NPM 14.1: Percent of women who smoke during pregnancy​

 

Activity: Maternal Mortality and Morbidity Review

The multidisciplinary Texas Maternal Mortality and Morbidity Review Committee (MMMRC), with facilitation and support from MCH, continued throughout FY20 to comprehensively review deaths of women during or within a year of pregnancy and state trends in maternal mortality and morbidity to understand causes, contributors, risk factors, and racial and ethnic disparities to inform development of targeted, actionable recommendations to prevent future deaths

 

The MMMRC assessed tobacco use as part of the case review process. Tobacco use may be selected by the MMMRC as a contributing factor on the Maternal Mortality Review Information Application (MMRIA) Committee Decisions Form (versions 18 and 19) to describe the patient’s use of tobacco as compromising the patient’s health status.

 

The MMMRC Subcommittee on Maternal Health Disparities created the Discrimination Assessment and Social Determinants of Health Facilitated Discussion Tool (DASH Tool), which provides a standardized process to guide targeted discussion, evaluate information relevant to each case, and determine whether social determinants of health factors contributed to the death. Section B of the DASH Tool includes a checkbox for tobacco use of the decedent as a life course factor that potentially impacts family wellbeing. MCH piloted an early version of the DASH Tool in October 2019. Findings and priority recommendations of the MMMRC raised awareness among partners and stakeholders of the Perinatal Quality Improvement Network on the drivers of maternal mortality.

 

Healthy Texas Mothers and Babies (HTMB) Community Coalitions

The HTMB Community Coalitions provided programmatic and technical assistance to support perinatal community coalitions across Texas in communities with the greatest disparities in infant health. The Maternal and Child Health (MCH) Unit directs each HTMB Community Coalition to develops and maintains a network of partners in maternal and infant health. These partnerships allowed the Community Coalitions to carry out assessment activities to identify needs in their communities, including reviewing and assessing infant morbidity and mortality data such as Perinatal Periods of Risk mapping. Additionally, the HTMB Community Coalitions conducted strategic planning to develop, implement, and evaluate data-driven programs, initiatives, and community outreach, education, and awareness activities tailored to their population to address specific identified needs and factors. All four Healthy Start sites in Texas were part of these HTMB Community Coalitions. DSHS funded and collaborated with local health structures, including public health departments and a public hospital district, to establish multidisciplinary community coalitions to reach target populations in their communities. The fiscal year (FY)20 HTMB Community Coalitions were:

1. Healthy Amarillo Women – City of Amarillo Public Health Department (five counties in Public Health Region [PHR] 1)
2. Breastfeeding for a Healthy Brownsville – City of Brownsville (located in PHR 11)
3. Dallas Healthy Start Community Action Network – Parkland Health & Hospital System (seven counties in PHR 2/3)
4. Laredo Health Coalition – City of Laredo Health Department (located in PHR 11)
5. Healthy Me, Healthy Babies – Northeast Texas Public Health Department (one county in PHR 4/5N)
6. Healthy Mothers and Babies of Jefferson County – Port Arthur City Health Department (one county in PHR 6/5S)
7. Healthy Families Network – San Antonio Metropolitan Health Department (one county in PHR 8)
8. Infant Health Network – Tarrant County Public Health Department (one county in PHR 8)
9. Healthy Waco Women – Waco-McLennan County Public Health Department (one county in PHR 7)

 

HTMB Community Coalitions are important partners at the grassroots level to implement evidence-based efforts to change behaviors and connect pregnant women to resources. Examples of HTMB community coalitions’ community-based maternal health interventions in FY20 included:

• Provision of 6-month supplies of prenatal vitamins to pregnant women.
• Classes to increase understanding about key health topics such as pre-eclampsia and gestational diabetes.
• Community outreach through education and professional support using social media, promotional materials, community-based events, and partnerships. Topics of education included:
  • Preconception, prenatal, and postpartum health.
  • Substance abuse (smoking and alcohol consumption).
  • COVID-19 prevention for women and mothers.

 

Texas Health Steps Online Provider Education

MCH collaborated with the Health and Human Services Commission (HHSC) Texas Health Steps Online Provider Education (THS OPE) program to promote its MCH-supported suite of continuing education modules focused on preconception and prenatal health. Physicians, nurses, social workers, and other providers completed a variety of modules related to women’s and maternal health in FY20. In FY20, 550 providers completed Preconception Health: Screening and Intervention and 632 providers completed Prenatal Health: Screening and Intervention. DSHS released a new module, Postpartum Health: Screening and Intervention at the beginning of FY20 and 560 providers completed the module. In FY20, DSHS also released the revised and redesigned Breastfeeding module. Nearly 2,300 providers completed this module. These modules contain information about screening, brief intervention, referral, and treatment to promote tobacco cessation in the preconception, prenatal, postpartum, and interpregnancy periods.

 

Information for Parents of Newborn Children

Texas Health and Safety Code 161.501 requires hospitals, birthing centers, physicians, nurse-midwives, and midwives who provide prenatal care to pregnant women during gestation or at delivery to provide the parents or adult caregiver for the infant with a resource pamphlet. This pamphlet includes information about a variety of maternal and infant health considerations including information about the importance of smoking cessation and smoke free environments for maternal and infant health. Providers may distribute the DSHS booklet or develop and use a similar material that contains the information that is required by statute.

 

In FY20, DSHS distributed 47,784 physical pamphlets in English and 10,544 physical pamphlets in Spanish to health care providers to share with parents of newborns. These numbers may not accurately reflect demand, as the ability to print pamphlets during some of FY20 was impacted by the COVID-19 pandemic. Additionally, there were 77 pamphlets (63 English, 14 Spanish) downloaded from the MCH website.

 

High-Risk Maternal Care Coordination Services Program Pilot

In Regular Session 2019, the Texas Legislature added Texas Health and Safety Code 1001 Subchapter K directing DSHS to develop and implement a high-risk maternal care coordination services pilot program (HRMCCSP) in one of more areas of Texas.

 

DSHS is charged to implement and study a pilot program to provide one or more sites with guidance, resources, training, and support to complete risk assessments in a clinical setting with pregnant women at elevated risk for poor pregnancy, birth, or postpartum outcomes. As indicated by the risk assessment, women will be referred into a program that integrates services of community health workers (CHWs) into the women’s care.

