Improving women’s health before, during and between pregnancies is an important public health goal. To meet this goal Maine is focusing on the percent of cesarean deliveries among low risk first births, reducing the percentage of pregnancies that are unintended (in the 18-24-year-old population), and decreasing the percent of women who smoke during pregnancy.

Cesarean Deliveries

In 2017, almost 1 in 4 low-risk first births in Maine were delivered via cesarean section (C-section). Maine’s low-risk C-section rate is statistically significantly lower than the U.S. rate of 26.0% and has been decreasing over time (8% between 2009 and 2017). This decrease may be due, in part, to several Maine hospital systems adopting policies around inductions prior to 39 weeks without cause.

During FY18 Maine’s largest Level III hospital, Maine Medical Center, began reviewing and changing its policies around admission of women in active labor. The Perinatal Outreach Consultant worked with the hospital on an obstetrical clinical transformation project, Safe Prevention of the Primary C-section. The goal of the project was to encourage women in labor to remain at home during early labor and only go to the hospital when in active labor. The hospital developed a patient handout, ‘Ready, Set, Not Yet!’ along with a sample script for nurses. Staff are monitoring to determine if fewer women are presenting during early labor.

Maine Medical Center formed two subgroups to provide input on ways to improve C-section rates; these groups meet monthly. One subgroup focuses on patient education and the other on guidelines and policies. Discussions about C-section reduction take place at quarterly Perinatal Nurse Manager meetings. The nurse managers receive updates on workgroup activities.

The obstetrician at one of the hospitals participating in a quality improvement process to reduce the rate of low risk C-sections left his position and the hospital hired three midwives. With a change in Provider, the hospital experienced a decrease in the number of low risk C-sections and did not require technical assistance.

Current Efforts

Analyses of C-section rates overall and by hospital continue. Our MCH epidemiologists receive monthly provisional vital records data from Maine’s Data, Research and Vital Statistics Program. Based on provisional data, it appears that Maine’s C-section rates increased slightly in 2018 and are higher in the first two quarters of 2019. We continue to monitor the data by hospital to identify hospitals that could benefit from technical assistance.

During FY19 hospitals continued to receive technical assistance as needed. At the December 2018 Perinatal Nurse Manager meeting, Maine Medical Center, one of the hospitals participating in the quality improvement initiative, shared lessons learned on C-section prevention and primary C-section. Maine Medical Center continues to share educational materials on ways to reduce low-risk C-sections.

In November 2018 and January 2019, the Perinatal Outreach Consultant shared data on C-section rates (based on updated data reviews) with two newly identified hospitals and another two hospitals requested their data. The Perinatal Outreach Consultant is working with these hospitals to assess their interest in receiving technical assistance on reducing their low risk C-section rates. The Perinatal Outreach Consultant has been challenged with engaging hospitals in quality improvement processes to reduce low-risk C-sections. Perinatal outreach is focusing on the Eat, Sleep and Console (ESC) method of newborn assessment for babies who are opiate exposed. The ESC is part of a larger effort in Maine to develop a comprehensive systemic response to the impact of the opioid crisis. During FY20 we will evaluate the feasibility of continuing this ESM.

Unintended Pregnancy

Unintended pregnancies are pregnancies that are mistimed, unplanned or unwanted at the time of conception. In 2016, more than 1 in 3 (37%) new mothers reported their pregnancy was unintended; they wanted to be pregnant later or not at all (20%) or they were unsure whether they wanted to become pregnant (16%).[1] This translates into about 4,700 infants born to women not intending to get pregnant when they conceived. In the United States, among States participating in the PRAMS survey, the percent of unwanted/mistimed/unsure pregnancies was 49.6% in 2015. Maine’s rate of unintended pregnancies has been decreasing in recent years; in 2012, almost 50% of pregnancies were unintended.

