Priority: Women’s mental health

Cesarean Deliveries

Update on PM annual objectives:

 

NPM 2: Percent of cesarean deliveries among low-risk first births was 21.2%. The annual objective for reporting year 2019 was 20.2%. The annual objective was not met. The annual objective for reporting year 2020 is 20.0%.

 

ESM 2.2: Number of Colorado birthing hospitals with NTSV c-section rates exceeding the HP 2020 and Colorado-specific target of 23.9% implementing at least one strategy from the CMQCC toolkit was 2. The annual objective for reporting year 2019 was 5. The annual objective was not met. The annual objective for reporting year 2020 is 8.

 

For this reporting period, MCH Block Grant dollars funded staff from the Maternal and Infant Wellness team at CDPHE to serve on the steering committee for the Colorado Perinatal Care Quality Collaborative’s reducing primary cesarean project. This Collaborative leads implementation efforts for this priority with funding through a five-year grant from the Centers for Disease Control and Prevention ’s state-based perinatal quality collaborative grant. The grant provides needed resources to adequately support the organizational capacity of the Colorado Perinatal Care Quality Collaborative and fund implementation of quality improvement implementation efforts. The strategies and associated outcomes for this priority are summarized below. For a more detailed description, refer to the full state action plan.

 

This NPM is reported in the women’s mental health priority section since research suggests that women who experience an unplanned cesarean may be at increased risk for postpartum depression. During this reporting period, the Colorado Perinatal Care Quality Collaborative continued to advance the implementation of evidence-based quality improvement strategies from the California Maternal Quality Care Collaborative toolkit to reduce the percent of nulliparous, term, singleton, vertex (NTSV) cesarean deliveries. Participating hospitals log all of their cesarean births in a REDCap database, including the following key data points associated with increased cesarean birth: cervical dilation at the time of cesarean, timeline of labor, and induction/augmentation agents. The data are analyzed by the Collaborative’s Quality Improvement Specialist and an epidemiologist in CDPHE’s Vital Statistics Office in the Center for Health and Environmental Data. Outcomes are shared with the hospitals to guide internal hospital discussions and strategies. Additionally, data are shared with the group of participating hospitals in structured discussions to troubleshoot operational challenges. The Colorado Perinatal Care Quality Collaborative facilitates technical assistance between the Medical Consultant and providers at participating hospitals. The initiative is known as SOAR (SuppOrting vAginal births for low Risk mothers) and represents the Collaborative’s first formal perinatal quality improvement initiative.

 

To guide implementation of the reducing primary cesarean work through continuous quality improvement, the SOAR Steering Committee was formed as a sub-group of the Colorado Perinatal Care Quality Collaborative, which met regularly throughout the year. This multidisciplinary committee includes the Collaborative’s Executive Director, SOAR MD Consultant, a labor and delivery nurse representative, an obstetrician representative, a neonatologist representative, a nurse-midwife representative, CDPHE’s Maternal Health Clinical Consultant, who is the lead for this MCH priority, and the SOAR Quality Improvement Specialist.

 

Over the past year, the Colorado Perinatal Care Quality Collaborative spearheaded the process of Colorado becoming part of the Alliance for Innovation on Maternal Health (AIM), a national data-driven maternal safety and quality improvement initiative based on the implementation of evidence-based safety bundles. The AIM NTSV cesarean bundle is similar to the SOAR project and will be the first AIM bundle the Collaborative adopts. The Collaborative is pursuing financial support from the AIM initiative that would further support the NTSV cesarean reduction work. CDPHE’s Maternal Health Clinical Consultant sits on the AIM steering committee and has provided technical assistance, including data and data interpretation and clinical expertise.

 

Hospital recruitment efforts to participate in the SOAR initiative to reduce NTSV cesarean deliveries began in December 2017. The initial goal was to recruit three hospitals in the first cohort, but when more requested to join, the Executive Committee accepted additional hospitals for a total of six. In this reporting year, two of the six hospitals met the target recruitment criteria of NTSV cesarean rates ≥23.9%. The cesarean rates for participating hospitals is 23.1% at present, down from an average baseline of 25.4%. The SOAR Steering Committee is hopeful that with the new AIM designation and adoption of other bundles, more hospitals will join the SOAR project as they embrace continuous quality improvement work in their maternity departments. However, recruitment for additional hospital participation has been challenging due to staff turnover at Colorado Perinatal Care Quality Collaborative and the COVID-19 pandemic. CDPHE is assisting in targeted recruitment of hospitals with a cesarean rate ≥24% using birth certification data available only to CDPHE staff.

 

Each of the last two years, biannual Summits were held with hospitals participating in the SOAR initiative. The Summit in spring of 2019 focused on shared learning about implementation steps and challenges in sustainability. The SOAR MD Consultant presented a review of recent literature and led a discussion on strategies to respond to provider and patient inquiries about the ARRIVE (A Randomized Trial of Induction Versus Expectant Management) trial, as well as how the research impacts the SOAR initiative. Two hospitals interested in implementing the reducing primary cesarean quality improvement project attended the Summit to collect information, including representation from a large health maintenance organization. The most recent summit in September 2019 highlighted successes of the SOAR initiative and other perinatal quality improvement activities over the past year, and provided updates on cesarean rates and future efforts for Colorado's health care improvements through the AIM initiative.

