Improving the domain of Women's/Maternal Health is crucial to the State Priority Need of Increasing Equity in Healthy Births (SPN #1) and the National Outcomes Measures (NOMs) related to decreasing: NOMs 2, 3, 4,  5, 6, 8,9.1, 9.2, 9.3, 9.4, 10, 11,23 and 24. The selection of NPM #1 (Well Women Visits) during the Five-Year Needs Assessment process recognizes the impact the life course approach will have on increasing healthy births and improving women's health across their life span. The Life Course Perspective to conceptualizing health care needs and services evolved from research documenting the important role early life events play in shaping an individual’s health trajectory. The interplay of risk and protective factors, such as socioeconomic status, toxic environmental exposures, health behaviors, stress, and nutrition, influence health throughout one’s lifetime. NJ has had a long-standing priority of improving the health of women and has utilized several evidence-based strategies to increase preventive medical visits (NPM #1) including: the HWHF, MIECHV, FIMR, and Maternal Mortality Review. Additional emphasis has been placed by the Governor and the First Lady on reducing maternal mortality and morbidity through the Nurture NJ Initiative.

3.e.2.c.2.a - Annual Report - NPM #1 (Percent of women with a past year preventive medical visit)

Data Source: Behavioral Risk Factor Surveillance System (BRFSS) in NJSHAD. Visited a Doctor for a Routine Checkup in the past year (Age-adjusted).

** Data not available on NJSHAD

Evidence-Based Informed Strategy Measure (ESM) 1.1 (Increase First Trimester Prenatal Care) was selected for its positive impact on National Performance Measure (NPM) #1 (Well Women Care) and State Performance Measure (SPM) #1 (Increasing Healthy Births).

In 2020, the overall percentage of adequate prenatal care based on the Kotelchuck Prenatal Care was 71.1%.[1] However, racial/ ethnic disparities are observed.  Specific race/ethnicity related rates for adequate prenatal care for 2020 were 77.4%, 58.1%, and 66.1% for White, NH, Black, NH, and Hispanic, respectively[2]. These existing disparities align with the need for TVP to improve NPM #1 by focusing on preconception care and early prenatal care. Improving access to prenatal care is essential to promoting the health of NJ mothers, infants, and families. Early and adequate prenatal care is an important component of a healthy pregnancy and birth outcome because it offers the best opportunity for risk assessment, health education, and the management of pregnancy-related complications and conditions. Prenatal care is also an opportunity to establish contacts with the health care system and to provide general preventive visits.

Moreover, preconception care is a critical component of prenatal care and health care for all women of reproductive age. The main goal of preconception care is to provide health promotion, screening, and interventions for women of reproductive age to reduce risk factors that might affect future pregnancies. Given the relationship between pregnancy intention and early initiation of prenatal care, assisting women in having a healthy and planned pregnancy can reduce the incidence of late prenatal care and promote NPM #1 (Well Women Visits).

Through the HWHF initiative, TVP uses CHWs and Connecting NJ to focus on improving maternal and infant health outcomes including women's health with preventive medical visits, preconception care, prenatal care, interconception care, preterm birth, and low birth weight, and infant mortality. The primary focus of Connecting NJ is to assist pregnant people, caregivers (mothers, fathers, grandparents, kinship, foster parents, legal guardians), and young children (birth-five) in efficiently accessing the most appropriate services. On the Connecting NJ portal, reported data includes but is not limited to health status, diagnosis, socio-demographic characteristics, and more. TVS on the project team have access to data collected on this secure system. Connecting NJ is designed to simplify the referral process, improve care coordination, provide developmental screening, and ensure an integrated maternal, infant, and early childhood care system. From July 1, 2018, to March 30, 2022, more than 90,000 women have been screened since July 2018, over 24,000 clients received a service referral, and 32,000 clients received a program assignment.

To better align the ESM with our current initiatives, TVS decided to add ESM 1.2 (Number of individuals trained to become community-based doula). Number of individuals trained to become community-based doula) was selected for its positive impact on National Performance Measure (NPM) #1 (Well Women Care) and State Performance Measure (SPM) #1 (Increasing Healthy Births).