Despite our overall success in decreasing unintended pregnancy rates, we remain concerned about the unintended pregnancy rate among young women. About half of Maine women under age 20 and 25% of young women aged 20-24 years who had a recent live birth had not planned to get pregnant at that time or in the future.1 We are seeing condom use among high school students slowly decrease[2], while STD rates among youth are increasing, especially among those aged 20-24 years.[3] However, Maine’s teen birth rate and young adult birth rate have been steadily decreasing, along with the percent of Maine high school students who ever had sexual intercourse. To reduce unintended pregnancy, STDs, and reduce risky sexual behaviors among Maine youth, several efforts are underway to gain access to this population and provide education around family planning.

Teen Pregnancy Prevention funding provided to Maine by the federal Agency for Children and Families/Family and Youth Services Bureau’s Personal Responsibility Education Program (PREP) educates youth about preventing pregnancy and sexually transmitted diseases (STDs). FY18 programming focused on reaching at-risk youth in alternative settings (such as homeless youth and youth in alternative school settings) and partnering with Maine’s foster care system to deliver training for staff and foster parents on how to reduce unintended pregnancy and promote healthy sexual decision-making among youth in and transitioning out of system’s care.

Maine Family Planning (MFP), in partnership with New Beginnings, worked with ten youth-serving agencies and alternative high schools in the 2017-2018 school year to deliver “Be Proud, Be Responsible!” to young people across the state. Be Proud is a six-session curriculum that has been shown to reduce sexual risk behaviors and to increase condom use. It provides adolescents with the knowledge, skills and motivation to change their behaviors.

Maine Family Planning provides technical assistance to Maine schools and community-based organizations to address pregnancy and STD prevention. The focus is on Maine communities with higher than state-average rates of teen pregnancy. Providing this information to youth in middle and high school provides a foundation for healthy sexual decision-making and prevention well into their future reproductive years.

Maine Family Planning assists school and organization staff in identifying and implementing evidence-based programs that focus on preventing unintended pregnancies, STDs, risk and harm reduction. MFP assists schools in choosing an age-appropriate, medically accurate curriculum that fits with community norms and expectations, trains staff to implement the curriculum, helps to evaluate the results and provides on-going resources and support as needed. Additional youth-serving professionals receive resources, information, and education through e-newsletters, tabling at conferences and attending workshops and training sessions.

Maine Family Planning is tracking the prevalence of long acting reversible contraceptives (LARCs) with those they serve and have seen an increase in use. In calendar year 2017, MFP providers inserted 917 LARCs; this compares to 809 in CY16. MaineCare and private insurance cover the cost. The MCH Medical Director worked with MaineCare to unbundle the reimbursement of LARCs from the labor and delivery fee, reimbursement code. As a result, greater use of LARCs is encouraged. MFP also tracks, at 6 months, whether the LARC was removed. The goal was to have under 10% removed; in CY16, the removal rate was 4%. MFP tracks the percentage of LARC patients as a marker for provider knowledge and satisfaction with LARCs. Utilization increased from 30% to 31% between CY17 and CY18.

It has long been demonstrated that LARCs are an effective method of contraception in the 18-24-year-old population however, the provider community remains reluctant about recommending its use. Provider education on the appropriateness of LARCs for this population is very important. MFP reached out to pediatric practices in the State and they have been very receptive. While they are not inserting IUDs or hormonal implants, they are willing to make referrals to MFP.

Maine Family Planning trains their providers and tracks the number trained by site so they can observe how the percentage of LARCs has increased over time. In CY18 MFP trained four providers and documented each provider by site to track LARC utilization.

Maine Family Planning also collects data on reproductive life plans. MFP expects every visit to have a reproductive life plan initiated or review of an existing one. The question asked is “do you plan to be a parent in the next year?” and the response guides the discussion about what they are using for a method. MFP asks the same question to men and women. It has been an effective way to talk with young people about their contraceptive care. MFP tracks that the conversation is happening and is looking at the trends of contraceptive use. Forty-seven MFP funded clinics share information and counseling on LARCs with their clients. MFP provides counseling methods to all patients requesting contraception based on the CDC/WHO recommendations, which call for counseling based talking about the most to least effective methods. MFP bases all patient materials, web messages and social marketing on the CDC/WHO recommendations.