 

DSHS will develop, adapt, or adopt: CHW training courses to prepare promotoras and CHWs in assessing risk and educating and supporting women at risk for serious complications during pregnancy and in the postpartum; a model of care coordination services for women at high risk; and an assessment tool or tools for identifying women who are at higher risk for poor pregnancy, birth, or postpartum outcomes. The design and implementation of the pilot will be guided by best practices in pilot studies and will focus on assessing feasibility and acceptability of the interventions being tested while using rapid-cycle testing and scaling of the model. [1],[2],[3],[4],[5]

 

Research on existing resources and best practices for development of a risk assessment tool, a CHW training curriculum, and a care coordination model began in March 2020. Staff began work to create a risk assessment tool prototype for the pilot based on existing risk assessment tools and stakeholder input.

 

Additionally, staff conducted a statewide scan of 27 existing CHW training modules certified by DSHS as well as modules developed for the national Healthy Start program. Staff reviewed the modules to identify those that included information in the modules’ learning objectives and content of the courses about risk factors and risk assessment for high-risk pregnancy. Recommendations from the scan of CHW module topics included health equity and maternal outcomes in Texas, the role of CHWs and care coordination for women with maternal risk factors, and maternal health promotion, risks, and warning signs.

 

MCH staff also reviewed over 40 CHW care coordination models from statewide and national programs to guide model development. The pilot model will integrate CHWs into care coordination as part of multidisciplinary care teams which will enable timely response for women at elevated risk, including those with chronic health conditions and behavioral health needs.               

 

In FY20, MCH staff began coordinating with the DSHS CHW Certification Program staff to create a long-term plan for development of a specialty certification track within the DSHS CHW Certification Program. MCH will continue to work with the DSHS CHW Certification Program to design a High-Risk Maternal Care Coordination Services Certification for CHWs who complete a suite of specialized trainings for educating and supporting women with maternal risk factors. The suite of trainings will be based on the trainings developed and tested as part of the HRMCCSP.

 

Regional Activities

DSHS Public Health Regional (PHR) staff conducted several activities to educate communities about the dangers of smoking and the importance of not smoking during pregnancy. PHR 7 continued to provide smoking cessation education to individuals who visited PHR clinics and promoted the Texas Tobacco Quitline, a confidential advice and information service for people who want to quit smoking. Staff participated in webinars offered by DSHS and other agencies to increase their knowledge of the dangers and current trends of smoking, including the use of e-cigarettes, vaping, hookah, and the use of synthetic marijuana among adolescents. This education enabled staff to provide smoking cessation education more effectively to the community.

 

PHR 9/10 partnered with hospitals, local health care providers, community health organizations, the U.S. Department of Housing and Urban Development, and other organizations to promote smoking prevention and cessation activities. Activities from these partnerships reached 92 individuals and included:

• Promoting THS OPE modules to local hospitals and providers.
• Providing education and support for tobacco-free multi-family housing units.
• Promoting the Texas Tobacco Quitline to DSHS clinic patients.
• Engaging CHWs in smoking cessation and prevention activities.

 

PHR 11 collaborated with the DSHS Regional Tobacco Prevention Coordinator and DSHS Office of Border Public Health to translate the DSHS CHW curriculum, Helping Pregnant Women Quit Smoking: Best Practice Interventions, into Spanish. Fifty CHWs completed the Spanish module, which included education on the dangers of secondhand smoke exposure to pregnant women and children and information about the Quitline. Through partnerships with the Regional Tobacco Prevention Coordinator, United Way, and local schools, PHR 11 staff also educated 27 pregnant teens on the dangers of secondhand smoke exposure and vaping to their health and the health of their baby and their families.

Other PHR activities included:

• Educating women on the harmful effects of smoking and vaping during pregnancy through Becoming a Mom/Comenzando Bien, a comprehensive prenatal program designed by the March of Dimes.
• Presenting on the dangers of vaping and e-cigarettes to school nurses and counselors, middle and high school students, and professional organizations. These presentations were a request from the Educational Training Center in East Texas. PHR 4/5N staff presented 38 times to approximately 4,330 people.

 

Adopted in December 2017, the DSHS Healthy Texas Mothers and Babies (HTMB) Strategic Framework is modeled after the Prevention Institute’s Spectrum of Prevention, and provides strategic direction for alignment, improvement, and development of existing and new interventions to support the triple aim of healthy women, healthy mothers, and healthy babies. The HTMB Framework integrates all of DSHS Maternal and Child Health (MCH) women’s, maternal, perinatal, and infant health programming and expands upon MCH commitment and investments toward improved infant health outcomes through the previous Healthy Texas Babies (HTB) Initiative by elevating and amplifying an emphasis on women’s and maternal health and safety.  

 

The HTMB framework includes the domains of Individual and Public Awareness and Knowledge, Professional Education, Community Empowerment, Community Improvement, and the Perinatal Quality Improvement Network, which includes a variety of interrelated and complementary initiatives that provide public health knowledge, partner mobilization, and implementation resources to drive system changes to support adoption and diffusion of quality improvements for maternal and infant health and safety.  

 

Effective February 1, 2019, the HTMB Branch was established within the MCH Unit to elevate this framework and provide structure to support MCH ongoing commitment to women’s, maternal, and infant health improvement.  

 

Figure 1: Healthy Texas Mothers and Babies Framework 

 

 

The 2020 Title V Needs Assessment identified care coordination and health disparities among maternal and child health populations as priority needs. MCH programmatic efforts in the women’s and maternal health domains included policy, environmental, and systems level approaches to improve systems of care, increase health equity, prevent and control acute morbidity and chronic disease, and promote wellness throughout a woman’s reproductive years. Women in Texas experienced high rates of obesity, diabetes, hypertension, substance abuse disorder, and other morbidities as well as marked racial, ethnic, and geographic disparities.

 

Self-reported health status is a helpful measure to account for the multiple factors that impact a woman’s preconception and interpregnancy health beyond the primary care visit. As described by Broussard et al (2011), DSHS epidemiology and program subject matter experts contributed, along with experts in other states, to a multi-state consensus-based selection process to develop a set of Core State Preconception Health and Health Care Indicators. SPM 5 is a core preconception health indicator and is the only indicator of general health status included by the Council of State and Territorial Epidemiologists in this core measure set. A lower rating of self-rated health status has consistently been associated with “increased mortality, incident adverse health events, health care utilization, and

illness severity, even after medical risk factors have been accounted for.” [6]

 

Maternal Mortality and Morbidity Review (MMMRC)

The 86th Texas Legislature, Regular Session, 2019 added several additional charges relating to the MMMRC. Actions of the 86th Texas Legislature, Regular Session, 2019, relating to the MMMRC that impacted work in FY2020 included:

• Senate Bill (SB) 436 – amended Texas Health and Safety Code (HSC), Chapter (Ch.) 34, by adding § 34.0158 to direct the Department of State Health Services (DSHS), in collaboration with the MMMRC, to develop statewide initiatives to improve maternal and newborn health for women with opioid use disorder.
• SB 748 – amended HSC Ch. 34 to direct the Health and Human Services Commission (HHSC) to:
  • Collaborate with the MMMRC to perform annual data collection of specific information from the Medicaid and Healthy Texas Women (HTW) programs,
  • Consult with the MMMRC for development of a telehealth or telemedicine services program, and
  • Conduct program evaluations, including to explore expanding certain services.

