MCH sets the allocations for LHDs based upon a formula using population estimates of number of children and women of childbearing age enrolled in Medicaid, and families residing in service are of LHD at 200% below federal poverty level. Allocations are used for reimbursement of costs of the in provision of deliverables per package guidelines. LHDs, stakeholders, and collaborative partners are engaged at both the local and state level, building an integrative strategic plan across all levels.
Women/Maternal Health Domain Annual Report
In 2015, MCH began, as part of the national effort to “Put the M back in MCH,” to intentionally evaluate ongoing maternal health efforts. In 2017, MCH became a catalyst in program change to incorporate new information from national resources and align data measurements, with national data sets. In 2019, MCH continued to promote best practice with local collaboration with an extensive group of partners both internally and externally to address issues related to women/maternal health. Three vital and successful partnerships with the KY Perinatal Association (KPA), KY Chapter of March of Dimes (MOD), and the Healthy Start Program in Louisville have created opportunity for MCH to work with grass roots organizations and collaborations beyond the reach of the LHD or birthing hospitals. This work led to establishment of the Kentucky multidisciplinary MMRC, KY Perinatal Quality Collaborative (KyPQC) and Alliance for Innovation on Maternal Health (AIM) designation in 2020. This work convened by MCH Title V leadership, continues to be a primary source of information for perinatal health. The collaboration has the highest level of leadership involved in DPH, BHDID, local hospital leadership, KPA, AWHONN KY, MOD, and more.
As efforts to address outcomes progressed, KY elected to retire in FY20, NPM #2: Percent of cesarean deliveries among low-risk first birth. KY preterm birth rates prior to 37 weeks gestation remain higher than national averages supporting efforts to reduce early elective deliveries and address maternal morbidities that may lead to a medically necessary early delivery. Work to improve this outcome included legislation to limit payment for early elective deliveries by state MCOs and Medicaid, multiple awareness and health promotion campaigns, dissemination of KY specific data, webinars, and regional/state meetings. Through all efforts, KY worked closely with March of Dimes and the Kentucky Perinatal Association. During this time, it was noted hospitals which developed a strong review system to determine medical necessity, had lower rates of elective C-section.
During the 2020 needs assessment, local stakeholders were vocal about improving the health of women of childbearing age. This concern had the highest count from participants for this domain. Many comments related to obesity, tobacco use, substance use, and morbidities that lead to early deliveries were discussed. One participant in a large urban area noted women who are not actively seeking family planning options may not have a well woman visit until pregnancy. Available data from the Behavioral Risk Factor Survey System (BRFSS) shows 70.8% of KY women report having an annual well woman exam. This visit is critical, which serves as an opportunity to counsel the woman on a healthy lifestyle to minimize health risks and poor outcomes across the life course.
With a heightened awareness regarding morbidity, referral, and improving the overall health of the woman, KY MCH shifted program plans to address NPM #1 Percent of women, ages 18 through 44, with a preventive medical visit in the past year and the well woman visit with a goal to improve rates of visits and reduce morbidities in pregnancy.
KY MCH has had a strong partnership with the CHFS Division of Women’s Health (DWH), which has developed relationships with many federally qualified health centers (FQHCs) for family planning and collaborates with the LHDs and FQHCs for delivery of services for breast and cervical cancer screening, evaluation, referral, and treatment. This relationship allows both the DWH and MCH to extend messaging deeper into the community.
During 2020, the MCH perinatal program nurse consultant met with leaders from Healthy Start, March of Dimes, local Jefferson County Doulas, midwives, and others to understand best practice efforts for encouraging women to prioritize themselves and their annual exam. This effort also had many discussions related to health equity, particularly in the west side of Louisville and ongoing issues with racial bias. From these discussions, a new MCH best practice package was developed and initiated beginning with state FY22 to address promotion of well woman exams, ongoing care of chronic health conditions, resource and referral for any identified needs, media promotions or other innovative ideas the LHD may have to improve rates of women getting their annual exam, immunizations, and screenings.
Maternal Morbidity:
Discussions held during 2020 with the DMS Chief Medical Officer, Dr. Judy Theriot, DPH Deputy Commissioner Dr. Connie White, KPQC, and KPA included how Kentucky women have multiple risk factors for poor pregnancy/birth outcomes ranging from smoking, substance use, obesity, diabetes, hypertension, or SDoH factors such as abject poverty, lack of healthy food, housing instability and others.