In addition to the above activities, CDPHE’s Maternal Health Clinical Consultant engaged in several activities locally and nationally to reduce primary cesareans. She was appointed the Colorado AIM liaison for the American College of Nurse Midwives and HRSA reached out to her to determine how to support midwifery workforce development with the aim of improving maternal and infant morbidity and mortality. She conducted a webinar for the American Association of Birth Centers on provider wellness and association with maternal and fetal outcomes. In collaboration with CDPHE colleagues in the Center for Health and Environment Data (CHED), she wrote a data brief on NTSV cesarean births in Colorado. Finally, the Colorado Maternal Mortality Review Committee agreed to add a question to their review to determine whether a cesarean birth, at any point, contributed to the person’s death.

With financial and technical assistance from CDPHE, the Colorado Perinatal Care Quality Collaborative has planned a training in labor support and intermittent auscultation for nurses across the state. Both labor support and intermittent auscultation are demonstrated strategies to reduce the risk of a cesarean birth. The labor support workshop will adapt a curriculum originally developed by the Florida Perinatal Quality Collaborative.  A train-the-trainer model will help to develop a team of nurses, midwives, and doulas who are able to conduct training around the state. The first labor support training was originally planned for March 2020, but is being rescheduled for late 2020 due to the COVID outbreak.

 

In the 2021-2025 MCH cycle, low-risk c-section reduction is not continuing as one of the seven priorities. However, the MCH program staff will continue to serve on the leadership team of the Colorado Perinatal Care Quality Collaborative, which will continue to lead implementation of the project.

 

Pregnancy-related depression

Update on PM targets:

 

SPM 1: Percent of mothers that report a doctor, nurse, or other health care worker talked with them about what to do if they felt depressed during pregnancy or after delivery was 79.0%. The annual objective for reporting year 2019 was 83.9%. The annual objective was not met. However, because there was a decline in 2017 (74.2%), reaching 79.0% successfully shifted the overall trend for this measure upwards. Increased awareness among affected women and health care providers might have contributed to this increase from 2017 to 2018, albeit direct attribution to the public awareness campaign is not possible. A data point related to the SPM - percent of women who reported being asked by providers at their postpartum visit about depression - showed a statistically significant improvement from 88.3% to 93.0% between 2016 and 2018.

 

The annual objective for reporting year 2020 is 85.8%.

 

For this reporting period, MCH Block Grant dollars funded approximately 1.2 FTE of the Maternal and Infant Wellness team at CDPHE; implementation of the strategies outlined in the state action plan; and contracts with local public health agencies to implement pregnancy-related depression local action plans. To advance and expand impact, MCH aligned with and leveraged funding from Project LAUNCH (a grant from the Substance Abuse and Mental Health Services Administration), the Colorado-based Zoma Foundation, and the ERASE Maternal Mortality grant through the Centers for Disease Control and Prevention (CDC). The funded strategies and associated outcomes for this priority are summarized below. For a more detailed description, refer to the full state action plan.

 

During the reporting period, the most robust strategy of the state action plan continued to be the public awareness campaign that began in the fall of 2016. In addition, MCH staff enhanced referral resources and systems with an emphasis on integrating mental health and substance use; improved  workforce competency to address maternal mental health; collaborated with key partners; and provided technical assistance to 13 local public health agencies that selected pregnancy-related depression in their local action plans.

 

The public awareness campaign initially launched as a pilot in 2016. The campaign exceeded its goal number of unique visitors who accessed the campaign landing page  with 66,562 unique visits at the end of June 2020. For the time periods where data are available, the cumulative total impressions for advertising have exceeded 70 million, with the PSI national toll-free warmline fielding more than 600 calls from Colorado callers, and PSI Colorado coordinators responding to more than 250 inquiries (phone calls, emails, etc.). Evaluation documents include a report by the media vendor, localized and statewide summaries of a survey conducted with 263 pregnant and postpartum individuals, and a summary of partner campaign implementation. Mechanisms to sustain the campaign’s success included the additional campaign images and messages, and the development of a menu of strategies for local campaign continuation that accounts for costs, resources, capacity, and impact.

 

The Spanish Campaign Task Force continues to be a resource for spokespersons and ambassadors to expand reach and depth among Spanish-speaking and Hispanic/Latino communities. The task force improved the state’s capacity to address the cultural and linguistic needs of Spanish-speaking, pregnant and postpartum Coloradans, including recruiting the first Spanish-speaking/bilingual coordinator for the Colorado Chapter of Postpartum Support International, conducting trainings in Spanish, and developing a diverse advisory board.

 

Campaign promotion will continue this year as pregnant and postpartum individuals are likely experiencing heightened symptoms of depression and anxiety due to the COVID-19 pandemic. In spring 2020, the Zoma Foundation provided $80,000 to be used in conjunction with MCH funds to expand media and digital advertising to additional Colorado counties and develop additional messages to address emergent needs of pregnant and postpartum individuals related to COVID-19. The campaign leverages efforts by local public health agencies in the largest Colorado metro counties (Adams, Arapahoe, Douglas, Denver, and Jefferson), as well as rural and frontier counties.