A Request for Application (RFA) was issued for the creation of a Doula Learning Collaborative (DLC), which was awarded to Health Connect One. The focus of the DLC is to reduce maternal and infant mortality and eliminate racial disparities in health outcomes by providing training, workforce development, supervision support, mentoring, technical assistance, direct billing, and sustainability planning to grow the community doula workforce.

To date, approximately 150 women were trained to become community doulas, and as of December 2021, 547 births have been attended by doulas from the pilot sites. Preliminary results from an evaluation conducted by researchers from Montclair State University in 2021 for the 3-year Doula Pilot Program indicate that positive birth and/or pregnancy outcomes (e.g., lower rate of cesarean deliveries, increase in breastfeeding rate) are linked to community doula services.

A mixed-methods outcome evaluation was conducted to examine the outcomes and benefits of the Doula Pilot Program as measured by quantitative data (i.e., program data from the Maternity Neighborhood database) and qualitative data (i.e., interviews with program stakeholders). Program outcomes and benefits were observed at three stakeholder levels: 1) client, 2) doula and grantee agency, and 3) NJDOH and state system levels (Figure 17).

Figure 17. Program Outcomes Across Clients, Doula and Grantees Agencies, NJDOH, and State Systems

Several actionable recommendations have emerged from the evaluation project on how to improve the implementation and outcomes of ongoing efforts related to the Doula Pilot Program. Overarching recommendations are provided and specific actions that may be taken by multiple stakeholder groups are offered to provide targeted guidelines for program improvement. The recommendations emphasize collaboration across stakeholder groups and are mutually reinforcing.

To ensure the sustainability of community doula services in NJ, TVS worked collaboratively with Medicaid to offer doula services to women through Medicaid Benefits. NJ Medicaid benefits have been expanded to cover doula services. Presently, birthing people who are covered by Medicaid can now be served by a doula as a covered benefit.

Moreover, to infuse additional services in the communities, TVP established the CLG-CHWI through a NJ Department of Labor Apprenticeship. TVP collaborate with universities to create a standardized community health worker training and certification program, resulting in a robust CHW workforce. This has allowed the state to educate an emerging and critical component of its workforce – creating a needed infrastructure to support CHWs and enhance CHW skill sets and lead sustainable efforts to support this indispensable workforce. Graduation of the initial cohorts has already begun, with new cohorts continuously being enrolled.

In collaboration with the CLG-CHWI, the Epidemiology Laboratory and Capacity (ELC) grant emphasizes the prevention of disease and enhanced detection of COVID19. The ELC focused on hiring and training CHWs to assist in contact tracing efforts; assisting with the surveillance of vulnerable populations; implementing prevention strategies with vulnerable, diverse populations; and providing alternative testing and vaccine sites for COVID-19. The COVID Community Corps and Vaccine Ambassador Programs also support these efforts.

Moreover, CHWs and their supervisors through Title V grantees have received and continue to receive breastfeeding education. This unique training focuses on women of color and was developed to address health disparities, as they relate to reproductive justice. Breastfeeding support is also being provided by International Board-Certified Lactation Consultants (IBCLC) either in groups or in one-to-one sessions.

The programs being implemented in the communities through HWHF initiative allow TVP to implement specific activities aiming at supporting communities with limited public health resources and the highest need where impacts will be greatest to improve population health outcomes and reduce health disparities. The HWHF Initiative addresses the disparities in birth outcomes through case management and assures that appropriate referrals are made and tracked including medical care referrals to promote NPM #1 (Well Women Visits).

To ensure that the HWHF initiative is successful, NJ TVP collaborates with the NJDOH Office of Population Health and the Population Health in Action Teams, and established linkages with sister agencies (Department of Labor, Department of Education, Department of Transportation, etc.) to address some of the barriers that exist in the scope of SDOH. NJ TVP and Office of Population Health continue to work with national maternal health experts to develop a strategic plan to promote maternal health and reduce maternal morbidity and mortality as well as develop the activities for the Maternal Health Innovations Program and expanded Maternal Mortality Review Commission. Additionally, efforts to reduce maternal mortality and morbidity have been and continue to be developed under First Lady Tammy Murphy’s Nurture NJ Initiative whose goal is to “make NJ the safest place to give birth in the country”.