Kentucky joined a Medicaid Innovation Accelerator Program looking at development of data analytic capacity to support reduction of maternal mortality and severe maternal morbidity in Medicaid. Review of DMS data sets by maternal ICD codes revealed alarmingly high rates of some severe maternal morbidities.
Rates of maternal mortality (MM) and severe maternal morbidity (SMM) are rising and disproportionately affect African American and rural moms. Recognizing these challenges, the Kentucky Department of Medical Services has interested in strengthened its partnerships with the Kentucky Department of Public Health (DPH), specifically with the recently established Maternal Mortality Review Committee and Perinatal Quality Collaborative, thereby building analytic capacity to examine MM and SMM in Medicaid enrollees. SMM was identified based on the Center for Disease Control and Prevention’s (CDC’s) 21 indicators of severe maternal morbidity. Key findings from the Preliminary analyses include the following:
- In 2017, the prevalence of MM was 13.5 per 10,000 live births. The prevalence of SMM was 350.4 per 10,000 live births.
- Beneficiaries with one or more SMM diagnoses were 20.5 times more likely to die in the first year after delivery than beneficiaries without SMM diagnoses.
- The rate of MM among women with SMM was more than double the rate among women without SMM, consistent with the notion that SMM and MM are part of a continuum of increasing adverse maternal outcomes.
- The most common forms of SMM that led to death were cardiac arrest/ventricular fibrillation, ventilation, and acute myocardial infarction.
Kentucky Medicaid has been chosen to participate, as one of nine state teams, in the Improving Postpartum Care Affinity Group.
- A key challenge and major intervention for this population is in increasing both the quantity and quality of postpartum care visits, as well as continued screening and support systems for women in this population.
- Beginning in 2021, Medicaid’s managed care organization partners all have value added services for pregnant and parenting women. Women with high-risk pregnancies will receive care management services, and all women will receive incentives for attending prenatal care visits and postpartum care visits.
Despite all the advances in science, maternal morbidity and mortality has not decreased in recent years. In fact, as KY developed better analytics for the Maternal Mortality Review Committee (MMRC), it was evident there was growing concern for looking at all causation for maternal mortality. Drivers for morbidity became a topic of concern for the MMRC with a need to engage and continue development of the KY Perinatal Quality Collaborative (KyPQC).
The health care delivery system in KY has undergone significant changes in the past few years through Medicaid expansion and the implementation of components of the ACA. The number of individuals in KY without insurance has decreased dramatically. The women who have health care coverage are now able to access preconception and interconception care.
Other changes such as public health transformation reduced services through local health departments. LHDs continue to struggle with adapting to population health services for prevention and promotion. Successful LHD endeavors are ongoing assistance to apply for KY Medicaid and the wrap around services that create a safety net for clinical services for pregnant women. They assist with presumptive eligibility for Medicaid. LHDs provide assurance that women can access prenatal care in their community, whether by referral to local obstetricians or contracts with local providers.
Access to prenatal care is enhanced by presumptive eligibility (PE) for a short duration of time, 60 days, while eligibility for full Medicaid benefits is determined. While PE is very valuable, women who ultimately are denied benefits may not apply for PE until late in pregnancy to assure some form of coverage for the expensive cost of delivery. As local health departments move to PH Transformation, the safety net provided by LHDs may greatly decrease.
Title V grant funding may be used to support education, outreach, or enabling services for this population. Referrals to address smoking cessation, domestic violence, mental health services, and substance use disorders is standard service for each LHD. Many have many contracts with a FQHC in the area.
Preconception health counseling, including the distribution of folic acid/multivitamins, continue at LHDs and partner providers through MCH and Family Planning Programs. Women seen in the LHD or through contracted providers were provided preconception counseling and, when needed, a year’s supply of multivitamins. Clients, with positive pregnancy tests, received prenatal vitamins and counseling by the local health department staff, along with counseling on how to obtain prenatal care, apply for Medicaid, and referral for other services if noted during initial screening.
