Massachusetts has three Maternal and Women’s Health priorities for 2020-2025:
- Strengthen the capacity of the health system to promote mental health and emotional well-being.
- Prevent the use of substances, including alcohol, tobacco, marijuana and opioids, among youth and pregnant people.
- Reduce rates of and eliminate inequities in maternal morbidity and mortality.
Priority: Strengthen the capacity of the health system to promote mental health and emotional well-being.
Findings from the Fall 2020 COVID-19 Community Impact Survey (CCIS) underscore the continued importance of this Title V priority due to the pandemic. Compared to the 2019 Behavioral Risk Factor Surveillance System (BRFSS), reports of poor mental health among CCIS respondents were three times higher, with one third of adults currently reporting poor mental health. People experiencing persistent poor mental health were 2-3 times more likely to experience barriers to accessing care, such as appointment delays/cancellations, concerns about contracting COVID-19, not having a private place for a telehealth appointment, cost/insurance coverage and lack of safe transportation. Requests for suicide prevention and crisis management resources were as high as 11% among certain subpopulations, and highest among transgender people, non-binary people, and people questioning their gender identity.
People experiencing poor mental health are more likely to report having had a change in their work status because of childcare or being worried about basic needs like getting medication and paying bills. While there has been an increase in people reporting poor mental health across all demographic groups, some populations are more likely to report poor mental health: transgender people, non-binary people and those questioning their gender identity; people with disabilities; American Indian/Alaska Natives; Hispanic/Latinx community; people who identify as multi-racial; people aged 25-44 years; people with lower income; and caregivers of adults with special needs.
In 2021, 88.3% of birthing people reported having moderate or high social support, a modest improvement from 87.3% in 2019 and 86.3% in 2020, the latter most likely due to isolation and social restrictions during the COVID-19 pandemic. Because PRAMS is typically administered two to four months postpartum, all 2020 respondents would have completed the survey after the onset of the COVID-19 pandemic in March 2020.
Perinatal Mental Health Training and Technical Assistance (TA)
MDPH provided training and TA on perinatal mental health (including maternal mental health and co-morbidities such as substance use and interpersonal violence) to state agencies (such as the Department of Children and Families (DCF) and the Department of Early Education and Care), providers (including home visiting programs and community health centers), and health plans. The training and TA will contribute to increasing awareness and reducing stigma about perinatal mental health issues and will support continued implementation of the MA Postpartum Depression regulations.
Early Intervention Parenting Partnerships Program (EIPP)
EIPP is a home visiting program that uses a team approach to engage with and support families during pregnancy, continuing through the child’s first birthday. Maternal mental health is a key topic of discussion, education, support, and referral. In FY22, 148 (62%) participants reported a history of depression, including postpartum depression (PPD), at enrollment. At the initial visit, all 237 participants were screened for PPD using the Edinburgh Postnatal Depression Scale (EPDS) with 22 (9%) screening positive for mild depressive symptoms and 36 (15%) screening positive for moderate or severe depressive symptoms. Of the 40 participants referred to individual counseling, 27 (68%) were enrolled in services, 10 (25%) declined the referral, 4 (10%) were ineligible for services largely due to lack of adequate insurance coverage and 8 (20%) were placed on a waiting list.
EIPP participants are assessed on a three-question social connectedness screening tool at key prenatal and postpartum stages. At the initial visit, 237 participants were screened, with 48 (20%) reporting that they do not have the support they need from others to care for themselves and their infant. Each EIPP site facilitates one 10-week support group annually for its participants. Topics include maternal mental health, mother/infant attachment, self-care, and parenting skills. Transportation, childcare, and food are provided to facilitate attendance.
MA Maternal, Infant, and Early Childhood Home Visiting Initiative (MA MIECHV)
MA MIECHV, funded by HRSA/MCHB, provides evidence-based home visiting services to pregnant and parenting families in 18 communities. MA MIECHV aims to improve the lives of children and families by supporting parenting, improving maternal and child health, and promoting child development and school readiness. MA MIECHV promotes emotional wellness and social connectedness among program participants in several ways.
MA MIECHV home visitors and supervisors attend training on common mental health concerns, strategies for supporting parents who experience mental health challenges, and mindful self-regulation skills to support home visitors when working with parents experiencing mental health challenges. The training incorporates reflective conversations and engages participants in help-seeking in response to episodes of mental distress, illness, or crisis. A three-day Facilitating Attuned Interactions training further supports staff to engage in reflective practice.
All MA MIECHV programs hold parent support groups and group series to facilitate connections among families. Programs identify topics based on the needs and interests of their participants and the larger community.