The bill added § 34.021 to direct the HHSC Executive Commissioner (via DSHS), to apply for grants under the Federal Preventing Maternal Deaths Act of 2018 (PMD). The bill also amended HSC Ch. 1001 by adding Subchapter K, which charges DSHS to develop and implement a high-risk maternal care coordination services pilot program (HRMCCSP) in one or more areas of Texas.

• SB 750 – amended HSC Ch. 34 to change the committee’s name from the “Maternal Mortality and Morbidity Task Force” to the “Texas Maternal Mortality and Morbidity Review Committee” and added a provision making limited allowances for reporting in compliance with the Federal Preventing Maternal Deaths Act (PMD).
• SB 2132 – added HSC § 531.0995 and directs HHSC to consult with the MMMRC on improving the process for providing required information to women enrolled in the HTW program.
• 2020-21 General Appropriations Act, House Bill (HB) 1 (Article II, Health and Human Services, Rider 28) – over the biennium, appropriated:
  • $1.33 million and six Full Time Employees (FTEs) to implement maternal safety initiatives statewide,
  • $1.17 million and two FTEs to develop and establish the previously mentioned high-risk maternal care coordination services pilot, and
  • $1 million to increase public awareness and prevention activities related to maternal mortality and morbidity.
• HB 25 – added HSC § 531.024141 directing HHSC to collaborate with the MMMRC to develop and implement a pilot program for providing services to women and children under the Medicaid medical transportation program

 

In December 2019, the MMMRC received the DSHS Commissioner's Partner in Public Health Shine Award for the group’s outstanding contribution in partnership with DSHS to advance the mission and vision of the agency.

 

The DSHS commissioner appointed two members to the MMMRC: Dr. Sherri Onyiego, a physician specializing in family practice, and Kimberley Williams, a community advocate. Both members began participating in MMMRC activities in September 2019. In March 2020, the DSHS commissioner appointed Dr. Kelly Fegan-Bohm, DSHS Community Health Improvement Medical Director, as the State Epidemiologist Interim Designee.

 

The MMMRC established the Subcommittee on Maternal Health Disparities (Subcommittee) in December 2018 to further investigate factors contributing to disparities in maternal mortality. MCH provided administrative and programmatic support for the activities of the Subcommittee. In September 2019, Changing the Conversation: Applying a Health Equity Framework to Maternal Mortality Reviews was published in the American Journal of Obstetrics by Kramer et al. [7] The article provided a call to action for maternal mortality review committees and provided a framework for the Subcommittee to guide the MMMRC to ground its case review processes in a health equity framework to study drivers and root causes of racial disparities in maternal mortality in Texas.

 

The Subcommittee conducted the following activities in FY20:

1. Studied pregnancy-related death cases in the 2012 case cohort and the association of women’s race or ethnicity with the number and types of contributing factors that the MMMRC identified during their review. In December 2020 during the MMMRC Quarterly Public Meeting, MCH Epidemiology Director, Dr. Michelle Cook, presented the findings from this analysis.
2. Provided consultation to DSHS on the development of the Texas Socio-Spatial Context Dashboard to provide community-level context when studying pregnancy-associated deaths. The MMMRC began to use the dashboard as part of its standard review process in November 2019.
3. Drafted a review committee-facilitated discussion tool for social determinants that may impact a woman’s health, health care experiences, and health disparities throughout her life and in the time leading up to her death (called the Social Determinants of Health and Discrimination Assessment Facilitated Discussion Tool). The MMMRC began testing the use of this tool during case review to enhance their identification of factors that contribute to preventable maternal mortality.

 

DSHS and MMMRC members continued to contribute to and learn from national conversations about reducing maternal mortality and severe maternal morbidity.

Dr. Carla Ortique, MMMRC Vice-Chair and Subcommittee Chair, participated in a national workgroup to develop standard definitions for state maternal mortality review committees. The conclusion of this work was formally presented via webinar in April 2020, by the workgroup chair Dr. Elizabeth Howell. Subsequently these contributing factors and supporting definitions were added to the MMRIA Committee Decisions Form, Version 19 in May 2020. 

 

The Association of Maternal and Child Health Programs (AMCHP), the Centers for Disease Control and Prevention (CDC) Foundation, and the CDC Division of Reproductive Health partnered to develop a resource called Review to Action, which promoted the maternal mortality review process as the best way to understand causes and contributors to maternal mortality to prioritize interventions to improve maternal health.

 

In September 2019, DSHS received funding through the CDC’s Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM) Program. This funding supports DSHS efforts to coordinate and manage MMMRC activities to identify, review, and characterize maternal deaths as well as identify prevention opportunities.

 

In partnership with the MMMRC and the University of North Texas Health Science Center (UNTHSC) and with consultation from CDC, DSHS worked throughout FY20 to hire four MCH staff and develop the infrastructure to increase capacity for case review. The ERASE MM grant supports DSHS efforts to identify pregnancy-associated deaths within one year of the date of death and supports the MMMRC in review of potentially pregnancy-related deaths that fall within the defined scope of the MMMRC. DSHS, in coordination with UNTHSC contract partners, aims to abstract and enter clinical and non-clinical data into the Maternal Mortality Review Information Application (MMRIA) data system, support the MMMRC to conduct timely multidisciplinary pregnancy-associated death reviews, and enter committee decisions in MMRIA within two years of death. Through ERASE MM funding, MCH aims to improve data quality, completeness, and timeliness through use of quality assurance processes in partnership with the CDC. Activities of the ERASE MM grant will also support analysis and communication of findings with stakeholders throughout the Perinatal Quality Improvement Network to inform policy and prevention strategies to reduce maternal mortality in Texas.