Substance use disorder creates further challenges in identifying and protecting the pregnant woman. Women have fears of removal of the infant at birth and do not readily seek out prenatal care. Treatment options across the state are varied, and social supports for these women are inherently limited. While the work and planning for a plan of safe care has progressed to piloting the Healing, Empowering, and Actively Recovering Together (HEART) Program, communities across the state are needed for expansion of this promising program. Establishing HEART requires time, workforce, funding, and a strong community collaborative team that has all stakeholders at the table with each entity actively supplying funds, staff, and knowledge to assure success.
As MCH worked with providers for the needs assessment, reviewed mortality cases, and began the KyPQC, other concerns were raised regarding domestic violence, depression, and use of alcohol or marijuana during pregnancy, and oral health. PRAMS provided a unique understanding of the values and beliefs held by Kentucky mothers.
2019 PRAMS Cohort:
Among this cohort’s unintended pregnancies:
- Three out of five mothers were not using contraceptives at the time of conception.
- Half of mothers that never wanted to be pregnant were not using contraceptives at the time of conception.
- More than half of the mothers who had unintended pregnancies fall between the ages of 20-29 years.
Smoking/Substance Use:
- Roughly one in four mothers reported smoking at some point during their pregnancy (27%)
- Just over 6% of respondents report e-cigarette use before pregnancy; 2% report e-cigarette use in the last three months of pregnancy.
- 5% of mothers report marijuana use during pregnancy.
- 14.5% of women reported alcohol use prior to pregnancy.
Prenatal Care:
- Four out of five PRAMS mothers received adequate prenatal care, based on the Kotelchuck Index.
- Four out of five PRAMS mothers report having some sort of dental insurance. Of respondents 9% report having trouble finding a dentist to take Medicaid patients.
KBSR:
For NOM 10, KY does not have a reliable data source. In review of birth surveillance data, the number of children with FAS annually is listed below. It is anticipated that the 2018-2019 counts could be artificially low as diagnosis can occur as late as age 3-5 when a child may miss developmental milestones.
- 2015: 27 children
- 2016: 23 children
- 2017: 28 children
- 2018: 22 children
- 2019: 17 children
Prenatal Health:
With an understanding of the risks associated with late prenatal care, additional data sets were reviewed. Overall, 76% of all live births in Kentucky have early prenatal care initiated. Most of these were in rural areas of the state. The Healthy People 2020 goal was for 77.9% of pregnant women to receive early prenatal care.
While Kentucky is close to 2020 Healthy people goal, there are still areas of rural Kentucky well below the state average.
Resources to a birthing hospital and providers are likewise limited for these areas. Far eastern Kentucky is served by the University of Kentucky, Baptist Health, Saint Joseph chain of hospitals, and the Appalachian Regional Hospital systems. Within these systems of care, there are many opportunities for regional care clinics and providers. In western Kentucky, there are far fewer birthing hospitals limiting access to care.
With the advent of Public Health Transformation, LHDS have limited access and provide minimal screening to the pregnant woman. LHDs are assisting women in KY needing prenatal and postnatal care with family planning, pregnancy tests, referrals to obstetric providers, and wraparound services, including HANDS, WIC, and support for smoking cessation, dental care, interpersonal violence counseling and substance abuse treatment. To improve pregnancy outcomes, LHDs departments have established contracts or collaborations with service providers within the community to furnish care to lower income and high-risk women and their children. This system allows the LHD to set the appointment and have a warm handoff of the pregnant woman care.
Early prenatal care among the Medicaid population is slightly less than those insured with other sources. Anecdotal discussions with stakeholders at the LHDs were varied for “why” they felt this occurred. Some noted many women do not qualify for Medicaid benefits prior to pregnancy and that they may not know the pregnancy may qualify them for benefits. Other reports were that undocumented immigrants did not apply as they understood presumptive eligibility (PE) time limitations and waited to obtain Medicaid so their PE time would be during delivery to cover the expensive hospitalization. For this group of women, when denied Medicaid, their ability to seek care. The greatest ideas were that some women with substance use disorders cannot mentally or cognitively complete the process of enrollment or are frightened of engagement with healthcare providers as they fear their child will be removed from their care upon birth. Kentucky continues work to understand barriers and build systems of care to overcome using local resources when available.
