accurate statewide surveillance of pregnancy-related mortality (up to one year after the end of pregnancy) through rapid-cycle case reviews by an expert committee. Meanwhile, CDPH/MCAH’s CA-PARC aims to identify contributing factors, clinical quality improvement and public health strategies, and preventability through in-depth case reviews by one or more committees of clinical and community experts. Findings from CA-PARC inform actionable recommendations for preventing pregnancy-related deaths and reducing health inequities.

 

CDPH/MCAH maintains an ongoing CA-PMSS expert committee and has two active CA-PARC subcommittees: (1) a population-based Southern California Pregnancy-Associated Mortality Review (PAMR), which is reviewing all-cause deaths in a four-county Southern California region which includes the counties of Los Angeles, Orange, Riverside, and San Bernardino; and (2) a topic-focused COVID PAMR, which is reviewing pregnancy-related deaths from COVID-19 statewide. Deaths reviewed by CA-PARC subcommittees are not also reviewed by a CA-PMSS expert committee. All deaths, whether reviewed in CA-PMSS or CA-PAMR, are included in the CA-PMSS surveillance data.

 

As of June 30, 2023, the CA-PMSS expert committee completed rapid reviews of all suspected pregnancy-related deaths in 2021 (43 deaths) and 28% of deaths in 2022 (11 of 40 deaths, number not final). The Southern California PAMR expert committee completed in-depth reviews of all suspected pregnancy-related deaths in the four-county region for both 2020 and 2021 (32 and 22 deaths, respectively). The COVID PAMR expert committee completed in-depth reviews of all COVID-19 deaths suspected to be pregnancy-related in 2020 (23 deaths) and 43% of deaths in 2021 (19 of 44 deaths). To date, CA-PMSS has identified 15 deaths from COVID-19 for 2023 (number not final).

 

Activity:

CDPH/MCAH will lead surveillance and reporting of pregnancy-related mortality as mandated by Senate Bill (SB) 464 – California Dignity in Pregnancy and Childbirth Act and SB 65 – Maternal Care and Services.

 

Narrative:

CA-PMSS satisfies the mandated surveillance and reporting of pregnancy-related mortality. Following the completion of CA-PMSS reviews, near real-time updates for pregnancy-related mortality data are accessible on CDPH/MCAH’s Pregnancy-Related Mortality Data Dashboard, and accompanying teaching slide decks are available for download on the CA-PMSS webpage.

 

Activity:

CDPH/MCAH will focus surveillance and reporting on disparities to inform MCAH programs and promote health equity in California.

 

Narrative:

Findings from CA-PMSS and CA-PARC are disaggregated by sociodemographic characteristics, such as race/ethnicity and delivery payer source, to identify which characteristics correlate with higher or lower pregnancy-related mortality ratios. Disparities in pregnancy-related mortality are also examined by geographic region and by community conditions defined using the California Healthy Places Index, a validated measure that captures information on social determinants of health at the census tract level.[6] Additionally, CA-PARC’s case reviews include deliberations of system- and community-level contributing factors and the contributions of discrimination and structural racism to pregnancy-related deaths and associated health inequities. For reviews of deaths that occurred in 2020-2022, case review materials were modified to capture the impact of the COVID-19 pandemic on pregnancy-related mortality.

 

Activity:

CDPH/MCAH will continue to lead and fund data products associated with pregnancy-related mortality.

 

Narrative:

CDPH/MCAH and its partners presented findings on pregnancy-related mortality at a national scientific conference, two meetings with key stakeholders in California, and published two CA-PMSS data updates. Scientific presentations included (1) a poster presentation titled, “Less advantaged community conditions are associated with higher pregnancy-related morality in California,” and (2) a poster presentation titled, “Comparing early and later-gestation pregnancy-related deaths in California 2009-2019,” both presented at the 2022 American Public Health Association Annual Meeting. In October 2022, CDPH/MCAH and its partners presented findings from the Hemorrhage PAMR back to the expert committee. CA-PMSS published reporting is described above.

 

Activity:

CDPH/MCAH will lead the dissemination of data findings from CA-PMSS and CA-PAMR case reviews to raise awareness about pregnancy-related deaths and to improve clinical best practices in maternity care.

 

Narrative:

CDPH/MCAH routinely updates the CA-PMSS and CA-PARC webpages to promote the release of surveillance reports, manuscript publications, and data updates. (CDPH/MCAH also launched a new webpage on maternal mortality that includes the latest information, data products, and resources on this topic.) Communications/media packages–including promotional messaging, fact sheets, and social media content–routinely accompany CA-PMSS and CA-PARC data releases. Additionally, CDPH/MCAH delivers near real-time updates for the Pregnancy-Related Mortality Data Dashboard upon the completion of CA-PMSS reviews. This dashboard, along with other indicator-specific dashboards for California, are designed to serve the data needs of our partners and stakeholders. State-, county-, and/or regional-level indicator data are shown by various stratifications or subgroups and by year. Each dashboard also includes a link to download the data. The dashboards are organized by the five Title V health domains.

 

Women/Maternal Objective 1: Strategy 2:

Partner to translate findings from pregnancy-related mortality investigations into recommendations for action to improve maternal health and perinatal clinical practices.

 

Activity:

CDPH/MCAH will lead the development of recommendations for prevention of pregnancy-related mortality.

 

Narrative:

Data analyses of quantitative and qualitative data, prioritization of recommendations, and plans for dissemination of findings from the Southern California PAMR and COVID PAMR are underway. Preliminary quantitative and qualitative data were presented to the two committees, and positive feedback was received, indicating the analyses are heading in the right direction. Several data products (i.e., manuscript, data brief, fact sheet) summarizing findings and recommendations from in-depth review of obstetric hemorrhage deaths that occurred in 2014-2018 are in progress. (The Hemorrhage PAMR expert committee reviewed 49 obstetric hemorrhage deaths between November 2020 and May 2022.)

 

Activity:

CDPH/MCAH will partner with community stakeholders to disseminate best practices related to improving maternal health and support systems based on data findings.

 

Narrative:

With dissemination and translation of findings in mind, CDPH/MCAH and partners convened CA-PAMR and CA-PMSS committees that include clinical and community experts with ties to provision of care, support services, and advocacy for pregnant and birthing people. Plans are also underway to develop an inclusive, bidirectional engagement plan with local community partners who are from or represent communities disproportionately affected by pregnancy-related mortality.

 

In addition, in response to the California Momnibus Act (Chapter 449, Statutes of 2021) which requires CDPH to analyze common causes of severe maternal morbidity and make recommendations on strategies to prevent maternal mortality and morbidity, CDPH/MCAH established a new program section to address Maternal Morbidity/Mortality Prevention. This section will have subject matter experts to support the CA-PARC, develop and implement key informant interviews and help translate findings and other results into meaningful action, including partnering and engaging with the community. These positions are currently being filled.

