Priority: Social Emotional Wellbeing

Performance Measures and Annual Objectives

NPM 14a: Percent of women who smoke during pregnancy was 3.7%. The annual objective for reporting year 2022 was 4.9%. The annual objective was met. The annual objective for reporting year 2023 is 4.5%.

ESM 14.1: Percent of pregnant people insured by Medicaid who smoke during the last three months of pregnancy was 8.3%. The annual objective for reporting year 2022 was 11.1%. The annual objective was met. The annual objective for reporting year 2023 is 9.4%.

SPM 4: Percent of women of reproductive age (18-44 years) who report good mental health was 69.0%. The annual objective for reporting year 2022 was 72.0%. The annual objective was not met. The annual objective for reporting year 2023 is 73.0%.

The data source for the NPM is the National Vital Statistics System that is administered annually. The data source for the ESM is the Pregnancy Risk Assessment Monitoring System that is administered annually. The data source for the SPM is the Behavioral Risk Factor Surveillance System that is administered annually. As mentioned above, the annual objective for the SPM was not met.  Contributing factors may include the negative effects that the pandemic has had on mental health, along with the rising cost of living and economic stressors.

Resource Allocation to Advance this Priority

For this reporting period, MCH Block Grant dollars funded 1.0 FTE of the Maternal and Infant Wellness team at CDPHE across multiple positions; MCH Block Grant dollars were also braided with state General Funds to support 1.0 FTE on the CYSHCN team at CDPHE for the implementation of strategies in the state action plan and for contracts with local public health agencies to implement local action plans. To advance and expand impact, MCH aligned and leveraged funding from the CDC grant that supported the Colorado Perinatal Care Quality Collaborative, state General Funds to reduce maternal mortality, the ERASE Maternal Mortality grant through the CDC, and HRSA funding through the State Maternal Health Innovation and Data Capacity grant. In addition, MCH Block Grant dollars continued to fund a portion of a Tobacco program staff position (0.25 FTE) to serve as a liaison between the Tobacco and MCH programs. Amendment 35 tobacco state tax revenue and a CDC grant continued to provide annual funding for additional tobacco program staff and comprehensive Tobacco program efforts, including MCH-related tobacco activities. Leveraging combined funds enabled the Tobacco program to extend the reach of strategic efforts that reduce the burden of perinatal tobacco use and exposure, increase positive birth outcomes and improve the health of families throughout the lifespan. Funded strategies and key outcomes are summarized below and are reflected in the state action plan for this priority. For a more detailed description, refer to the state action plan.

Strategy Implementation

The social emotional well-being state action plan was designed with the understanding that unmet behavioral health needs negatively impact the health of the individual and their family. The plan includes three broad strategies that allow state and local partners to implement a variety of activities that are meaningful to individual communities and will support social emotional well-being across the lifespan: 1) increase screening, referral, and connection to intervention for mental health and substance use treatment; 2) implement public awareness and school policy efforts focused on reducing the stigma associated with behavioral health and increase social connectedness for school age youth (see the Adolescent Health section for updates on this strategy); and 3) use data to better understand the root causes of inequities related to social and emotional well-being.

Strategy One: Increase screening, referral and connection to intervention for mental health and substance use treatment.

This first strategy in the social emotional state action plan aims to help systems achieve universal behavioral health screenings for the MCH population in a manner that is trauma-informed, non-stigmatizing, and done with cultural humility. MCH staff from the Maternal and Infant Wellness team partnered with the Colorado Perinatal Care Quality Collaborative to work with Colorado birthing hospitals on a series of quality improvement initiatives to increase screening for behavioral issues in the perinatal population. During this reporting period, 19 hospital labor and delivery units participated in a learning collaborative that provided support in implementing the Alliance for Innovation on Maternal Health’s patient safety bundle for Obstetric Care for People with Substance Use Disorders. Hospitals received customized technical assistance to implement screening, identify local resources, support provider education, assist with data collection, and use customized reports to track outcomes and progress towards ensuring universal screening and care for patients identified with behavioral health concerns. This included participation in Screening Brief Intervention Referral to Treatment (SBIRT) trainings and assistance in selecting validated screening tools, revising workflows/protocols, updating electronic medical records, and developing resources and community connections to strengthen patient referrals. As of September 2022, 64 percent of the Colorado hospitals in the learning collaborative reached sustainability in screening practices for substance use disorder, screening at least 90 percent of patients admitted to the labor and delivery unit. In the same period, 82 percent reached sustainability for screening for depression and anxiety.