When working with the medically fragile clients, public health nurses address unintended pregnancy by providing client materials on birth control options and community resources to address factors that lead to unintended pregnancies, if appropriate.

A focus of Maine Families Home Visiting (MFHV) is to counsel around reproductive life plans. Nearly 90% of MFHV enrolled postpartum women received their postpartum exam within 56 days after the birth of their child.

Maine Department of Education (Maine DOE) provides pregnancy prevention and HIV/STD Prevention Curriculum Program trainings for health educators, which provide a foundation for healthy practices and choices regarding pregnancy throughout life. The Maine DOE held a contraception session at its’ Annual Comprehensive Sexuality Education Conference in April 2018. Seven health educators and school nurses attended the session. Maine DOE, in collaboration with partners including MFP, offers its’ Best Practices curriculum training. After taking the training, teachers implemented the Best Practices curriculum lessons in the classroom to improve skills for increasing healthy behavior in sexual practice, i.e. condom use, birth control methods including LARCs, communication skills around healthy relations and healthy practices. Maine DOE makes available resources on pregnancy prevention and related topics to students, parents and educators.

Current Efforts

The PREP program is working with health care providers who work with at-risk youth in alternative settings (such as homeless youth and youth in alternative school settings). PREP is also partnering with Maine’s foster care system to deliver training for staff and foster parents on how to reduce unintended pregnancy and promote healthy sexual decision making among youth in and transitioning out of system’s care.

Maine Family Planning is training their providers and tracking the number trained by site, so they can observe how the percentage of LARCs has increased over time. MFP trained one provider to date in FY19 and is documenting to track LARC utilization going forward.

Maine Families home visitors support new mothers to have an identified primary care provider and to attend their postpartum exam within 56 days of the birth of their baby. This follow up appointment includes a conversation about birth control options. Family visitors also offer assistance applying for MaineCare within 14 days of enrollment. In general, family visitors help to connect female caregivers with community resources and supports to avoid unintended pregnancy, as directed by the client.

Smoking During Pregnancy

In Maine, about 1 in 8 (13.1%) women smoke during pregnancy.[4] Maine’s smoking rates during pregnancy are among the highest in the U.S. and our quit rates during pregnancy are low. However, we are optimistic; the rate of smoking during pregnancy in Maine has been declining since 2014.

Data on pregnancy and smoking highlight significant disparities within some geographical areas of the state. The rates are highest in many of Maine’s most rural counties, including Aroostook, Washington, Somerset and Oxford Counties; about 1 in 4 pregnant women in Washington County smoke during pregnancy.

During FY18, the Tobacco and Substance Use Prevention and Control Program (TSUPCP) developed effective partnerships across and external to the Maine CDC to leverage efforts to reduce smoking among pregnant women and to improve birth outcomes. This joint effort with MaineHealth’s Center for Tobacco Independence (MaineHealth-CTI) and District Tobacco Prevention Partners, achieved a number of outcomes.

The Non-Clinical Outreach (NCO) initiative is an effort where tobacco public health partners’ work with statewide social service programs or service agencies, such as Maine Families Home Visiting (MFHV), Women Infants and Children Program (WIC) or other service providers such as faith-based organizations to increase the number of people referred to the Maine Tobacco HelpLine (MTHL) through the QuitLink.