 

Women/Maternal Focus Area 2: Reduce the impact of chronic conditions related to maternal morbidity.

 

Women/Maternal Objective 2:

By 2025, reduce the rate of severe maternal morbidity from 93.5 per 10,000 delivery hospitalizations (2018 PDD) to 88.8 per 10,000 delivery hospitalizations.

 

Story Behind the Curve:

Contrary to CDPH/MCAH’s objective for Severe Maternal Morbidity (SMM), the rate of SMM increased from 104.4 per 10,000 delivery hospitalizations in 2020 to 110.5 per 10,000 delivery hospitalizations in 2021. In 2021, Black women were more likely than all other racial/ethnic groups to have at least one severe maternal complication (173.8 per 10,000 delivery hospitalizations). Pacific Islander women were the next most likely to experience SMM (173.5), followed by American Indian and Alaska Native (167.0), Multi-race (140.7), Asian (126.9), Hispanic (106.6), and White women (92.9). California’s experience is not unique, as SMM is increasing nationally.[7] Likely this upward trend in SMM is due, in part, to “rescue care” (i.e., preventing the death of a high-risk birthing individual) and to increasingly greater burdens of chronic diseases and associated risks within the birthing population.

 

Women/Maternal Objective 2: Strategy 1:

Lead surveillance and research related to maternal morbidity in California.

 

Activity:

CDPH/MCAH will lead surveillance and reporting of maternal morbidity, including measurement of trends and disparities, and review of scientific literature to remain current with respect to both scientific methods and emerging issues. Special focus will be given to any reference discussing the coding change from ICD-9-CM to ICD-10-CM, which began October 1, 2015, in patient discharge data.

 

Narrative:

CDPH/MCAH continued to monitor maternal morbidities at time of delivery using patient discharge data. Several data dashboards on maternal morbidity were developed and published. Dashboards are available for severe maternal morbidity, maternal health conditions (asthma, diabetes, and hypertension), selected maternal complications, and substance use disorders. When possible, each dashboard contains maps, bar charts, and trend charts using state- and county-level delivery hospitalization data for 2008-2021.

 

CDPH/MCAH continues to review scientific literature to maintain currency with respect to both scientific methods and emerging issues related to maternal morbidity. Special focus was given to any reference discussing the coding change from ICD-9-CM to ICD-10-CM. Morbidity definitions and data continue to be refined or updated based on ongoing literature review and evolving subject matter experts’ knowledge.

 

CDPH/MCAH reviewed the definition of SMM as described in HRSA’s Federally Available Resource Document (version April 1, 2023). There were no changes from the previous definition used to report data (version April 1, 2022).

 

Activity:

CDPH/MCAH will lead surveillance and reporting of severe maternal morbidity as mandated by SB 464 (now Health & Safety Codes 123630-123630.4), the California Dignity in Pregnancy and Childbirth Act. Mandated reporting will occur at least once every three years and will include, but is not limited to, data on the conditions listed in the California Dignity in Pregnancy and Childbirth Act aggregated by state regions and race/ethnicity.

 

Narrative:

CDPH/MCAH developed and published a Selected Maternal Complications data dashboard based on state-level delivery hospitalization data for 2016-2021. The dashboard includes all conditions listed in the California Dignity in Pregnancy and Childbirth Act as mandated to report (i.e., obstetric hemorrhage, hypertension, preeclampsia, eclampsia, venous thromboembolism, sepsis, cerebrovascular accident, and amniotic fluid embolism). The dashboard shows bar charts and trends charts for each maternal complication aggregated by state regions and race/ethnicity. To protect patient confidentiality, rates of maternal complications that occur infrequently are not shown.

 

Activity:

CDPH/MCAH will identify and partner with subject matter experts to conduct population-based data analyses to inform decision-making for coordination, support, and possible implementation of coordinated regionalized system of maternal care.

 

Narrative:

CDPH partnered with the California Maternal Quality Care Collaborative (CMQCC) at Stanford University and the Centers for Disease Control and Prevention (CDC) to encourage hospitals to complete the Maternal Care Module of CDC’s Level of Care Assessment Tool (LOCATe) survey. The survey includes a question module about maternal care and requests data on a small set of maternity and neonatal statistics (e.g., number of births), most of which are available to CMQCC member hospitals through the Maternal Data Center (MDC).

 

CDC’s LOCATe survey collected hospitals’ self-reported responses to assess their levels of maternal care. Facilities were allowed to review their assessed level and the rationale, submit revisions for any inaccuracies, and have their data run again through the algorithm for a revised assessment. A facility’s results are confidential and can only be shared with their organization, CDPH, CMQCC, Regional Perinatal Programs of California (RPPC) regional staff, and CDPH-approved investigators.

 

Participating facilities received their final LOCATe-assessed levels of maternal care in May. Approximately 68% of California hospital facilities with 50 or more births per year participated in LOCATe. Facilities participating in the MDC can include their hospital’s LOCATe information in their private account page and benefit from benchmarking against aggregated metrics of same-level hospitals. For hospitals that participate in RPPC, the RPPC directors may use facility-specific LOCATe data to inform site visit discussions and improve regional coordination, while maintaining the confidentiality of the LOCATe data in these efforts.

 

Another effort to inform CDPH/MCAH’s decision-making for a coordinated regionalized system of maternal care is an investigation into potentially preventable, hospital-acquired Severe Maternal Mortality (pSMM), conducted in partnership with the University of California, Los Angeles and the Maternal Quality Indicators Work Group. This work suggests that monitoring hospital performance, given pSMM, can inform how care systems are defined, established, and sustained.[8]

 

Women/Maternal Objective 2: Strategy 2:

Lead statewide regionalization of maternal care to ensure women receive appropriate care for childbirth.

 

Activity:

CDPH/MCAH will continue to fund the Regional Perinatal Programs of California (RPPC) directors to focus on quality improvement in participating labor and delivery hospitals throughout the state and to coordinate and support a regionalized perinatal system.

 

Narrative:

Eighty-four percent of birthing facilities received a virtual or in-person site visit. Nearly all site visits included the promotion of California Maternal Quality Care Collaborative (CMQCC) toolkits and other resources, and technical assistance to adapt resources to individual facilities. Some topics elevated for discussion included equity, doula care, disparate rates for severe maternal mortality, preterm birth, breastfeeding, Nulliparous, Term, Singleton, Vertex (NTSV) or low-risk, first-time mothers cesareans by race/ethnicity, and birth certificates with race and ethnicity unknown/missing. Facilities consulted with RPPC in preparation for compliance with legislative requirements like the adoption of the "Ten Steps to Successful Breastfeeding" per Baby-Friendly USA's Baby-Friendly Hospital Initiative or an alternate process by 2025, Hospital Equity Reports measures to the Department of Health Care Access and Information beginning in 2025, and the new 2023 Joint Commission Health Equity National Patient Safety Goal.