MA MIECHV home visitors screen for depression and social connectedness according to evidence-based model requirements and make referrals to services as needed. Depression screens are conducted using the EPDS or Center for Epidemiologic Studies Depression Scale (CES-D) within three months of delivery (for those enrolled prenatally) or within three months of enrollment (for those not enrolled prenatally). In FY22, 75% of MA MIECHV participants were screened for depression within the required time frame, a decrease from 90% in FY21. The decrease is due to a new contracted home visiting program misunderstanding due dates defined by this performance measure. The expected depression screens for this program account for approximately 10% of the total expected screens for this measure, and therefore our performance decreased overall for FY22. In FY22, 43% of caregivers referred to services for a positive screen for depression were documented to have received one or more service contacts, a slight decrease from 45% in FY21. MA MIECHV programs continue to report limited language and cultural capacity among mental health services in many communities as barriers to successful access to treatment. The long waitlists for mental health supports were exacerbated by the COVID-19 pandemic.
Welcome Family
Welcome Family, funded by MA MIECHV, is a universal nurse home visiting program for families with newborns in five communities. It offers a one-time nurse home visit and follow-up phone call to caregivers with newborns in Boston, Fall River, Lowell, Holyoke and Springfield. The goal of Welcome Family is to promote optimal maternal and infant physical and mental well-being and provide an entry point into a system of care for families with newborns. The visit is conducted up to eight weeks postpartum. Nurses identify and respond to family needs by providing brief intervention, education, support, and referrals to community services and resources. Welcome Family nurses screen for depression using the Patient Health Questionnaire-2 (PHQ-2) and social connectedness at the time of the visit. In FY22, 98% of Welcome Family participants were screened for depression and social connectedness. Of those screened, 11% screened positive for depression and, of those, 64% received a referral to services. A family may decline a referral, or the nurse may not offer a referral if the family is already receiving services. Families who did not receive a referral received brief interventions by the nurse.
F.O.R. Families (Follow-Up Outreach Referral)
The F.O.R Families program serves families experiencing homelessness with complex medical needs, substance use disorder, safety concerns, and high levels of depressive symptoms. The program is a joint initiative between BFHN and the MA Department of Housing and Community Development (DHCD). During the intake assessment, and as needed in subsequent visits, home visitors assess participants for symptoms of depression, identify any potential risks to the parent and baby, and make referrals to mental health services. Mental health is a key topic of discussion, education, and support with families.
In FY22, 169 families were assessed. Twenty-six percent of participants reported that someone in the household had been diagnosed with depression and 17% reported that a household member had been hospitalized for a mental health crisis. Home visitors provide support through reflective listening during their visits and refer clients to mental health treatment in their community. Families are encouraged to maintain connections with their natural supports as a source of assistance when facing housing instability.
This priority focuses on primary prevention of substance use as well as overdose prevention, prevention of subsequent substance exposed newborns, prevention of substance use in the next generation, and prevention of more significant use or negative sequelae.
Findings from the CCIS indicated that two out of five people who reported using substances in the last 30 days had increased substance use during the pandemic. Respondents with a cognitive disability and parents and caretakers of persons/children with special needs were more likely to report increased substance use. Nearly half of respondents reported alcohol use, and of those, 38% reported increased use during the pandemic. Over half of those who reported using tobacco in the past 30 days reported increased use since prior to February 2020. People using substances were more likely to report poor mental health but delayed seeking mental health care. Respondents – particularly those using cocaine, heroin, or other opioids – reported interest in accessing health services related to counseling, tobacco cessation, peer and recovery support.
Objective 1 (NPM 14). By 2025, reduce the percentage of people who report smoking during pregnancy from the baseline of 4.3% in 2018 (RVRS) to 3.0%.
Title V plays an important role in preventing substance use during pregnancy. NPM 14 tracks progress on reducing tobacco use during pregnancy to mitigate the high mortality, morbidity, and economic costs attributed to tobacco use. The percentage of people who reported smoking during pregnancy decreased to 2.8% in 2021, meeting the previous 2025 objective of 3.0%. MDPH therefore revised the 2025 objective to 2.0%.
