Massachusetts has four priorities for Women’s and Maternal Health for 2015-2020.

1. Promote equitable access to preventive health care including sexual and reproductive health services.
2. Promote equitable access to dental care and preventive measures for pregnant women and children.
3. Address substance use among women of reproductive age to improve individual and family functioning.
4. Promote emotional wellness and social connectedness across the lifespan.

 

Priority: Promote equitable access to preventive health care including sexual and reproductive health services.

Progress towards this priority is measured by the percent of women with a past year preventive visit. Key MDPH programs that contribute to improving this priority include the Sexual and Reproductive Health Program, Early Intervention Parenting Partnerships Program, MA Maternal, Infant and Early Childhood Home Visiting, Welcome Family, and FOR Families.

 

NPM 1: Percent of women with a past year preventive visit

According to the 2018 Behavioral Risk Factor Surveillance System survey (BRFSS), 70.7% of women had a preventive visit in the past year. Because the BRFSS routine checkup item changed in 2018, this percentage is not comparable to previous survey years.

 

Sexual and Reproductive Health Program

Through MDPH’s Sexual and Reproductive Health Program (SRHP), providers offer comprehensive family planning services to decrease unintended pregnancy and sexually transmitted infections (STIs). Vendors operate in communities with higher rates of teen births and STIs, and with low-income, uninsured, adolescent, refugee and immigrant populations. Vendors must provide clinical family planning services on site or by referral, and may provide education on family planning, outreach to promote family planning services, and/or supportive services to assist priority populations to access clinical family planning services.

 

SRHP funds 17 agencies statewide to provide clinical family planning services at over 85 sites. Clients eligible for these services include:

1. Uninsured residents living at or below 300% Federal Poverty Level (FPL).
2. Clients with MassHealth Limited.
3. Insured clients whose insurance does not cover contraceptives at the time of service, and also meet residency and income criteria. This includes plans that never cover contraceptives as well as plans with annual spending caps on prescriptions and/or medical devices (e.g., IUD).  
4. Insured clients who need confidential family planning care and cannot be assured that using their insurance will not violate their confidentiality, and also meet residency criteria. Clients who may require confidential care include clients under 26 years of age who are covered under a parent/guardian plan and survivors of domestic violence.  

 

Agencies bill MDPH for clinical services for eligible clients by using Medicaid billing codes; six of these codes are for preventive health visits. This billing information provides data for the Title V Block Grant. In FY19, of all preventive health visits MDPH funded in family planning services, 95.3% (n=1,946) were with females.

 

Through federally-funded Title X family planning clinics and SRHP, MA promotes the 2014 Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs (QFP). These recommendations expand family planning to include preconception and other preventive health services, including screening for obesity, smoking, diabetes, violence, mental health, reproductive life planning, and screening for and treating STIs. Additional preventive health services include breast and cervical cancer screening, immunizations, and other services based on nationally recognized standards of care. Women entering Title X clinics or other family planning service centers seeking contraceptive services often do not have another source of primary health care. Family planning services visits are opportunities for clinicians to offer broad preventive health services beneficial to overall health as well as to reproductive health.

 

Implementing broad preventive health services in family planning visits is an evidence-based strategy supported by CDC findings.[1] The ESM for NPM 1 is the percent of female clients younger than 25 years old at Title X clinics who are screened for chlamydia. Chlamydia screening is a component of CDC’s QFP because untreated chlamydia contributes to tubal infertility. In 2018, MDPH added new providers to its Title X network, some entirely new to the Title X program. In FY19, 58% of clients were screened; the objective is to reach 65% by 2020. SRHP staff is working with agency staff to improve the provision of chlamydia screening as well as data collection and reporting.

 

Early Intervention Parenting Partnerships Program

The Early Intervention Parenting Partnerships (EIPP) Program is a Title V-funded home visiting program for expectant parents and families with infants who are high need due to practical barriers (e.g., low financial resources, housing instability), emotional and/or behavioral health challenges (e.g., depression, substance use), or other stressors (e.g., immigration-related stress). The goals of EIPP are to connect families with local resources; build families’ social support; appropriately engage families in health care systems; provide parenting education; promote positive parent-child attachment and healthy child development; and support families experiencing multiple stressors to prevent child social and emotional delays, and link with Early Intervention services where appropriate. The EIPP team includes an MCH nurse, a mental health clinician and a community health worker.

 

Among the 338 pregnant and postpartum participants enrolled in EIPP in FY19, 53.3% self-identified as White, 35.2% Hispanic/Latino/Spanish, 22.2% Black and 13% Asian. Successful EIPP programs ensure their MCH team members reflect the cultural, linguistic, racial, and ethnic diversity of the population served. Annual cultural competence training and pay differentials for bilingual staff have been successfully implemented in several EIPP sites. However, staff turnover, particularly within the community health worker position, has been a challenge for those sites where the annual salary is low and a pay differential for bilingual staff is not offered.

 

EIPP supported participants to attend preventive care visits by helping the participant contact the health care provider to schedule visits, arranging for transportation, and providing reminder phone calls and texts. In FY19, 27 participants were referred to a primary care provider. In addition, 67% of participants had a documented reproductive life plan that included family planning counseling and an identified method of contraception at two months postpartum. This percentage is a decrease from last year’s performance and less than the EIPP performance measure goal of 80%. The complexity of EIPP cases has increased over the year and as a result, preventive and reproductive health are not immediate priorities for many participants. Participants experience multiple and complex needs, such as mental health issues, opioid use and violence in the home, which take precedence over accessing health care services. For example, in FY19 49.1% of participants had a history of depression, including postpartum depression; 62.7% had inadequate food or clothing; 33.7% were homeless or experiencing housing instability; 14.5% reported tobacco use; 9.8% reported substance abuse in the home; and 3.3% reported violence in the home.