In December 2019, DSHS staff and the MMMRC Chairs, Dr. Lisa Hollier and Dr. Carla Ortique, participated in the CDC ERASE MM MMRIA User Meeting. Dr. Carla Ortique presented on MMMRC work, including:

• High Volume Case Review: The Texas MMMRC Experience- This presentation details the primary review case categorization process. A process developed by MCH staff, in coordination with a small pilot group of the MMMRC to increase case review efficiency; and
• Innovations for Improvement- This presentation focused on the work of the Subcommittee on Maternal Health Disparities.

 

MCH work throughout FY20 focused on MMMRC-related infrastructure building activities, including hiring four ERASE MM grant-funded FTEs and developing an ERASE MM Workplan and Evaluation and Performance Management Plan. The CDC Maternal Mortality Prevention Team visited Texas in March 2020 to provide on-site technical assistance and provide subject matter expertise during the MMMRC’s maternal mortality case review meeting. After execution of a data use agreement with the CDC, MMRIA went live in Texas in July 2020. In FY20, MCH continued to contract with UNTHSC to ensure high quality case redaction and case abstraction reporting for MMMRC case review. MCH staff worked to coordinate strategies to support UNTHSC’s internal quality assurance process and met weekly with UNTHSC program staff to optimize contract efficiencies and ensure completion of 15-25 cases per quarter for review by the MMMRC. MCH provided ongoing subject matter expertise for additional quality assurance oversight and feedback. UNTHSC and DSHS staff participated in virtual CDC ERASE MM MMRIA training in June 2020. MCH staff worked throughout FY20 to plan for integration of the MMRIA system into the case abstraction and data management processes.

 

Before COVID-19 emergency orders beginning in March 2020, the MMMRC met in person quarterly and the MMMRC review teams met by phone monthly for preliminary review and analysis of each case. After March 2020, case calls and virtual web-based quarterly meetings continued throughout FY20. From September 2019 through June 2020, the MMMRC reviewed and closed 79 cases from the 2013 pregnancy-associated death cohort. Quarterly MMMRC meetings included programmatic updates from DSHS programs relevant to the MMMRC, presentation of data on severe maternal morbidity and mortality trends in Texas, refinement of MMMRC processes, and closed-session confidential case reviews.

Dr. Lisa Hollier, the MMMRC chair co-authored Maternal Mortality from Coronavirus Disease 2019 (COVID-19) in the United States. The manuscript published in August 2020 highlights the role of maternal mortality review committees in understanding emerging health issues and the utility of contemporary case review.[8]

 

Many MCH-supported maternal health and safety activities of the HTMB are informed by previously published MMMRC recommendations and resulting legislation, including the TexasAIM Initiative and work to develop the HRMCCSP Program and a Maternal Health and Safety Campaign. In late FY20, MCH coordinated the development of the 2020 MMMRC/DSHS Joint Biennial Report for release on December 1, 2020.

 

Online Provider Education for Preconception, Prenatal, and Postpartum Health

MCH collaborated with Texas Health Steps Online Provider Education (THS OPE) to promote its MCH-supported suite of continuing education modules focused on preconception, prenatal, and postpartum health. The modules were refreshed in FY19 and are designed to equip health care professionals with knowledge and resources to improve the health of Texas women before and during pregnancy. In FY20, 550 health professionals completed 1.25 hours of continuing education in Preconception Health: Screening and Intervention, 632 health professionals completed 1.25 hours of continuing education in Prenatal Health: Screening and Intervention, 560 health professionals completed 1.25 hours of continuing education in Postpartum Health: Screening and Intervention, and 2,298 health professionals completed 2.0 hours of continuing education in Breastfeeding. Health professionals also completed quick courses and tutorials that were available without continuing education, including: Fetal Alcohol Spectrum Disorders: Promoting Early Identification and Support for Children; Integrating Postpartum Depression Screening into Routine Infant Medical Checkups; Opioid and Substance Use: Caring for Texas Mothers and Babies; Oral Health and Dental Services for Pregnant Women; and The Virus Among Us: Protecting Texas Mothers and Babies from Cytomegalovirus. The modules may be accessed at www.txhealthsteps.com.

 

HTMB Community Coalitions

HTMB Community Coalitions worked to reduce racial and ethnic health disparities in maternal and infant health in their communities by applying evidence-based multi-pronged approaches. These approaches include tailored programs designed to meet the needs of women, mothers, and infants based on identified gaps and needs of their respective communities. Specific activities are listed below.

• The coalition in Laredo collaborated with March of Dimes Foundation to launch a nine-week educational course called Becoming a Mom/Comenzando Bien. This course covered topics related to pregnancy health, healthy lifestyle behaviors, labor, birth preparation, infant care, familial support, and mental health and reached 6,000 community members.
• The Breastfeeding for a Healthy Brownsville coalition facilitated 11 educational and outreach events addressing maternal and infant health disparities. Events and information reached 26,200 community members.
• The Healthy Waco Women Community Coalition (HWCC) partnered with a local Federally Qualified Heath Center to encourage women to receive annual well women exams. They distributed 400 Healthy Waco Women Wellness Bags—including a multi-vitamin with folic acid, among other wellness items—at 13 clinics for clients that redeemed vouchers after receiving their annual exam. Women who signed up to receive a voucher also received subscriptions to a monthly newsletter with women’s health tips. 
• HWCC offered contraception counseling training to 30 key stakeholders caring for women of color to improve knowledge and skills on motivational interviewing, reproductive life planning, and contraception options.
• HWCC Women’s Health Advocacy Committee held key informant meetings with seven active participants to learn more about the health needs of women of color between the ages of 18-25 and how best to engage these populations in preventive health services and programs.
• HWCC offered continuing education opportunities at monthly meetings with approximately 20 maternal and child health program and service providers to increase awareness about implicit biases and maternal and child health disparities.
• Despite setbacks related to COVID-19, Tarrant County Public Health in collaboration with the Infant Health Network community coalition implemented the Preconception Peer Educator Program with local universities. Staff used the student training guide published in 2008 from the Office of Minority Health and the program outline from HTMB staff to create a relevant and relatable curriculum.