The ESM for this NPM is the percentage of people using the statewide smoking quitline who are pregnant, with a goal of increasing to 6.2% by 2025. 1-800-QUIT-NOW provides free and confidential services in English and Spanish, and translation for other languages, by a trained quit coach to stop smoking. Quit coaches connect callers with quit-smoking resources through the caller’s community programs, and callers may be able to receive free nicotine replacement therapy. According to the Surgeon General’s report, “lines are an effective population-based approach to motivate quit attempts and increase smoking cessation.”[1]While smoking during pregnancy has been declining, the number of people, both pregnant and not pregnant, using the quitline annually has decreased from 1,933 in FY19 to 1,770 in FY22. Overall use of the quitline among pregnant people has also decreased from 24 pregnant people in FY19 to 16 in FY22 with the percentage at 0.9% use among pregnant people for FY22. To promote the use of the quitline among pregnant patients, the DMCHRA director and the Community Cessation Coordinator for the MA Quitline gave a webinar using PRAMS data 2012-2021 for the Perinatal Neonatal Quality Improvement Network (PNQIN) Perinatal Opioid Project on March 30, 2023, and DMCHRA staff and the Community Cessation Coordinator also presented PRAMS findings at the PNQIN summit on April 12, 2023. At both presentations, the benefits of the quitline were shared with prenatal providers to inform them of the program and promote resources for quitting such as the quitline incentive program for pregnant people who seek support in quitting smoking. The ESM objective of increasing the percentage of people using the quitline who are pregnant has been changed to 1.2% by 2025 to reflect recent years’ experience and a more realistic target.
MA PRAMS updated a study to assess agreement of the reporting of cigarette smoking between PRAMS and birth certificate (BC) during the last three months of pregnancy among a population-based sample of people giving birth from 2012 to 2021. People reported higher prevalence of smoking during the last three months of pregnancy in PRAMS than in BC, but both PRAMS and BC had significantly decreasing trends in smoking prevalence (7.8% in 2012 to 4.2% in 2021 in PRAMS; 4.4% in 2012 to 3.2% in 2021 on BCs). The overall percent agreement between PRAMS and BC was high (97.9%) and the Kappa statistics showed a moderate level of agreement (0.64) between PRAMS and BC. However, the Kappa statistics for subgroups including people who were Black non-Hispanic, Hispanic, aged less than 20 years, had less than a high school education and a preterm birth showed a lower level of agreement, even after adjusting for bias and prevalence. MA PRAMS will present these findings to the Title V Substance Use Priority Workgroup and the Registry of Vital Records and Statistics to support quality improvement (QI) efforts around data collection on the BC Parent Worksheet.
PRAMS and birth certificate findings on smoking in pregnancy and alcohol consumption were presented to perinatal clinicians including physicians, nurses, midwives, doulas, and social workers during a PNQIN Perinatal Opioid Project webinar in March 2023 and at the PNQIN annual summit in April 2023.
MA Tobacco Cessation and Prevention Program (MTCP)
In FY22 MTCP worked with Tufts Interdisciplinary Evaluation Research (TIER) to analyze data from their mixed methods research aimed at tailoring smoking cessation efforts to meet the unique needs of pregnant and parenting people and synthesize the data into a final report. Findings were presented to substance use treatment providers that serve people who are pregnant and family support providers. Given limitations to engaging pregnant people in phase I of the project due to COVID, MTCP also developed a RFQ to procure services to include research with people who are pregnant and parenting as phase II. The research vendor will conduct focus groups with pregnant and parenting people to develop harm reduction and trauma-informed messaging that includes vaping, identify appropriate channels for disseminating messages, work with tobacco/nicotine TA providers to include research findings into updating provider trainings and services, and identify mechanisms to more effectively promote quitting resources by using racial equity and intersectionality frameworks.
MA MIECHV
MA MIECHV provides training on substance use and trauma-informed practice, and all home visitors routinely screen participants for substance use. During federal FY22, 8% of the households enrolled in evidence-based home visiting services reported a history of substance use or need for substance use treatment, a slight decrease from 10% in FY21. However, this result is likely an under-report of the true number of households with a history of substance use given the community-level substance use data for MA MIECHV communities. During the same time, 10% of households reported that someone in the household used tobacco products in the home, down from 12% in federal FY21.
In FY22, 40% of primary caregivers enrolled in home visiting who reported using tobacco or cigarettes at enrollment were referred to tobacco cessation counseling or services within three months of enrollment. This represented a decrease from 50% in FY21. MA MIECHV developed a Tobacco Cessation Toolkit to support home visitors with resources on tobacco cessation and strategies for having conversations with participants about tobacco use.
Objective 2. By 2022, improve measurement of marijuana use/consumption among pregnant people by adding specific questions to the PRAMS survey.
PRAMS
In 2021, 3.8% of people reported any use of marijuana during pregnancy (4.2% for White non-Hispanic, 4.9% for Black non-Hispanic, 3.5% for Hispanic and 0.4% for Asian non-Hispanic). This is a modest increase from 2020, during which 2.3% of respondent reported marijuana use. People with lower SES were more likely to use marijuana during pregnancy; among those with Medicaid, 8.8% used marijuana during pregnancy, compared to 0.5% with private insurance, and among people ≤100% federal poverty level vs. >100%, rates were 13.0% and 1.5%, respectively. These data were presented at PNQIN’s Perinatal Opioid Project described above, under Objective 1. MA PRAMS continues to analyze data to understand marijuana use during pregnancy and will include the Marijuana supplement in PRAMS Phase 9 in June 2023.
