NPM 14.1 – Percent of women who smoke during pregnancy

Overview: According to the Pregnancy Risk Assessment Monitoring System (PRAMS), cigarette smoking rates have continued to decrease among Texas women in the months before, during, and after pregnancy. The percentage of women who reported they smoked cigarettes in the 3 months before pregnancy, last 3 months of pregnancy, and at the time of the survey (typically within the first year after giving birth) decreased respectively from 15%, 5.1%, and 9% in 2015 to 13.1%, 4.6%, and 6.3% in 2019. NOTE: These survey questions do not explicitly assess for vaping or e-cigarette use.

 

Texas Maternal Mortality and Morbidity Review Committee (MMMRC)

Maternal and Child Health (MCH) administers and facilitates the multidisciplinary MMMRC to comprehensively review deaths of women that occur during pregnancy or within a year of the end of pregnancy and study state maternal mortality trends to understand causes, contributors, risk factors, and racial and ethnic disparities. Based on findings, the MMMRC develops targeted, actionable recommendations to help prevent future deaths. The MMMRC routinely assesses and documents tobacco use as part of the case review process to determine whether it contributed to death. The MMMRC also uses its Discrimination Assessment and Social Determinants of Health Facilitated Discussion Tool (DASH Tool) to evaluate whether tobacco use was a life course factor potentially impacted family wellbeing. In Fiscal Year 2021 (FY21), the MMMRC assessed 59 cases to determine whether tobacco contributed to maternal mortality.

 

Healthy Texas Mothers and Babies (HTMB) Community Initiatives

MCH encouraged HTMB Community Coalitions (CCs) and Peer Dad programs to disseminate Texas Department of State Health Services (DSHS) Tobacco Prevention and Control program social media posts about the state tobacco quitline including on and around Father’s Day.

 

Texas Health Steps Online Provider Education (THSteps)

MCH provides subject matter expertise for developing the Health and Human Services Commission’s THSteps program’s continuing education modules.

 

THSteps preconception, prenatal, and postpartum health modules include information about screening, brief intervention, referral, and treatment for tobacco cessation. The THSteps online provider education portal also includes tools and referral resources for smoking and e-cigarette cessation.

 

In FY21, the number of physicians, nurses, social workers, and other health care professionals receiving continuing education from the modules were:

• Preconception Health: Screening and Intervention – 615 professionals;
• Prenatal Health: Screening and Intervention – 748 professionals; and
• Postpartum Health: Screening and Intervention – 808 professionals

 

Information for Parents of Newborn Children

Texas Health and Safety Code, Section 161.501 requires health care providers to give a resource pamphlet to the parents or adult caregivers of an infant during pregnancy and at delivery. Providers may distribute DSHS’ Information for Parents of Newborn Children pamphlet or use any similar material that contains the required information. The DSHS pamphlet is available in English and Spanish and covers a variety of maternal and infant health topics including information about the importance of maternal smoking cessation and smoke-free environments for infant health and safety and prevention of sudden infant death syndrome.

 

In FY21, DSHS distributed 50,894 printed pamphlets to health care providers to share with expectant and postpartum parents. Additionally, 732 pamphlets were downloaded from the MCH website.

 

High-Risk Maternal Care Coordination Services (HRMCCS) Pilot Program

MCH worked throughout FY21 to research and plan the HRMCCS pilot program. In the program, CHWs will screen and counsel program participants for tobacco and electronic cigarette dependence using the Ask, Advise, Refer (AAR) model. See the SPM 5 section in this report for more information about the HRMCCS pilot program.

 

Regional Activities

• MCH Public Health Region (PHR) 7 partnered with the Regional Tobacco Coordinators to implement AAR and the Smoking Cessation and Reduction in Pregnancy Treatment Program, a program provided through the Society for Public Health Education. Regional clinics and sub-offices also promoted the Texas tobacco quitline and distributed business cards with the quitline information along with providing direct quitline referrals for clients.
• PHR 9/10 worked with state and local partners to promote THSteps modules to local hospitals and providers, conduct tobacco prevention education to regional field clinic patients, and promote the quitline to regional field clinic patients.
• PHR 11 collaborated with a managed health care plan to distribute tobacco prevention education, including information on the dangers of secondhand smoke exposure, to at least 50 families during drive-through events. In July 2021, PHR 11 also collaborated with the Tobacco Prevention Coordinator during Operation Border Health and Preparedness (OBHP) to encourage tobacco users to quit Participants received Quit program information and were referred to quitline services, including counseling and nicotine replacement therapy (nicotine patch, gum, or lozenge). A total of 57 referrals were collected from all OBHP sites in five counties.

 

Tobacco Use and My Baby Publication

In August 2021, MCH worked with the DSHS Tobacco Prevention and Control Branch to update the publication. The brochure provides guidance about prenatal and postpartum tobacco use and risk minimization behaviors.

 

Performance Analysis

Tobacco prevention among women of childbearing age continues to be an MCH priority. MCH partners with the DSHS Tobacco Prevention program and integrates tobacco prevention information, education, screening, brief intervention, and referral throughout maternal health efforts.  The percentage of Texas women who smoke before, during and after pregnancy appears to be declining.

 

Challenges/Opportunities

While current maternal health surveillance systems do not assess for prevalence of vaping among pregnant women, MCH is working to identify opportunities for assessing the extent of vaping and e-cigarette use in this population to inform future program efforts.