 

Additionally, PHR staff conducted various activities to promote health and wellness for women of childbearing age. PHR 6/5S hosted Becoming a Mom/Comenzando Bien. Classes were in English and Spanish. Women received educational information on prenatal care, nutrition, stress, things to avoid during pregnancy, labor and birth, postpartum care, and newborn care.  In PHR 7, staff continued to implement the Whole Person Project. The Whole Person Project promotes consideration for all health needs and concerns of the person instead of just the issues for the clinical visit. When women of childbearing age visited the clinic, staff routinely asked clients the One Key Question (OKQ), “Would you like to become pregnant in the next year?” Staff offered tailored support based on the response and individual needs of the woman including encouraged over 80 clients to visit a primary care giver, distributed 60 bottles of prenatal vitamins, provided contraception to women, and provided referrals to food assistance programs, the Texas Tobacco Quitline, and social workers.

 

High Risk Maternal Care Coordination Services Program Pilot (HRMCCSP)

In FY20, MCH started developing the HRMCCSP Program to pilot test a program for identification of, and improvement of care coordination for, women at increased risk for poor pregnancy, birth, and postpartum outcomes for prevention of severe maternal morbidity and mortality. HTMB staff convened an internal pilot design team. The team’s FY20 activities included:

• Review of existing risk assessment tools from other states and programs that determine if a woman is at risk for poor pregnancy, birth, or postpartum outcomes. Staff analyzed and compared tools and made recommendations for essential health status factors to include in an adapted high-risk assessment tool prototype.
• A statewide scan of 27 DSHS-certified Community Health Worker (CHW) training courses related to maternal health. Staff used the scan to create recommendations for the development of a suite of trainings to prepare CHWs to educate and support women with maternal risk factors. The training suite prototype will be one of the HRMCCSP Program components tested during the pilot. Additionally, MCH staff began work with the DSHS CHW Certification Program to plan for development of a CHW specialty certification track recognizing CHWs who have received continuing education through completion of the final training suite.
• A literature review of over 40 models of high-risk care coordination from statewide and national programs. Staff used lessons learned from other programs to identify and refine model components. The proposed model included use of a high-risk assessment tool, multidisciplinary care teams, CHW-led care coordination, health education and outreach, and a focus on health equity.
• Development of a logic model for the program, defining maternal high-risk, and identifying maternal outcomes that the program will address.
• Efforts to share research findings with a multidisciplinary team of stakeholders from DSHS and the Texas Health and Human Services Commission (HHSC). Staff also held separate meetings with the DSHS Health Equity Advisor, CHW Program managers, and HHSC Medicaid team to ensure awareness, coordination, and alignment of the pilot program with related initiatives.

 

In August 2020, MCH began to develop a proposal for participation in the Virtual CDC/Harvard MCH Program Evaluation Practicum for development of an evaluation framework for the pilot. Each year in January, the CDC Division of Reproductive Health, Harvard’s T.H. Chan School of Public Health (HSPH), and the Association of Maternal and Child Health Programs co-present a hands-on Program Evaluation Practicum course. HSPH students who apply and enroll in the course are matched with a MCH program in need of evaluation.

 

The HRMCCSP that will be piloted will be designed with the goal of improving coordination of care for maternal and child health populations, particularly women with elevated risk and Non-Hispanic Black women. The program will reach women of reproductive age in the pilot area, specifically women who are at high-risk for negative pregnancy, birth, or postpartum outcomes. The pilot will also reach CHWs and CHW Trainers with expanded training material and skills and continuing education on maternal health, particularly for populations at elevated risk.

 

The design and implementation of the pilot project will be guided by best practices in pilot study design and will focus on assessing feasibility and acceptability of the interventions being tested while using rapid-cycle testing and scaling of the model.

 

Maternal Health and Safety Campaign

In FY20, MCH began to plan and procure a contract for development of a maternal health and safety awareness, education, and communication campaign. Staff identified a contractor through a competitive process and identified Fleishman Hillard (FH) with the contract beginning in May 2020.

 

FH conducted market research in July 2020 to inform development of messaging and communication methods. This research included engagement with Texas women through focus groups and phone interviews and stakeholders through key information sessions. Focus groups and phone interviews took place with women ages 18-44 in Dallas and Tarrant Counties, Bexar and Atascosa Counties, Nueces County, Southeast Texas, West Texas, and the Texas-Mexico border region. The women were primarily of low-income; were in preconception, interpregnancy, prenatal, or postpartum periods; and spoke English and Spanish. Additionally, FH conducted in-depth telephone interviews with key stakeholders to gather insights and experiences related to Texas women before, during, and after pregnancy. Interviews focused on women most at risk for maternal health complications. FH also reviewed past and existing maternal health and safety awareness, education, and communication campaigns. FH provided a summary report of the research and held stakeholder meetings to present this information and receive feedback for campaign development.

 

Because of this research, work is in progress to develop marketing and educational materials, campaign website, a media strategy, and a robust outreach plan. Additionally, staff have aligned this campaign with national efforts, including the CDC’s Hear Her Campaign and the Council on Patient Safety’s Maternal Urgent Warning Signs.

 

Messaging for the campaign efforts will focus on:

• The impact of severe maternal morbidity and mortality on Texas women, families, communities, and the state overall.
• The disproportionate impact of severe maternal morbidity and mortality on Non-Hispanic Black and Hispanic women, particularly those with a low income.
• Activities that communities can do to lower the risk and improve health outcomes.
• The importance of, and opportunities for, promotion of maternal health, safety, and wellbeing.
• Evidence-based or promising prevention strategies and the role and responsibility of providers to implement these strategies.

The campaign will apply a health equity lens to address disparities in all strategies. Through this work, MCH will disseminate information and initiatives to mothers, their support networks, and providers statewide through targeted public awareness and community mobilization.

 

The maternal health and safety campaign will reach Texas women, their support networks, and providers. The primary target audience includes women of childbearing age (18-44 years) in the preconception, interpregnancy, prenatal, and postpartum periods, focusing on Non-Hispanic Black and Hispanic women. The secondary target audience will include families, support networks, professionals, and paraprofessionals that provide health or social services to women; health and social service institutions; and professional organizations, collaboratives, and networks.

 

Objective 5: By 2020, enroll 75% of Texas birthing facilities in the TexasAIM Initiative with 50% enrolled at the Plus Level in a Learning Collaborative.

 

TexasAIM

MCH is the lead coordinating entity in Texas with the Council on Patient Safety in Women’s Healthcare’s Alliance for Innovation on Maternal Health (AIM) as administered by the American College of Obstetricians and Gynecologists. MCH has committed to implement AIM-endorsed maternal patient safety bundles to address leading and causes of maternal mortality in Texas through a large-scale quality improvement effort called the TexasAIM Initiative. DSHS started TexasAIM with a five-cohort learning collaborative to support Texas birthing hospitals to implement the Obstetric Hemorrhage (OBH) Bundle and with a limited pilot of the Obstetric Care for Women with Opioid Use Disorder (OB-OUD) Bundle. DSHS will launch learning collaboratives to support hospitals to implement the Severe Hypertension in Pregnancy (HTN) Bundle and the OB-OUD Bundle in FY21. The TexasAIM Initiative was recognized with the DSHS Commissioner’s Excellence in Public Health Shine Award in December 2019.