 

More than 200 birthing hospitals, which represent 99% of California's delivery volume statewide, submitted their discharge data to the Maternal Data Center (MDC); and nearly every facility that had a site visit by RPPC discussed their MDC profile report with them at the site visit. The MDC's benchmarking data shapes quality improvement activities and measures the impact of interventions. The MDC hosted well attended monthly user group meetings.

 

Activity:

CDPH/MCAH will continue to partner with the Comprehensive Perinatal Services Program (CPSP), Women, Infant & Children (WIC) Regional Breastfeeding Liaisons, and local MCAH programs to ensure a coordinated delivery system for women during and after their pregnancy.

 

Narrative:

The Perinatal Service Coordinators at the local health jurisdictions continued to partner with CDPH/MCAH, WIC, CPSP, RPPC, Medi-Cal, and other key stakeholders to coordinate resources and quality improvement efforts to ensure a coordinated delivery system for women during and after pregnancy.

 

Local MCAH Program Examples: 

Examples from the Local MCAH annual reports of partnering to ensure a coordinated delivery system for women during and after their pregnancy include:

 

• Santa Barbara County (SBC) partnered with Nutrition services and WIC to develop an evidence-based, CPSP reimbursable curriculum. This standardized gestational diabetes mellitus (GDM) Education program was successfully piloted at the SBC Public Health Department diabetes in pregnancy clinic and integrated with provider visits.
• Sierra County participated in Tahoe Truckee Perinatal Outreach Team meetings in Nevada County which includes a birthing center, International Board-Certified Lactation Consultant, local childcare center/advocate, MCAH, WIC, and public health nurse to collaborate, promote programs, and consolidate efforts. Sierra County’s MCAH Director has learned a great deal and met the director of Child Advocates through these groups who will be the subcontractor for its first ever California Home Visiting Program Parents as Teachers program in Sierra County.

 

Activity:

CDPH/MCAH will continue to coordinate the planning, collaboration, and promotion of integrated regional perinatal systems for the delivery of high-quality, risk-appropriate health care and social support to pregnant women and their newborn infants.

 

Narrative:

All RPPC regions reported increased networking between public health staff/programs and hospitals. RPPC assessed current relationships between birthing facilities and public health, linked facilities where gaps were identified, actively recruited hospital staff and leadership to participate in community meetings and advocated for public health representatives at the site visit. With frequent staff turnover on the side of birthing facilities and local health jurisdictions, RPPC worked to restore dropped communications.

 

The FY 2022-23 Scope of Work included a new activity to support statewide and local response to disasters and emergencies as appropriate to RPPC's role. MCAH convened information-sharing meetings between CDPH's Office of Emergency Preparedness (OEP) and RPPC. RPPC examined their current regional activities and reported those that fall broadly under emergency preparedness. By deepening bidirectional familiarity, MCAH/OEP/RPPC identified opportunities for RPPC to leverage its expertise and relationships with clinical and community organizations to inform regional preparedness activities.

 

Activity:

CDPH/MCAH will fund a contractor to partner with RPPC Directors to improve the system of care for high-risk women by encouraging the growth and maturation of transfer agreements for the provision of risk-appropriate care specific to maternal health needs.

 

Narrative:

CDPH/MCAH and expert contributors revised the strategy to improve the system of care for high-risk women because of many barriers to implementing regional cooperative agreements in California. MCAH/RPPC directed efforts toward the following:

 

• Promoting more standardized risk assessment to identify when transfer is needed
• Building transport relationships through stronger maternal transport guidelines

 

The RPPC contractor leading maternal risk-appropriate care and transport presented at the RPPC statewide meeting. The presentation included levels of maternal care, regulations surrounding maternal transport, challenges/barriers to maternal transport, and an overview of work accomplished in developing transport guidelines, policies, and tools. The meeting also included a discussion of RPPC's role to support a regionalized system of care through regional networks.

 

The RPPC Directors discussed maternal transport policies with their facilities and encouraged the development of policies specific to obstetrics. Sixty percent of facilities reported that they have a specific policy for labor and delivery that guides their step-by-step process of transport for women needing higher-level care. Sample policies were provided to regions requesting them. Completion of the Centers for Disease Control and Prevention Level of Care Assessment Tool survey in May 2022 supplemented site visit discussion around risk-appropriate care and transport. Through relationships established by RPPC, a region-wide program to improve education and collaboration may be established.

 

Activity:

CDPH/MCAH will continue to support and sustain a statewide collaborative of public and private entities that combine clinical medicine and systems of care that contribute to improvements in the quality of maternity and obstetrical care.

 

Narrative:

CMQCC reported monthly updates to RPPC, sharing resources and engaging RPPC Directors on best approaches to discussions with hospitals about performance measure disparities.

 

CMQCC launched a pilot Low Dose Aspirin (LDA) campaign to reduce preeclampsia and subsequent preterm births. One key strategy to connect with patients was meeting with MCAH Directors in San Bernadino, Riverside, San Diego, and Sacramento counties to engage them in the LDA campaign. A developing strategy is to identify ways to engage outpatient clinics as partners working upstream on important maternal health issues.

 

CMQCC developed a Culture of Equity Survey and launched the first cohort of learning initiative participants. The survey was designed to help hospital leaders understand the perspectives of health care team members on common issues that directly affect equity and respectful care.

 

The maternal health community, as defined by CMQCC, included a wide range of partners including clinicians, midwives, doulas, hospitals, the Department of Health Care Services, health plans, public health, community, and patients with lived experience. CMQCC presented three of five webinars on team-based care and partnering with doulas and midwives to improve perinatal outcomes and promote birth equity.

 

Women/Maternal Objective 2: Strategy 3:

Partner to strengthen knowledge and skill among health care providers and individuals about chronic conditions exacerbated during pregnancy.

 

Activity:

CDPH/MCAH will lead the development and implementation of a work plan to reduce the rate of diabetes in pregnancy and overweight/obesity in childbearing parents.

 

Narrative:

CDPH/MCAH has developed a transitional workplan due to the sunset of the California Diabetes and Pregnancy Program to include materials and resources centering GDM and associated risk factors, such as overweight and obesity, pre-eclampsia, and development of type 2 diabetes. The workplan aims to bring awareness to disparate populations most affected by GDM as part of CDPH/MCAH’s newly developed Gestational Diabetes and Postpartum Care Initiative.

 

CDPH/MCAH hosted two Title V interns in the Summer of 2023 to conduct informational interviews with MCAH directors in San Mateo, Santa Barbara, and Alameda counties who were currently doing work around GDM. The information gathered will be used to help inform the workplan.

 

CDPH/MCAH is in the process of establishing partnerships with the Department of Health Care Services (DHCS) to improve continuation of support after delivery for individuals diagnosed with diabetes through referrals into Diabetes Prevention Programs, and/or Diabetes Self-Management Education and Support programs.