 

To strengthen referral networks to address maternal mental health, MCH staff worked with 2-1-1 to add resources, primarily focused on maternal mental health and substance use, to their existing database and develop a dedicated webpage for pregnant and postpartum people. The new webpage was vetted by more than 100 community members and local public health agencies and also links users to other resources such as housing, food and safety. Between October 2019 and January 2020, the webpage had more than 650 unique views. Additionally, Bright by Text, a free texting platform for Coloradans interested in parenting information and educational resources, added new content on maternal mental health. The Perinatal Content Subcommittee, convened by Bright by Three and led by MCH staff, incorporated more than 40 messages from the public awareness campaign on a variety of topics including perinatal mood and anxiety disorders, transitions, parent-newborn attachment, parental/caregiver self-care and parental/caregiver support.

 

To improve workforce competency, MCH staff provided or coordinated training and presentations to highlight the intersections between disparities and maternal mental health. Home visitors, public health partners, family planning providers, dietitians, medical providers, the state employee assistance program and staff working in community-wide resource and referrals centers such as Colorado Crisis Services, 2-1-1, and Medicaid’s Regional Accountable Entities (RAEs) participated, and some presentations were conducted in Spanish.

 

Through a cross-agency Mental Health in the Workplace initiative, MCH staff referred the Executive Director of the state employee assistance program to obtain her maternal mental health certification through Postpartum Support International. Since 2019, the state employee assistance program has embedded maternal mental health into their menu of support to 30,000+ state employees, and delivered two webinars on perinatal mood and anxiety disorders to raise awareness and support new parents across state agencies. In June 2019, following successful previous Lunch and Learns for CDPHE employees on mental health for new and expectant parents, a Lunch and Learn event focused on the role of the non-birthing parents’ experience of pregnancy-related depression. Resources were compiled and shared with eight individuals who identified as new or expectant fathers. In February 2020, MCH staff led an effort to co-convene the annual 2020 Mom conference with four other statewide organizations: the Colorado Association for Infant Mental Health, the Colorado Chapter of Postpartum Support International, the Colorado School of Public Health, and the Colorado Breastfeeding Coalition. Attended by more than 50 participants, this new approach demonstrated an effective model for coordination across different sectors that support new and expectant parents and their families.

 

To measure progress on maternal mental health, MCH staff helped to identify questions related to pregnancy-related depression and anxiety, stigma, resources, coping, care, and barriers to care for the Health eMoms survey. Data from 2018 show that about 12% of mothers report that they had depression during their recent pregnancy, and up to 30% of mothers have a score on the EPDS-3A screening tool indicative of a possible anxiety disorder.

 

MCH staff also monitored progress through Medicaid claims data. Based on reports provided by the state Medicaid agency, as of September 2018, 34 percent of new mothers with Medicaid received depression screening, exceeding the MCH annual objective. Following the 2018 state election, the Governor’s priority performance dashboard no longer included this measure, and the state Medicaid agency no longer tracks this data. A data-sharing plan is now in place with the state Medicaid agency to re-analyze current data using different criteria to capture progress.

 

MCH staff continued to support the statewide coordination of maternal mental health efforts through the Colorado Maternal Mental Health Framework and Collaborative. As of the spring of 2020, the Colorado Perinatal Care Quality Collaborative became the backbone organization for the Framework and Collaborative, which includes more than 30 partner organizations. MCH staff co-lead and/or participate in the Steering Committee and workgroups to address policy change, financing, programs and services, communication, measurement, equity and workforce. To date, accomplishments of the Collaborative included distribution of the Framework to state legislators; supporting passage of the 2019 Maternal Mortality Prevention Act; supporting development of the Perinatal Continuum of Care tool; developing a communications plan and products, an evaluation plan and theory of change; and capacity building around gender equity.

 

The Pregnancy-Related Depression State Advisory Committee developed a plan for engagement of faith-based organizations in partnership with local public health agencies and the Center for African American Health. The committee supported state staff to engage African American community leaders in metro Denver, including sharing information and resources with Restoration Christian Fellowship and Dayton Street Opportunity Center. The committee discussed ways to leverage the most recent 2018 results of the PRAMS and Health eMoms surveys, incorporate community perspectives and sustain the momentum of the public awareness campaign. MCH staff presented to the MCH Community Advisory Board on pregnancy-related depression efforts in January 2020 and elicited their feedback on the direction of community engagement strategies in the upcoming 2021-25 MCH cycle.

 

Based on Colorado’s maternal mortality review committee data, suicide and substance use overdose continue to be leading causes of maternal mortality. MCH staff integrated maternal mental health into statewide strategies and activities for maternal mortality prevention and responded to media requests about maternal mortality, which provided an opportunity to highlight the state’s MCH work on maternal mental health and substance use. In October 2018, MCH staff presented at the annual Harvey Cohen Maternal Mortality and Morbidity Summit, the largest statewide medical conference hosted by the American College of Obstetricians and Gynecologists. In November 2018, state MCH staff hosted a summit on maternal mortality prevention for HRSA’s Region VIII, supported by MCHB, AMCHP and CDC. The two-day summit enabled the Region VIII states to collaborate, which continued through regional calls and a listserv. In the fall of 2018, MCH staff informed legislation to establish the Maternal Mortality Review Committee in statute, an effort led by the Colorado Children’s Campaign and the policy workgroup from the Maternal Mental Health Collaborative. MCH staff embedded gender-inclusive language to support equity and ensured fiscal allocation in the bill draft prior to introduction. The legislation was introduced in the state General Assembly in January 2019 and passed in May 2019. MCH staff testified and answered technical questions during the legislative process. The signed act designated $145,167 per year for ten years for CDPHE administration of maternal mortality review. In December 2018, federal legislation created the CDC’s Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM) grant to improve maternal mortality review and prevention. Colorado MCH staff applied in May 2019 and were awarded $375,000 per year for five years to support community-led interventions, public health programs and clinical quality improvement to prevent maternal deaths starting in September 2019. Two other Region VIII states also applied, including a budget line to host and/or participate in two regional summits during the five-year grant cycle.