 

COVID-19 continues to affect program capacity in health care and other settings. In response to the continued impact of the pandemic, MCH adjusted some program timelines for initiatives that integrate tobacco prevention strategies. MCH is using feedback from health care organizations to responsively adapt program plans to current needs.

 

SPM 5 – Percent of women of childbearing age who self-rate their health status as excellent, very good, or good

 

MMMRC

MCH supports the MMMRC to evaluate causes, contributors, risk factors, and disparities in pregnancy-related deaths and make recommendations for prevention to reduce maternal mortality and severe morbidity in Texas. In December 2020, DSHS released its MMMRC and DSHS Joint Report. The report included statewide rates, ratios, trends, and case review findings and MMMRC recommendations for reducing preventable maternal mortality and morbidity in Texas. The findings and recommendations directly inform MCH maternal health activities.

 

In FY21, the MMMRC met quarterly and fully reviewed and closed 59 cases including the final 35 cases of the 2013 pregnancy-associated death case cohort and the first 24 cases from the 2019 case cohort. Contemporary case review includes case identification, preparation, committee review, committee determinations, committee recommendations, and case finding entry into the Maternal Mortality Review Information Application (MMRIA) system within two years of each pregnancy-related death. MCH participates in the Centers for Disease Control and Prevention (CDC)’s Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM) Program, which sets targets for contemporary case review. Consistent with the MMMRC recommendation to support strategies to continuously improve the maternal mortality investigation and case review process, MCH worked throughout FY21 to strengthen the case review process by:

• Finalizing and initiating MMMRC use of a supplemental Medicaid coversheet for each case with Medicaid as the payor. The coversheet describes the decedent’s Medicaid claims and visually depicts when the decedent was enrolled in Medicaid and Medicaid claim timelines;
• Participating in the Council of State and Territorial Epidemiologists (CSTE)/CDC Maternal Mortality Review Committee (MMRC) Qualitative Analysis Training series to support skill-building for qualitative analyses of MMRIA data; and
• Developing a mock case narrative for the University of Utah per a request from the CDC ERASE MM program. The mock case will be used in a study to test MMRC criteria for determining pregnancy-relatedness in overdose or suicide cases. Three MMMRC members volunteered to participate in the study.

 

Throughout FY21, MCH and MMMRC members participated in educational opportunities including the MMRIA User Meeting, ERASE MM site visit, and monthly abstractor, coordinator, and analyst office hours. MCH and MMMRC members disseminated MMMRC findings, recommendations, and program practices by presenting at:

• MMMRC public meetings;
• ERASE MM Analyst Office Hours and Abstractor and Coordinator Office Hours;
• The TexasAIM Virtual Summit;
• MCH’s Summer Speaker Series;
• The TCHMB Executive Committee Meeting;
• American Heart Association’s Maternal Health webinar; and
• American College of Obstetrics and Gynecology (ACOG) webinar, Maternal Cardiac Conditions: Addressing a Leading Cause of Pregnancy-Related Death.

 

MCH submitted MMMRC success stories to the Association for Maternal and Child Health Programs for posting on the Review to Action website Texas profile page including:

• Incorporating a Health Equity Framework;
• Policy Impact; and
• Maternal Health and Safety Initiatives.

 

Texas Strategic Action Partnership to Reduce Violent Pregnancy-Associated Deaths (TSAP-RVPD)

In FY21, MCH competitively applied for the five-year State, Local, Territorial, and Tribal Partnership Program to Reduce Maternal Deaths due to Violence grant from the U.S. Department of Health and Human Services’ Office of the Assistant Secretary for Health. The TSAP-RVPD program involves convening partners to study patterns and context of maternal mortality caused by homicide, suicide, and overdose; developing a strategic action plan; and implementing evidence-based, sustainable interventions for prevention. The program will be informed by the MMMRC’s recommendations to improve infrastructure and programs to address violence and intimate partner violence and to improve access to integrated behavioral health services for women with mental and substance use disorders. DSHS received the grant award in September 2021 and will begin developing and implementing the TSAP-RVPD program in FY22.

 

HRMCCS Pilot Program

Texas Health and Safety Code, Chapter 1001, Subchapter K directs DSHS to develop and implement the HRMCCS Pilot Program in one or more area of Texas. DSHS will provide a pilot site with guidance, resources, training, and support to complete risk assessments with pregnant women and integrate CHW services into care delivery for women with identified risk factors for poor pregnancy, birth, or postpartum outcomes. CHW services will include:

• Providing health promotion, education, and support for participating women to help manage and prevent chronic disease;
• Facilitating care coordination and navigation activities; and
• Identifying and Reducing barriers to health care.

 

When planning the program, MCH is considering findings and best practices related to the MMMRC’s recommendation to “[i]ncrease access to comprehensive health services during pregnancy, the year after pregnancy, and throughout the preconception and interpregnancy periods to facilitate continuity of care, enable effective care transitions, promote safe birth spacing, and improve the lifelong health of women.”

 

During FY21, MCH finalized a review of existing CHW models related to care coordination and maternal health, analyzed model components, and identified elements to adapt for use in the pilot. Additionally, MCH applied to participate in the Harvard T.H. Chan School of Public Health and Centers for Disease Control and Prevention MCH Program Evaluation Practicum for designing the HRMCCS Pilot Program’s evaluation plan. MCH was selected and competitively matched to participate in a virtual one-week program evaluation training along with two practicum public health students. The following week, the students met virtually with MCH and partners to draft an evaluation plan for assessing the feasibility and acceptability of pilot interventions.