 

Activity:

CDPH/MCAH will continue to lead the development and dissemination of culturally appropriate materials to address chronic disease in disparate populations such as an overweight and obesity brief, a MyPlate for preconception, and a heart disease fact sheet.

 

Narrative:

CDPH/MCAH continued to promote the dissemination of culturally appropriate materials such as the MyPlate tools for Preconception, Pregnant and New Parents, and Gestational Diabetes, including corresponding Perinatal Food Group Recall tools. Each MyPlate resource is also provided in Spanish. In addition, CDPH/MCAH continues to promote, “Healthy Weight for Healthy Birth and Beyond Brief and Toolkit.”

 

Activity:

CDPH/MCAH will lead the development of a social media campaign to disseminate information about maternal overweight and obesity.

 

Narrative:

The “Healthy Weight for Healthy Birth Toolkit” includes social media messaging. Plans to update the messaging with the most recent data were put on pause due to staffing changes and changing priorities. CDPH/MCAH will revise social media messages with the most current data available and make this resource available in FY 2023-24.

 

Activity:

CDPH/MCAH will continue to fund local Black Infant Health (BIH) sites to develop a statewide media campaign to inform Black women about chronic health conditions and the BIH program.

 

Narrative:

CDPH/MCAH funds Fresno and Long Beach BIH programs to lead the statewide campaign for all BIH programs. The campaign includes a participant-friendly website with materials about chronic health conditions for Black women. Program staff also participate in public awareness events throughout the year like the Black Joy Parade and Women’s Health Expo to share information more widely about these chronic conditions and more broadly about health and wellbeing during the perinatal period.

 

Women/Maternal Focus Area 3: Improve mental health for all mothers in California.

 

Women/Maternal Objective 3:

By 2025, increase the receipt of mental health services among women who reported needing help for emotional well-being or mental health concerns during the perinatal period from 49.6% (provisional 2018 MIHA) to 52.1%.

 

Story Behind the Curve:

It is estimated that approximately 20% of women will experience a perinatal mental health challenge. Mental health challenges can range from mild depression and anxiety to mania and psychosis. In California, approximately half of birthing individuals who reported needing help for emotional well-being or mental health concerns during the perinatal period received mental health services. Promoting mental health and healthy behaviors during pregnancy is important to optimize maternal and infant health outcomes. Therefore, one of the priorities identified in the 2021-2025 needs assessment is to increase access to mental health services among women and birthing people who reported needing help for emotional well-being or mental health concerns. CDPH/MCAH is also committed to exploring and elevating primary prevention approaches for supporting overall mental health and wellbeing among the birthing population in California.

 

Women/Maternal Objective 3: Strategy 1:

Partner with state and local programs responsible for the provision of mental health services and early intervention programs to reduce mental health conditions in the perinatal period.

 

Activity:

CDPH/MCAH will partner and collaborate with state departments responsible for the provision of mental health services (California Mental Health Services Authority, the Department of Health Care Services [DHCS]) to identify gaps and opportunities in the availability, quality, and use of mental health services for women of reproductive age, and support and promote policy that would reduce mental health conditions in the perinatal period.

 

Narrative:

DHCS informed CDPH/MCAH about several health care initiatives for its MCAH population which include Enhanced Case Management (ECM). ECM is available to specific groups or populations of focus including pregnant and postpartum individuals. Enrolled members receive comprehensive care management from a single lead care manager who coordinates provision of social services, as well as health and health-related care, including physical, mental, and dental care. ECM makes it easier for members to get the right care at the right time in the right setting and receive comprehensive care that goes beyond the doctor’s office or hospital. CDPH/MCAH aims to learn and engage more on policy and implementation of ECM as this initiative rolls out.

 

Activity:

CDPH/MCAH will continue to partner at the state and local levels to identify and promote best practices to address mental health, including stigma and discrimination due to mental health diagnosis.

 

Local MCAH Program Examples: 

Examples of Local MCAH activities to reduce mental health conditions in the perinatal period:

• In El Dorado County several women with high Edinburgh scores were supported by public health nurses, received access to Infant Parent Center counseling services, and maintained bonding and breastfeeding in the immediate postpartum period.
• San Benito County Public Health Services partnered with Mabie Perinatal Clinic registered nurses to identify women experiencing maternal mental health issues and refer them to the counselors and clinicians. Resources from San Benito County Behavioral Health and Anthem Blue Cross Group were distributed to patients in need of maternal mental health services. These resources were distributed to the clinic by the health department staff.
• Santa Cruz County public health nurse home visiting teams began to strengthen relations with Janus Perinatal, which offers support for substance use disorder and mental health services to home visiting clients. This was a long-anticipated agency connection with plans for increased bidirectional referrals to serve and support some of the most vulnerable clients.

 

Activity:

CDPH/MCAH will continue to support state and local workforce development to address mental health with the population we serve.

 

Narrative:

CDPH/MCAH continues to provide funding for each local health jurisdiction implementing Black Infant Health to hire a mental health professional to assess participants throughout their time in the program and provide resources and referrals as necessary.

 

A new initiative funded by California’s Future of Public Health Spending Plan began in 2022 with the goal of providing training, technical assistance, and data-driven support to local public health agencies and other partners on mental health and wellness for the MCAH population. The first positions for this new initiative were filled in the spring and summer of 2023 and hiring continued into the fall of 2023. The new team is tasked with addressing the mental health crisis in the state using a life-course framework to support children, adolescents, and families, focused on building resiliency, equity, and prevention. Needs assessment and strategic planning activities will be reported on in next year’s annual report.

 

Activity:

CDPH/MCAH will lead to translate findings from the Maternal Suicide PAMR report into a resource for use by health care providers, individuals, and communities.

 

Narrative:

CDPH/MCAH developed and promoted the Maternal Suicide Fact Sheet, “Is your loved one showing signs of suicidal thinking during or after pregnancy?” in February 2022. The fact sheet is also available in Spanish, Chinese, Korean, Tagalog, and Vietnamese.

 

Women/Maternal Objective 3: Strategy 2:

Partner to strengthen knowledge and skill among health care providers, individuals, and families to identify signs of maternal mental health-related needs.

 

Activity:

CDPH/MCAH will continue to partner with existing MCAH programs and other Title V-funded programs in raising awareness about mental health and promoting mental health resources.

 

Narrative:

CDPH/MCAH continues to promote the Mental Health Fact Sheet (2019) with local MCAH programs and began promoting the newly developed maternal suicide fact sheet, “Is your loved one showing signs of suicidal thinking during or after pregnancy?” (Feb 2022).

 

The Black Infant Health (BIH) public awareness campaign developed a podcast about the importance of mental health for Black women. BIH also includes information about postpartum depression and anxiety in the group curriculum to reduce stigma around mental health diagnoses for Black women within our case management.