Center for Birth Defects Research and Prevention (CBDRP)
The CBDRP collects data on marijuana use during pregnancy through the Birth Defects Study To Evaluate Pregnancy ExposureS (BD-STEPS) telephone interview, a population-based case-control study to understand the causes of birth defects and identify potential risks for having a baby with a birth defect. As part of the study, individuals participate in an hour-long telephone interview on a range of topics, including medications used during pregnancy, and smoking and alcohol use in pregnancy. The interview includes questions on marijuana use in the month prior to pregnancy through the third month of pregnancy, the route of marijuana use (e.g., smoke, vape, eat), the frequency of use, and the reason for use (e.g., relieve nausea/vomiting, relieve stress/anxiety). Participants include control birthing people who had a liveborn infant with no birth defect and case birthing people who had an infant with one of the 23 eligible birth defects. Control participants are randomly selected from the birth population and their responses represent marijuana exposures in the MA birth population.
The Stillbirth Study was incorporated into BD-STEPS to leverage the existing study design to understand risk factors and interventions to reduce the occurrence of stillbirths. As part of this study, people whose pregnancies ended in a stillbirth and were not affected by a birth defect are recruited into the study and participate in the main interview, as well as a follow-up interview focused on risk factors for stillbirth. People who participate in this study include 1) control participants who had a liveborn infant with no birth defect and 2) case participants who had a pregnancy that ended in a stillbirth (includes stillbirths with and without a birth defect). People in this study are asked the same questions on marijuana use as above. Given this is a population-based study, responses represent those in the general population.
The questions related to marijuana use and consumption were added in 2019 and the data are expected to become available with the next data release in late 2023.
PRAMS
MA-PRAMS does not currently have data on alcohol consumption during pregnancy. The current Phase 8 survey asks about alcohol consumption in the past two years and during the three months before pregnancy. MDPH will include the alcohol consumption during all trimesters of pregnancy questions on the MA PRAMS Phase 9 survey in June 2023 starting with January 2023 births. PRAMS and birth certificate data on alcohol consumption were presented at PNQIN’s Perinatal Opioid Project described above, under Objective 1.
Center for Birth Defects Research and Prevention
Interim findings from BD-STEPS show that 58% of respondents giving birth during 2014-2019 (n=224) reported consuming any alcohol from the month before their pregnancy began to the third month of pregnancy. This proportion was similar among those who reported trying to become pregnant (58%) and those who did not (57%). Among respondents reporting any alcohol consumption during this period, 41% reported alcohol consumption during the first month of pregnancy, 6% during the second month of pregnancy, and 5% during the third month of pregnancy. These figures represent alcohol use among respondents who gave birth to liveborn infants without a birth defect whose patterns of substance use are meant to reflect those in the general population.
Fetal Alcohol Spectrum Disorders (FASD) Task Force
The goal of the state FASD Task Force, co-chaired through FY22 by the Title V MCH Director, is to highlight this developmental disability and strategies to prevent FASD, support families with children diagnosed with an FASD and support children, youth, and young adults living with FASD. In response to the 2020 Title V needs assessment, the FASD Task Force has been reframed to explicitly focus on prevention efforts. The Task Force convenes families, state agencies, academic institutions, and community agencies to address FASD at the policy, state, and community levels.
FY22 saw multiple changes in staffing for the MA FASD State Coordinators and at the state level. The previous Statewide FASD Coordinator, funded by MDPH through a contract with the Institute for Health and Recovery, retired at the end of Q2. Two new staff, both parents of children with FASD, were hired to take over the role. They have been supporting the FASD Task Force by continuing to engage families through support groups, meetings, and linking to the center at William James College that provides diagnosis for families with children suspected of having FASD. The Task Force met twice in 2022.
Additional activities to prevent the use of substances among youth and pregnant people
PNQIN
PNQIN, the state PQC (Perinatal Quality Collaborative), is dedicated to improving health outcomes of birthing people, newborns, and families through a QI collaborative of providers and partners. PNQIN aims to achieve collaborative learning through sharing of data and best practices and use of real-time data to drive improvement, while targeting health inequities. PNQIN receives financial and leadership support from MDPH. Since 2017, PNQIN has focused on addressing perinatal opioid use during three time periods: during pregnancy, focusing on increasing medication assisted treatment for mothers with opioid use disorder during pregnancy; at delivery, focusing on improving breastfeeding rates among birthing parents of infants with NAS; and during the first year of life, focusing on increasing the enrollment of infants with NAS in Early Intervention (EI) services. PNQIN held its Perinatal Opioid Project Fall Summit in November 2021, with over 400 attendees.