 

Maternal, Infant, and Early Childhood Home Visiting Initiative

The MA Maternal, Infant, and Early Childhood Home Visiting Initiative (MA MIECHV), funded by HRSA/MCHB, provides evidence-based home visiting services to help pregnant and parenting families attain and sustain optimal health and well-being for all family members. MA MIECHV prioritizes services to families who qualify as high need according to statute and the state MA MIECHV Needs Assessment. The MA MIECHV 2016 Needs Assessment confirmed that families experiencing homelessness, with parental substance use disorders, who recently immigrated to the United States, and who are affected by mental health stresses and social isolation have substantial challenges and could benefit from home visiting. MA MIECHV serves pregnant and parenting families in 17 communities. Through regular, planned, voluntary home visits, parents learn how to improve their family’s health and provide better opportunities for their children.

 

MA MIECHV home visitors support preventive health and prenatal practices for women by facilitating connections with the health care system, including connecting families to preventive care services when needed. Home visitors also receive training on preconception and interconception care education, including how to support families with developing a reproductive life plan and facilitating access to reproductive health services. During federal FY19, MA MIECHV served 2,012 families and conducted 23,898 home visits.

 

Welcome Family

Welcome Family is a universal short-term postpartum nurse home visiting program funded by MA MIECHV. It offers a one-time nurse home visit and follow-up phone call to all mothers and 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 to 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.

 

Universal home visiting programs like Welcome Family serve all families regardless of income, age or other criteria. They can reach a broader range of families than programs with traditional risk-based eligibility, thereby identifying needs that might otherwise go undetected. Universal programs can reduce stigma associated with participation in eligibility-based programs, allowing home visitors to triage families with varying levels of need and connect them to services.

 

During the Welcome Family visit, nurses screen participants for access to health care providers, assess barriers, and facilitate connection to providers. In FY19, 88% of Welcome Family participants (n=1,759) had a health care provider after giving birth, consistent with the 87% reported in FY18. A majority (84%) of caregivers with a health care provider reported that it was “easy” to access health care services. Among those who reported difficulty in accessing services, transportation (94%) was the main barrier.

 

FOR Families

FOR Families (Follow-up, Outreach and Referral) is a home visiting program managed jointly by MDPH and the Department of Housing and Community Development that helps families transition from homelessness to stable permanent housing. Services are provided to families who are temporarily housed in shelters in the Western, Northeast and Boston regions of the state. FOR Families home visitors, human service professionals with extensive public health, community health and child welfare experience, work intensively with families experiencing complex challenges. They assess family needs, make appropriate referrals, and coordinate services with primary health care, WIC, Early Intervention, domestic violence, and substance use treatment. FOR Families collaborates with Housing Assistance Programs, the Department of Children and Families, the Department of Transitional Assistance, and the Department of Mental Health to coordinate care. Home visitors identify local volunteer groups and faith-based organizations to provide families with transportation, activities for children, meal programs, and other necessities. FOR Families’ funding decreased in FY19, resulting in the loss of one home visitor position.

 

FOR Families assessed 159 families in FY19, 8% of whom reported a pregnant woman in their household, compared to 11% in FY18. Families were asked about the frequency of visits with their primary care doctor; 31% reported annually, 24% more than three times per year, 19% one to three times per year, and less than 1% reported never. Families were also assessed for contraceptive use; 35% reported not using a form of contraception and 33% always or sometimes use contraception. This information guides conversations about and referrals to preventive and reproductive health services.

 

Additional activities to promote equitable access to preventive health care including sexual and reproductive health services

Sexual and Reproductive Health Program

MDPH completed its fourth year as a Title X grantee; it expanded its program from three to 11 sub-recipients due to increased state and federal funding in FY19. This larger program allowed for economies of scale and reduced administrative burden for clinical service sites. MDPH provided technical assistance, intensive onboarding consultation, and oversight for new Title X providers, including site visits and monthly telephone meetings. Technical support was provided for all aspects of the Title X program, including data collection, training requirements, and program administration.

 

MDPH offered family planning education and training sessions to community-based agency staff, including: Commercial Sexual Exploitation of Children; Identification, Engagement, and Connection to Resources; Services for Adolescents; Sexually Transmitted Infections;  Reproductive Justice 101; Cannabis Use and its Relevance to Decision Making in Adolescents; HIV Prophylaxis; and Suicide Risk and Prevention in the LGBTQ Community.

 

SRHP clients using long-acting reversible contraception (LARC) increased 12% since FY13, with 27% of female clients using a LARC method in FY19 compared to 15% in FY13. SRHP continued to work with MassHealth staff to provide LARC usage reports to inform administrative and operational processes to improve access among family planning providers and community health centers (CHCs).

 

In FY19, MassHealth and SRHP co-launched program oversight of two organizations funded to provide five-year, statewide training and technical assistance regarding contraceptive counseling and service delivery. One organization focuses on outpatient care service delivery, with a special focus on CHCs, while the other targets hospitals and hospital-based clinics. Both organizations sub-specialize in LARC training for clinical staff.

 

SRHP also funds a highly successful Access Program to reduce barriers to care by providing pregnancy options counseling and case management services to women who are at least 18 weeks, six days pregnant by ultrasound, or are experiencing serious/complex medical or social issues that make it difficult to be seen in a clinic. In FY19, the Access Program provided case management services to 324 women, representing a 5% decrease over FY18. However, the program continued to grow its insurance enrollment services and served over 100 additional women.