 

Throughout FY21, MCH met with partners, stakeholders, and subject matter experts to share information about the project and seek their feedback and insights about developing specialty CHW curricula focused on high-risk maternal care coordination and identifying one or more potential pilot sites in communities with disparities in severe maternal morbidity.

 

TexasAIM

MCH is the lead coordinating entity in Texas for supporting hospitals with implementing the Alliance for Innovation on Maternal Health’s (AIM) endorsed maternal patient safety bundles (bundles). MCH engages hospitals to address leading causes of maternal mortality in Texas through a large-scale quality improvement initiative called the TexasAIM Program. While planning TexasAIM activities, MCH considers findings and best practices related to the MMMRC’s recommendations to:

• Implement statewide maternal health and safety initiatives to reduce maternal mortality and morbidity;
• Engage Black communities and apply health equity principles in the development of maternal and women’s health programs;
• Improve postpartum care management and discharge education for patients and families;
• Improve access to integrated behavioral health care for women with mental and substance use disorders; and
• Support coordination between emergency and maternal health services, and implement evidence-based, standardized protocols to identify and manage obstetric and postpartum emergencies

 

In December 2020, MCH published the Maternal Health & Safety Initiatives legislative report, which describes TexasAIM structure, operations, and progress through August 2020. Since TexasAIM enrollment began in 2018 through August 31, 2021, a total of 224 hospitals with obstetric (OB) lines of service have enrolled to participate in the program. Accounting for discontinued services and hospital closures, 219 of an estimated 224 hospitals with OB service lines were participating in the TexasAIM Obstetric Hemorrhage (OBH) Initiative through December 2020. Among the 219 OBH participating hospitals, 181 (83%) were enrolled in the TexasAIM OBH Plus Learning Collaborative while 38 (17%) were enrolled as TexasAIM AIM Basic participants. Hospitals that enroll as TexasAIM Basic participants commit to form TexasAIM improvement teams, participate in quarterly quality improvement metric reporting, and work in their units to implement the bundle, but choose not to participate in collaborative learning activities.

 

In September 2020, after a six-month hiatus from OBH learning collaborative activities to focus on providing the TexasAIM Obstetric Care and COVID -19 series, MCH relaunched the TexasAIM OBH Initiative’s Action Period 3. During this time, participating hospitals focused on testing and scaling up OBH bundle implementation and sustainability. TexasAIM Hospital improvement teams (teams) submitted quarterly and monthly data, engaged in online platforms, and networked with their peers. MCH held monthly TexasAIM OBH Action Period collaborative calls from September through November 2020. Topics included Simulation, Drills and Debriefs; Sustainability; and Maternal Early Warning Signs. More than 190 participants attended each call. Action Period 3 continued through December 2020, when MCH closed out the TexasAIM Plus OBH Learning Collaborative and initiated OBH bundle Sustainability Support. During the bundle’s sustainability phase, participating hospitals are encouraged to continue tracking quality data, conducting improvement activities, using TexasAIM resources and chat boards, and seeking TexasAIM technical assistance as needed until processes are standardized and sustained.

 

Beginning in September 2020, MCH began developing the infrastructure for a new TexasAIM Learning Collaborative that would be launched in the December. Throughout September and October, MCH solicited applications for volunteers to form the TexasAIM Plus Severe Hypertension in Pregnancy (HTN) Learning Collaborative faculty team. Through a competitive application process, MCH recruited 13 nurses and physicians with practical experience leading quality improvement efforts, implementing HTN bundle components, and coaching and mentoring multidisciplinary teams. By December 2020, MCH assembled the full TexasAIM HTN Learning Collaborative (HTN LC) Faculty Team (HTN LC faculty team) including the 13 volunteer faculty members and the TexasAIM Leadership Team, including the TexasAIM Program Director, TexasAIM Improvement Advisor Consultant, TexasAIM Medical Director Consultant, TexasAIM HTN Collaborative Deputy Medical Director Consultant, HTN Collaborative Simulation Chair, HTN Collaborative Patient Advocate Advisor Consultant, and HTN Collaborative Maternal Early Warning Signs Advisor.

 

In December 2020, MCH hosted the TexasAIM Virtual Leadership Meeting and Summit. More than 100 administrative and clinical leaders attended the half-day Leadership Meeting, and approximately 600 TexasAIM nurse and physician hospital improvement team members (team members) participated in the TexasAIM Summit for two days of continuing education related to OBH, severe hypertension in pregnancy (HTN), and using health care quality improvement to address maternal health disparities.

 

Throughout Winter 2020, as TexasAIM hospitals celebrated TexasAIM OBH Learning Collaborative achievements, MCH conducted outreach and coordinated enrolling and onboarding hospitals in the TexasAIM Plus HTN Learning Collaborative. As of August 31, 2021, 208 hospitals were fully enrolled and 2 hospitals partially enrolled in the TexasAIM HTN initiative. HTN-enrolled hospitals represent approximately 93% of all the birthing hospitals in Texas and provide care for approximately 99% of births in Texas which translates to approximately 10% of all births in the nation. Among the 208 hospitals fully enrolled in TexasAIM HTN Initiative by August 31, 2021, 176 hospitals (85%) were enrolled to participate in the TexasAIM HTN Plus Learning Collaborative while 32 (15%) enrolled for TexasAIM Basic participation.