 

MCH staff were accepted into the 2019 cohort of the MCH Workforce Development Center and leveraged the six-month engagement to set the foundation for the team to plan the next iteration of MCH work related to women’s behavioral health. Specifically, the team identified evidence-based, cross-cutting strategies and activities to address the social determinants of health, support the health of the mother-infant dyad, and achieve health equity as it relates to maternal and infant wellness. Two community members and state MCH staff attended a two-day workshop in September 2019 to build capacity for managing upcoming changes using implementation science and ensure strategies to address racism and discrimination in the work.

 

As the COVID-19 pandemic spread across Colorado, the Maternal and Infant Wellness team, in partnership with the Colorado Children’s Campaign and others, convened a virtual town hall to understand the barriers and solutions to providing equitable, safe, and patient-centered care for people giving birth during the pandemic. The conversation focused on changes to patient care, infant separation for people with COVID-19, support-people allowed at birth, and increased demand for community (out-of-hospital) birth. Additional conversations were held with partners throughout the spring and summer to further explore the equity issues and maternal mental health concerns experienced by pregnant, birthing and postpartum Coloradans during the pandemic.

 

Priority: Substance misuse reduction (tobacco, marijuana and prescription drugs) among pregnant and postpartum women

Tobacco

Update on PM targets:

 

NPM 14A: Percent of women who smoke during pregnancy was 5.9%. The annual objective for reporting year 2019 was 6.0%. The annual objective was met. The annual objective for reporting year 2020 is 5.9%.

 

 

 

NPM 14B: Percent of children who live in households where someone smokes was 13.3%. The annual objective for reporting year 2019 was 13.8%. The annual objective was met. The annual objective for reporting year 2020 is 13.7%.

 

ESM 14.1.1: Percent of women who report that a doctor, nurse, or other health care worker talked with them about how smoking could affect their baby was 64.4%. The annual objective for reporting year 2019 was 62.0%. The annual objective was met. The annual objective for reporting year 2020 is 62.0%.

 

ESM 14.1.2: Percent of women who report that a doctor, nurse, or other health care worker advised them during pregnancy and postpartum about the harms of their child’s exposure to secondhand smoke was 34.9%. The annual objective for reporting year 2019 was 36.0%. The annual objective was not met. The annual objective for reporting year 2020 is 36.3%.

 

ESM 14.2.1: Percent of children whose parents report that their child’s health care provider talked to them about their child’s exposure to secondhand smoke was 36.8%. The annual objective for reporting year 2019 was 34.1%. The annual objective was met. The annual objective for reporting year 2020 is 34.6%.

 

Nearly all annual objectives were met, with the exception of ESM 14.1.2. While it is difficult to definitively know why this objective was not met, one contributing factor could be that the training to providers emphasizes education on smoking while pregnant over secondhand smoke exposure and/or the provider may emphasize quitting over reducing secondhand smoke exposure.

 

Throughout this reporting period, MCH Block Grant dollars funded .25 FTE, which was braided with revenue from Colorado’s tobacco excise tax and funding from the Centers for Disease Control and Prevention (CDC). Leveraging these funds enabled CDPHE’s State Tobacco Education Prevention Partnership program and MCH program to extend the reach of strategic efforts to reduce the burden of perinatal smoking and exposure to secondhand smoke. Together, these programs support positive birth outcomes and improve the health of whole families throughout the lifespan. The funded strategies and associated outcomes are summarized below. For a more detailed description, refer to the full state action plan.

 

In the 2021-2025 MCH cycle, decreasing substance misuse is not continuing as one of the seven priorities. However, the national performance measure to reduce tobacco use among pregnant women will continue to be monitored and reported on through the priority to increase social emotional well being. Many of the current strategies to reduce tobacco use among pregnant women will continue to be implemented.

 

According to the Colorado Pregnancy Risk Assessment Monitoring System (PRAMS) data, year-over-year smoking in the last 3 months of pregnancy among Medicaid members continues to decline. However, women who are enrolled in Medicaid are nearly five times more likely to smoke while pregnant (11.8%) compared with women who are enrolled in private insurance (2.4%).

 

During this reporting period, CDPHE’s tobacco program continued its partnership with Medicaid to expand barrier-free access to evidence-based tobacco treatment for pregnant members and their families. In November 2018, the tobacco program worked with Medicaid to remove prior authorization request requirements and annual limits for all FDA-approved cessation medications. Research has shown that the prior authorization request process and annual or lifetime limits are barriers that impede patients’ ability to obtain access to quit medications, which can deter motivation to follow through on a quit attempt and reduce quit success. Also in November 2018, Medicaid expanded the role of pharmacists in supporting cessation by extending pharmacists' prescriptive authority to include over-the-counter nicotine replacement therapy, which can increase the accessibility of cessation medication for pregnant persons. To support awareness and utilization of covered Medicaid benefits, CDPHE’s tobacco program revised a suite of educational materials, including postcards for Medicaid members in English and Spanish; and clinical palm cards, an at-a-glance benefit chart and fact sheets for providers. The rate of smoking during pregnancy of Medicaid members continues to decline, dropping from 13.2% in 2013 to 10% in 2017. Subsequently, 2018 data shows an up-tick to 14.4% and although not statistically significant, a shift in the wrong direction.