 

Priority: Promote equitable access to dental care and preventive measures for pregnant women and children.

Progress towards the oral health priority is measured by a) the percent of women who had a dental cleaning during pregnancy and b) the percent of infants and children, ages 1 through 17, who had a preventive dental visit in the last year. The latter measure is discussed in the Child Health domain.

 

NPM 13A: Percent of women who had a dental visit during pregnancy

During 2018, 57.8% of mothers had a cleaning during pregnancy, compared with 56.2% in 2017 (PRAMS). The percentage of mothers receiving oral health care during pregnancy increased modestly among Asian mothers, from 46.9% to 48%, and among White mothers, from 61.5% to 64.6%. Hispanic and Black mothers both showed slight declines from 49% and 49.3% to 48.1% and 43.7% respectively between 2017 and 2018. Among women with a college degree, 67.3% had their teeth cleaned during pregnancy in 2018, a slight decline from 67.6% in 2017, while among women with a high school degree, 48.1% had their teeth cleaned during pregnancy in 2018, up from 37.9% in 2017.

 

Office of Oral Health

With funding from HRSA’s Perinatal and Infant Oral Health Quality Improvement (PIOHQI) Project, in 2016 MDPH began piloting the MA Perinatal Oral Health Practice Guidelines (the Guidelines) in three CHCs to integrate oral health care into primary care, address inequities in access to dental care, and reduce the prevalence of oral disease in pregnant women. MDPH and the Perinatal Oral Health Advisory Committee supported the pilot sites to implement the Guidelines and establish best practices that can be replicated statewide.

 

The ESM for this NPM was previously the percent of CHCs that adopt or implement the Guidelines, which was tracked by surveying MA’s 49 CHCs for information on Guideline adoption/implementation. In FY19, two new CHCs, Lowell Community Health Center and South Boston Health Center, joined the project for a total of five participating CHCs. The PIOHQI grant ended in November 2019 and implementation of the Guidelines will not be tracked moving forward. Therefore, MDPH replaced this ESM (see WIC below).

 

In FY19, CHCs tested medical-to-dental referral procedures to establish a mechanism by which all pregnant women and infants are referred for dental screening and treatments, and to establish a dental home. At each of the three sites, obstetricians, midwives, family practitioners, and pediatricians implemented referral procedures to ensure that all pregnant women and infants receive a referral to the dental department. At South Cove CHC, the percentage of pregnant patients who were seen in the dental department during their pregnancy increased from 45% at baseline (FY18) to 47% in December 2018. In the South Cove pediatric clinic, 0% of infants between 6-36 months of age were seen in the dental clinic at baseline, which increased to 42.8% in May 2019. Monthly performance reports were shared across sites to build relationships and foster coaching among teams.

 

WIC

WIC nutrition staff regularly screen women and children for dental care, offer oral health nutrition education, online nutrition education, and provide dental referrals as needed. Several WIC programs collaborated with community-based dental practices to offer screening and fluoride varnish in the WIC clinic setting. The WIC program distributed educational materials to WIC local programs during National Dental Health Month in February. In FY19 a new ESM was established for this NPM: the percentage of pregnant women enrolled in WIC who receive oral health education. To track this measure, “dental care during pregnancy” was added to the WIC data system as a prenatal education topic in order to distinguish between oral health education provided to the child versus the mother.

 

Priority: Address substance use among women of reproductive age to improve individual and family functioning.

The 2015 Title V needs assessment yielded suggestions for program improvement including more services for families, education for service providers and parents, earlier identification of mothers and infants needing services, and better integration of care. These suggestions continue to guide the Title V substance use priority. The Bureau of Family Health and Nutrition (BFHN) partners closely with the Bureau of Substance Addiction Services (BSAS), other MDPH stakeholders, birth hospitals, and community-based organizations to address this priority.

 

Perinatal opioid misuse continues to be a significant concern. The Neonatal Abstinence Syndrome (NAS) rate in MA is almost three times the national average. Related activities in FY19 included increasing access to medication assisted treatment for pregnant women, improving care of the opioid exposed newborn, increasing family supports, and at the policy level, developing a state response to the federal mandate for Plans of Safe Care.

 

SPM 1: Percent of infants diagnosed with neonatal abstinence syndrome in Massachusetts hospitals who are receiving Early Intervention services.

This SPM was selected because these data are readily accessible, the measure reflects both a more integrated system of care and potentially better family engagement, and because in MA, an NAS diagnosis confers automatic eligibility for EI for the infant through 12 months of age. MA focuses on the dyadic relationship because promoting attachment and bonding helps mitigate the severity of NAS, strengthen the parent’s recovery, and lead to better outcomes for parent and child. The Title V program therefore grounds activities related to NAS in the Maternal Health domain.

 

The MA EI system is increasing its capacity to serve infants with NAS and their families. In 2017, 70.3% of infants with NAS were referred to EI within six months of birth, and 42.3% of infants with NAS were enrolled in EI within 12 months; the goal is to reach 75% and 50%, respectively, by 2020. In FY19, an engagement pilot was implemented with six EI programs and birth hospital partners. Five of these continued from previous years, and one new program served two hospitals. The goals of the pilot were to increase the enrollment of families of infants with NAS in EI by providing a non-reimbursable engagement visit in the hospital before discharge, decrease stigma experienced by parents of infants with NAS, ease the transition of families into a professionally-supported home environment, and familiarize hospitals with the benefits of EI. The pilot was scaled back due to a decrease in funding, continuing reluctance at some hospitals to have outside personnel providing hospital visits, and staff turnover at hospitals. Data linkage protocols were established and data shared so that hospitals and the EI system could identity points of attrition between initial eligibility at birth and EI enrollment at one year of age. Preliminary data linkages demonstrated increased enrollment among families who received an engagement visit.