Early prenatal care data was reviewed from multiple perspectives. By age, it is not surprising that the highest rates of initiation of care were between 20-34 years of age. Likewise, lower rates were in the teen population or among those women who did not complete high school. Educational attainment resulted in improved likelihood of early prenatal care initiation.
As reported on Kentucky live birth certificates, early prenatal care was disproportionally and significantly higher among Caucasian mothers (85.2%) as compared to Black mothers (8.3%). Black mothers were almost 3 times more likely to have no prenatal care. Black mothers had higher rates of late prenatal care as compared to Caucasian mothers.
With the largest population of black Kentuckians residing in urban areas of the state, where the largest number of resources, hospitals, and providers, this is an alarming fact.
One major resource is the work by Healthy Start Louisville who strives to understand and overcome barriers for engaging women earlier in pregnancy. This group focuses on embraces racial, ethnicity, and cultural differences to ensure each client can have strength in understanding their opportunities for care, insurance, or resources. More information regarding the work of Healthy Start Louisville is included in the Perinatal Health domain narrative.
Preterm Birth:
KY’s prematurity prevention activities began through a pilot project to reduce preventable preterm birth with funding from the MOD and Johnson & Johnson Pediatric Institute with many activities developed out of the Healthy Babies are Worth the Wait campaign. Lessons learned from this campaign are ongoing in health promotion to reduce early elective deliveries by the LHDs, hospitals and providers. This community-based, multi-layer approach to prematurity prevention in three intervention communities with a range of health care settings was successful in showing that a partnership between hospitals, health departments, and communities could reduce preterm birth from EED which could also influence prematurity rates. In pilot sites that engaged all parties in reducing preterm rates, they noted a 12 percent decline for their areas. However, over the years, this activity at the LHDs shifted in focus to harm reduction activities, and linkage to care.
Overall, the rates for KY preterm births have been static and above the national rate. Data from the OVS birth certificate files show the percentage of births were higher for black infants (14.1%) than for white infants (11.2%). Preterm births were more likely in women age 35 or older and in women with less education, further reinforcing a need to continue health promotion and prevention activities to improve the health of the woman prior to conception and across the life course.
Preterm rates are significantly higher in the far eastern part of Kentucky with limited resources, higher rates of poverty, higher rates of substance use, and other SDoH risk factors. Efforts to reduce preterm birth rates are focused on behavior changes and outreach.
Preterm birth primarily occurs (74.1%) at 34-36 weeks of gestation. Of preterm births it is notable that 80% of preterm births had smoking during pregnancy as a risk factor.
Data Dissemination:
During 2020, MCH convened meetings with KY MOD Chapter, KPA, and Healthy Start Louisville to address social determinants of health, provide data from many MCH programs, and present quantitative KY specific data. From this effort, 5 web-based training opportunities were developed and placed on KY TRAIN for attendance of any discipline. Reviews of the courses have been positive with the greatest response to the presentations about NAS and the MCH opioid response for Kentucky.
Additionally, MCH distributed the annual NAS report, and other data briefs topic specific for MCH programs or initiatives via email distribution lists, and in collaboration with the KPQC, or KPA work.
Hepatitis C:
The Viral Hepatitis Program (VHP) had a large impact from pandemic as the two staff members in this program were assigned to the DPH Covid-19 response full time. During this time, the VHP was still able to add three additional FTEs in the coming months: an additional epidemiologist, a perinatal hepatitis C epidemiologist/coordinator, and a prevention coordinator. The perinatal hepatitis C position is part of the CDC Epidemiology and Laboratory Capacity (ELC) grant, housed within the Reportable Diseases Section. Hepatitis C was an optional project in the base grant focused on congenital infections. Despite competing priorities with pandemic response, VHP recognizes the following accomplishments:
- Collaboration with CDC to build a perinatal hepatitis C page in the National Electronic Disease Surveillance System (NEDSS) during the hepatitis Message Mapping Guide implementation process. The page is currently in the staging environment in NEDSS. There is a page for the birth parent and infants/children and these pages can be associated with one another. This will replace the current tracking system, GenTrack (a homegrown system).
- Collaboration with the Kentucky Health Information Exchange (KHIE) and Deloitte to build pages for electronic case reporting for hepatitis C. Once complete, this will replace the EPID 394 paper form that is completed and faxed to public health. Eventually, the goal is to automate the electronic case report entering into the NEDSS page mentioned above.