A key component of this strategy is building the capacity of a perinatal mental health workforce that is well equipped to support patients who are facing challenges with perinatal substance use. MCH staff partnered with the state’s Behavioral Health Administration, the Colorado Chapter of Postpartum Support International, and the University of Denver Graduate School of Professional Psychology, to develop and host an in-person training entitled Connecting the Dots: Understanding the Intersection of Maternal Mental Health and Substance Use During Pregnancy and Early Parenthood. Ninety perinatal professionals representing a wide variety of roles (therapists, nurses, doulas, case managers, etc.) registered for the training, with a waitlist of over 40 people. The training covered:

• understanding maternal perinatal substance use;
• social justice, systemic racism, and substance use disorders;
• the intersection between substance misuse, attachment histories, and our regulatory system; and
• a history of perinatal substance use and treatment.

In pre- and post-training surveys, participants indicated: 

• an increase in knowledge and comfort across all domains (average of at least a full one point increase);
• 96% of respondents said they would recommend the training to a colleague;
• 85% of respondents said the program substantially enhanced their professional experience; and
• 96% of respondents found the content extremely useful.

Program staff are working on future iterations of the training, including a virtual option for greater statewide reach, online modules, and working with Postpartum Support International Central on the possibility of incorporating this content into their training materials.

MCH resources also supported the launch of a Colorado Chapter of the Perinatal Mental Health Alliance for Professionals of Color (“Health Alliance”). The Health Alliance serves to build infrastructure for mental health professionals of color to collaborate and strengthen support and referral networks. The Health Alliance is the result of a year-long series of targeted stakeholder interviews that focused on community-based solutions to address birth equity in Colorado and to increase the community’s collective capacity to care for and support pregnant and parenting people. The Health Alliance is a national model that is embedded within the Colorado Chapter of Postpartum Support International. Collaboration with Postpartum Support International will allow Colorado’s Health Alliance to connect with other communities across the nation, while also keeping a local voice and perspective. During this first phase of convening, the Health Alliance will develop a strategic vision and related goals to guide future efforts. Ultimately, the goal is to support a more diverse perinatal mental health workforce that will allow more people of color to receive culturally congruent care.

The MCH program at Tri-County Health Department and the Public Health Institute at Denver Health created a no cost training and action planning sessions to promote perinatal mental health and build workforce capacity. The two-hour sessions are designed to help service providers, organizations, and communities understand and embrace their role in supporting perinatal mental health. Participants learned about the Perinatal Continuum of Care, a framework that highlights opportunities across sectors to promote and address perinatal mental health and develop action plans that incorporate effective strategies that are applicable across sectors.

MCH staff also participated in the leadership team of the Colorado Maternal Mental Health Collaborative and Framework. The Collaborative represents a partnership of individuals and organizations committed to accelerating progress toward improved mental health and wellness of all pregnant and postpartum people in Colorado. This year the Collaborative had multiple policy impacts, with participating partners informing and monitoring bills that advance the four primary goals of Colorado’s Maternal Mental Health Framework: Supportive Community; Maximized Prevention; Universal Screening and Appropriate Referral; and Comprehensive, Inclusive, and Responsive Continuum of Care.

An analysis of labor and delivery practices highlighted that the use of toxicology testing for substance use in pregnancy and during the labor and delivery period varied across hospitals and among individual providers. This analysis indicated that families of color were being tested at higher rates than white families, without adherence to consistent guidelines. To address this issue, MCH staff co-chaired a Policy Analysis Workgroup in partnership with Illuminate Colorado, a non-profit organization whose mission is to strengthen families and prevent child maltreatment. The workgroup created an evidence-based, equitable framework that labor and delivery hospitals can use to shape policy and practice for when and how to use toxicology tests to guide the care of birthing parents and newborns, understand lactation considerations, and determine how and when to engage child welfare. The members of the workgroup ranged from people with lived experience, lactation consultants, advocates, toxicologists, and providers, leading to many diverse perspectives and challenging conversations about the most equitable ways to support families and the most appropriate uses of toxicology testing. The guide was finalized in the spring of 2023 and was shared with the Colorado Perinatal Care Quality Collaborative. 

Tobacco use continues to negatively impact pregnancy outcomes and disproportionately impacts families with lower incomes, people of color, LGBTQ+ populations, and persons with a mental health diagnosis. There are a variety of reasons for these disparities, including these populations being historically targeted by the tobacco industry, as well as the chronic exposure to stress caused by racism as a determinant of health. In November 2020, Colorado voters approved a new tobacco tax that went into effect in January 2021, resulting in an increase of $1.10 per pack of cigarettes. Tobacco price increases are known to decrease smoking among pregnant people. The decrease in smoking reflected in the NPM and ESM, may be partly due to the tax increase. The QuitLine continued to offer a suite of evidence-based phone and digital tobacco cessation and treatment services for pregnant people, including a tailored pregnancy and postpartum protocol. During the reporting period, 263 pregnant people enrolled in the pregnancy protocol program.