 

The EI/NAS workgroup continued to meet monthly to discuss eligibility, programming, collaboration and marketing. Boston University graduate students led meetings, focus groups, and a literature review to support a determination of automatic EI eligibility for all substance exposed newborns (SEN) as opposed to only infants with an NAS diagnosis. The conclusion reached was not to confer automatic eligibility, but to add additional child and family eligibility factors (SEN, and previous child with NAS or SEN diagnosis) to better reach families affected by substance use disorder. Other activities included presenting data at the semi-annual statewide NAS conference, supporting parents to present at the conference, and beginning to collaborate with the Tufts Medical Center NAS taskforce to support its EI enrollment initiative. Data and programming efforts related to serving SEN and infants with NAS in the EI system were presented at two national conferences.

 

This SPM continues to fluctuate because the diagnosis and treatment of infants with NAS is evolving. As more non-pharmacologic care is provided, fewer infants are receiving an NAS diagnosis. As more infants are being cared for outside of neonatal intensive care units, referrals to EI are more challenging. There are more providers, often a less controlled discharge system, less awareness of EI, and perhaps less perceived need for EI if infants have shorter hospital stays. These challenges are being addressed through quality improvement (QI) projects and provider education in hospitals.

 

Additional activities to address substance use among women of reproductive age to improve individual and family functioning

Massachusetts Perinatal Neonatal Quality Improvement Network 

The MA Perinatal Neonatal Quality Improvement Network (PNQIN) is an umbrella collaborative that unites the efforts of MDPH, the Neonatal Quality Improvement Collaborative (NeoQIC), the MA Perinatal Quality Collaborative (MPQC) and the MA chapter of March of Dimes. The need for such cooperation has never been clearer than when responding to the opioid epidemic.

 

BFHN continues to provide financial and leadership support to PNQIN. In FY19, MDPH sponsored the PNQIN semi-annual perinatal opioid summit. The goals of the summit were to identify how statewide efforts to address opioid use improve the clinical care of mothers and newborns, learn about recent data trends and innovations in non-pharmacologic techniques in the care of newborns at risk for NAS and mothers with opioid use disorder, and determine potentially sustainable peer recovery coach service delivery models to support pregnant and parenting women with substance use disorders. The summit brought together over 30 hospitals that participate in data collection and QI work, community and advocacy groups, the Department of Children and Families, the Health Policy Commission, the Department of Mental Health, and the Attorney General’s Office. Through BFHN’s guidance, there has been increased focus on the parents, the dyad/triad, providing care both upstream and downstream of the hospital stay, and extending care postpartum. Part of PNQIN’s three pronged approach to addressing perinatal opioid use included a QI component to increase hospital referrals to EI for NAS. In FY19, six hospitals submitted data to link NAS births with EI referral and enrollment data (an increase from two hospitals in FY18).

 

PRAMS

MDPH applied for and was awarded funding for the opioid supplement survey, the opioid call-back survey, and the disability supplement survey. The opioid supplement survey began in April 2019 and will continue through April 2021. Although MDPH has taken a number of steps to understand and respond to the opioid epidemic, MA PRAMS, a population-based survey, we provide data on the use of prescription pain relievers and other opioids during pregnancy, particularly among women who have not been diagnosed and treated for substance use disorder (not captured in the programmatic and administrative data), and data on whether women received care for substance use disorder from providers, including medication-assisted treatment during pregnancy.

 

The opioid call-back survey (OCBS) was implemented in October 2019 and concluded in April 2020. The call-back survey evaluates women several months after they complete the initial PRAMS survey, and at a time when women with substance use disorders are at greatest risk of having a fatal or non-fatal opioid overdose. For the OCBS, MA PRAMS oversampled women who delivered in hospitals reporting higher rates of NAS in the state during the first five months of 2019. The addition of a targeted set of questions related to opioid use and misuse in the postpartum period to the PRAMS survey will allow MDPH to assess maternal behaviors and experiences related to the use of prescription pain relievers and other opioids, and to help understand the effects of opioid use and misuse on the health of both mothers and infants in MA. The OCBS data will provide much needed information that can be used to support and enhance state surveillance systems to better identify community needs and policy gaps. The OCBS data on maternal opioid use, reason for use, interactions with health care providers related to prescribing and counseling, and need for and access to treatment services will inform current opioid initiatives and programs focused on the MCH population. CDC plans to complete the weighting of OCBS data to send to MDPH in August 2020.

 

Moms Do Care

In FY19 seven new Moms Do Care (MDC) sites were funded through SAMHSA’s State Opioid Response and Medication Assisted Treatment - Prescription Drug and Opioid Addiction grants, and were jointly administered by Title V staff. MDC uses an integrated multi-disciplinary team model of peer-guided care navigation, case management, and recovery and parenting support. MDC expanded its eligibility criteria to include pregnant, postpartum or parenting women (who are 18 or older, pregnant and/or parenting a child 36 months or younger).

 

The program development, training and evaluation teams provided technical assistance to onboard newer sites. The more established MDC sites mentored the newer sites; a series of cross site MDC events were held, designed to share lessons learned and build capacity of providers to implement the MDC model. MDC assisted in the expansion of the perinatal peer recovery coach workforce and of buprenorphine-waivered obstetricians, and assisted women to gain access to trauma-informed providers and behavioral health, obstetrical, and pediatric care. MDC provided training and technical assistance to each of the health care organizations and their regional partners in creating collaborative and trauma-informed systems of care. MDC expanded its statewide stakeholder peer workforce development learning community and its statewide advisory council to include all MDC sites as well as other MDPH-funded initiatives serving this population. 