 

Local MCAH Program Examples: 

• Orange County Community Nursing worked in partnership with the county's Mental Health and Recovery Services Division to develop an online local resource guide for Pregnancy and Postpartum Supports, which are available in nine languages.
• Sutter County and 14 community agencies/groups participated in Blue Dot photos which were posted to the Sutter County Public Health, Sutter County Children and Families Commission, and Yuba First 5 Facebook pages. They also partnered with Sutter County Children and Families Commission and First 5 Yuba to conduct two stakeholder engagement meetings for both counties as part of the Yuba-Sutter Blue Shift Project, a local effort to assess and address maternal mental health.
• Yuba County served 372 perinatal women with resources regarding mental health. Resource packets were sent via mail to 310 Yuba County women and families (hospital factsheets with information were provided by local birthing hospital) which included a flyer on Postpartum Depression, Postpartum Support International information, and local mental health resources. The annual Yuba County Baby Fair MCAH tabling event served 55 perinatal women with resources including mental health resources. Support persons present (father, grandparents, aunts, etc.) were also educated on early sign and symptoms of mental health disorders.

 

Activity:

CDPH/MCAH will continue to partner with local Comprehensive Perinatal Services Program (CPSP) Perinatal Service Coordinators (PSC) to support new state requirements for provider screening of mental health at least once during pregnancy and postpartum, as well as ensure CPSP providers receive the required training on mental health.

 

Narrative:

CDPH/MCAH continued to partner with the PSCs to assist CPSP providers in utilizing evidence-based mental health screening tools such as PHQ-9 and Edinburgh Postnatal Depression Scale during pregnancy and postpartum. PSCs were encouraged to provide or promote webinars and roundtable discussions about maternal mental health in local communities.

 

Local MCAH Program Example: 

Kings County Local MCAH program held a CPSP technical assistance event where participants engaged in conversation about mental health screening and local resources. Participants reported on their event evaluations excellent reviews and compliments for the presenter.

 

Women/Maternal Objective 3: Strategy 3:

Partner to ensure pregnant and parenting women are screened utilizing standardized and validated tools and linked to needed services for mental health conditions in the perinatal period.

 

Activity:

CDPH/MCAH will continue to partner with MCAH-funded programs to utilize validated mental health screening tools.

 

Narrative:

Local MCAH Perinatal Services Coordinators (PSC) continue to provide technical assistance to providers and review local Comprehensive Perinatal Services Program (CPSP) protocols related to psycho-social assessments to ensure women are screened for mental health services.

 

The Black Infant Health program requires each participant to be assessed with the Edinburgh Postnatal Depression Scale (EPDS). Staff conducting assessments at any other point during the program must utilize validated mental health screening tools.

 

The California Home Visiting Program (CHVP) continues to use validated mental health screening tools and provide referrals to appropriate services as necessary. Core services within CHVP also are preventative of later mental health challenges, for example, support with basic needs, early attachment, stress reduction, access to needed services and healthy relationships all are protective and preventive of mental health challenges for the parent and child.

 

The Department of Health Care Services American Indian Maternal Support Services (DHCS/AIMSS) programs use validated screening tools for all DHCS/AIMSS clients and are encouraged to screen each trimester, post-delivery, and as needed. DHCS/AIMSS programs are required to connect with county mental health resources to learn what is available in each community to serve their clients and to inform outside agencies of their own services provided at their clinics. DHCS/AIMSS clinic sites have behavioral health experts who are connected to the county mental health departments for cross collaboration. Local traditional practices include healing circles, medicine wheel, sweat lodge, and the Red Road to Recovery. Trained mental health staff utilize evidenced-based screening tools and Native American culture as healing practices.

 

Local MCAH Program Examples:

• The implementation of universally screening clients with the PHQ-9 has allowed identification of existing and the severity of mental health status in the clients. For example, a mother in Monterey County, who had lost her child at one year and 11 months was administered the PHQ-9 and responded with thoughts of suicide ideation (SI) and a plan to commit suicide. Prior to this response, the participant had not presented with any signs and symptoms of SI. This allowed the nurse to make appropriate interventions due to the score on the PHQ-9.
• The City of Pasadena MCAH worked with the Black Infant Health Program to ensure that all new participants were screened for depression using the Edinburgh Postnatal Depression Screening tool. There were 50 participants enrolled during the year and 40 were screened with the Edinburgh tool. Participants were screened 6-8 weeks postpartum and as needed. Two participants were referred to mental health counseling. They shared this success story: Program staff conducted the Edinburgh with a participant who scored quite high, indicating that she was possibly experiencing depression. The participant confirmed that she was experiencing some depression and that it was also causing some concerns in her relationship.

 

Activity:

The DHCS/AIMSS program will continue to partner with Indian Health Service, local MCAH, CPSP, Family Spirit, and other resources to provide evidenced-based screening tools to use for mental health screening on all perinatal and postnatal American Indian women.

 

Narrative:

DHCS/AIMSS programs use validated screening tools for all clients and are encouraged to screen each trimester, post-delivery, and as needed. Screening is followed by linkage to supports and services, when needed.

 

Activity:

CDPH/MCAH will continue to partner with PSCs to ensure CPSP providers utilize the most up-to-date standardized mental health screening tools and appropriate referrals are made to community resources for CPSP clients.

 

Narrative:

CDPH/MCAH continued to partner with the PSCs to assist the CPSP providers in utilizing evidence-based mental health screening tools such as PHQ-9 and EPDS with integration of the CPSP Assessments Tools, Individualized Care Plans, CPSP Protocols, and referrals to community resources to promote maternal mental health.

 

Women/Maternal Focus Area 4: Ensure optimal health before pregnancy and improve pregnancy planning and birth spacing.

 

Women/Maternal Objective 4:

By 2025, increase the percentage of women who had an optimal interpregnancy interval of at least 18 months from 73.6% (2017 CCMBF) to 76.4%.

 

Women/Maternal Objective 4: Strategy 1:

Partner to increase provider and individual knowledge and skill to improve health and health care before and between pregnancies.

 

Story Behind the Curve:

Pregnancies that occur less than 18 months after a live birth are associated with delayed prenatal care and increased risk for adverse birth outcomes. Access to services that promote appropriate birth spacing can reduce the risk for poor birth outcomes such as preterm birth and low birthweight. Access to family planning counseling and contraception plays a key role in birth spacing and reduced risk for poor birth outcomes.

 

Activity:

CDPH/MCAH will continue to partner, communicate, collaborate, and coordinate preconception and interconception program work, best practices, resources, and education cross-sectionally and department wide.