 

Hospitals engaged in TexasAIM started work to implement the AIM OBH Patient Safety Bundle in August 2018. Since the enrollment began in 2018 through August 31, 2020, a total of 223 hospitals with obstetric (OB) lines of service have enrolled to participate in implementation of the TexasAIM OBH Bundle. However, some hospitals have subsequently discontinued their OB service lines or closed services altogether. Accounting for closures, 218 of an estimated 223 hospitals with OB service lines were participating in TexasAIM as of August 31, 2020. These hospitals represent approximately 98% of all the birthing hospitals in Texas and provide care for approximately 99% of births in Texas and approximately 10% of births in the nation.

 

Hospital participation in TexasAIM is voluntary. Participating hospitals may choose to join one of two levels of participation: TexasAIM Basic or TexasAIM Plus. Hospitals that participated at the Basic level received the fundamental tools to adopt AIM bundles. All enrolled hospitals committed to forming a quality improvement team within their hospitals for implementing the bundles; reporting structure and process measures in the AIM National Data Center portal; and participating in TexasAIM surveys. TexasAIM Basic hospitals worked independently to adopt AIM bundle practice changes. TexasAIM provided them with access to webinars, annual networking events, and technical assistance upon request.

TexasAIM provided programming to support hospitals enrolled at the Plus level with process and quality improvement through shared learning and collaboration using the Institute for Health Care Improvement (IHI) Breakthrough Series (BTS) Collaborative Model for Achieving Breakthrough Improvement.[9] TexasAIM Plus Learning Collaboratives created a structured framework for incremental rapid-cycle improvement; access to a team of expert faculty who have experience with, and provide coaching in, implementing practice changes for improvement in the topic; and a network of support from partnering hospitals for accelerated improvement through collaborative learning to support uptake of the AIM bundles’ recommended practices by participating hospital improvement teams.

 

TexasAIM Plus hospitals completed all the TexasAIM Basic requirements and reported on the same quarterly measures but had the option to report on additional TexasAIM monthly process improvement measures. In the Learning Collaborative, hospitals identified goals for improvement and made plans to achieve them. Participating TexasAIM Plus hospitals received access to quality- and process- improvement training and guidance as well as practical information about the bundles’ components from experts. They could access shared learning and support of their peers across the state through in-person Learning Session (LS) meetings, networking calls, peer-to-peer mentoring, targeted coaching, online toolkits and discussion boards, a bi-weekly newsletter, and other supports, resources, and partnerships including support with using monthly and quarterly data to drive their improvement.

 

TexasAIM Plus hospitals were assigned to one of five geographic cohorts for in-person LSs. DSHS developed cohorts based on Public Health Regions (PHRs), Perinatal Care Region (PCR)/Regional Advisory Council (RAC) territories, and the number of hospitals per geographic area. Each cohort had 30-50 participating hospitals.

Figure 2. TexasAIM Plus Cohorts by Perinatal Care Region

 

Figure 3 TexasAIM Hospitals by TexasAIM Cohort Region, September 15, 2020i[10]

Of hospitals enrolled in TexasAIM, 180 hospitals (83%) were enrolled as TexasAIM Plus hospitals as of August 31, 2020. TexasAIM Plus OBH activities facilitated and directed by MCH from September 1, 2019 through August 31, 2020 included:

• Action Period 2 September 2019 Collaborative Call: Reporting and Systems Learning (190+ participants)
• Action Period 2 October 2019 Cohort Calls: A cohort-specific networking call was held for each of five cohorts (148+ participants across five calls)
• Cohort Learning Sessions 3 in November and December 2019 (472 attendees at five cohort-specific 2-day meetings held across Texas)
• Action Period 3 January 2020 Collaborative Call: Simulation and Drills (170+ participants)
• February 2020 TexasAIM Teamwork, Communication, and Simulation Training of Trainers Course (described below)
• Facilitation of collaboration among 1,068 subscribers within the TexasAIM Plus Obstetric Hemorrhage Information and Resources Online Collaboration Portal
• Communication with 1,505 subscribers in the TexasAIM Bi-Weekly Bulletin

 

During Action Periods 2 and 3, TexasAIM Plus hospitals worked to test and scale up OBH bundle components for full implementation, and submitted quarterly and monthly data, engaged in online platforms, and networked together.

 

TexasAIM Teamwork, Communication, and Simulation Training of Trainers Course

MCH TexasAIM staff worked with partners to schedule and recruit TexasAIM training teams that included a nurse leader and physician leader for Train-the-Trainer workshops held in February 2020 in five locations across Texas. 

 

Safety Program for Perinatal Care (SPPC-II) Project Train-the-Trainer Workshop

Beginning in November 2018, DSHS partnered with the American College of Obstetricians and Gynecologists (ACOG)/AIM National, the Johns Hopkins University (JHU) Armstrong Institute for Patient Safety and Quality, and the Agency for Healthcare Research and Quality (AHRQ) to support JHU in coordinating a one-day workshop (Day 1) to pilot a training course on teamwork and communication as part of the of the Agency for Healthcare Research and Quality (AHRQ) Safety Program for Perinatal Care-II, Phase 2 (SPPC-II) demonstration project. The workshop was designed to apply teamwork and communication methods for implementation of the obstetric hemorrhage bundle.

 

TexasAIM Practicing for Patients Obstetric Hemorrhage Simulation Workshop

DSHS and partners planned and organized a one-day Train-the-Trainer course (TexasAIM Practicing for Patients Obstetric Hemorrhage Simulation Program). While the SPPC-II training took place on Day 1 of the TexasAIM Teamwork, Communication and Simulation Training of Trainers Course, MCH and partners hosted the TexasAIM Simulation Training-of-the-Trainer on Day 2. This full-day Simulation Training was a free event offered to all Texas birthing hospitals, regardless of TexasAIM enrollment status. The training was planned in partnership with Dr. Shad Deering (a recognized expert in obstetric simulation), Dr. Carey Eppes, who is the TexasAIM Plus Faculty Chair, members of the TexasAIM Plus OBH Learning Collaborative Faculty Team, additional volunteer faculty with simulation expertise, and partner hospitals who volunteered to host the events.