 

Plans of Safe Care

The Child Abuse and Prevention Treatment Act mandates a Plan of Safe Care for every substance affected newborn. In FY19, MDPH finalized and disseminated relevant materials and guidance. A searchable, web-based resource map with over 1,200 perinatal addiction resources in the state was developed and regularly updated with community input. Tips for trauma-informed warm referrals to facilitate Plans of Safe Care were disseminated. Multiple webinars and in-person trainings were developed and conducted with substance use treatment providers and perinatal health providers to help them support families in need of a Plan of Safe Care. The CDC-funded Essentials for Childhood also worked directly with one community to develop a brief on their approach to addressing perinatal opioid use in their community. This was finalized in FY19 and serves as an example of a community’s response to developing a Plan of Safe Care.

 

Injury Prevention and Control Program

A safe sleep ad campaign was launched in October 2018, and included a focus on families using nicotine and sedating medications, which can increase the risk of sudden unexpected infant death. An event launch was held at the State House to present the media campaign. Through Facebook and YouTube, the campaign resulted in 3 million views of the campaign video and 22,000 views of the new safe sleep website. On average, webpage visitors spent one minute and 13 seconds on the page. Campaign posters, which emphasized the importance of having a smoke-free environment, were distributed to inpatient facilities and displayed throughout public transportation systems in Boston, Fall River, New Bedford, Athol, Gardner, and Greenfield. It was so well received by the Athol and Gardner transit authority that they offered to post signs for free in Fitchburg and Leominster. Safe sleep trainings were also provided at family residential treatment programs. Funding for the campaign was exhausted by December 2018 and there are no plans to run additional online or transit ads. The website will be updated annually. All hard-copy materials from the campaign will remain freely available from the MA Health Promotion Clearinghouse until the stock runs out.

 

Fetal Alcohol Spectrum Disorders (FASD)

BFHN and BSAS co-lead the state FASD Task Force that convenes families, state agencies, academic institutions and community agencies to address FASD at the policy, state and community levels. The Task Force has worked to reduce stigma and raise awareness of strategies for prevention and support for families of children with FASD. Prevention strategies include addressing barriers that substance-using women encounter in trying to access services. The Task Force has developed strategies for supporting parents and their children with FASD, working with early childhood systems including EI, and working with school departments. A statewide Zoom FASD support group for parents was started in FY19. Trainings were offered for addiction provider treatment agencies on universal strategies for working with adults who may have cognitive impacts from prenatal alcohol exposure.

 

The Journey Recovery Project

The Journey Recovery Project is an interactive, web-based resource for pregnant and parenting women with questions or concerns about substance use, or who are in recovery. In FY19, a new vendor was engaged to revise the Journey website and add new video and print content.

 

Early Intervention Parenting Partnerships Program

EIPP screened participants for tobacco, unhealthy alcohol, and drug use at enrollment and during postpartum. Substance use is a key topic of discussion, education, support and referral. Many EIPP staff report that participants use tobacco to manage anxiety. Among the 338 EIPP participants in FY19, 49 reported tobacco use at enrollment, 33 reported substance abuse in the home, and 21 reported smoking during the last three months of pregnancy. Of the 49 participants who reported prenatal or postpartum tobacco use, two were supported in maintaining connections with smoking cessation services they were already receiving, and nine were referred to smoking cessation services, all of whom declined the referral. In addition, 36 participants were supported in maintaining connections with substance use services they were already receiving while two participants were referred to substance use services. 

 

FIRST Steps Together

In FY19, MA received a $1.8 million State Opioid Response (SOR) grant from the Substance Abuse Mental Health Services Administration. The funding was allocated to a new six-site home visiting initiative called FIRST (Families in Recovery SupporT) Steps Together for opioid affected families, providing parenting and recovery support by peer family recovery support specialists. Program services included: integrated home-based peer recovery support, evidence-based individual and group parenting interventions, care coordination, Plans of Safe Care, mental health services, dyadic therapy and systems advocacy. Building capacity of the peer recovery perinatal/parenting workforce was supported through extensive curriculum development training and monthly learning collaboratives. Goals of the program included overdose reduction and an increase in access to medication for opioid use disorder. All sites began to see families in April 2019, and 107 clients had been enrolled by the end of FY19. Clients readily engaged in services provided by peers who are themselves in recovery from addiction and who often also had experience with the child welfare and criminal justice systems. Almost all of the clients had open or past child welfare cases, and half did not have custody of their children. 

 

MA MIECHV

MA MIECHV home visitors screened participants for tobacco, unhealthy alcohol, and drug use. Screening provides opportunities for intervention with substance users before more severe consequences occur. All MA MIECHV participants are screened for substance use routinely. Home visitors discuss substance use with participants and make referrals to services when appropriate.

 

MA MIECHV requires home visitors to attend a full-day training on substance use. The training curriculum includes an overview of addiction and substance use, a review of the different categories of drugs and tobacco products, and effects of substance use, including the impact exposure can have prenatally and on the ability to parent. The training also teaches home visitors how to recognize symptoms, behavior patterns, and family dynamics that may indicate substance use, and strategies to support participants affected by substance use.