Through the NCO initiative, MaineHealth-CTI delivered 19 clinical outreach sessions reaching 78 social service providers including the MFHV, WIC, and other agencies across the State. Additionally, MaineHealth-CTI delivered two training sessions on Brief Tobacco Intervention for tobacco cessation and use of the QuitLink website to social service providers. Social service providers that participated in the training reported increased confidence when having conversations with women about their tobacco use during pregnancy; greater ability to use the Ask/Advise/Refer model when assessing a pregnant women’s readiness to quit; and increased ability to use the QuitLink referral process to connect pregnant women who smoke to the MTHL. These outcomes reflect a coordinated effort to empower social service providers to have conversations with pregnant women regarding their tobacco use as well as promoting evidence-based tobacco assessment and treatment.

The MTHL received 76 referrals from the QuitLink. Of the 76 referrals, 13 were WIC staff, 12 MFHV, and eight from Head Start. The increase in referrals is the direct result of two trainings held that focused on Brief Tobacco Intervention for tobacco cessation and use of the QuitLink website implemented by MaineHealth-CTI and District Tobacco Prevention Providers for social service providers.

The Substance Exposed Infants (SEI) campaign added a tobacco specific component. The TSUPCP found this component successful after reaching a benchmark metric Ad Recall lift of 12.37% (the estimated number of people likely to remember the ad within two days). The campaign also generated 16,598,274 impressions, the number of times the particular ad was viewed/located and loaded; 13,601 clicks refers to the amount of engagement or shares received on social media networks; and in turn, drove 10,000 unique visitors (women) to https://preventionforme.org/pregnant-women/. The campaign aim was to increase awareness and educate women of childbearing age of the dangers of substance use, including tobacco, while pregnant. The campaign target was a statewide reach for 15-44-year-old women with an additional focus towards pregnant women.

The Maine CDC, TSUPCP manages the Maine Prevention Store www.mainepreventionstore.org that provides a host of materials including tobacco and substance use during pregnancy including posters and brochures.

During FY18, the TSUPCP increased its programmatic reach by developing new relationships with stakeholders and improving those with existing stakeholders. This strategy aimed to encourage coordination, and leverage efforts to serve pregnant women better. The TSUPCP initiated several collaborations with stakeholders (MaineCare, WIC, PRAMS) at the state and local level. To remain current on the epidemiological profile of the overall pregnant women population and the specific groups (MaineCare insured, WIC participants ), TSUPCP maintained its representation on the Pregnancy Risk Assessment Monitoring System (PRAMS) Steering committee. Being a part of this maternal and child health committee provided TSUPCP with the unique opportunity to network with various stakeholders and deliver coordinated messages to the target population.

At the community level, the Reaching More Moms (RMM) online workgroup is an effort funded by the March of Dimes. RMM utilizes a three-pronged approach to engage pregnant women in more quit attempts resulting in greater success in not using tobacco before, during and after pregnancy. This statewide workgroup provides additional resources to community public health providers in seven counties to support pregnant women in obtaining further tobacco cessation support. The strategies aim to convene diverse tobacco champions in a statewide virtual advisory and learning group to guide the project and connect with local providers, and work directly with moms, their friends, and families to inform, develop and disseminate materials, messages, and engagement strategies that they identify as supportive. Work with social service, behavioral health, healthcare providers and MaineHealth-CTI to use best practice tobacco treatment strategies including the 5As to counsel women, utilize culturally appropriate materials developed through RMM; and make treatment referrals that ultimately result in an increase in the number of women who quit.

Although TSUPCP has moved the needle in decreasing tobacco use among pregnant women, barriers continue to exist. The U.S. Preventive Task Force limits eligibility for pregnant women to receive pharmacological therapy (nicotine replacement). Other hindrances (poverty, lack of agency, etc.) to progress are factors that can best be addressed at the structural level. It is worth noting that the MTHL offers free Cognitive Behavioral Therapy (CBT) for pregnant women.