 

Narrative:

CDPH/MCAH facilitates monthly meetings that include staff from all MCAH Title V domain workgroups to share program/initiative work that include preconception/interconception topics. Programs/initiatives shared resources and best practices on maternal mental health and identified gaps where support was needed. CDPH/MCAH also facilitated and hosted a meeting with the CDPH Substance and Addiction Prevention Branch to learn more about overdose prevention initiatives, campaigns, and resources, and are partnering in the future to improve maternal/infant outcomes.

 

Activity:

CDPH/MCAH will continue to support and coordinate the Preconception Health Council of California (PHCC) quarterly meetings and biweekly PHCC Executive Committee meetings.

 

Narrative:

CDPH/MCAH leads, coordinates, and facilitates the PHCC. CDPH/MCAH held quarterly meetings and developed a strategic plan. Workgroups were formed to focus on improving midwifery, Medi-Cal coverage, comprehensive postpartum care, and reproductive access in schools. The PHCC Executive Committee met biweekly to inform the PHCC quarterly meeting agendas and direction of the PHCC.

 

Activity:

CDPH/MCAH will continue to support and share preconception and interconception best practices, resources, and MCAH local program updates to PHCC to guide and inform statewide preconception and interconception efforts.

 

Narrative:

CDPH/MCAH supports and shares preconception and interconception best practices, resources, and MCAH local program updates with the PHCC through email, newsletters, and at Executive Committee and PHCC Quarterly Meetings. The best practices, resources, and MCAH local program updates shared amongst the PHCC helped to inform the PHCC strategic plan and priority areas of focus. The PHCC prioritizes issues through regular Council meeting and issue-specific workgroups and provides direction for 1) Integration of preconception health and health care in clinical and public health practice; 2) Promotion of key preconception health messages that address physical and psychosocial well-being of individuals of reproductive age; and 3) Increase access to preconception care to eliminate disparities in maternal and infant morbidity and mortality.

 

Activity:

CDPH/MCAH will continue to support the use of the Every Woman California website to be used as a platform for sharing best practices, resources, and education for preconception and interconception health, health care, sexual and reproductive health services, and psychosocial well-being information for the public and health professionals.

 

Narrative:

CDPH/MCAH hosts and updates the Every Woman California Website. This is the official website of the Preconception Health Council of California.  This website is meant to service all people with the capacity for pregnancy and their partners. The website shares best practices, local and national resources, training, and education on preconception and interconception health, health care, sexual and reproductive health services, and psychosocial well-being. The website is intended to target Women, Teens, Men, LGBTQ+ and Health Professionals.

 

Activity:

CDPH/MCAH will support disseminating and promoting best practices, resources, and education from key preconception initiatives and local MCAH programs through statewide channels of communication (i.e., newsletters, eblasts, collaborative updates, briefings, etc.).

 

Narrative:

CDPH/MCAH supports dissemination and promotion of best practices, resources, and education from key preconception initiatives and local MCAH programs. Links to local, state and national resources and trainings are shared on the CDPH/MCAH Preconception Health Webpage. Links to resources include Healthy Body, Healthy Mind, Planning Ahead, Healthy Relationships, Healthy Surroundings and Access to Care. CDPH/MCAH partners with the PHCC and other organizations to disseminate preconception and interconception information through statewide channels of communication (i.e., newsletters, eblasts, collaborative updates, briefings, webinars, etc.).

 

Local MCAH Program Examples: 

Examples of Local MCAH activities to disseminate and promote best practices, resources, and education from key preconception initiatives include the following:

• Santa Clara Public Health Nurses in the Nurse-Family Partnership (NFP) Home-Visiting Program educate and discuss Long-Acting Reversible Contraceptives (LARCs) during pregnancy. They bring a birth control kit to show clients the different birth control methods. Nurses provide handouts for clients to read. Most of them have received birth control at their six months appointments. One home visitor had a client who was ambivalent about birth control during pregnancy. The client wanted to use a natural birth control method and she wanted to avoid chemicals or side effects from the birth control plan. The nurse educated the client regarding the types of birth control and focused on her goals and emphasized the benefits of birth spacing such as time with baby, achieving her future goals, and health benefits for her. After delivery, client tried birth control pills but decided to change to Implanon. The client had a goal to graduate high school in October 2023.
• In San Joaquin County, 85 clients were provided education on preconception by home visiting nurses. Nurses provided 2 adolescent sexual health teachings.

 

Activity:

CDPH/MCAH will support Perinatal Services Coordinators (PSC) in disseminating and encouraging best practices, resources, and education to local Comprehensive Perinatal Services Program (CPSP) providers to promote preconception and interconception care to eligible individuals.

 

Narrative:

CDPH/MCAH continued to encourage the PSCs to assist the CPSP providers in utilizing the CPSP Assessments Tools, Individualized Care Plans, and referrals to community resources to promote preconception and interconception care.

 

Women/Maternal Objective 4: Strategy 2:

Lead a population-based assessment of mothers in California, the Maternal and Infant Health Assessment Survey (MIHA), to provide data to guide programs and services.

 

Activity:

CDPH/MCAH will continue to partner with the University of California San Francisco (UCSF) Center for Health Equity (CHE) to refine the MIHA questionnaire with new topics of interest and revise the MIHA sampling plan as needed to ensure representative data at the state, regional, and county levels.

 

Narrative:

The total sample size for MIHA remained the same at around 10,000 to allow for stable representative data at the state, region, and county levels. Survey development for MIHA 2023 occurred from August 2022 through March 2023 and involved collaboration between MCAH subject matter experts, leadership, and UCSF CHE, as well as input from other CDPH programs, the Centers for Disease Control and Prevention, and key MCAH/MIHA partners and data users. New topics added and past topics cycled back on MIHA 2023 included the following:

 

• Questions assessing maternity care experiences
• Gaps in postpartum health insurance coverage
• Questions assessing the infant sleep environment
• Postpartum contraception use and reasons for not using postpartum contraception
• Provider advice about infant oral health care.

 

Activity:

CDPH/MCAH will support the UCSF CHE to implement data collection activities and maximize participation among individuals selected to participate in the survey.

Narrative:

CDPH/MCAH supported the UCSF CHE in MIHA data collection to maximize participation among individuals selected to participate in the survey. Data collection for MIHA 2022 began in May 2022 was completed in January 2023. Data collection for MIHA 2023 began in May 2023 and is expected to conclude in January 2024. MIHA 2022 had an overall response rate of 58.9% (5,893 participants), a slight decline from previous years.

 

 Activity:

CDPH/MCAH will support the UCSF CHE to weight the study data and prepare an annual MIHA analytic dataset and codebook.

 

Narrative:

CDPH/MCAH reviewed the MIHA weighting procedures and supported UCSF in creating final weights to complete the MIHA 2021 dataset and in creating provisional weights for MIHA 2022 data. Using the Vital Records Business Intelligence System, final weights will be calculated when the final California Comprehensive Master Birth File is available for 2022. CDPH/MCAH coordinated with UCSF to re-code and validate variables for raw MIHA 2022 data.