Moreover, the regional quality improvement activities within each of the three Maternal Child Health Consortia (MCHCs) coordinated by the Reproductive and Perinatal Health Services (RPHS) Program include the regular monitoring of indicators of perinatal and pediatric statistics, fetal-infant mortality review, maternal mortality review, and maternity services reporting through the New Jersey Vital Events Registration & Information (NJ-VERI). Regional quality improvement activities include regular monitoring of indicators of perinatal and pediatric statistics and pathology, including 1) transports with death; 2) non-compliance with rules regarding birth weight and gestational age; 3) cases in which no prenatal care was received. 4) all maternal deaths; 5) all fetal deaths over 2,500 grams not diagnosed as having known lethal anomalies; 6) selected pediatric deaths and/or adverse outcomes; 7) immunizations of children 2 years of age; and 8) admissions for ambulatory care sensitive diagnoses in children.

Quality improvement is accomplished through the FIMR and Maternal Mortality Review systems, as well as analyzing data collected through electronically submitted birth certificates. The Total Quality Improvement (TQI) Committee reviews the data and makes recommendations to address either provider-specific issues or broad system issues that address multiple providers or consumer groups within each consortium region.

Annual Report - NPM #14:

 A) Percent of women who smoke during pregnancy and

 B) Percent of children who live in households where someone smokes

Adverse effects of parental smoking on children have been a clinical and public health concern for decades and were documented in the 1986 U.S. Surgeon General’s Report. Unfortunately, millions (more than 60%) of children are exposed to secondhand smoke in their homes. These children have an increased frequency of ear infections; acute respiratory illnesses and related hospital admissions during infancy; severe asthma and asthma-related problems; lower respiratory tract infections leading to 7,500 to 15,000 hospitalizations annually in children under 18 months; and sudden Unintended infant death (SUID).

As a result of the many health consequences, the health costs from smoking in pregnancy are significant. The excess costs for prenatal care and complicated births among pregnant women who smoke exceed $4 billion a year. (See NJ Pregnancy smoking rates in table A below) It has been estimated that a 1% drop-in rate of smoking among pregnant women could result in savings to the US of $21 million in direct medical costs in the first year. Another $572 million in direct costs could be saved if the rates continued to drop by 1% a year over seven years. Secondhand smoke also has significant health effects on an infant. Pregnant women exposed to secondhand smoke have a 20% increased risk of having an infant born with low birth weight, and secondhand smoke exposure also increases the risk for infections in the infant, and even death from SUID (Refer to the Perinatal Risk Assessment [NJ Medicaid recipients] below). Children living with smokers are also more likely to have more frequent and acute asthma attacks, ear infections, and serious respiratory illnesses like pneumonia and bronchitis due to second and third-hand smoke exposure (See NJ exposure in table B below). The cost to care for childhood illnesses resulting from exposure to second and third-hand smoke is estimated at $8 billion a year. In addition to the effects during the perinatal period, health consequences for older children and adults (whether from directly smoking or from second and third-hand exposure) are well documented in the literature and include respiratory infections and disease, cancer, and death. In 2018, the New Jersey State Health Assessment Data shows that 51% of nonsmoking high school youth are exposed to secondhand smoke.

Perinatal Risk Assessment Data

*Majority of assessments completed by Medicaid recipients and not representative of the state overall

Initiated in 2001 with funding from the NJDOH-Comprehensive Tobacco Control Program, Mom’s Quit Connection (MQC) is NJ’s maternal child health smoking cessation and education program. There have been changes in the services provided and their capacity to be a statewide program through the years based on availability of funds. MQC utilizes a proactive behavior modification model, offering face-to-face individual cessation counseling, telephone counseling, and texting support to assist clients in developing a customized quit plan. Through these direct services, both for consumers and professionals, MQCF focuses its efforts to reach the women and family members who need help to quit, educate them about the dangers of tobacco use, and offer judgment-free, evidenced-based treatment methods by Nationally Certified Tobacco Treatment Practitioners and NJ Certified Tobacco Treatment Specialists.

The program was expanded during FY 2015 and Mom’s Quit Connection (MQC) was able to develop a multi-pronged and comprehensive statewide approach to perinatal smoking cessation activities. The new activities include:

• Promoting Mom’s Quit Connection (MQC) to further expand its reach to pregnant and parenting mothers in NJ.
• Increasing capacity of Mom’s Quit Connection with respect to direct services for pregnant and parenting mothers statewide.
• Preventing relapse after delivery.