 

From January through July 2021, MCH planned and coordinated:

• A 3-session virtual expert meeting with the HTN LC faculty seek their input and guidance for developing the HTN LC driver diagram, change package, and family of measures. MCH and the HTN LC faculty team considered health care quality equity principles— including the MMMRC’s recommended actions— while designing the HTN LC’s change package;
• Two TexasAIM The Joint Commission (TJC) Perinatal Care Measures calls to provide information about the new TJC OBH and HTN quality measures. The calls illustrated alignment between TexasAIM bundle change packages, TJC measures and Texas’ maternal levels of care criteria. More than 400 team members participated in one or both of the calls;
• Engagement of hundreds of team members in TexasAIM HTN pre-collaborative calls and prework activities to prepare for the HTN LC;
  • Pre-collaborative calls included the HTN LC Collaborative Prework Call (with 236 attendees) and the HTN LC Data Managers Call (with 157 attendees).
  • With guidance, templates, and technical assistance from MCH, hospital teams conducted prework activities including convening and developing hospital quality improvement teams, assessing bundle readiness and gaps, developing data capacity, conducting targeted chart reviews, and setting unit aim statements and goals;
• Five a 2-day virtual HTN Learning Session 1 interactive events throughout April and May for TexasAIM’s five geographic cohorts. Almost 600 participants from 164 hospitals participated in the learning sessions. These interactive, collaborative events focused on:
  • Establishing a shared understanding of the HTN LC change package and measures;
  •  Sharing change ideas across hospitals;
  • Using quality improvement methods including testing small changes while rolling out bundle components; and
  •  Developing team-based action plans to implement during HTN LC Action Period 1;
• Five events of TexasAIM HTN Practicing for Patients Simulation virtual train-the-trainer course sessions throughout May and June 2021. The course is likely be the first statewide virtual obstetric simulation train the trainer event in the country. More than 540 participants, comprising training teams from 102 hospitals, participated to develop skills for administering simulation programs in their units. Training teams learned to set up, run, participate in, and debrief “in situ” (onsite, within the unit) severe hypertension drills. The purpose of in situ drills is for teams to regularly practice technical skills, teamwork, communication, and debriefs in simulated but realistic conditions to help achieve standardized responses to obstetric emergencies. MCH mailed participating hospitals and all other Texas birthing hospitals simulation implementation kits to facilitate their ability to train and runin situ simulations. The kits included:
  • A spiral-bound Practicing for Patients manual;
  • Laminated training aids, including vital signs, fetal heart rate tones, clinical scenarios, and debriefing forms;
  • A quality improvement book titled The Improvement Guide: A Practical Approach to Enhancing Organizational Performance; and
  • A birthing simulator including a 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 practicing placement of obstetric balloon tamponade;

• Two TexasAIM HTN Action Period 1 calls, including How to Listen to Patient Stories to Influence QI in June 2021 (119 participants), and Physician Engagement in July 2021 (213 participants);
• Preparing and mailing the TexasAIM Bi-Weekly Bulletin to more than 1,870 subscribers; and
• Ongoing collaborative learning throughout HTN LC Action Period 1 among the more than 1,600 subscribers to the TexasAIM Plus Obstetric Hemorrhage and Severe Hypertension in Pregnancy Information and Resources Online Collaboration Portal.

 

OB Care and COVID-19 Support

During FY21, TexasAIM continued to host the OB Care and COVID-19 Support Calls that began in March 2020 on an as-needed basis. The content and timing for the OB Care and COVID-19 Support Calls were based on hospital needs and trends in COVID-19 cases and hospitalizations and new developments in COVID-19 treatments. In September 2020, TexasAIM hosted an OB Care and COVID-19 Support Call focused on racial disparities in COVID-19 and steps that hospitals can take to address health care disparities. Between September 2020 and August 2021, MCH returned to standard Learning Collaborative programming to support OBH and HTN bundle implementation. However, in response to hospitals’ experience with the summer 2021 COVID-19 surge, MCH paused all learning collaborative activities. Beginning in August 2021, MCH pivoted to reinstate the OB Care and COVID-19 Support Calls to provide guidance, support, and resources to hospital teams for the new COVID-19 Delta variant wave. The first OB Care and COVID-19 Support Call in the new series was held on August 19, 2021, with weekly webinars continuing throughout August and into FY22. In August 2021, TexasAIM held 2 OB Care and COVID-19 Support Calls. One call focused on critical care, the use of monoclonal antibodies, and extracorporeal membrane oxygenation (ECMO) for treatment of COVID-19. The other call addressed vaccination from a quality improvement perspective and the use of motivational interviewing to increase vaccine uptake. The average attendance for the August webinars was over 200 attendees, with about 14% of attendees participating through views of the recorded webinar. Throughout the OB Care and COVID-19 Support Calls, TexasAIM used a variety of approaches to engage participants, gather feedback, assess needs, and respond to questions.

 

In addition to calls, TexasAIM used an online OB Care and COVID-19 Support collaboration space for teams and hospital partners to communicate with one another and share information and resources. All recordings, slides, handouts, and other resources from the OB Care and COVID-19 Support Calls were posted online, and all hospitals with OB service lines were invited to use these resources. More than 1,700 health professionals from approximately 220 Texas hospitals and other organizations within and outside of Texas accessed information from the subscription-based TexasAIM OB Care and COVID-19 portal. Additionally, more than 1,800 health professionals received COVID-19 information from the TexasAIM bi-weekly newsletter.

 

Obstetric Care for Women with Opioid and other Substance Use Disorders (OB-OSUD)

Since June 2018, MCH has engaged 10 “early adopter” hospitals in learning about the AIM Obstetric Care for Women with Opioid Use Disorder (OUD) Bundle. The hospitals worked independently to pilot test implementing bundle components from the time the bundle was released in late fall 2018 through February 2020.