- Awarded new program funding for continued prevention and surveillance efforts: CDC PS21-2103 Integrated Viral Hepatitis Surveillance and Prevention Funding for Health Departments. Kentucky was one of fourteen jurisdictions awarded for an optional component focused on prevention of hepatitis in persons who inject drugs.
- Continued progress in utilizing robust electronic lab report data to determine prevalence, disease distribution, and continuums of cure and care for hepatitis B and C.
Tobacco Use:
Reducing tobacco use among pregnant women in KY continues to have a high priority. Over the years, many efforts and programs were initiated with minimal success in reducing and engaging women to stop smoking prior to conception or during pregnancy. The current MCH Assistant Director, Andy Waters has noted on many occasions the difficulties in establishing a program that can successfully engage pregnant women. The perinatal nurse consultant has noted small successes with previous endeavors only when there was a full-time employee at the pilot program who kept a warm 1 on 1 relationship with the mother seeking to stop smoking. In areas in which there is not an actual person making ongoing care coordination/case management contact, and doing referral services only, rates were far less successful to getting the pregnant woman to engage with the KY QUIT line or other smoking cessation initiatives.
While the percentage of women who smoke during pregnancy steadily declined in it is well above the US rate of 6.5%. Smoking during pregnancy is more likely to occur in women with less than college education. Caucasian women were more likely to smoke in pregnancy than black women, and over 2/3 of those who smoked during pregnancy in 2018 had a high school education or less.
Geographical distribution of smoking during pregnancy continued to be highest in KY districts with the highest poverty rates and other social determinants of health impacting access to care, education, employment, and transportation. Tobacco use is a common factor in premature birth, birth defects, and it is a risk factor for sudden unexpected infant death. These outcomes have higher rates in the same areas of KY in which tobacco use and substance use rates are higher in pregnancy.
Quit Now KY has a pregnancy/postpartum protocol that is available to all KY residents 15 years of age or older who are currently pregnant. This protocol includes a designated female coach assigned to each pregnant woman. During pregnancy, each woman receives $5 per completed call for up to $25 and during postpartum each woman receives $10 per completed call up to $40.
In 2019, MCH explored the Tobacco Prevention and Cessation Program methods to improve outcomes for pregnant women who smoke. The following Prenatal Smoking Performance Improvement Plan (PIP), through an enhanced Obstetric Care Management model, continues to be refined in partnership with Medicaid MCOs and the Quality Improvement Branch. The suggested PIP template suggests the following areas:
- Develop a care management program to enhance reach to target the smoking subpopulation for smoking cessation outreach and follow-up.
- Tailor care coordination with care management to susceptible subpopulations as indicated by risk factors identified in focused study.
- Use Health Risk Assessments (HRAs) and develop new methods to identify smokers.
- Improve HRA response rates by collaborating with providers to complete HRAs for new members.
- Develop a MCO smoker registry to identify smokers for outreach, engagement in cessation counseling, and referral to the KY Quitline.
- Work to track members who contact the Quitline, receive services, and monitor quit status.
While KY has made some progress in decreasing the number of women who smoke during pregnancy, the rates of smoking during pregnancy in KY remain almost double that of the nation. KY is consistently one of the worst states on this indicator. Initial efforts to encourage participation of pregnant smokers in Quit Now KY have not been successful. In 2020, there were a total of 56 women enrolled in the pregnancy protocol and 43 women enrolled in the post-partum protocol.
Title X Family Planning:
The Division of Women’s Health (DWH) continues to administer the Title X Family Planning Program (FPP) with a priority to provide all citizens of KY, especially low-income citizens, with quality family planning services. KY Public Health (PH) Transformation in 2019 has changed how the FPP is providing access to family planning across the state. PH Transformation removed family planning as a core public health service, defining it as a service based on local public health priorities.
As a result of PH Transformation, 26 of the 62 LHDs chose to either decline Title X funding or receive limited funding to provide only STD testing and pregnancy testing. These 26 LHDs also declined all Kentucky Women’s Cancer Screening Program (KWCSP) funding to provide breast and cervical cancer screening. The DWH has worked to partner with the FQHCs and other providers in all areas of the state where LHDs limited or stopped providing family planning services.