 

Since 2010, the Colorado Quitline has offered a smoking cessation program tailored for pregnant and postpartum populations, which features dedicated coaches and incentives for participation. In the fall of 2018, CDPHE’s tobacco program partnered with National Jewish Health, the state’s Quitline vendor, to launch an innovative, web-based, bi-directional coaching platform called e-Coach. Quitline data shows that young people prefer to engage with the Quitline through digital services available online and by text. Sixty-two percent of e-Coach clients served to date are under 44 years old. E-coaching can reduce barriers to traditional phone coaching, including those experienced by persons who are socioeconomically disadvantaged, rurally-based, or living with a disability or chronic condition. In March 2019, the Quitline began piloting a re-engagement project, which normalizes relapse and increases participation and quit rates of formerly enrolled participants through proactive, personalized phone, text, and email outreach. During this reporting period, 185 pregnant persons enrolled in the Quitline, with 137 choosing to participate in the Pregnancy Program. Of the total number of pregnant persons who enrolled in Quitline services, 61% self-reported having Medicaid, and 4% reported having no insurance coverage. The high proportion of Medicaid and uninsured enrollees is evidence that the Quitline is serving Colorado’s most vulnerable pregnant population.

 

The Baby and Me Tobacco-free Program continues to serve pregnant people and their partners across Colorado by providing perinatal smoking cessation services. The program is fully funded through CDPHE and administered by the Rocky Mountain Health Foundation. During this reporting period, the program had 50 active sites serving 54 Counties, which together enrolled 636 women and 118 partners in the program. The program provides up to four prenatal and 12 postpartum monthly counseling sessions with carbon monoxide testing used as validation of abstinence at each visit. As an incentive, women and partners who remain smokefree were provided a $25 diaper voucher. The Baby and Me Tobacco-free Program was designated a best practice by the Association of Maternal and Child Health Programs in 2018. To ensure continued success and quality improvement, the Rocky Mountain Health Foundation works with the University of Colorado Cancer Center to evaluate program effectiveness and fidelity. At the close of this reporting period  and for the third consecutive year, women who completed the program gave birth, on average, to the same percentage of healthy weight babies as non-smokers.

 

In December 2019, a manuscript highlighting the success and cost-effectiveness of the Colorado Baby and Me Tobacco-free Program was accepted for publication by Public Health Nursing, a peer-reviewed journal that publishes research based on the social determinants of health conducted with vulnerable populations. The publication received robust coverage as numerous state and local media outlets covered the impacts of the program outlined in the study, including Colorado Public Radio; 9News; and local news outlets. Some of the key findings from the study include data showing that program participants saw a 24% to 28% reduction in the risk of preterm birth and a 24% to 55% reduction in the risk of neonatal intensive care unit  admissions. Total per-person cost savings of the program compared to the birth certificate and PRAMS reference populations was $6,040 and $2,182, respectively. Total annual cost savings for Colorado associated with the intervention was $4,144,118 and $1,497,299 compared to birth certificate and PRAMS reference populations, respectively. Although the program reaches many areas of the state, there are a few counties that are not currently being served due to challenges, such as decline in state tobacco tax funding and inadequate capacity for local partner agencies to run the program. CDPHE and the Rocky Mountain Health Foundation are exploring other avenues to help make the program available to pregnant people in these areas.

 

The U.S. Housing and Urban Development (HUD), required Public Housing Authorities to implement its smoke-free rule by July 2018. CDPHE’s tobacco program worked to expand smoke-free policies in public housing beyond the requirements of the HUD smoke-free rule through a contract with Denver Health and Hospital Association and local public health agencies. From 2018 to 2019, 566 additional public housing units were covered by a smoke-free policy bringing the total to 19,062. Sixty-five out of the 84 Colorado Public Housing Authorities have smoke-free policies. Significant progress has been made in the percent of households that report smoking occurs inside the home. In 2011-2012, 14.7% of Colorado adults who lived in multi-unit housing reported smoking inside the home. In 2018, the percent dropped to 3.5% (Behavioral Risk Factor Surveillance System). However, people who live in multi-unit housing remain much more likely to report secondhand smoke drifts into their home than people who live in single family homes (51.3% vs 29.9%, 2018, BRFSS).

 

CDPHE’s tobacco program continues to collaborate with American Lung Association of Colorado to provide the ONE Step program. ONE Step aims to reduce children’s secondhand smoke exposure through the promotion and adoption of smoke-free home and car rules. During this reporting period, the American Lung Association of Colorado engaged organizations that serve low income families, such as WIC, in addition to traditional child care providers and early childhood educators, to provide training to 129 individuals. They also updated the website www.raisesmokefreekids.com to include current information on electronic smoking devices, aerosols, and secondhand marijuana smoke, along with updated information about Quitline and other cessation resources in English and Spanish. In the coming years, the expanded ONE Step programs will creatively work to increase training across the state with a focus on sustainability. The expansion of these programs will increase access to harder to reach populations, especially in rural areas of Colorado.