 

In FY21, MCH gathered resources to support hospitals with implementing the OUD bundle and identified faculty to continue program planning. In January 2021, a core team of MCH staff and faculty analyzed the OUD bundle to identify essential bundle components and key drivers for improvement, drawing heavily from the lessons learned from qualitative research conducted in FY20 with pilot hospitals and other stakeholders. Between February 2021 and April 2021, DSHS convened 3 working group meetings with national and state partners to seek input for developing the collaborative strategy. MCH used these learnings to establish a timeline and strategy for the TexasAIM Obstetric Care for Women with Opioid and other Substance Use Disorder Innovation and Improvement Learning Collaborative (OB-OSUD IILC). Based on hospital feedback and general information that was available about AIM’s upcoming bundle revisions, the TexasAIM OB-OSUD IILC will focus on substance use disorders more broadly while maintaining an emphasis on Opioid Use Disorder. All 10 pilot teams recommitted to the OB-OSUD collaborative to comprise the first wave (Wave 1) cohort of the OB-OSUD IILC.

 

In the summer 2021, 2 MCH interns conducted qualitative research and desk review for an environmental scan of 2 Texas communities. The goal was to identify resources available to pregnant women with opioid and other substance use disorders and gain provider perspectives on available services, gaps, needs, and barriers. Environmental scan findings will be used to develop a resource guide for Wave 1 hospitals. MCH will share these resources with participating hospitals during the OB-OSUD IILC pre-work period.

 

In August 2021, before pausing learning collaborative activities in response to the COVID-19 Delta variant surge, DSHS held a 4-part continuing education workshop series for Wave 1 hospital teams to provide foundational knowledge for supporting process and culture change in their units related to obstetric care for women with OSUD. Six multi-disciplinary Wave 1 teams attended the workshops to learn about Trauma-Informed Care; Stigma and Bias; Motivational Interviewing and Screening, Brief Intervention, and Referral to Treatment, and quality improvement methods for large-scale change.

 

Birthing Center Workshop Series

During FY21, MCH began planning and seeking stakeholder input for the TexasAIM Birthing Center Workshop Series, which will launch in FY22. The series will provide education about adapting AIM bundles for free-standing birthing centers and will facilitate networking and sharing of best practices among Texas Licensed Birthing Center staff.

 

Maternal Health and Safety Public Awareness and Professional Education

Consistent with the MMMRC recommendation to continue and strengthen activities to increase public awareness and prevention, MCH worked to increase awareness and education about maternal health and safety throughout FY21.

 

Maternal Health and Safety Campaign

MCH procured a new contract in FY21 to develop a maternal health and safety awareness, education, and communication campaign. FY21 efforts included: developing a campaign media and creative strategy, key messaging and communication methods for the DSHS website, a stakeholder outreach plan, and educational activities.

 

The campaign will reach Texas pregnant and postpartum people and their support networks with a focus on reaching non-Hispanic Black women, families with lower incomes, and people who are underserved by the health care system. Secondary target audiences include health care and social service providers who serve pregnant and postpartum women, local public health partners, and community-based organizations.

 

The DSHS Hear Her Texas campaign aims to prevent maternal morbidity and mortality by increasing awareness of serious pregnancy-related complications and their warning signs among Texas women, their partners, and other advocates. The campaign also aims to empower women to know their health risks and warning signs and speak up when they have concerns. The campaign will launch next fiscal year, in October 2021.

 

MCH is aligning the campaign with national efforts, including the CDC’s Hear Her Campaign and the Council on Patient Safety’s Maternal Urgent Warning Signs. DSHS signed licensing and co-branding agreements with the CDC to integrate elements of their campaign within the Hear Her Texas campaign. The Hear Her Texas campaign will include a focus on Texas women affected by maternal mortality and expand maternal health messaging beyond that included in the national Hear Her campaign.

 

THSteps

As previously described, hundreds of health care professionals received continuing education in FY21 through the completion of MCH-supported THSteps modules focused on preconception, prenatal, and postpartum health. The modules provide education, tools, and resources to support health care professionals in clinical assessment, treatment, and referral for pregnant and postpartum people experiencing obesity, diabetes, hypertension, substance use disorder, and other conditions that impact women’s health and wellbeing.

 

A Call to Action: Maternal Health Speaker Series

MCH hosted a 3-part virtual event series in August 2021 titled, A Call to Action: Improving Maternal Health Outcomes in Texas. The purpose of this series was to share recommendations for improving maternal health and reducing maternal mortality and morbidity and advancing maternal health equity in Texas. The content was based on recommended strategies and actions to improve maternal health and reduce maternal mortality and morbidity that are published in The Surgeon General’s Call to Action to Improve Maternal Health (SGCTA). This series was part of the Maternal Health and Safety Campaign in the Healthy Texas Mothers and Babies Branch. Each 3-hour session featured state and national speakers, including Dr. Jerome Adams, the 20th Surgeon General of the United States.

 

The first session focused on defining a life course approach to health and its relation to maternal health. Speakers in the second session identified healthy behaviors that improve women’s health and identified social determinants of health and how they influence behavior, maternal health, and birth outcomes. MCH also shared state-level breastfeeding data and information on best practices to address barriers to breastfeeding and increase breastfeeding support. The final session focused on identifying risk factors and early warning signs for maternal mortality and morbidity, identifying strategies to reduce the risk, and describing how maternal mortality and morbidity impact families and communities.