Promotion of an annual exam is encouraged for patients receiving family planning services. The year 2020 has proved difficult for family planning and other clients to obtain annual exams due to the restrictions caused by the COVID19 pandemic. Although telehealth visits helped bridge the gap for some of the visits, there are some parts of annual exams that must occur in-person. This resulted in a decrease in the number of family planning visits. 24,173 women were served by Title X for the year of 2020 compared to 35,518 women served by Title X for the year of 2019.
Teen Birth:
Since 2008, KY has experienced a steady decline in teen birth rate of fifteen to nineteen-year-olds. The teen birth rate has steadily decreased from 13.1% in 2008 to 6.4 in the current reporting period.
MCH collaborated with the Division of Women’s Health (DWH) Adolescent Health Program on many adolescent health issues. The DWH Adolescent Health Program continues to receive federal funding to prevent teen pregnancy and promote positive youth development through the Sexual Risk Avoidance Education (SRAE) grant and the Personal Responsibility Education Program (PREP) grant. Beginning in state FY22, Adolescent Health, the SRAE and PREP grant work is being organized to the Child and Family Health Improvement Branch of Maternal and Child Health.
KY continues to struggle with high teen birth rates in comparison to the national rates. Historically, KY’s teen birth rate ranks 5th to 7th highest in the nation, depending on the year. While the overall teen birth rate is improving, a geographical view revealed areas in eastern Kentucky have teen births accounting for as much as 10.8%.
The teen birth rate is higher in Blacks at 7.4% compared to 6.2% in Caucasians.
Teen births were more likely to have early prenatal care.
Another alarming finding is the number of births to KY children less than age 15, reinforcing the need for intervention with child abuse and for education at younger ages regarding sexual intercourse. KY Youth Risk Behavior Survey data had data showing between 5.5-9.7% of middle school students reported having sexual intercourse in the past 3 years.
In the past 3 months, the MCH Adolescent Health program began collaboration planning with the Department for Community Based Services (DCBS) Division of Family Support and their "The Assistance for Needy Families" (TANF) grant. One of the goals of the TANF grant is to "Prevent and reduce the incidence of out-of-wedlock pregnancies" which mirrors the premises of the Sexual Risk Avoidance and Personal Responsibilty grants. A second goal of TANF that fits well with these two grants is to "Encourage the formation and maintenance of two-parent families" to "foster economically secure households and communities for the well-being and long-term succcess of children and families".
Kentucky participates in the Youth Risk Behavior Survey (YRBS) Program through the Centers for Disease Control and Prevention (CDC). Biennial surveys taken from Kentucky middle and high school students in the areas of Nutrition, Physical Activity, Injury and Violence, Tobacco Use, Alcohol and Drug Use and Sexual Activity are recorded. The following table describes trend data for 2015 to 2019 in several areas
Maternal death is the worst outcome of pregnancy with one death being too many. Maternal deaths have significant repercussions, as women are crucial to a prosperous and healthy community. In KY, maternal mortality rapidly increased with some years double or triple the rate known prior to 2013. This prompted a deeper evaluation for cause and manner to attempt to understand the rise of cases. As in the figure below, the rate of maternal deaths in KY nearly doubled between 2013 and 2018. With a deeper review of only death certificate data, it became evident that many of the maternal deaths had influencing factors associated with substance use disorder.
Further review of accidental deaths found over half had at least one ICD code related to substance use disorder or drug overdose.
In 2017, the Maternal Mortality Review Committee (MMRC) was developed and began reviewing deaths from calendar year 2017. The pregnancy-associated but not related causes such as accidental injury, suicide, and homicide, appear to be the precipitating cause of most of these deaths. Pregnancy relatedness was determined by the MMRC of each case reviewed. Findings from 2018 cases are below:
Additionally, the MMRC determined with the death certificate data and case findings the immediate cause of death. From the 2018 Cohort the greatest number of cases had multiple causes of death and one immediate cause was not determined. The second largest category was directly related to drug intoxication and/or overdose.
DPH reviewed the 2018 substance use cases for more detailed information. With an increasing rate, it became imperative for Maternal and Child Health (MCH) to understand the factors influencing this increase. The MMRC was able to contribute substance use as a contributing factor in over half of the maternal mortality cases.