Twenty target municipalities (TMs) were identified on which to focus MQC outreach and intervention, thus maximizing efforts to areas with the greatest need. The TM’s were chosen based on the high numbers of pregnant women who used tobacco during pregnancy, and the high rate of preterm delivery among Black, Non-Hispanic women in these municipalities. Seven of the twenty municipalities were located in five counties outside of the southern region; the remainder were within the seven southern counties. In January 2018, the MQC database software program was redesigned and upgraded to a web-based system using the Salesforce platform to support more detailed reporting and integration of planned mobile technology.

 Given the declining rate of maternal smoking and the stagnant and in some cases increasing numbers of postpartum women who were returning to smoking after delivery, MQC chose to rebrand to MQC for Families. According to PRAMS Briefs published by the NJDOH, living with other smokers represented the most prevalent indicator for postpartum relapse. Expanding the program to MQC for Families has enhanced its cessation population parameters to include parents and caregivers of children under 8 years old along with the pregnant woman to address not only the individual smoker but all smokers in the home environment. By helping the clients quit smoking, there is significant harm reduction for their children. Multi-level interventions are standard, including mailing self-help materials, phone calls, texting, and direct individual cessation services. Relapse prevention interventions are an important part of the program to address the high relapse rates post-partum.

From July 1, 2021, thru June 30, 2022, there were 384 referrals to the program, 26% from the Central region, 26% from the Northern Region, and 37% from the Southern region. 320 of these referrals came from the automated Perinatal Risk Assessment (PRA) system: 21 referrals were faxed from providers; and, 43 were self-referrals from the MQC website and Facebook page online registration option. All 384 referred clients were sent self-help cessation information and texted the option of enrolling in MQC’s cession counseling program. Forty-five clients received a Level 1 cessation counseling session, and 43 clients went on to enroll in intensive cessation counseling. There was a total of 347 counseling sessions with clients enrolled in case management and 225 providers received client status reports on newly enrolled and existing clients. Of the enrolled pregnant clients, 93% quit or significantly reduced their consumption and 30% quit completely (the national average maternal quit rate is 24%). Among non-pregnant clients enrolled in cessation counseling, 66% quit or significantly reduced consumption, of which 21% completely quit. Throughout this year, 379 MQCF referred clients, and their family members/caregivers were referred to the NJ Quitline.

Due to COVID 19, all work between July 1, 2020, and June 30, 2021, by MQCF was completed through the Zoom or Teams platforms. MQCF provides statewide training to clinicians, medical professionals, social service agencies, and educators on the Ask Advise and Refer: Brief tobacco Intervention Model (AAR), to improve assessing of tobacco use and refer pregnant women, mothers, fathers, and caregivers who use tobacco to MQCF. AAR as a CDC Best Practice intervention, teaches the trainees how to successfully talk to their clients/patients about smoking, how to advise them to quit, and where to make a referral that will facilitate quitting. Brief tobacco dependence treatment is effective as stated in the Treating Tobacco Use and Dependence: Clinical Practice Guidelines. From July 2021 through June 2022, 482 professionals received AAR training through the Zoom and Teams platforms. Professional outreach and networking are vital for reaching new providers, offering MQCF Program Orientations, and enhancing their services with professional and consumer education, tobacco resources, and a system for direct referral for cessation counseling. From July 2021 thru June 2022, an additional 1,486 professionals received orientation and information sessions about MQCF and NJ Quitline. MQCF participates in conferences to increase professional awareness of the available services. Nine hundred and forty-three professionals received information through conference tabling, toolkits, resource requests, and networking opportunities. Approximately 238 pregnant women and families received information about the dangers of maternal smoking and MQCF and NJ Quitline services through formal education sessions via the Zoom platform. Both virtual and in-person community outreach and partner events reached an additional 1,213 mothers and families. MQCF staff now follow up (421 letters and emails sent this year) with every new prenatal provider trained on the use of the PRA, about scheduling a MQCF program orientation session and to promote ASK ADVISE REFER training. A vast amount of tobacco resource information has been made available online by MQCF for anyone interested, removing any barriers to access.