 

Each session was attended by an average of more than 200 participants, including clinicians, hospital staff, community-based organizations, state agency staff, managed care organizations, local health departments, university staff, and other stakeholders who work with maternal populations. Workshop recordings are available on the Healthy Texas Mothers and Babies Webinar Channel.

 

DSHS Grand Rounds Series: Perinatal Mood and Anxiety Disorders

The MMMRC recommends improving access to integrated behavioral health care from preconception through 1 year postpartum for women with mental and substance use disorders with emphasis placed on early identification, intervention, treatment, and appropriate referral for mental disorders and SUD can prevent pregnancy-related death.

 

MCH organized a 3-part summer semester DSHS Grand Rounds Perinatal Mood and Anxiety Disorders Grand Rounds Series to provide continuing education to health care and public health professionals on perinatal mood and anxiety disorder, including their impact on maternal mortality and morbidity in Texas and best practices for screening, early detection, treatment, and referral as well as trauma-informed care. More than 500 participants attended each session which  provided 1.5 hours of continuing education credits for disciplines including physicians, nurses, Certified Health Education Specialists, Licensed Professional Counselors, social workers, and other health and health care disciplines. Recordings of the sessions are now available on the Healthy Texas Mothers and Babies Webinar Channel.

 

Health and Human Services Postpartum Depression Strategic Plan

The Texas Health and Human Services Commission (HHSC) is legislatively directed to develop and implement a 5-year strategic plan to improve access to postpartum depression (PPD) screening, referral, treatment, and support services. MCH 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 of perinatal mood and anxiety disorders in the Maternal Health and Safety Public Awareness Campaign;
• Promoting awareness of perinatal mood and anxiety disorders in the Information for Parents of Newborn Children pamphlet, distributed to all parents and other adult caregivers of infants;
• Including perinatal mood and anxiety disorders in the development of the High-Risk Maternal Care Coordination Services Pilot Program; and
• Planning and hosting DSHS Grand Rounds continuing education series on perinatal mood and anxiety disorders.

 

HTMB Community Initiatives

MCH administers community-based programs focused on improving maternal and infant health outcomes. Efforts are informed by the MMMRC recommendation to foster supportive community environments and leverage programs and services that help women of childbearing age achieve their full health potential.

 

Lactation Support Center (LSC) Services Strategic Expansion Program (LSCS-SEP)

HHSC’s WIC program and MCH partner to provide LSCs in 5 communities across the state. MCH funds the HTMB LSCS-SEP to provide population-based lactation support services and maternal and infant health promotion activities not otherwise provided through WIC funding. Along with lactation promotion and support services, the LSCS-SEP provides information, education, and referrals for key maternal, infant, and early childhood health topics that impact infant feeding outcomes, including perinatal mood and anxiety disorders. As part of this work, the Houston, San Antonio, and Hidalgo LSCs screened women for postpartum depression throughout FY21 using the Edinburg Postnatal Depression Scale and made referrals for community-based mental health services as indicated. LSC staff provided 975 depression screenings for women seeking services with 88 women who screened positive for signs of depression received referrals to mental health resources. See the Perinatal and Infant Health annual report for more information about other LSCS-SEP services.

 

HTMB CCs

HTMB CCs collaborate with community partners and stakeholders to strengthen local capacity to improve maternal and infant health outcomes. Local public health partner organizations in nine communities across the state receive MCH funding to coordinate and support community coalition efforts. HTMB CCs conduct activities related to community needs assessment, strategic planning, coalition capacity development, and education and awareness to engage community stakeholders and motivate audiences to address identified needs for maternal and infant health improvement. FY21 activities related to women’s and maternal health included:

•       Local public awareness campaigns to communicate strategic messages and promote preventive health and social services;
•       Coordination with partners to develop referral systems among service providers for improved continuity of care; and
•       Coordination with local colleges and universities to assess opportunities to sustainably develop preconception peer education programs within their student services structures.

 

HTMB Peer Dad Programs

A woman’s partner can be an important advocate and source of support for her health and wellbeing before, during, and beyond pregnancy. Engaging and educating fathers about risk factors and healthy behaviors empowers them as partners in improving maternal and infant health outcomes. Peer Dads are men experienced in parenting and supporting their partners during pregnancy, breastfeeding, and postpartum and who have completed specialized training in peer counseling, breastfeeding, normal baby behavior, urgent maternal warning signs, and other relevant topics.

 

MCH funds Peer Dad programs in 2 communities. The programs:

• Conduct outreach;
• Engage fathers in direct communication through texting, email, and 1-on-1 counseling;
• Provide group discussion, education, counseling; and
• Facilitate connection to local resources including referrals related to workforce training, food insecurity, mental health counseling, and other services based on identified needs.

In addition to their peer support work, Peer Dads served as subject matter experts on fatherhood engagement and networked and consult with community programs to increase fathers’ involvement in maternal and infant services. For example, the Northeast Texas Health WIC program has made program changes to increase the inclusion of fathers throughout their program services. Their engagement efforts are highlighted on the Fatherhood Resource Hub website as an example of program excellence in this video.

 

Regional Activities

Public Health Region (PHR) clinic staff across the state used the Whole Person Project throughout FY21 to assess the health of women of childbearing age and ask female clients, “Would you like to become pregnant in the next year?” Based on client responses, the staff offered condoms and referred clients to the tobacco quitline, food assistance programs, and other organizations based on the individual’s identified needs. PHR 11 staff reached out to half (12) of the colleges and universities in the region in FY21, to promote the “Go Before You Show” campaign to inform young women about the importance of seeking preconception and prenatal health.