Comparison of the 2017 and 2018 cohorts for key factors is displayed below. Cardiac diagnosis related to substance use along with polysubstance use was one driver in recommendations for the KPQC planning committee.
The greatest sobering factor was the categorization that resulted in some probability of preventability in all of the maternal mortality cases with 1 of 9 cases determined to have been preventable with intervention during the pregnancy, delivery, or postpartum period.
Many had substance use involvement, mental health concerns, or other identifiable causes that if intervention had been taken could have potentially saved the life of the mother. These includes seatbelt use, substance use treatment with care coordination, early referral/treatment and management of underlying health conditions such as diabetes or infectious disease. Likewise, it is known that social determinants of health, such as transportation, homelessness, access to care, domestic violence, and a geographically rural state, limit early preventive care to reduce risk and address morbidities. Factors affecting morbidity, such as tobacco use, obesity, socioeconomic disparities, depression, mental health conditions, and substance use disorder increase the risk of mortality in Kentucky.
Disparities in KY vary by geography, race, and access to care. Appalachian communities are unique and deserve special attention given the rural, resource-limited, socio-economically impoverished nature of families in this part of KY with an additional burden of low health literacy and limited access to care. Nationally, African American women are estimated to be three to four times more likely to die from a pregnancy-related complication.
From review of death certificates, maternal deaths appear to be higher among black women in the two largest urban cities of Lexington and Louisville. Providers and birthing hospitals are more readily available in these urban cities. Although providers and birthing hospitals are readily accessible, there are other factors such as lack of transportation, lack of insurance, and systems issues that may be a barrier when seeking prenatal care that may explain disparity in maternal mortality by race.
Prenatal care visits among maternal mortality cases were evaluated to determine at what point mothers engaged in healthcare. The chart below shows the highest rate had 10 or more visits during pregnancy.
In addition, DPH categorized the deaths within the periodicity below to examine how these maternal deaths related to the timing of labor and delivery.
A recommendation from the review of the data in the graph below is for obstetricians to follow-up with mothers within 3 days to 1 week from delivery and more intensive 6 weeks visits, screenings, or assessment instead of a general follow-up in 6 weeks. As shown in the table, over 20% of cases occurred within 3 days of delivery.
During the past year, the Covid-19 pandemic affected the MMR process by increasing the amount of time in receiving the requested records from various facilities. Some facilities changed their internal process of requesting records and so the MMRC coordinator had to adjust the process of requesting records. Some facilities with only one medical record staff person work only work one day a week, thus slowing down the timeframe in receipt of records. During the pandemic, the MMRC continues to meet every 2-3 months but these meetings are held virtually. With most maternal deaths determined to be preventable, it is imperative KY identify factors involved in maternal deaths and translate MMRC recommendations into prioritized strategies for primary, secondary, and tertiary prevention to reduce maternal mortality. New recommendations from the review of cases this past year include address the continuation of respiratory and cardiac evaluation as well as comprehensive healthcare evaluations of the woman throughout her pregnancy, providing targeted case management and incentive based postpartum visits, and addressing substance use through the development of standard of care, linkage to prenatal care for substance use women and creating a consultation team related to opioid usage and intervention.
Kentucky Perinatal Quality Collaborative:
In November 2018, KYMCH, DPH, and Medicaid began exploring options to revive the KY Perinatal Quality Collaborative (KyPQC). This involved research with successful perinatal collaboratives in other states, research into the successes and barriers previously experienced in KY, and collaboration with the MOD, KPA, and the Association of State and Territorial Health Officials (ASTHO). The planning began with a federal ASTHO strategic meeting involving the DPH Commissioner, Chief Medical Director for KY DMS, MCH Division and Title V Block Grant Director, and the BHDID Director. From this meeting, a strategic plan was developed for the next 18 months that included development of a KyPQC to address substance use in pregnancy and Neonatal Abstinence Syndrome (NAS) plan of safe care.
This effort grew with the CDC grant award to the KIPRC for establishment of a KyPQC to work on the program plan developed with ASTHO and a field agent housed in DPH from ASTHO. With this support, KY held the official launch meeting of the KyPQC in October 2019 at Churchill Downs in Louisville, KY. The KyPQC Central Office is housed in the DPH, which serves as a means to enhance networking and collaboration with other statewide programs that work in the realm of improving maternal and infant health throughout the state of Kentucky. The overall mission and vision of the KyPQC is to make Kentucky a great place for every woman to have a baby and a great place for every baby to be born!