The Baby and Me Tobacco FreeTM Program continued to serve pregnant people and their partners across Colorado by providing perinatal smoking cessation services. During the reporting period, the program enrolled 391 pregnant people and their partners. Enrollees participated in either the in-person or telehealth modality. Baby and Me focused on increasing enrollment of Black pregnant people and their partners by actively engaging with organizations and providers that serve pregnant people of color. It also ensured that both in-person and telehealth modalities were available for potential enrollees in areas with significant BIPOC populations. The State Tobacco Education, Prevention, and Cessation Grants Program (STEPP) collaborated with the Colorado Black Health Collaborative to increase awareness of Baby and Me Tobacco FreeTM and the QuitLine pregnancy protocol program in order to increase reach, especially to Black pregnant people and their partners. The Baby and Me Tobacco FreeTM Program Coordinator and STEPP Project Officer were invited to join the Colorado Black Health Collaborative’s Real Talk Facebook Live to talk about the program.

Comprehensive tobacco treatment benefits, including individual and group telephone counseling and FDA-approved medications, were available to all Colorado Medicaid members with no cost-sharing or prior authorization requirements. Tobacco treatment services offered through the QuitLine, Baby and Me Tobacco FreeTM, and Medicaid were available to any pregnant person or partner seeking help for any form of nicotine use or dependence, including e-cigarette use. Of the 391 total enrollments to the program, approximately 80 percent were Medicaid members.

Screening and connection to early intervention for mental health and behavioral concerns should begin early in the lifespan, and in the past year, MCH staff strengthened partnerships with programs that support pediatric behavioral health through both practice and evidence-based interventions. HealthySteps®, a program of ZERO TO THREE®, is an evidence-based and team-based pediatric primary care program that promotes nurturing parenting for babies and toddlers to support healthy development. In Colorado, Assuring Better Child Health and Development (ABCD) is the state intermediary for the implementation of the HealthySteps® program serving a wide range of communities throughout the state. HealthySteps® sites serve a high number of families with at least one of six risk factors that indicate a greater need for family support to promote healthy child development and integrated behavioral health. In the last year, HealthySteps® added almost 7,000 new children and onboarded six new sites, expanding the program’s reach to 33,130 children ages 0-3 across the state via 29 sites. Technical assistance for sites was provided by ABCD to optimize program implementation. Professional development included monthly community of practice calls, a professional development series, and consultation on shared decision-making and motivational interviewing. As the state intermediary, ABCD supported the development of a “billing playbook” with a training webinar to maximize sites’ Medicaid billing,which can help with overall site sustainability. The MCH Early Childhood Systems Specialist joined the Regional HealthySteps® Advisory Council, along with members from the state’s Medicaid agency, and representatives from Medicaid’s Regional Accountable Entities, to support the sustainability and growth of the program.

Strategy Three: Increase state investment in addressing inequities and population disparities related to social emotional well-being through data collection and dissemination and by incorporating people with lived experience into decision making processes.

With support from the MCH program, in 2021 CDPHE’s Center for Health and Environmental Data published a report based on Health eMoms data entitled Postpartum Behavioral Health in Colorado. This report was shared widely, and stakeholders have been using it to drive funding decisions and local programming. MCH staff partnered with community stakeholders to inform legislation in 2022 that resulted in the allocation of ongoing state General Funds to provide sustainable funding for this unique source of data. 

Colorado’s Maternal Mortality Review Committee is charged with reviewing all the cases of maternal death in the perinatal period in Colorado to determine the factors surrounding the death and to make recommendations to help prevent future deaths. While the reviews represent the most tragic and worst case scenarios, recommendations have far reaching implications that would decrease maternal morbidity and improve maternal health and well-being. In alignment with the MCH strategic anchors of community inclusion and racial equity, the Review Committee diversified its membership to include more people who have been affected by the drivers of maternal mortality. In 2021, 19 new members were onboarded, including ten members who identify as being from a marginalized community and six members with lived experience related to maternal health. In 2022, an additional two community members joined the committee. To support recruitment, MCH staff worked with the state Medicaid agency to share the opportunity in a patient-facing Medicaid newsletter. The application was also shared through various social media channels, such as parent support groups and other community-facing organizations. In an effort to address barriers to participation on the committee, participants were offered compensation for their time and expertise. The community members have been essential in naming the ways in which racism and discrimination are embedded within the healthcare system and affect a person’s health outcomes.

The Maternal Mortality Prevention Program disaggregated data from 2016-2020, focusing on the disparities in maternal mortality across race and ethnicity. For the first time, by aggregating multiple years of data, Colorado data mirrored the national data that shows Black pregnant and postpartum people are three times more likely to die during the perinatal timeframe from causes directly related to pregnancy. A legislative report discussing these disparities will be released later this summer.

MCH contributed to funding a regional oversample of the National Survey of Children's Health that includes questions about social emotional well being. See Section III.E.2.b.iii. MCH Data Capacity for more about the oversample.