This past year, FHI Prematurity Prevention Initiative (PPI) funding from DOH was utilized to continue MQCF services to target municipalities with the highest rates of black infant mortality, specifically, Atlantic City and Newark. These efforts resulted in Atlantic City gaining the number one position in client referrals this year at 22%, with Newark following in second position at 20%. According to the MQCF data by target municipalities, these communities with the highest rates of Black Infant Mortality and adult smoking were approximately 42% of all referrals. These results demonstrate that collaboration and targeted efforts were impactful in reaching mothers most at risk for maternal and infant mortality. Collaboration with the FHI Prematurity Prevention Initiative (PPI) facilitated the launch of the Quit for Kids (QFK) texting support Program in May 2020. QFK is offered to stand alone, as texting support to quit or to coexist with the individual MQCF cessation services. To target the difficulties of quitting smoking, texts are personalized for each participant and geared toward their triggers, cravings, and problems. If the participant would like to talk to an MQCF quit coach, they can connect through QFK. From July 2021 to June 2022, 18 clients opted to talk to a quit coach. PRA clients with a current or past history of smoking are automatically enrolled to QFK, with an opt-out option. Clients working with MQCF can be enrolled through the client database. The texting program uses the GOMO platform to provide smoking cessation and child development messages to pregnant and post-partum women, as well as dads and family members of children up to eight years old. The goal of the texting program is to engage a broader range of clients, including a demographic naturally drawn to online services, and clients who may not initially be comfortable with one-on-one counseling. Enrolling with an MQCF cessation specialist is encouraged, but not required. This type of customized perinatal texting program is relatively new; therefore, extensive analytics and evaluation have been built into the program to help determine its effectiveness in engaging clients and helping them to quit. From July 2021 to June 2022, 355 clients enrolled in QFK.

MQCF program information remains on the NJ Quitline website and in the downloadable NJ Provider Cessation Toolkit. MQCF is also assisting with cessation content for the PPI website, and “pay attention cards”. MQCF program information is included in the PPI “COVID19 - GO KITS” project, providing supplies and resources for mothers at risk for preterm labor to be better informed and prepared for self-monitoring at home. Go-kits include critical resources such as blood pressure monitors, digital thermometers, face masks, and information on achieving a healthy pregnancy and birth. Since the inception of the Go-kit project in March 2020, 2,469 kits have been distributed to New Jersey pregnant and postpartum women. Within the last 6 months, 489 kits have been received. To date, 15% of Go-kits were given postpartum women, while 85% were distributed to prenatal women. Tobacco-Free Ride NJ-Clean Air for Kids in Cars (TFR) is a joint project between the FHI-FAS MQCF team and the SNJPC tobacco control program. TFR is designed to educate drivers about the risk of second and third-hand smoke and vapor exposure to younger passengers. Those who pledge to keep their cars smoke-free for children under 18 receive an incentive that includes a mobile bag, keychain flashlight, tire gauge, mini first aid kit, car magnet, and educational materials. The campaign ran from January 1, 2021, through April 30, 2022, and 595 pledges were received from New Jersey drivers in the 2021/2022 pledge year.

Tables NPM 14A & B:

A) Percent of women who smoke during pregnancy (last 3 months)

Notes - Data is from the NJ PRAMS Survey

B) Percent of children who live in households where someone smokes

Data Source: National Survey of Children's Health (NSCH)- NSCH 2018 19: Children who live in households where someone smokes, Nationwide vs. New Jersey (nschdata.org)

[1] New Jersey State Health Assessment Data. “Query Results for New Jersey Birth Data: 1990-2020 - Percentage With Kotelchuck Prenatal Care=Adequate”. Accessed on April 20, 2022 at NJSHAD -  NJSHAD - Query Builder - New Jersey Birth Data: 1990-2020 - Percentage With Kotelchuck Prenatal Care=Adequate (state.nj.us).

[2] New Jersey State Health Assessment Data. “Query Results for New Jersey Birth Data: 1990-2020 - Percentage With Kotelchuck Prenatal Care=Adequate”. Accessed on April 20, 2022 at NJSHAD -  NJSHAD - Query Builder - New Jersey Birth Data: 1990-2020 - Percentage With Kotelchuck Prenatal Care=Adequate (state.nj.us).