 

Last year, Children’s Hospital Colorado built upon previous successes by developing and implementing a standardized pediatric workflow to improve screening and intervention for tobacco use and secondhand smoke exposure among parents and caregivers through a new Tobacco Cessation Clinic. The clinic offers evidence-based counseling and medication treatment for parents and caregivers who smoke or use other tobacco products, including the provision of Chantix at no cost to patients. The U.S Preventive Services Task Force research has demonstrated that cessation counseling delivered in pediatric settings is effective in increasing abstinence among parents who smoke. Living with parents who smoke is a critical factor influencing intergenerational transmission of smoking. Additionally, adolescents whose parents smoke are more likely to develop more intense smoking patterns, and this risk increases with longer duration of exposure, making accessible, comprehensive tobacco treatment programs for parents and caregivers a critical strategy for reducing the burden of tobacco use on families. During this reporting period, the Children’s Hospital Colorado administered a total of 75,243 screenings for tobacco use and secondhand smoke exposure during pediatric visits. One significant challenge this program experienced was high rates of attrition among caregivers seeking tobacco treatment through the clinic. Although the program successfully enrolled a record number of caregivers who expressed interest in quitting smoking and other forms of tobacco use, many were unable to complete all sessions. Barriers to completing these sessions included: scheduling conflicts, challenges with securing childcare, and lack of transportation. To address these barriers, Children’s Hospital Colorado is exploring the use of telehealth to increase reach and sustained engagement with the program so that more caregivers can receive the support they need to successfully reach their tobacco treatment goals.

 

While there has been progress over the past decade in reducing smoking before (23.2% in 2009 to 16.7% in 2018), during (12.8% 2009 to 10.8% 2018) and after pregnancy (9.0% 2009 to 7.1% 2018), it appears to have stalled between 2016 and 2018. CDPHE’s tobacco program is closely monitoring the data to understand the trends. It is possible that the increase in e-cigarette use particularly among nonsmoking youth and young adults may be related. E-cigarette use among 18-24 year old young adults increased from 13.5% in 2017 to 23.6% in 2018 (BRFSS). Use of e-cigarettes in the two years prior to pregnancy was unchanged, however, among women who reported using e-cigarettes prior to pregnancy, the percent of women who reported using e-cigarettes more than once a day, increased from 12.5% in 2017 to 34.1% in 2018, which is approaching statistical significance (PRAMS). 

 

Marijuana and prescription drugs

MCH Block Grant dollars supported contracts with local public health agencies to implement local action plans for this priority. CDPHE continued to braid MCH Block Grant funds with state cash funds and Centers for Disease Control and Prevention (CDC) funding to implement the state action plan for this priority. Leveraging these funds enabled CDPHE’s Mental Health Promotion-Violence and Injury Prevention Branch to extend the reach of implementation efforts to the MCH population. The funded strategies and associated outcomes are summarized below.

 

Marijuana

Update on PM targets:

SPM 3: Percent of women who report using marijuana at any time during their pregnancy was 8.2%. The annual objective for reporting year 2019 is 7.0%. The change has not been statistically significant, as the n is so small that the confidence interval is quite large. The annual objective was not met due to a number of contributing factors. Use rates among all adults is increasing in Colorado, including last 30 day use and daily or near daily use. Women of child bearing age that consumed during their pregnancy were also most likely to be younger, have an unplanned pregnancy, have lower educational attainment, lower income, and to have consumed marijuana regularly before their pregnancy. These populations are historically difficult to reach with health messaging, and the difficulty is compounded by the normalization of marijuana use and preference among some pregnant women to use marijuana as a stress or nausea relieving medication. The annual objective for reporting year 2020 is 6.8%.

 

The MCH state performance measure focused on pregnant women, captures a subset of Colorado’s MCH goal of decreasing the percent of all women of reproductive age (ie, ages 15-44) who used marijuana during the past 30 days from 15.9% in 2018 to 14.5% by 2020. To meet the MCH state performance measure, CDPHE continued to work with partners to inform and disseminate mass-reach health education campaigns that prioritizes pregnant and postpartum women with marijuana prevention messages. The marijuana education campaign, Responsibility Grows Here, has been focused on young moms, ages 15-19, which is the cohort that reported the lowest perception of risk of daily or near daily use of marijuana during pregnancy. Focusing on this cohort will help decrease the percentage of women ages 15-44 who perceive daily or near daily use of marijuana as "no risk" in Colorado from 20.4% in 2017 to 18.4% by September 2020. The campaign reaches pregnant and breastfeeding women with messages about the passage of THC from marijuana to the baby during pregnancy and while breastfeeding and the importance of talking to a doctor to make the healthiest decisions for themselves and their babies. Specific strategies utilized multiple flights of social media (Instagram, Snapchat, and Facebook) and digital media (banner ads on websites or apps for new and expecting moms, blog sites, and hyper local targeting for consumers visiting dispensary websites or clinic websites). Additionally, the campaign materials were distributed to local clinics, hospitals, Title X family planning agencies, substance treatment centers, and housing centers for young moms. The wording of this measure was changed in the Summer of 2019 to "using marijuana can be harmful to the baby" on a likert scale of strongly agree to strongly disagree. Our most recent study showed that among women that were or were planning to become pregnant in the near future, 24.1% of women who saw our campaign ads did not agree with this statement. This is not a representative sample, but rather develops an understanding of the degree to which the Responsibility Grows Here campaign reaches, resonates with, and influences Coloradans who are pregnant or breastfeeding, or who plan to be pregnant or breastfeed in the near future.