 

Performance Analysis

Efforts to integrate women’s and maternal health promotion continued across assessment, strategic planning, educational, community-based, and health care quality improvement programs and activities. MCH uses the MMMRC’s findings and recommendations to prioritize maternal health and safety activities in the preconception, prenatal, postpartum, and interpregnancy periods.

 

Challenges/Opportunities

MCH and many contractors experienced staffing changes and vacancies, impacting program capacity. Additionally, COVID-19 continues to impact program capacity in community and health care settings. Contractors continued to develop approaches for virtual community engagement strategies. MCH is using ongoing feedback from stakeholders and health care organizations to responsively adapt program plans to current needs.

 

 

SPM 4 – Maternal Morbidity Disparities: Ratio of Black to White severe maternal morbidity rate

 

Analysis of the 2020 Title V Needs Assessment findings and stakeholder input identified implementing health equity strategies across all maternal and child health populations as a State Priority Need.

 

MMMRC

MCH supported the MMMRC Subcommittee on Maternal Health Disparities (subcommittee) throughout FY21 to study drivers and root causes of racial disparities in maternal mortality and morbidity to guide the MMMRC for case review continuous improvement.

 

The subcommittee developed the DASH Tool to provide a standardized process to guide targeted discussion, evaluate information relevant to each case, and assess whether social and environmental determinants of health factors contributed to the death. The MMMRC discusses the elements in the tool for each case to inform the completion of the MMRIA Committee Decisions Form in their assessment to identify what factors contributed to the death and whether discrimination contributed to the death. The subcommittee continued to refine the DASH Tool in FY21 based on MMMRC feedback through their experience with testing the use of the tool.

 

MCH consulted with the subcommittee in FY21 to:

• Develop a pilot study design and obtained IRB approval to work with other states’ maternal mortality review committees (S-MMRCs) to test the DASH Tool in their case review processes. Staff submitted the study to the DSHS Internal Review Board and received approval in June 2021. MCH recruited 7 S-MMRCs study teams to participate in the pilot.
• Develop a case presentation guide to standardized efficient case presentation process across MMMRC members. Efficiency improvements are needed to support an increase in the volume of cases that are reviewed each year to meet the requirements of the ERASE MM Program.

 

Additionally, MCH coordinated to help plan training on racial health disparities for the nurse abstractors who review and abstract medical and medico-legal records to develop the case reports that MMMRC members use as the basis for their case review of pregnancy-associated deaths.

 

HTMB Community Initiatives

HTMB CCs

MCH leverages partnerships with HTMB CCs to promote and support women’s and maternal health and safety. Examples of HTMB CCs FY21 activities that targeted maternal health disparities included:

• The City of Amarillo HTMB CC conducted community conversations and surveys during community events and through other outreach efforts throughout FY21 to assess the needs of the local populations most at risk for poor maternal and infant health outcomes. The City developed content for the Healthy Amarillo Women website based on findings from the community needs assessment so that the information and resources on their website were directly responsive to the community’s self-identified needs. The Amarillo website generated 519,593 impressions in FY21 (the number of times an ad was viewed);

• The City of Port Arthur HTMB CC hosted virtual Mom Squad breastfeeding support group meetings for Black mothers throughout FY21, and developed a Mom Squad Ambassador Program to encourage participants to promote awareness of available services and resources through social media posts and word of mouth; and
• The Dallas County HTMB CC partnered with Parkland Hospital’s Extending Maternity Care After Pregnancy program to expand medical and case management services to women who reside in zip codes in Dallas County with the highest rates of maternal mortality and morbidity. The CC also educated coalition members and community stakeholders and service providers about the use of MCH’s Reproductive Life Planning and Implementation tool, the March of Dimes Becoming a Mom and Beyond curricula, and Preconception Peer Education.

 

Texas Mother-Friendly Worksite (TMFW) Program

Breastfeeding is one of several healthy behaviors included in the 2020 Surgeon General’s Call to Action to Improve Maternal Health and improves health across the life course for both mothers and their infants. Breastfeeding reduces a mother’s risk for hypertension, type 2 diabetes, breast, and ovarian cancer, and decreases the risk for postpartum hemorrhage.

 

Return to work remains a top barrier to initiation and continuation of exclusive breastfeeding in Texas with more than half of Texas WIC mothers reporting early weaning due to return to work or school (2018 WIC Infant Feeding Practices Survey).

 

In FY21, breastfeeding support activities continued to target known disparities and barriers to breastfeeding. Non-Hispanic Black mothers are more likely to return to work in the first year after delivery and return to work earlier, on average, than mothers of other races or ethnicities. Non-Hispanic Black women are also disproportionately represented in low-wage jobs, with less flexible work hours and less social support to breastfeed. Previous analysis of WIC Infant Feeding Practices Survey data showed that non-Hispanic Black mothers were less likely than mothers of other races or ethnicities to report that their worksites were supportive of breastfeeding.

 

The TMFW Program provided targeted technical assistance to employers on a 1-on-1 basis throughout FY21. Additionally, a direct outreach campaign specifically targeted employers in the service and low-wage industries in Texas sectors that employ large numbers of low-wage earners. These employers received information about the TMFW Program and were invited to attend an informative webinar. The webinar promoted best practices for worksite lactation support as well as information about TMFW Program and available support for employers to become designated as Texas Mother-Friendly Worksites. Representatives for 20 employers attended the webinar. The webinar and direct outreach campaigns resulted in engaging 9 employers in the Texas Mother-Friendly technical assistance process, and 2 worksites were designated during FY21 from these efforts.