 

The training was one of the first of its kind in the country to happen at a state-wide level. During the simulation training, training teams learned to run in situ (onsite, within the unit) obstetric hemorrhage drills to practice technical skills, teamwork, communication, and debriefs on their units for standardized responses.

 

DSHS provided a simulation implementation kit to participating training teams, including a spiral bound Practicing for Patients manual and laminated blood product and vital signs scenario training aids, to facilitate the attendees’ ability to train others within their facility on running low-fidelity unit-based simulations. There were five trainings with a total of 297 attendees representing 120 hospitals. MCH was able to award continuing education unit credits to those who attended the event.

 

DSHS began working to procure for each TexasAIM hospital the low-fidelity birthing simulator which includes a simulated uterus with adjustable tone, placenta (delivered complete, partially retained, or fully retained), neonate, umbilical cord, blood reservoir, urine bladder, a rectum, and a postpartum uterus for placement of obstetric balloon tamponade use.

 

​COVID-19 Support

Beginning in March 2020, the TexasAIM Faculty Chair, Dr. Carey Eppes, who has expertise in infectious disease and who had begun to feel an impact of COVID-19 in the hospital where she practices, described a sense of urgency for hospital collaboration around COVID-19. The TexasAIM Team quickly mobilized to review literature and practice guidance and to organize the first TexasAIM OB Care & COVID-19 webinar. MCH hosted the first webinar on March 20, 2020. The TexasAIM team developed an OB Care & COVID-19 “4 Rs” Framework to organize recommendations of the CDC, ACOG, and the Society for Maternal-Fetal Medicine into four patient care domains used by AIM to address quality care: Readiness, Recognition and Preparedness, Response, and Reporting and Systems (4 Rs) learning. MCH developed an online information, resources, and collaboration space as well as a bi-weekly electronic newsletter to round out the program. All hospitals with OB service lines were invited to use these resources. The hospitals’ informational needs were assessed through polls during the calls and with surveys between webinars. Webinars were initially held weekly, reduced to biweekly webinars in the latter half of May and all of June, with a final webinar scheduled in September 2020. Over the course of the 12 calls, there were an average of more than 250 attendees each week. More than 1,200 health professionals from approximately 220 Texas hospitals and other organizations within and outside of Texas accessed information from the subscription-based TexasAIM OB Care & COVID-19 portal. Additionally, more than 1,500 health professionals received information from the bi-weekly newsletter.

 

Obstetric Care for Women with Opioid Use Disorder

Starting in June 2018, ten “early adopter” hospitals with experience caring for infants with neonatal abstinence syndrome convened OB-OUD improvement teams to independently plan and begin trial implementation of components of the bundle while also participating in the TexasAIM Plus OBH Learning Collaborative. MCH TexasAIM staff shared information related to the OB-OUD bundle information with these hospitals as it became available from the National AIM program.

 

Throughout FY20, DSHS gathered resources to support the implementation of the opioid bundle and worked to identify gaps, challenges, and lessons learned from National and State partners to inform programming. MCH and Texas Hospital Association (THA) hosted a “Deep Dive” meeting in October 2019 for Hospital OB-OUD improvement teams. Improvement teams participated in gap analysis, brainstorming, and process mapping exercises to identify opportunities to improve obstetric care for women with opioid use disorder.

 

MCH held a series of five collaborative calls between November 2019 and February 2020 for the participating hospitals to share experiences and discuss implementation barriers and knowledge gaps. Some topics covered during these calls included pain management; screening, brief intervention, referral, and treatment (SBIRT); maternal and family participation in care of opioid exposed newborns; and incorporating breastfeeding and infant care into prenatal, intrapartum, and postpartum clinical pathways. Additionally, participating hospitals were added to the AIM National Data Center’s OB-OUD portal to begin trialing collection and entry of the bundle’s measure set.

 

Qualitative research involving interviews with the hospitals’ improvement teams and with state and national stakeholders began in the summer of 2020. The purpose was to capture lessons learned from their experiences with implementing OB-OUD bundle components. This research is still underway and will continue through winter 2021. While assessment is ongoing, MCH began applying lessons learned from these activities, and from consultation with state and national experts, to inform development of an approach and programming to support implementation of OB-OUD practice changes in Texas hospitals and their communities.

MCH plans to launch a TexasAIM “First Wave Cohort” OB-OUD Innovation and Improvement Learning Collaborative in spring 2021 to support the early adopter hospitals and will continue to plan for the subsequent roll out of the TexasAIM Plus OB-OUD Learning Collaborative in cohorts across the state.

 

Planning for Future TexasAIM Efforts

In summer 2020, MCHS resumed planning for several TexasAIM activities that had been delayed due to COVID-19. Planning began for the TexasAIM 2020 Leadership Meeting and Summit. The Summit, originally scheduled for June 2020, will be held in December 2020 to highlight the successes of the TexasAIM OBH Program and to mark the launch of the TexasAIM Plus Severe Hypertension in Pregnancy (HTN) Learning Collaborative. Planning also resumed for the HTN Learning Collaborative, a rural hospital maternal health and safety forum, and a TexasAIM birthing center project to adapt OBH and HTN Bundles for the needs of birthing center settings. Additionally, MCH and the TexasAIM Plus Faculty Chair, who was also Chair of the Texas Collaborative for Healthy Mothers and Babies (TCHMB), began working with TCHMB to develop a collaboration framework to better align efforts to address regionally and locally specific issues that impact hospitals’ implementation of AIM Bundles.

 

Peer Dads

MCH funded two community-based Peer Dads contracts in Cameron County and in Smith County (south and east Texas respectively). Each of the Peer Dad programs are housed within a Women, Infants, and Children (WIC) local agency but may provide services throughout the community. Peer Dads are men who have partners and a child currently or previously enrolled in the WIC program and whose child was breastfed. Peer dads received training on the United States Department of Agriculture’s (USDA) Loving Support Peer Counselor Training with opportunities for continued education to build capacity to engage and support community-based fathers with education and support for:

• Breastfeeding
• Infant safe sleep
• Baby behavior
• Appropriate introduction of solid foods
• Responsive feeding
• Maternal and infant health, safety, risk factors, and warning signs
• Sudden Infant Death Syndrome (SIDS) awareness
• Community-based referrals

Peer Dads coached WIC clinic staff on how to best engage fathers in WIC’s education to support breastfeeding success for WIC mothers. WIC clinic staff incorporated input from Peer Dads in messaging for training, materials, and communications. Approximately 100 fathers were engaged in Peer Dad activities and education in FY20.