In FY22, with additional funding from MDPH, PNQIN partnered with the Institute for Perinatal Quality Improvement to conduct the SPEAKP UP Against Racism Action Pathway Training-Recognizing Bias, Inequity, and Racism in Perinatal Care training. The pathway is action-oriented and supports individuals and groups to develop and implement action plans to dismantle racism, provide respectful, equitable, and high quality care, and eliminate perinatal health disparities. As of February 15, 2022, 404 perinatal health professionals in MA completed SPEAK UP Champion education, representing 34 birthing hospitals.
Moms Do Care (MDC)
MDC is an opioid addiction program in seven project sites that offers pregnant and postpartum people recovery treatment. In FY22, MDC continued the work of implementing peer led, seamlessly integrated, trauma informed continuums of wrap around care for pregnant, postpartum and parenting women with opioid use disorders. The MDC TA team provided extensive TA and training in building the program model and assisted the MDC health care systems to plan for ways to sustain the regional, integrated systems of support established by the program. MDC advanced the perinatal peer mentor workforce by assisting the health care systems to hire, develop and sustain this workforce through: identification and training of peer mentor candidates and supervisors; consulting on HR policies and procedures; assisting health care systems to understand and value the roles and competencies of peer mentors; implementation of statewide learning collaborative calls; and continued collaboration with BSAS to assist peer mentors through the recovery coach credentialing process. The MDC training and TA team' trainings included the staff and leaders of multiple hospital and health care center departments and community partners. Trainings focused on ways to develop trauma informed, family-focused and recovery-oriented systems of care. MDPH continued to work with MassHealth and public health stakeholders to bring this direct service and system change model to a statewide reimbursable scale. In FY22, 186 new participants were enrolled, in addition to existing participants continuing from the previous fiscal year(s).
Plans of Safe Care (POSC)
The Child Abuse and Prevention Treatment Act mandates a POSC for every substance affected newborn. The purpose of the POSC is to support the prevention of ongoing substance use among pregnant people and new parents. POSC can also serve as a primary prevention strategy for a future generation of children by connecting children with developmental services and helping parents access recovery, parenting, and concrete supports. In FY22, BFHN and BSAS conducted trainings for substance use treatment providers, including family residential treatment programs and methadone programs, on how to support families in need of a POSC. FIRST (Families in Recovery SupporT) Steps Together and Moms Do Care sites, as well as certain birth hospitals continued to take the lead on developing and promoting POSC. The Journey Recovery Project Birth Planning Kit for pregnant women affected by substance use was disseminated to Massachusetts residents through the Health Promotion Clearinghouse. This resource provides a walk-through guide of the perinatal process, with worksheets, organizational tools, and resources to help with the Plan of Safe Care process.
FIRST (Families in Recovery SupporT) Steps Together
FIRST Steps Together, funded by the State Opioid Response grant, is a home visiting initiative for substance affected families that provides parenting and recovery support by peer family recovery support specialists to prevent ongoing substance use and subsequent substance exposed newborns. Program services include integrated home-based peer recovery support, evidence-based individual and group parenting interventions, care coordination, POSC, mental health services, dyadic therapy, and systems advocacy. In FY22, FIRST Steps Together expanded its funding base and began to see families affected by all types of substances, rather than just opioids and stimulants. During FY22, 195 new adult participants were enrolled in the program, in addition to the families continuing to be served in FY22.
FIRST Steps Together contributed to building the capacity of the peer recovery perinatal/parenting workforce through extensive curriculum development training and monthly learning collaboratives. In FY22, monthly webinars became available for any interested providers in the state. Topics included: Working with child welfare, burnout, children with special needs, and financial management. The “Taking the First Steps Together: A Guide to Creating Collaborative Peer-Led Services For Parents Affected by Substance Use” was written primarily in FY22 for release in FY24. In FY22, Mothering From the Inside Out (MIO), an evidence-based intervention developed by the late Dr. Nancy Suchman to increase reflective capacity among parents with substance use disorders, become available to participants at all sites with clinicians. To expand the use of this intervention through other services in the state, a Train the Trainer curriculum was developed and piloted. Seven MIO clinicians were trained in the MIO train-the-trainer model. Four went on to deliver the full didactic training to new MIO clinicians. Fifteen clinicians from FIRST Steps Together, SUD treatment programs, and medical clinics began supervision in January 2022, and 11 clinicians completed the full MIO training.
Systems Collaboration for Substance Affected Families
In FY22, FIRST Steps Together participated in a workgroup with the Executive Office of the Trial Courts to create the state’s first family dependency drug court in the juvenile court system with participation from BFHN. The efforts of the workgroup resulted in a successful OJJDP grant application, and the initiation of 7 Family Treatment Courts.