 

High-Risk Maternal Care Coordination Services (HRMCCS) Pilot Program

In FY21, MCH continued developing the pilot, as described earlier in this report. The purpose of the pilot is to reduce poor outcomes for pregnant and postpartum women. Non-Hispanic Black women experience disproportionately higher rates of maternal mortality compared to other racial/ethnic groups.[1] Racial and ethnic maternal health disparities are considered components throughout program planning, including planning for the risk assessment tool, the CHW curricula, CHW-led patient education, and identification of location(s) for the pilot site(s).

 

TexasAIM

In FY21, MCH studied resources and used recommendations by the MMMRC as well as elements from the Alliance on Improvement in Maternal Health’s Reduction of Peripartum Racial/Ethnic Disparities Supporting Bundle, the Agency for Healthcare Research and Quality, the U.S. Health and Human Services’ Office of Minority Health, American Hospital Association’s Institute for Diversity and Health Equity, Institute for Health Care Improvement, The Joint Commission, the University of Chicago/Robert Wood Johnson Foundation’s Advancing Health Equity Center, and the National Academy of Sciences’ Engineering and Medicine, Health and Medicine Division to integrate best practice principles in health care equity into the change package for the TexasAIM’s Severe Hypertension in Pregnancy (HTN) Learning Collaborative.

 

The TexasAIM HTN change package includes the promotion of the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (National CLAS Standards), use of Race, Ethnicity, and Language (REaL) data, shared decision-making practices, and other best practices strategies for increasing health care quality through the provision of equitable health care. Additionally, TexasAIM hospital improvement teams are supported to collect and disaggregate their data by race and ethnicity to inform their quality improvement efforts and target improvements to address disparities. Presentations during the TexasAIM HTN Learning Session 1 events included Mechanism and Process to Assess and Respond to Patient, Family, and Staff Experiences Related to Culturally and Linguistically Appropriate Care, and Centering Equity and the Aim to Eliminate Health Disparities.

 

Texas Collaborative for Healthy Mothers and Babies (TCHMB)

In partnership with the University of Texas Health Science Center at Tyler and the University of Texas System, MCH continued to fund the facilitation and activities of the TCHMB, which functions as Texas’ state perinatal quality collaborative. TCHMB is a collaboration of over 150 health care providers, hospitals, state agencies, and other stakeholders with a shared goal of developing strategies, designing projects, and collecting data to improve birth outcomes in Texas.

 

In February 2021, TCHMB hosted its 2021 annual summit virtually. The summit included presentations on Texas data on maternal and birth outcomes, incorporating health equity lens into quality improvement projects to address racial and ethnic disparities, lessons learned and future considerations of the impact of COVID-19 on perinatal care, and other maternal and infant health topics. TCHMB has a workgroup that aims to help reduce and eliminate health care disparities. 920 unique attendees participated in the summit and its pre-session workshops.

 

Maternal Health and Safety Public Awareness and Professional Education

Maternal Health and Safety Campaign

The DSHS Hear Her Texas campaign, described in more detail earlier in this report, aims will focus campaign efforts to increase awareness about:

• 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 of severe maternal morbidity and mortality and improve maternal health outcomes;
• The importance of, and opportunities for, promotion of maternal health, safety, and wellbeing; and
• Evidence-based or promising prevention strategies and the role and responsibility of providers to implement these strategies.

 

MCH will apply an equity lens across all campaign strategies to disseminate information and initiatives to mothers, their support networks, providers, and other key stakeholders statewide through targeted media, communication strategies, and community mobilization to create awareness about the prevention of maternal morbidity and mortality in Texas.

 

A Call to Action: Maternal Health Speaker Series

MCH hosted the A Call to Action: Improving Maternal Health Outcomes in Texas workshop series in FY21. The series was based on recommended strategies and actions to improve maternal health and reduce maternal mortality and morbidity that are published in The Surgeon General’s Call to Action to Improve Maternal Health. This series was part of the Maternal Health and Safety Campaign. Each 3-hour session featured state and national speakers.

 

The purpose of this series was to share recommendations for improving maternal health and reducing maternal mortality and morbidity as well as eliminate health disparities and improve health care equity in Texas. The first session laid the groundwork for a life course approach to maternal health. The second and third sessions presented a more in-depth look at maternal health disparities, particularly among non-Hispanic Black women, the influence of social determinants of health, and how maternal health providers and stakeholders can work to reduce these disparities. The third session also emphasized the impact of maternal mortality on the families and communities left behind. The series is described in greater detail previously in this report.

 

Performance Analysis

Addressing maternal health disparities and closing disparity gaps remains an MCH priority. Maternal health outcome disparities persist, and Black women most disproportionately impacted by severe maternal morbidity and maternal mortality. MCH uses assessment findings to target opportunities for addressing maternal health disparities and works to prioritize and integrate disparity prevention strategies across all maternal health programs.

 

Challenges/Opportunities

MCH continues to develop and support mobilization of a wide network of partners across the state focused on maternal health and safety improvement. MCH will continue to assess opportunities to specifically address and work to eliminate racial disparities in maternal health outcomes.

 

[1] 2020 Healthy Texas Mothers and Babies Data Book (Rep.). (2021). Retrieved Texas Department of State Health Services. (2021). 2020 Healthy Texas Mothers and Babies Data Book. Pg. 57. dshs.texas.gov/healthytexasbabies/Documents/Healthy-Texas-Mothers-and-Babies-Data-Book-2020_REVISED.pdf