 

CDPHE began collaborating with a new evaluation partner in January 2019 to evaluate the new pregnancy and breastfeeding campaigns. Since July 1, 2018, the campaign has garnered more than 11 million paid media impressions. Perceptions of risk were assessed among women of reproductive age between two evaluation time points by an external evaluator. The perception of risk associated with a woman using marijuana once a week during pregnancy increased significantly (6 percent increase) among women of reproductive age, particularly among non-Hispanic white women (7 percent increase) though not significantly among the priority population of young moms.

 

Additionally, CDPHE continued to promote the online course for health care providers on the health effects and risks of marijuana use for pregnant and postpartum people. The course was developed to ensure that all providers who work with pregnant and breastfeeding people and their families have information readily available and contains pertinent health effect information, demographic information to inform provider outreach, screening best practices and access to print-ready materials to guide conversations with patients. All provider materials are free to order or download. From June 2016 to September 2019, 3,067 health care providers who provide care to pregnant, postpartum or women of reproductive age, completed the online course or attended in-person training. CDPHE anticipates reaching the target of 4,000 providers by September 2020.

 

Opioids

Update on PMs:

 

SPM 4: Rate of prescription opioid-related emergency department visits per 100,000 females ages 15-44 in Colorado was 22.9. The annual objective for reporting year 2019 was 21.8. The annual objective was not met. The annual objective for reporting year 2020 is 20.6.

 

SPM 5: Rate of prescription opioid-related hospitalizations per 100,000 females ages 15-44 in Colorado was 8.7. The annual objective for reporting year 2019 was 12.5. The annual objective was met. The annual objective for reporting year 2020 is 12.0.

 

While the rates of emergency department visits have not gone down enough to meet the target, the rate of hospitalizations has gone down much below the target. CDPHE hypothesizes that due to greater access to naloxone, people who have experienced an overdose might be in less respiratory distress when they arrive at the emergency department, so they can be treated and monitored in the emergency department and not need to be admitted to the hospital for treatment. Also, anyone can self select to go to an emergency department, but a person cannot self-admit to a hospital inpatient bed. CDPHE does not have data to back up these hypotheses.

 

CDPHE’s Opioid Overdose Prevention Program continued leveraging resources from Colorado’s Prescription Drug Overdose Prevention for States grant from the Centers for Disease Control and Prevention to decrease fatal and non-fatal opioid overdoses among women of reproductive age until this grant ended in August 2019. CDPHE successfully applied for the CDC’s new, three-year, competitive Overdose Data to Action funding. This new grant started in September 2019 and will continue to allow for leveraging and aligning with the MCH substance misuse priority. CDPHE will collect, analyze, and disseminate high quality, comprehensive, and timely data on overdose morbidity and mortality, use those data to inform prevention efforts across Colorado, and expand prevention. This will include conducting three surveillance activities, including linking risk and protective factors for multiple outcomes with overdose data to inform local prevention efforts and linking PDMP to birth certificate data to inform prevention among pregnant women and new mothers. This will also include expanding comprehensive statewide prevention and address Colorado’s overdose crisis with activities such as: monitoring the PDMP and expanding PDMP integration into health systems; local agency projects to address overdose through provider education, community education, community level interventions, targeted naloxone distribution, data strategies, and public awareness; improving linkage to care; funding a provider education training program; supporting the Healthy Youth Campaign at CDPHE; and preventing ACES by promoting shared risk and protective factors in communities, among others.

 

MCH Colorado aimed to decrease the percent of women ages 15-44 in Colorado who reported non-medical use of prescription drugs during the past 30 days from 15.3% in 2016 to 14.5% in 2020. To achieve this, the Opioid Overdose Prevention Program continues to collaborate with state and local members of the Colorado Consortium for Prescription Drug Abuse Prevention, housed at the University of Colorado Denver School of Pharmacy. Strategies include public awareness campaigns, safe disposal education and sites, provider education, and public health surveillance.

 

CDPHE helped increase the number of people who follow the Take Meds Seriously campaign through social media to 3,290 in March 2020 out of the goal of 4,000 unique followers. In the last half of this reporting period, the Public Awareness Work Group of the Consortium plans to update web content for the Take Meds Seriously campaign and develop new educational content that emphasizes safe use of medications. CDPHE will ensure that this new campaign content includes resources related to opioid use during and after pregnancy. The Consortium’s Harm Reduction Work Group, also released a new “Bring Naloxone Home” public awareness campaign to encourage members to spread the message that naloxone saves lives and is easy to administer. CDPHE continues to partner with the Consortium to reduce the stigma associated with seeking treatment and will ensure that local public health agencies are aware of treatment resources in their communities.

 

The Opioid Overdose Prevention Program continues to partner with CDPHE’s Environmental Health Division to recruit law enforcement, pharmacies and hospitals to host permanent drug take-back receptacles and with local communities to promote the use of these sites. As of March 2020, 62 of Colorado’s 64 counties had permanent prescription drug disposal sites. By September 2020, CDPHE plans to ensure 100% of Colorado’s counties have access to permanent disposal sites.