MA MIECHV
MA MIECHV continued the pilot of cross-training and enhanced supervision for a Parents as Teachers (PAT) home visitor with lived experience with substance use and recovery. The goals of the pilot are to: 1) fill a gap in cohesive parenting support for families in recovery, 2) build capacity of home visitor/recovery coaches to support pregnant and parenting families with substance use disorder and supervisors’ capacity to support home visitor/recovery coaches; and 3) engage in cross-systems collaboration to support reunification and promote family stability. In FY22, 30 families participated in the pilot.
MA MIECHV supports collaboration between home visiting and DCF offices at the state and local level to support services for families affected by substance use who are DCF-involved. Given racial inequities in the country’s child welfare system, policies that facilitate access to home visiting through transitions in custody arrangements promote more equitable access to home visiting. During custody disruptions, home visiting has the potential to support participants in their identities as parents, understand their children’s ongoing development, and allow for continuity of voluntary services through different stages of involvement with DCF. MA MIECHV programs identify strategies to enhance continuity of services for families who are working to regain custody of their children, including support and education for parents working toward reunification and support for families in which grandparents may have custody. To support families with varying custody arrangements, home visitors participate in supervised visitation at DCF offices and coordinate with DCF workers to support participants with their service plans.
MA MIECHV also addressed model-specific barriers to supporting families through custody disruptions. Historically, PAT has specified that a parent and child be present during visits, disincentivizing programs from working with families experiencing custody disruptions despite a gap in parenting support services for this population. PAT home visitors offer visits with parents and children during supervised visitation at DCF offices supplemented by visits with only the parent and report that these visits without children, although not historically counted, are central to reinforcing parenting topics and building parents’ confidence. In FY22, TIER, in partnership with MA MIECHV, continued the mixed methods implementation study to understand these strategies and inform potential PAT policy changes and implementation guidance.
Priority: Reduce rates of and eliminate inequities in maternal morbidity and mortality.
Since 1997, MDPH has convened the Maternal Mortality and Morbidity Review Committee (MMMRC) to review maternal deaths, study the incidence of pregnancy complications, and make recommendations to improve maternal outcomes and eliminate preventable maternal death. Understanding the causes of these deaths provides insight into the factors that contribute to maternal morbidity and mortality. The performance measure for this priority tracks efforts to improve the timeliness of the review process and the efficiency with which review findings can be translated into strategies to address inequities in maternal health outcomes.
Objective 2. By 2025, develop a structure for community input to the review process that is authentic and addresses the power dynamics between medical providers and community stakeholders.
Maternal Mortality and Morbidity Review Committee
MDPH aims to link birth and death files and other datasets (such as MassHealth) to identify pregnancy-associated and related deaths in a timely manner, strengthen and increase the number of memoranda of understanding and data sharing agreements with state agencies to ensure timely access to data, improve the process and timing for data abstraction into the Maternal Mortality Review Information Application (MMRIA), and establish a process/mechanism for community engagement in the review process.
Investigations by the existing MMMRC are authorized by the MDPH Commissioner, pursuant to M.G.L. c. 111, s. 24A. This statute allows MDPH to request birth and death records but does not require relevant entities to provide access to requested records nor does it authorize the MMMRC to access other sources of relevant data. As a result, there are critical records not consistently available, including autopsy reports from the Office of the Chief Medical Examiner, prenatal care records, toxicology reports, outpatient and emergency department records, and Emergency Medical Services records.
Competing demands associated with the COVID-19 pandemic have also caused delays in progress on these objectives. In FY22, 14% of pregnancy-associated deaths were reviewed within two years. MDPH used Title V funding to hire a Maternal Child Health Clinical Coordinator to ensure timely abstraction of pregnancy-associated deaths into MMRIA to support a review within two years of the death.
In FY22, MDPH members of the MMMRC completed a Lean Six Sigma QI training that identified activities to improve the timeliness of identification and review and community contribution to the review process. MDPH Vital Records is now sending linked birth and death certificates to the MMMRC electronically rather than in paper form, which supports increased timeliness in identification of pregnancy-associated deaths. MDPH established an MOU with the CDC so that the CDC now hosts the MA MMRIA and provides IT support. MDPH and CDC established a process for electronic download of linked vital records directly into MMRIA and are conducting data quality checks to ensure accuracy and completeness.
In FY22, MDPH responded to a Notice of Funding Opportunity (NOFO) from the CDC entitled “Preventing Maternal Mortality: Supporting Maternal Mortality Review Committees.” This NOFO aimed to improve data quality to identify and characterize pregnancy-related deaths and address health inequities by supporting the capacity to develop and implement data informed strategies to prevent pregnancy-related deaths and reduce disparities. With this funding, MDPH will recruit community members to join the MMMRC, including representation from doulas, birth justice organizations, and those who lost a family member or who themselves have experienced SMM. We aim to develop a structure that is authentic and addresses the power dynamics between medical providers and community members, including requiring racial equity and implicit bias training and establishing norms for how the MMMRC can be inclusive of all members’ expertise and perspectives. MDPH received the award in state fiscal year 2023.