 

Outreach for Peer Dad services was conducted through promotional efforts at health fairs, on social media, web-based training platforms, radio ads, posters, bulletin boards within WIC clinics, and with use of specialized fliers with information just for dads.

 

In Smith County, the WIC director reported the value of having a Peer Dad, noting “we now have pictures of fathers on the outside and inside of the clinic, so they feel welcome to enter the clinic. We no longer allow fathers to sit outside in the parking lot, we invite them into the clinic.” Peer Dads involved WIC fathers in the WIC assessment process and provided teaching during weight and height assessments as well as nutrition and breastfeeding counseling. Fathers were positioned as the “Keeper of Information” and education was offered on the impact of maternal fatigue and on remembering important health and breastfeeding information. WIC Clinic staff modified nutrition and breastfeeding classes to include information

 

Health and Human Services Postpartum Depression Strategic Plan

In the 2019 86th Regular Legislative Session, HHSC was directed to develop and implement a five-year strategic plan to improve access to postpartum depression (PPD) screening, referral, treatment, and support services. MCH staff collaborated in the development of the Postpartum Depression Strategic Plan FY21, including exploration of current practices of DSHS-administered programs relevant to perinatal mood and anxiety disorders and identification of specific activities to initiate or continue in FY21. Featured MCH activities included:

 

• Promoting awareness and screening for PPD with program partners including contractors and hospitals that participate in the TexasAIM initiative,
• Promoting public awareness about perinatal mood and anxiety disorders through the Maternal Health and Safety Public Awareness Campaign that is currently in development;
• Promoting awareness about perinatal mood and anxiety disorders through the Information for Parents of Newborn Children pamphlet that is distributed to pregnant women, their partners and other adult caregivers of infants;
• Ensuring that perinatal mood and anxiety disorders is addressed as a part of the High-Risk Maternal Care Coordination Services Pilot Program currently in development; and
• Planning and hosting a DSHS Grand Rounds series of continuing education presentations on perinatal mood and anxiety disorders with lectures to include information about the prevalence and effects of perinatal mood and anxiety disorders on outcomes for women and children; and PPD signs, symptoms, screening, diagnosis, treatment, and referral.

 

Perinatal Depression Awareness and Screening

MCH staff incorporated mental and emotional health content from the Eunice Kennedy Shriver National Institute of Child Health and Human Development’s Mom’s Mental Health Matters campaign into the WIC breastfeeding promotion campaign Breastmilk: Every Ounce Counts. The campaign’s website, BreastmilkCounts.com, included information, tips, and resources on self-care for women during pregnancy and after birth, information for women and their support networks on identifying the signs of perinatal depression and anxiety, and where to get help. This mental health content is available at the links below:

 

• Self-Care: Mental and Emotional Health section
• Teamwork: For Dad, For Grandma, and Friends and Family sections

 

In FY20, Information About Mental and Emotional Health Self-care had 36,553 (12,148 English and 24,405 Spanish) unique pageviews and helpful resources including resources for mental and emotional help and had 3,226 (2,385 English and 841 Spanish) unique page views. The Teamwork for Dads page had 8,235 (5,947 English and 2,288 Spanish) unique page views, the Teamwork for Grandma page had 2,237 (1,453 English and 784 Spanish) unique page views, and the Teamwork for Friends and Family page had 835 (353 English and 482 Spanish) unique page views.

 

HTMB-funded Lactation Support Centers (LSCs) in Austin, Dallas, Houston, McAllen, and San Antonio used the Edinburgh Postnatal Depression Scale in their intake- and follow-up assessment and referral procedures and workflow. LSCs staff provided depression screenings for all women seeking services. Women who screened positive for signs of depression received referrals to mental health resources.

 

High-Risk Screening and Referral “Red Flags” Training for WIC Staff

MCH staff had previously provided maternal and infant health subject matter expertise in development of the WIC High Risk Referral policy and, in FY19 reviewed and provided subject matter expertise and content for development of the High-Risk Screening and Referral “Red Flags” training to support implementation of the policy. At minimum, the policy required referral for signs of breastfeeding difficulties, labor initiation, substance use, and perinatal mood disorders. Referral guidelines also addressed anemia, low weight gain, weight loss, excessive weight gain during pregnancy, and signs of fetal demise, blood clots, hemorrhage, and preeclampsia/eclampsia. Over 252 WIC staff completed the Red Flags Training since 2019. Policy development was initiated in FY20 to consider requiring this training for WIC local agency staff.

 

PHR staff conduct various activities to promote health and wellness for women of childbearing age. The regional staff in Houston hosted the March of Dimes program Becoming a Mom/Comenzando Bien, a comprehensive prenatal program for pregnant women in a supportive group setting.

 

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[2] ExpandNet, World Health Organization. Beginning with the end in mind: planning pilot projects and other programmatic research for successful scaling up. Geneva, World Health Organization, 2010.

[3] Eldridge SM, Lancaster GA, Campbell MJ, et al. Defining Feasibility and Pilot Studies in Preparation for Randomised Controlled Trials: Development of a Conceptual Framework. PLoS One. 2016;11(3):e0150205.

[4] Kistin C, Silverstein M. Pilot studies: a critical but potentially misused component of interventional research. JAMA. 2015;314(15):1561-1562.

[5] Lancaster GA, Dodd S, Williamson PR. Design and analysis of pilot studies: recommendations for good practice. J Eval Clin Pract. 2004;10(2):307-312.

[6] CSTE, Core State Preconception Health Indicators, General Health Status Domain, Self Rated Health. September 2009. Avialable online at https://www.cste.org/page/PreconIndicators  

[7] Kramer MR, Strahan AE, Preslar J, et al. Changing the conversation: applying a health equity framework to maternal mortality reviews. Am J Obstet Gynecol. 2019;221(6):609.e1-609.e9.

[8] Metz TD, Collier C, Hollier LM. Maternal Mortality from Coronavirus Disease 2019 (COVID-19) in the United States. Obstet Gynecol. 2020;136(2):313-316.

[9] The Breakthrough Series: IHI’s Collaborative Model for Achieving Breakthrough Improvement. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2003. (Available on www.IHI.org)

i. PREPARED BY: Maternal & Child Health Epidemiology, Division for Community Health Improvement, the Department of State Health Services (DSHS).