 

In FY19, MA MIECHV partnered with FIRST Steps Together to offer two trainings by the Brazelton Institute on the Newborn Behavioral Observation system. The training was an opportunity to build staff capacity around early development and infant/parent communication, with a specific focus on substance-affected dyads.

 

During federal FY19, 10% of the households enrolled in evidence-based home visiting services reported a history of substance use or need for treatment. This is likely an under-report of the number of households affected by substance use. During the same time, 16% of households reported that someone in the household used tobacco products in the home, down from 18% in federal FY18. In federal FY19, 56.1% of primary caregivers enrolled in home visiting who reported using tobacco or cigarettes were referred by a home visitor to tobacco cessation counseling or services within three months of enrollment, an increase from 54.2% in federal FY18.

 

The Early Head Start program that was intended to focus on serving opioid affected newborns through hospital collaboration was not successful due to a lack of referrals from the local hospital and substance use treatment system. Supporting families impacted by substance use continues to be a priority for the program. In FY19, the program has enhanced partnerships with the area child welfare office, police department, opioid taskforce and other agencies and programs that serve families impacted by substance use to offer Early Head Start as an additional support for families.

 

In FY19, MA MIECHV initiated a pilot that provides 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 September 2018 one PAT program hired a home visitor with lived experience with substance use and recovery, who later received training in Recovery Coaching and the PAT model and began recruiting and enrolling families in February 2019. The supervisor also completed Recovery Coach training and more recently attended the Recovery Coach Supervisor Academy in fall 2019. In FY19, three families were actively engaged in the pilot.

 

Welcome Family

Welcome Family nurse home visitors screen caregivers for substance and tobacco use, provide brief intervention and education, and refer women to substance use and smoking cessation resources. In FY19, nurses provided 168 brief interventions and offered 58 referrals to participants in response to concerns identified during screening. A common challenge the nurses face is that the substance use screen infrequently yields disclosures due to the sensitive nature of this topic and the difficulty of developing a relationship with the caregiver during a one-time visit. MDPH will leverage the universality of Welcome Family to de-stigmatize the topic.

 

Welcome Family nurses stay apprised of research, resources, and trainings on counseling families on marijuana use during pregnancy and breastfeeding. In FY19 they sought to improve collaborations with local substance use service agencies in their communities by emphasizing the importance of providing parenting support, which home visiting can offer, in addition to recovery support.

 

Priority: Promote emotional wellness and social connectedness across the lifespan.

Progress on this priority is measured by the percent of women who reported discussing what to do if they feel depressed during pregnancy or after delivery at any prenatal care visit with a health care worker. EIPP, MA MIECHV, FOR Families, PRAMS and the MA Postpartum Regulations address this performance measure.

 

Other initiatives at MDPH focused on improving emotional wellness and social connectedness in early childhood and adolescence are discussed in the Child and Adolescent Health domains.

 

SPM 5: Percent of women who report being screened for depression by a health care worker during any prenatal or postpartum visit.

Based on 2018 MA PRAMS data, 96.4% of women reported being asked by a health care worker if they feel depressed during either a prenatal visit or a postpartum visit. This is a slight increase from 95.6% in 2017. Women who were born in the U.S. (96.5%) or who were unmarried (96.7%) reported being asked if they feel depressed more frequently than women who were not born in the U.S. (96.2%) and those who were married (96.2%); however, these differences were not statistically significant. Differences in screening by race, education, insurance, federal poverty level and WIC participation were also non-significant. FY19 activities, accomplishments and challenges to address this measure are described below.

 

Early Intervention Parenting Partnerships Program

Maternal mental health is a key topic of discussion, education, support and referral with EIPP families. In FY19, 49.1% of participants reported a history of depression, including postpartum depression (PPD) at enrollment. At two months postpartum, 203 participants were screened for PPD using the Edinburgh Postnatal Depression Screen (EPDS) with 6.4% screening positive for mild depressive symptoms and 5.4% screening positive for moderate or severe depressive symptoms. Sixty-six EIPP participants were supported in maintaining a connection with their individual counselor and 70 participants were referred to individual counseling; of those referred, 15.7% were enrolled in services, 74.3% were placed on a waiting list, and 5.7% were denied services. Anecdotal data indicate that these women were denied mental health services due to insurance issues.

 

EIPP participants are assessed on a three-question social connectedness screening tool at key prenatal and postpartum stages. At the initial visit, 338 women were screened, with 12.4% reporting that they do not have the support they need from others to care for themselves and their infant. Each EIPP site facilitates a 10-week support group annually for its participants. Topics include maternal mental health, mother/infant attachment, self-care, parenting skills and others. Transportation, child care and food are provided to facilitate attendance.  

 

MA MIECHV

MA MIECHV promotes emotional wellness and social connectedness among program participants in several ways. All MA MIECHV home visitors and supervisors are required to attend a day-long mental health training focused on common mental health concerns, strategies for supporting parents who struggle with mental health challenges, and mindful self-regulation skills to support home visitors when working with parents facing 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 (FAN) training, also required for all MA MIECHV staff, further supports staff to engage in reflective practice.

 

MA MIECHV home visitors screen for both depression and social connectedness according to evidence-based model requirements, document the results of those screens, and make referrals to services as needed. Depression screens are conducted using the Center for Epidemiologic Studies Depression Scale (CES-D) or EPDS within three months of delivery (for those enrolled prenatally) or within three months of enrollment (for those not enrolled prenatally). Data on completed depression screens are collected and analyzed to assess progress on a MIECHV performance measure assessing the percent of primary caregivers enrolled in home visiting who are screened for depression using a validated tool. In FY19, 92.2% of MA MIECHV participants were screened for depression within the required time frame, an increase from 82.5% in FY18. In FY19, 37.2% of caregivers referred to services for a positive screen for depression were documented to have received one or more service contacts, down from 50.9% in FY18. MA MIECHV programs report limited language and cultural capacity among mental health services in many MA communities as barriers to successful access to treatment.