Maternal Mortality and Morbidity Review Committee
The MMMRC has identified barriers to accessing care, racial inequities, and the absence of systemic coordination of care as factors contributing to maternal deaths in MA. A Special Legislative Commission on Racial Inequities in Maternal Health, established by a legislative act in January 2021, was tasked with making recommendations to address barriers that result in racial inequities in pregnancy-related deaths. Specifically, the Commission was charged with gathering statewide data on maternal mortality and severe maternal morbidity (SMM) and making recommendations to eliminate racial barriers to accessing equitable maternal care. Representatives from MDPH and the MMMRC were appointed to this Commission. They presented a summary of current activities and identified gaps in services, such as limited legislative authority and staff capacity to support further community engagement in the process. A final report, filed with the legislature in May 2022, included findings of the data and draft legislation necessary to carry out the Commission’s recommendations.
In FY22, MDPH responded to the HRSA Maternal Health Innovation and Data Capacity Notice of Funding Opportunity. The proposal included the establishment of a Maternal Health Task Force (MHTF) to create a strategic plan to improve maternal health in the Commonwealth, building on the Title V Needs Assessment results, the 2022 Racial Inequities in Maternal Health Legislative Commission Report, and recommendations from the MMMRC. The MHTF will serve as the community and policy action arms of the MMMRC, mirroring and complementing the role of PNQIN, which serves as the clinical action arm. The MHTF will complement the work of the MMMRC and strengthen efforts to translate committee findings into prevention initiatives. The strategic plan will include strategies to strengthen maternal mortality and SMM data collection and support the adoption and implementation of community, state, and regional innovations and best practices that respond to identified state-specific gaps and improve maternal health more broadly. Representatives on the MHTF will include representative from organizations including MDPH, MassHealth, Title V, MA Chapter of ACOG, MA Chapter of ACNM, MA Association of Health Plans, Boston Public Health Commission, Boston Healthy Start, the North American Indian Center of Boston, the Black Doula Coalition, Massachusetts Childhood Psychiatry Access programs (MCPAP) for Moms, perinatal social work, fatherhood groups, residents with lived experience, and other partners as appropriate. MDPH received the award in state fiscal year 2023.
PNQIN
PNQIN implemented the Alliance for Innovation on Maternal Health (AIM), the goal of which is to reduce maternal mortality and SMM and reduce racial disparities by working with hospital teams to align hospital-level QI efforts. In FY22, PNQIN generated SMM reports stratified by race and ethnicity for eight pilot sites. These reports were shared with the participants sites and submitted to AIM. In FY22, PNQIN hosted 19 webinars to review the process and data reports. To date PNQIN met with all birthing hospitals to review their SMM data and offered TA as needed.
PNQIN also leads MA’s efforts around Levels of Maternal Care (LoMC). Staff from BFHN and the Betsy Lehman Center worked together to implement the Levels of Care Assessment Tool (LOCATe). LOCATe includes a series of questions designed to measure relevant facility and staffing capacities and asked the hospital to report its own self-assessed LoMC. All 40 birthing hospitals in the state completed the survey and CDC analyzed the responses and reported back LOCATe-assessed levels for each hospital. Fifty percent of hospitals self-reported a higher level than their LOCATe-assessed level. Of the 20 hospitals that over-reported their LoMC, most did so by only one level, but several hospitals over-reported by two levels. There were no discrepancies of more than two levels.
Surveillance for Emerging Threats to Pregnant People and Infants Network (SET-NET)
In FY22, the MA Center for Birth Defects Research and Prevention (CBDRP) continued surveillance for SARS-CoV-2 infection in pregnancy through their participation in CDC’s Surveillance for Emerging Threats to Pregnant People and Infants Network (SET-NET). The goals of MA SET-NET are to monitor the effects of COVID-19 on pregnant people and their infants, inform clinical guidance and practice, and ensure that MDPH is prepared to meet the needs of pregnant people and infants during public health emergencies.
MA SET-NET identified people with SARS-CoV-2 infection during pregnancy through deterministic linkages between infectious diseases laboratory data and birth and fetal death records and submitted data to CDC quarterly. This fiscal year, MA SET-NET hired and trained two new medical records abstractors to support infant follow-up, monitoring outcomes of infants born to people with SARS-CoV-2 infection during pregnancy by collecting data from the 2 week, 2-month, and 6-month well child visit records. MA SET-NET data contributed to four national-level publications for which MA SET-NET team members were included as co-authors.