 

The Opioid Overdose Prevention Program maintained contracts with 14 community-based agencies to educate providers about safe opioid prescribing practices as part of Colorado’s Prescription Drug Overdose Prevention for States grant until it ended in August 2019. Opioid Overdose Prevention Program staff provided technical assistance to local grantees and partners with the Consortium’s Provider Education Work Group to promote trainings, clinical guidance documents, and webinars for health care providers on talking points, health effects, and risks of prescription drug misuse. CDPHE’s Opioid Overdose Prevention Program evaluators developed and implemented a survey tool to measure the impact of prescription drug education trainings. This evaluation showed grantees hosted 97 provider education events between September 2017 and August 2019, reaching 5,198 attendees. Based on the survey results, attendees reported greater awareness of the CDC guidelines for prescribing opioids and greater confidence to apply the guidelines.

 

The Opioid Overdose Prevention Program issued a new request for applications for community grantees under Colorado’s new Overdose Data to Action grant and awarded 11 community agencies grants in January 2020. These community agencies will continue to educate providers about safe opioid prescribing practices through the end of this MCH year in September 2020 and through the end of the Overdose Data to Action grant in August 2022. CDPHE will continue to provide technical assistance and support to the new grantees.

 

During this reporting period, CDPHE also provided technical assistance to Tri-County Health Department, which serves three metro-Denver counties that represent 26% of the state's population. Tri-County conducted a scan of their program education needs specific to substance use and current SBIRT (Screening, Brief Intervention, and Referral to Treatment) practices in winter of 2019. The local public health agency is using the results to inform education and training activities primarily for internal staff, as well as to partners and coalitions in 2020. Additionally, Tri-County completed a written community-specific action plan to educate providers on best practices related to substance use and pregnant and breastfeeding people in collaboration with existing substance abuse coalitions or agencies in 2019. By September 2020, Tri-County plans to conduct at least one provider education activity in partnership with the Tri-County Overdose Prevention Partnership (TCOPP) provider education workgroup prioritizing OB/GYN and other perinatal providers. They also plan to incorporate substance use education in Warm Connections training modules for Tri-County WIC staff.

 

MCH Colorado hopes to decrease the percentage of women of reproductive age (ages 15-44) in Colorado who receive a high dose of opioid prescriptions (>90 medical morphine equivalents) from 5.7% in 2016 to 4.0% by September 2020. Preliminary data from March 2020 indicate Colorado is on track to exceed this goal, as only 3.3% of women ages 15-44 received high dose opioid prescriptions in the first quarter of 2020. CDPHE implemented a number of interventions to promote the use of the Prescription Drug Monitoring Program, housed by the Colorado Department of Regulatory Agencies. CDPHE worked with the Consortium’s Prescription Drug Monitoring Program Work Group and clinical partners to integrate the Prescription Drug Monitoring Program with Colorado’s two health information exchanges and with the electronic health record system in eight outpatient clinics. Additionally, CDPHE partnered with the Denver Health and Hospital Authority to pilot a platform called OpiSafe, which integrates Prescription Drug Monitoring Program data with electronic health records and measures providers’ adherence to CDC prescribing guidelines. CDPHE compiled a PDMP Integration Evaluation Report summarizing the impact of these pilots.

 

CDPHE also analyzed Prescription Drug Monitoring Program data for women ages 15-44 and/or prescribers who provide care to pregnant and postpartum women. To expand data collection and surveillance to deepen the understanding of the scope of prescription drug misuse, particularly for pregnant and postpartum women, CDPHE added questions to CDPHE’s Health eMoms panel survey. Questions focused on the types of prescription, illicit and/or over-the-counter drugs that pregnant and postpartum women have used and how they accessed them. Health eMoms draws a random sample of mothers from all eligible birth certificates, and survey responses are weighted to be representative of all mothers who gave birth in Colorado and who still live in the state. The 2018 results became available in the fall of 2019. Of the 1,098 women who gave birth in 2018, 3.6% of mothers reported using prescription pain relievers during pregnancy and 84.4% of these mothers indicated they were prescribed by one doctor or prescribed by more than one doctor. Only 0.1% reported using heroin during pregnancy. Approximately 17.2% reported using prescription pain relievers since the baby was born and 1.2% indicated they took them from a healthcare setting without a prescription.

 

In October 2018, CDPHE received a new $1,000,000, three-year grant from the Bureau of Justice Assistance to expand data collection and surveillance efforts by linking the Prescription Drug Monitoring Program data to hospital, emergency department, death, and emergency medical services data. By September 2020, the Opioid Overdose Prevention Program will analyze those linked data sets to glean additional information about women of reproductive age. CDPHE will also use Overdose Data To Action grant funds to link Prescription Drug Monitoring Program data to birth certificate data by August 2020.

 

CDPHE staff continued to serve as members of the Substance Exposed Newborn Committee of the Substance Abuse Trend and Response Taskforce. CDPHE staff continued to participate in a workgroup that focused on developing recommendations for improving data systems related to maternal substance abuse. As a result, the Opioid Overdose Prevention Program implemented selected recommendations, including the development and implementation of a formal process to include de-identified Prescription Drug Monitoring Program data into maternal mortality case reviews. For more about this data linkage project, see section III.E.2.b SSDI and Other MCH Data Capacity Efforts. CDPHE staff also participated on the Substance Exposed Newborn Committee’s provider education workgroup that focuses on the impact of substance misuse on the maternal and child health population. CDPHE funded Illuminate Colorado, which serves as the backbone organization for the Substance Exposed Newborns Committee, to create an online platform and search system to inventory of existing resources for perinatal providers.