 

Research suggests that social isolation contributes to stress and emotional fragility, particularly in populations served by MA MIECHV. All participants are screened for social connectedness at six month intervals throughout the duration of program enrollment. Each model uses different tools to assess the extent to which the participant is connected with social networks. All MA MIECHV programs hold a six-week group series to support their service population and to facilitate connections among families. MA MIECHV provides flexibility on topics for the group series to allow programs to better meet the needs of their participants and the larger community.

 

FOR Families

FOR Families serves homeless families with complex medical needs, substance use, safety concerns, and high levels of depressive symptoms. During the intake assessment, and as needed in subsequent visits, home visitors assess women for symptoms of depression, identify any potential risks to the mother and baby, and make referrals to mental health services.

 

The intake assessment does not capture data specifically for women during pregnancy or after delivery. Of the 159 families assessed in FY19, 57% reported that someone in the household had been diagnosed with depression, and 18% reported that a household member had ever been hospitalized for a mental health crisis. Home visitors provide support through reflective listening during their home 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.

 

Postpartum Depression Regulations

The MA Postpartum Depression regulations require health care providers to report their data to MDPH annually if they conduct a PPD screen during a clinical encounter with a postpartum woman. A single service code is used as a mechanism for reporting PPD screening by providers. Understanding statewide PPD screening patterns and outcomes through relevant data will improve detection and facilitate treatment for mothers in need of support.

 

Through an IRB, MDPH receives data from the Center for Health Information and Analysis (CHIA) to monitor PPD screening patterns. During January–December 2016, the most recent data available, there were 69,998 unique deliveries from the birth certificate, of which 69.6% were linked to a claim in the All Payers Claim Database (APCD). During this time, 12.1% of deliveries were screened for PPD and 10.8% had a positive screen. The proportion of women who were screened for PPD was higher among White non-Hispanic (13.6%) and Asian (14.6%) women compared to Hispanic (8.1%) and Black non-Hispanic (9.7%). The proportion of PPD screening was higher among women on private insurance compared to Medicaid, and among women with higher levels of education.

 

Among those screened, Hispanic women (15.3%) had higher positive proportion compared to White non-Hispanic (10.3%), Black non-Hispanic (10.4%), and Asian (8.3%). The positive proportion was also higher among women on Medicaid (14.1%) than those on private insurance (8.9%). Of concern is the finding that women who were more likely to screen positive for PPD also had lower percentages of screening, suggesting that women in greater need of support are less likely to be identified.

 

Although the PPD screening data presented above are useful for monitoring trends over time, the estimation of PPD screening through claims data has been challenging and these screening rates are believed to be substantial underestimates. Anecdotal data from birth hospitals participating in PNQIN indicate their PPD screening rates are as high as 80% and PRAMS data suggest that women are routinely being asked about depression during prenatal and postpartum visits. MDPH is exploring barriers to data collection (e.g. whether all health plans accept the claims code and report this information to CHIA) and identifying opportunities to improve the completeness of reporting.

 

MassHealth pays for the administration of standardized depression screening during pregnancy and postpartum. Perinatal care providers may submit claims for one prenatal and one postpartum depression screen for a pregnant or postpartum MassHealth member in a 12-month period. Pediatric providers may claim for the administration of one postpartum depression screen in conjunction with a well-child or episodic visit for a MassHealth member aged 0–6 months. Reimbursement for screening requires the use of a validated, MDPH-approved perinatal screening tool such as the Beck Depression Inventory, CES-D, EPDS, Postpartum Depression Screening Scale, or Patient Health Questionnaire-9. MDPH will continue to promote screening for all postpartum women by primary care and obstetric providers.

 

Additional activities to improve Women’s/Maternal Health

Other MDPH activities to improve women’s/maternal health that are not specific to the performance measures are discussed below.

 

Maternal Morbidity and Mortality Review

Preliminary data from 2017 indicate that there were 18 pregnancy-associated deaths, including one maternal death. A pregnancy-associated death is the death of a woman while pregnant or within one year of termination of pregnancy, irrespective of cause. Women who die from a cause related to pregnancy or childbirth either during pregnancy or up to 42 days after pregnancy termination are called maternal deaths and are a subset of pregnancy-associated deaths. The 2017 pregnancy-associated mortality ratio was 25.9 deaths per 100,000 live births and the maternal mortality ratio (maternal death) was 2.9 per 100,000 live births. More recent data entered into the Maternal Mortality Review Information Application (MMRIA), a web-based platform, were lost when MMRIA data became corrupted. MMRIA is now active again and MDPH will update reporting when lost data are re-entered.

 

The Maternal Mortality and Morbidity Review Committee (MMMRC) reviews all maternal deaths, studies the incidence of pregnancy complications, and makes recommendations to improve maternal outcomes and eliminate preventable maternal death. The work of the MMMRC, protected under M.G.L. c. 111, section 24A and 24B, assures the confidentiality of all records and proceedings. Understanding the causes of maternal deaths provides insight into the factors that contributed to both maternal morbidity and mortality, which can inform strategies to reduce the incidence of these tragic events. The MMMRC consists of obstetricians, certified nurse midwives, maternal fetal medicine specialists, neonatologists, pathologists, perinatal psychiatrists, academics, critical care specialists and the state medical examiner or his designee. The MMMRC is coordinated by Title V staff and any meeting costs (e.g. copying files) are covered by the Title V Block Grant.