MA SET-NET has also led analyses using state-level data including, “Characteristics of Pregnant People With and Without SARS-CoV-2 Infection During Pregnancy, Massachusetts, March 2020 – March 2021,” a study highlighting the elevated risk for COVID-19 during pregnancy that racially and ethnically minoritized pregnant people face due to socially mediated factors, such as structural racism, which drive differential risk for COVID-19 in communities of color. Another analysis examined the risk of pre-term birth conferred by SARS-CoV-2 infection during pregnancy and was published in Perinatal and Pediatric Epidemiology.
When COVID-19 vaccines became widely available, MA SET-NET linked data on COVID-19 vaccinations to birth and fetal death records to identify COVID-19 vaccine uptake among pregnant and postpartum people. A descriptive, disaggregated analysis by race/ethnicity and other sociodemographic factors (e.g., level of education, insurance status) was performed to identify inequities in COVID-19 vaccine uptake. Data were summarized in a presentation with key takeaways for healthcare providers and published online.
MA SET-NET continues to apply a racial equity framework to its analyses by highlighting inequities among racially and ethnically minoritized people in not only risk for SARS-CoV-2 infection during pregnancy, but also adverse birth outcomes such as pre-term birth and stillbirth and COVID-19 vaccine uptake during pregnancy. Sharing data through presentations, publications, and infographics called attention to these inequities and helped to inform equitable COVID-19 prevention and mitigation efforts for pregnant people.
COVID-19 Disparities Community Evaluator Project
MDPH engaged TIER to design and direct a 2-year evaluation and needs assessment project as part of MDPH’s National Initiative to Address COVID-19 Health Disparities Award from the CDC. The goals of the grant are to reduce pandemic-related health disparities, improve rural community health outcomes, and improve data collection and reporting capacity for populations disproportionately impacted by COVID-19. Using a community-based participatory research approach, TIER recruited, hired, trained, and supported a cohort of community evaluators (CEs) to ensure MA residents with lived experience in the communities prioritized in the grant were an active part of the evaluation process and public health response.
In FY22, CEs supported the first cohort of projects. Two projects focused on understanding barriers and facilitators to COVID-19 vaccine uptake among pregnant and postpartum people and pediatric populations with lower rates of vaccine uptake. CEs for these projects were hired based on their lived experiences, deep community knowledge, and interest in addressing health inequities through evaluation and needs assessment projects. Findings from these projects will be used to inform efforts to improve COVID-19 vaccine uptake among MCH populations.
PRAMS
MA PRAMS administered a COVID-19 supplement to collect data on how COVID-19 has affected pregnant and postpartum people and their infants for births from June 2020 through December 2021. PRAMS also administered a COVID-19 vaccine supplement, including questions about receipt of COVID-19 vaccination before, during and shortly after pregnancy, and reasons for not obtaining COVID-19 vaccination, for births January-December 2021. Data analysis and dissemination are on-going.
Fatherhood/Second Parenthood Survey
MDPH is planning to pilot a Fatherhood/Second parent experiences survey during Summer 2023. This survey will collect data about fathers’ experiences during pregnancy and the birth of their child, and their experiences with COVID-19 including testing, vaccination, health status, social determinants of health, mental health, and racism during the pandemic. See more about the Fatherhood survey in the Crosscutting domain under the family engagement priority.
PNQIN
PNQIN worked with MDPH to improve COVID-19 vaccination among pregnant people. In FY22 PNQIN attended 43 community vaccination events in 13 of the 20 VEI communities that were hardest hit by COVID-19. PNQIN co-hosted and led various Town Halls with expert speakers to promote the importance of vaccination.
In FY 22, PNQIN developed a curriculum that consisted of a 75-minute training titled “Communication Skills Training for Clinicians Discussing COVID-19 Vaccination” in collaboration with UMass Center for Integrated Primary Care and community members. This training was designed to provide information to clinicians about discussing COVID-19 vaccination with pregnant and postpartum people, parents and caregivers of young children, and families. The training focused on addressing vaccine hesitancy and eliminating racial disparities in vaccination rates. During November 2021-July 2022, PNQIN and UMass hosted 4 virtual trainings based on the curriculum. Continuing education credits were offered for all MA providers who participated. A total of 202 providers completed the training and submitted documentation for CE credit. This training remains available on the PNQIN website and CE credits will be available through April 2023. Post-training evaluations results were positive: 76% of participants reported the training content was very/extremely useful and 22% reported it was moderately useful. A best practice protocol and resource guide was developed with input from OB and Infectious Disease subject matter experts. This received final approval and was disseminated in April 2022 and posted to the PNQIN website.
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