 

Activity:

CDPH/MCAH will partner with the UCSF CHE to conduct analyses of CDPH/MCAH priority topics, develop surveillance products, and design and implement scientific research studies.

 

Narrative:

CDPH/MCAH collaborated with UCSF CHE on several analyses and surveillance products including: 2016-2018 MIHA Data Snapshots of Prenatal WIC participants; a series of data briefs focused on the secondary impacts of the COVID-19 summarizing key findings from MIHA 2020 data on the impacts of family income and job loss, mental health, and food and housing security on pregnant and postpartum individuals and their families; an analysis examining the impacts of childcare-related job disruptions on mental health and financial hardships early in the COVID-19 pandemic; and Centering Black Mothers in California, a comprehensive report focused on the health of Black birthing individuals and their infants.

 

Activity:

CDPH/MCAH will lead the dissemination of findings in a variety of MIHA data products.

 

Narrative:

CDPH/MCAH continued to disseminate the 2016-2018 MIHA Data Snapshots to state and local partners. The 2016-2018 MIHA Data Snapshots of Prenatal WIC Participants were released in October 2022. Findings from the analysis looking at the impacts of childcare-related job disruptions early in the COVID-19 pandemic were presented at the American Public Health Association annual meeting in November 2022.

 

MIHA data from 2013-2020 were made available on three MCAH Data Dashboards – daily folic acid use, mental health, and breastfeeding. CDPH/MCAH fulfilled nine custom data requests from data users external to MCAH by providing custom data tables on various topic areas including breastfeeding, oral health, contraception, insurance coverage, mental health, food insecurity, intimate partner violence, substance use, racial discrimination, and birthing individual demographics.

 

Women/Maternal Objective 4: Strategy 3:

Lead the implementation of the Comprehensive Perinatal Services Program (CPSP) to ensure access to comprehensive prenatal care for Medi-Cal Fee-for-Service clients.

 

Activity:

CDPH/MCAH will continue to lead in utilizing standards, set forth in legislation, for an applicant to become a CPSP provider, review applications, and notify the applicant if their application is accepted.

 

Narrative:

For FY 2022-23, CDPH/MCAH approved 52 new CPSP provider applications.

 

Activity:

CDPH/MCAH will continue to support local Perinatal Service Coordinators (PSC) to identify and recruit providers in medically underserved areas to increase access to perinatal care.

 

Narrative:

CDPH/MCAH supported the efforts of the PSCs to lead community outreach that identified and promoted recruitment of providers into CPSP. PSCs were encouraged to reach out to providers to assist with the CPSP enrollment/application process throughout all regions of California.

 

CDPH/MCAH has authority for CPSP provider enrollment and oversight for Medi-Cal Fee-for-Service providers. The Department of Health Care Services anticipates 99% of the Medi-Cal-eligible pregnant populations will be receiving services under Medi-Cal Managed Care. This prompted discussion to reassess current processes related to recruitment and enrollment of providers. Plans have been discussed to transition responsibilities of CPSP provider enrollment and oversight from local responsibility to the state level.

 

Activity:

CDPH/MCAH will continue to support expansion of community-based perinatal and postpartum services for California’s birthing population. CDPH/MCAH will continue to lead in monitoring and providing oversight of CPSP including quality improvement efforts to monitor providers and ensure quality of care for CPSP.

 

Narrative:

PSCs continued to provide technical assistance and training on CPSP provision of services to CPSP providers and conducted monitoring and oversight of CPSP through informal roundtable discussion, on-site and virtual visits, and conducting chart and administrative reviews.

 

Activity:

CDPH/MCAH will continue to fund the PSC Annual Meeting and asynchronous online training to ensure PSCs are equipped to provide technical assistance to CPSP providers who implement provision of CPSP services.

 

Narrative:

CDPH/MCAH virtually conducted the PSC Annual Meeting on April 4, 2023. The PSC Annual Meeting provides education and information including skill-based training to PSCs regarding improving maternal systems of care and allows the PSCs the opportunity to network.  Education Topics include Queer and Trans Perinatal Mental Health; Regional Asthma Management and Prevention (RAMP); Domestic Violence; and skill-based training on conducting effective roundtable discussions.

 

Women/Maternal Objective 4: Strategy 4:

Fund the Department of Health Care Services (DHCS) Indian Health Program (IHP) to administer the American Indian Maternal Support Services (AIMSS) to provide case management and home visitation program services for American Indian women during and after pregnancy.

 

Activity:

DHCS/AIMSS will continue to support and provide case management services to their programs using evidenced-based curricula and resources provided through Family Spirit, the Comprehensive Perinatal Services Program (CPSP), the American College of Obstetricians and Gynecologists, and other best practices.

 

Narrative:

DHCS/AIMSS continues to serve American Indian women from four tribal programs that are providing case management and home visitation (Family Spirit) using protocols and workflows aligned with culturally tailored, evidenced-based approaches. DHCS/AIMSS clients receive care coordination within their clinics and outside services. Clinical services include primary care, behavioral health, psychiatry, dental care, diabetes care, nutrition counselling, and social support. Identified client needs, such as Temporary Assistance for Needy Families (TANF), Early Head Start, WIC, lactation consultation, and CalFresh are presented to clients using available community resources. Health care services not available at clinics, such as maternal fetal medicine or gestational diabetes management, are provided through referrals made to an accepting provider.

 

Activity:

DHCS/AIMSS will continue to provide technical assistance to all program case managers to support home visiting-related activities.

 

Narrative:

Weekly or monthly conference calls with DHCS/AIMSS grant manager occur. Discussions included the progress of the DHCS/AIMSS program, specific cases, upcoming trainings and resources, and any other concerns. DHCS/AIMSS programs collect data each trimester and provide information for case managers to complete the plan of care and to monitor their clients. These forms were submitted to DHCS IHP for review and analysis. This information on the data forms guides the programs to track their client’s health changes, identify needed supports, and monitor client progress in their care management and receipt of services.

 

Activity:

DHCS/AIMSS will continue to support and share resources, education materials, and training related to American Indian perinatal and postnatal health and well-being.

 

Narrative:

DHCS/AIMSS programs receive resources as requested from CPSP, Indian Health Service, Centers for Disease Control and Prevention, Family Spirit, National Institute for Children’s Health Quality, and other AI specific trainings or resources. IHP regularly seeks out training and resources to share with AIMSS programs and links and registrations are sent out. AIMSS grantees also share local trainings that are occurring and share power-points and recordings.

 

Activity:

DHCS/AIMSS will continue to support and provide AIMSS programs with online or in person (when available) training opportunities to keep providers up to date with evidenced-based training from CPSP and Family Spirit.