 

In 2018, MDPH migrated its legacy data into MMRIA in an effort to collect more standardized data to inform the work of the MMMRC and to align with maternal mortality data reported by other states and captured at the national level. The transition to the MMRIA database has been challenging for MDPH. Although MMMRC staff were able to install MMRIA on MDPH computers and began entering MMRIA data, there was insufficient IT support to provide ongoing maintenance and ameliorate technical challenges. This led to delays in abstracting records, contributing to a significant backlog. To address the IT capacity challenge, MDPH is working with CDC to establish a MOU so that CDC can host the MA MMRIA and provide the needed IT support.

 

Levels of Maternal Care

During FY19, MDPH staff worked with clinicians, PNQIN leadership, and the Betsy Lehman Center for Patient Safety to explore the designation of levels of maternal care (LoMC) in MA and implementation of the CDC Levels of Care Assessment Tool (LOCATe). A stakeholder meeting was convened in September 2019 with representatives from 16 birth hospitals and 10 partner organizations. Stakeholders unanimously agreed to continue the conversation about moving forward with implementing LOCATe and LoMC in MA and emphasized the need to engage consumers in the work, especially regarding potential implications on access to care and health equity. Stakeholders also stressed the importance of considering health equity, the social determinants of health, and the broader spectrum of what influences care when moving forward with this work. Stakeholders expressed that they would be more comfortable with a quality improvement frame for the work and they did not want the state to be the lead, but instead felt that PNQIN is a natural fit to lead the work.

 

PRAMS Disability Supplement

In January 2019, MDPH applied for the CDC PRAMS Disability Research Supplement grant and was awarded funding to support the disability supplement activities. The disability supplement survey started in January 2019, and data collection will continue until April 2021. The MA PRAMS team and MA PRAMS Advisory Committee have a long-standing interest in monitoring maternal and infant outcomes by maternal disability status. Since its beginning in 2007, every phase of the MA PRAMS survey has included at least one question on disability status. Including a state-specific question(s) has allowed MA PRAMS to examine disparities in key indicators, including objectives listed in Healthy People 2020, by disability status. While MA PRAMS has collected data on disability status for more than a decade, the data have been limited to one or two questions and have not allowed comparison of MA data to national data. The six-question set in the PRAMS disability supplement will allow a more comprehensive assessment of disability status among MA mothers and will help to provide robust national data for comparison as MDPH examines maternal and infant outcomes by disability status. MDPH will finish the 2019 data collection by the end of July 2020 and is expecting to receive the 2019 weighted dataset in fall 2020. During April 2020, MDPH held a PRAMS Disability Key Stakeholders Meeting, and solicited feedback on the disability data analysis plan and identified priorities. Participants included MDPH staff, partners from universities and non-profit organizations, and medical providers.

 

Domestic Violence Services

During FY19, MDPH continued to improve collaboration between sexual and domestic violence (SDV) community-based programs and health care systems. In November 2018, MDPH launched the online training designed to meet the requirements outlined in the Mass General Law Chapter 260 on training and education in SDV Prevention for nine different boards of registration in the field of clinical and health and human services. This includes all physicians, nurses, social workers and other related professions.  

 

MDPH continued implementing seven Domestic Violence (DV) Service models in FY19, including Children Exposed to DV, Supervised Visitation Services, General Community-Based Services, Emergency Shelter, Housing Stabilization, DV Substance Misuse & Trauma Services, and SDV Services for Communities Experiencing Inequities.

 

Sexual Assault Prevention and Survivor Services

In FY19, MDPH funded 16 comprehensive rape crisis centers, providing quality, culturally-relevant, trauma-informed, accessible services throughout the state. Each rape crisis center has an assigned service area, collectively providing services to all 351 cities and towns in the state. Services assisted survivors of all genders and provided free, confidential support by trained rape crisis counselors, including 24/7 hotlines with access for people who are Deaf or hard-of hearing; short-term individual and group support sessions; individual client advocacy and supported referrals; 24/7 accompaniment to hospitals and police stations; advocacy and accompaniment to courts and to some educational institutions and human services agencies; outreach to primary and secondary survivors; and education and community mobilization focused on primary prevention of sexual violence. Several of the rape crisis centers engage with youth to provide leadership to their organizations’ sexual violence prevention programs. Youth lead and/or participate in advisory groups and serve as peer mentors and are compensated through stipends or gift cards for their work. In FY19, the 16 rape crisis centers directly served 4,691 clients ages 12 and older.

 

Intimate Partner Abuse Education

The Intimate Partner Abuse Education Programs (IPAEPs) function under a statutory set of standards and guidelines, considered best practices, which are promulgated by MDPH. IPAEPs work toward establishing privileged communication with the partners they contact by partnering with community-based DV agencies, which either conduct the contacts themselves, or provide supervision to IPAEP staff who conduct the contacts. Approximately 80% of IPAEP participants are court-ordered to the program as a condition of their probation. Data show that men of color are disproportionately represented in IPAEPs. All IPAEPs continue to increase their awareness of and skills to provide culturally-responsive services to African Americans. Through the intake processes and educational content in the weekly groups, programs acknowledge the role of structural oppression, and specifically racism, as it affects the lives of these men. Programs also respond to the known risk and protective factors that support and mitigate DV perpetration. One example is that programs now support participants to develop employment skills in lieu of traditional community service as a form of payment for the program. IPAEPs are strongly encouraged to hire more African American staff and to include African Americans among leadership and on Boards of Directors.

 

[1] http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6304a1.htm