Maine Families Home Visiting requires new staff to attend smoking cessation training within one year of hire and strongly recommends Motivational Interviewing training. Family visitors ask about tobacco use in the home and collect data on usage as part of the adult health history, Parents as Teachers Child Health Record, the Safe Home Checklist and the family centered assessment. Family visitors have access to and information about the QuitLink and provide to families as appropriate. Individual sites partner with local efforts to do more intensive training. Ninety-five percent of new enrollees who smoked upon enrollment received a smoking cessation referral. An evaluation of Maine’s home visiting program found that participants enrolled in Maine Families prenatally were more likely than those who enrolled postpartum to quit smoking during pregnancy or decrease the number of cigarettes they smoked during pregnancy.

Current Efforts

The Maine Title V Program and TSUPCP are committed to focusing their efforts on women who smoke during pregnancy. Increasing social service provider confidence and skills to assess pregnant women’s smoking status and maintain the QuitLink website as a means of referral is central to improving birth outcomes. The TSUPCP, jointly with MaineHealth-CTI, continues to implement trainings for social service providers serving pregnant women and new mothers. MaineHealth-CTI completed 42 outreach sessions targeting social service providers including the MFHV and WIC programs. Outreach efforts enabled five training sessions on brief intervention and access to evidence-based tobacco treatment to be implemented across the state. These sessions trained 10 social service providers. Training participants received information on how to use the QuitLink website to assist their clients with the self-referral process to the MTHL. Consequently, 30 WIC staff and four case management staff helped 55 of their clients refer themselves to the MTHL.

The SEI campaign aims to increase awareness and educate women of childbearing age of the dangers of substance use, including tobacco, while pregnant. This statewide campaign targets 15-44-year-old women with additional focus towards pregnant women. The campaign uses the Social and Paid Search Engine strategy to identify women of childbearing age (15-44 years old) to deliver preventive messages. The campaign engaged women through video views, ad clicks, likes, share and comments through July 2018. As a result, the campaign generated 174,476 impressions (number of times the ad was viewed/located or loaded); 696 clicks (amount of engagement or shares received on social media networks) and drove 9,347 unique visitors (women) to https://preventionforme.org/pregnant-women/. The TSUPCP relaunched the campaign in May 2019.

The Maine CDC Tobacco and Substance Use Prevention and Control Program developed a comprehensive Electronic Nicotine Device Systems (ENDS)/vaping Toolkit that includes a section on pregnancy and vaping. The Toolkit can be found at: https://preventionforme.org/resources/ends-toolkit/.

Other initiatives

MaineHealth-CTI implemented a soft launch of the new CTIMaine.org website. The unified website combines three existing websites in one. It allows a landing page to show connection between the different brands but also to highlight components that do not fit within the QuitLink, Breathe Easy or Sidekicks pages, specifically the Training, Education events, and projects that are outside of their state grants (Maine Lung Cancer Coalition efforts and MaineHealth projects). MaineHealth-CTI designed the site to have the same look and feel as other CTI brand sites but one difference includes the funding sources for the site/development. An attribution page for the Maine CDC was added: https://ctimaine.org/about-us/funding/ and throughout there are links to State sites and resources.

Additionally, on January 23, 2019 TSUPCP and MaineHealth-CTI held a webinar on smoking and pregnancy to support providers in helping pregnant women access evidence-based cessation services. Over 80 social service, public health and healthcare providers attended the webinar.

The TSUPCP and Maine Title V Program combined resources to leverage efforts in holding a two-day MCH and Substance Exposed Infants conference on May 22 and 23, 2019. They organized a conference planning committee to ensure a comprehensive educational experience to the audience serving this population. The conference serves as an opportunity to create awareness and engagement of providers in Maine around the adverse effects of tobacco and substance use on maternal health and birth outcomes. Approximately 200 community and healthcare providers attended the conference. Anecdotally we are hearing very positive feedback from attendees on speakers and information shared. Planning will soon begin for next year’s conference.

[1] Maine PRAMS, 2016

[2] Maine Integrated Youth Health Survey, 2009-2017.

[3] State of Maine HIV/STD Annual Surveillance Report, Five-Year Data Summary, 2011-2015.

[4] Maine Birth Certificate Data, 2017.