 

Narrative:

AIMSS Programs receive resources as requested from CPSP, Department of Health and Human Services Indian Health Service, Centers for Disease Control and Prevention, Family Spirit, National Institute for Children’s Health Quality, and other American Indian specific trainings or resources. IHP regularly seeks out training and resources to share with DHCS/AIMSS programs and links and registrations are sent out. DHCS/AIMSS grantees also share local trainings that are occurring and share PowerPoint presentations and recordings.

 

Activity:

DHCS/AIMSS program will continue to support and provide education on the importance of following up with their postpartum visits to the obstetrician partners.

 

Narrative:

DHCS/AIMSS clients receive care coordination within their clinics and outside services. Clinical services include primary care (including postpartum visits), behavioral health, psychiatry, dental care, diabetes care, nutrition counselling, and social support.

 

Women/Maternal Focus Area 5: Reduce maternal substance use.

 

Women/Maternal Objective 5:

By 2025, reduce the rate of maternal substance use from 20.7 per 1,000 delivery hospitalizations (2018 PDD) to 19.7 per 1,000 delivery hospitalizations.

 

Story Behind the Curve:

Any amount of any kind of substance use during pregnancy is unsafe, as the substance can affect the health of the pregnant individual and the fetus when it passes from the pregnant individual’s bloodstream to the fetus through the placenta. The consequences of substance use differ depending on the type of drug, how much and how often it is used, and the timing of use during pregnancy. Such consequences can affect the pregnant individual (e.g., hypertension, severe maternal morbidity), as well as the fetus (e.g., stillbirth, preterm birth, low birthweight, birth defects, fetal alcohol spectrum disorders, neonatal abstinence syndrome, and cognitive-behavioral issues). The American College of Obstetricians and Gynecologists recommends universal screening in the perinatal period, and, for those who screen positive for substance use disorder, both brief counseling about the potential adverse effects of continued substance use and referral to treatment. The most recent Needs Assessment indicated a pattern of significant racial disparity related to maternal substance use during pregnancy.

 

Women/Maternal Objective 5: Strategy 1:

Lead research and surveillance on maternal substance use in California.

 

Activity:

CDPH/MCAH will lead surveillance of maternal substance use (including measurement of trends and disparities), review of scientific literature, and dissemination of data findings to help inform programs and services.

 

Narrative:

CDPH/MCAH continued to monitor maternal substance use at time of delivery using patient discharge data and before, during, and after pregnancy using the Maternal and Infant Health Assessment (MIHA) survey. Patient discharge data show that the rate of maternal substance use at delivery decreased from 21.1 per 1,000 delivery hospitalizations in 2020 to 20.8 per 1,000 delivery hospitalizations in 2021. In 2021, American Indian and Alaska Native women were more likely than all other racial/ethnic groups to have a substance use diagnosis (69.4 per 1,000 delivery hospitalizations) at delivery. Black women were the next most likely to have a substance use diagnosis (58.0), followed by Multi-Race (29.8), White (27.6), Pacific Islander (17.0), Hispanic (16.6), and Asian women (3.8). Substance disorders included in this analysis are related to use of opioids, cocaine and other stimulants, alcohol, cannabis, sedatives, hallucinogens, inhalants, and other psychoactive substances.

 

MIHA data on alcohol use before and during pregnancy, cigarette use before, during, and after pregnancy, and cannabis use during and after pregnancy collected through 2021 showed that rates remained relatively stable, with no statistically significant increases or decreases. Most recent MIHA data available (2018-2020) on the MCAH Prenatal Substance Use Data Dashboard show that there are disparities in prenatal substance use by age, education, income, and race/ethnicity.

 

CDPH/MCAH continued to review scientific literature to maintain currency with respect to both scientific methods and emerging issues related to maternal substance use. CDPH/MCAH is also planning and developing data dashboards to disseminate surveillance findings related to maternal substance use.

 

Women/Maternal Objective 5: Strategy 2:

Partner at the state and local level to increase prevention and treatment of maternal opioid and other substance use.

 

Activity:

CDPH/MCAH will lead the creation of a social media toolkit to raise awareness about opioids and pregnancy.

 

Narrative:

CDPH/MCAH Outreach and Communications Unit initiated an update of its current Opioids and Pregnancy webpage with partners in the CDPH Substance Abuse Branch. While it is still in development, the update focuses on information about major substances, including opioids, and pregnancy. It will also include social media and resources for pregnant people and families.

 

Activity:

CDPH/MCAH will disseminate resources to stakeholders to promote prevention of maternal opioid and substance abuse.

 

Narrative:

These resources are still in development.

 

Activity:

CDPH/MCAH will disseminate consumer-facing resources and education materials via the MCAH website.

 

Narrative:

CDPH/MCAH Outreach and Communications Unit disseminated communications toolkits, fact sheets, one-pagers, and other consumer-facing resources and education materials via the MCAH website. The website updates are continuing with the goal of improving user experience. CDPH/MCAH Outreach and Communications Unit launched a multi-year project to update several webpages that are integral to the division, its partners, and the general public. The goal is to create webpages that are user friendly and consistent across programs and activities. Key design updates include changes to webpage layout, functionality, and templates. The updates also include reviews to ensure all webpages use plain and inclusive language.

 

[1] Centers for Disease Control and Prevention Pregnancy Mortality Surveillance System (CDC PMSS). Data from 1987-2019 are published at https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm

[2] California Pregnancy Mortality Surveillance System (CA-PMSS). Data from 2009-2020 are published at www.cdph.ca.gov/pmss and CDPH/MCAH’s Pregnancy-Related Mortality Data Dashboard

[3] California Pregnancy Mortality Surveillance System (CA-PMSS). Data from 2009-2020 are published at www.cdph.ca.gov/pmss and MCAH’s Pregnancy-Related Mortality Data Dashboard

[4] California Senate Bill 65 is published at https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=202120220SB65

[5] California Pregnancy-Associated Review Committee (CA-PARC), formerly called the California Pregnancy-Associated Mortality Review (CA-PAMR), currently has three PAMR subcommittees. The subcommittee compositions and their scopes of reviews are published at https://go.cdph.ca.gov/pamr

[6] The California Healthy Places Index (HPI) methodology and data are available at www.healthyplacesindex.org

[7] Fink DA, Kilday D, Cao Z, et al. Trends in Maternal Mortality and Severe Maternal Morbidity During Delivery-Related Hospitalizations in the United States, 2008 to 2021. JAMA Netw Open. 2023;6(6):e2317641. doi:10.1001/jamanetworkopen.2023.17641 

[8] Fridman, M., Korst, L. M., Reynen, D. J., Nicholas, L. A., Greene, N., Saeb, S., Troyan, J. L., & Gregory, K. D. (2023). Using Potentially Preventable Severe Maternal Morbidity to Monitor Hospital Performance. Joint Commission journal on quality and patient safety, 49(3), 129–137. https://doi.org/10.1016/j.jcjq.2022.11.007