The KyPQC is comprised of three workgroups: Obstetrics (OB), Neonatology (Neo) and Data & Analytics that develop goals and initiatives to improve maternal and infant health outcomes. A Steering Committee, an advisory board of 15 appointed members with representation from key stakeholders that includes health industry leaders, professional organizations, public and private payers, universities, and birthing hospitals, monitors the goals and initiatives developed by workgroups to ensure alignment with the mission of the KyPQC.
The OB and Neo workgroups developed two surveys (NAS Reporting Baseline Survey and Perinatal Pain Relief for Opioid Use Disorder (P-PROUD) Baseline Survey) that were administered on January 11, 2021 to all 46 birthing hospitals in the state to gain information about hospital-specific practices in regard to the care and treatment of women and infants affected by SUD/OUD. The results of these surveys allowed KyPQC to tailor our first quality improvement initiatives to the needs of each hospital and inform the development of training, guidance, resources, and clinical protocols for the standardization of care. KyPQC is currently recruiting 5-6 hospitals to serve as pilots for these first initiatives. The Data & Analytics workgroup supports both OB and Neo initiatives by establishing a data collection tool that the other groups can use when collecting hospital-specific data.
The KyPQC routinely provides updates of workgroup initiatives and accomplishments to a growing network of more than five hundred current newsletter subscribers. The KyPQC also hosts regular webinars on current and important topics in the perinatal care space that provides hour long education and training. Recordings of all webinars undergo a credentialing process that allows participants to receive nursing contact hours following the completion of an assessment.
Furthermore, the enrollment, of Kentucky into the Alliance for Innovation on Maternal Health (AIM) program as part of the 2021 spring cohort is another key resource for the data and quality improvement infrastructure. AIM is a national data-driven maternal safety and quality improvement initiative working towards reducing preventable maternal mortality and severe morbidity across the US. Kentucky joins 40 other states (including the District of Columbia) already participating in AIM to focus on national, state, and hospital-level quality improvement efforts for improving overall maternal health outcomes.
MCH Best Practice Strategy Packages:
In SFY19, the MCH Prenatal Care Tracking Package was selected by 23 LHDs with 1,944 women receiving assistance in obtaining and continuing prenatal services. This strategy helped LHDs improve their internal process of tracking the initiation and continuity of prenatal care. Pregnant women receive referrals for services such as WIC, HANDS, breastfeeding peer counseling, and other services as appropriate. The specific strategies include coordinating care for pregnant women with local providers, ongoing contact with pregnant women, assistance with enrollment in Presumptive Eligibility (PE) and Medicaid, and referral of women denied Medicaid to providers for the Title V Public Health Prenatal Program. Through this package, LHDs are tracking these women to see if they initiate prenatal care within the first two weeks of a positive pregnancy test, thus increasing the chances of improved perinatal outcomes. While following up with patients about initiation of prenatal care, LHD staff may also assess for barriers to care such as a payor source and assist with the application process for Medicaid, PE, or the Public Health Prenatal Program. By assuring that women are obtaining early and ongoing prenatal care, there are many opportunities to educate these women about the risks associated with cesarean sections and EEDs.
In SFY20, 10 LHDs implemented the Prenatal Care Referral best practice initiative practice. This work reached 1,408 women with referrals of 166 women for prenatal care within the first trimester, linked 352 women to WIC, 340 to the HANDS home visitation program, 363 for dental care, and over 400 being screening for intimate partner violence, depression, and substance use. This work often involved connections with local birthing hospitals, local OB/GYN and substance use centers that directly served pregnant women in obtaining MAT.
Other Programs Affecting Women and Maternal Health:
KY’s progress related to maternal morbidity continues through the Health Access Nurturing Development Services (HANDS) home visitation program. HANDS began in 1998 as KY’s voluntary home visitation program designed to assist overburdened expectant and first-time parents, prenatally through age 3. In 2011, HANDS expanded to serve multigravida families. HANDS’ focus on fostering early childhood development, nurturing relationships, and learning which serves more than 12,000 families statewide. The paraprofessional and professional HANDS home visitors build relationships with the parents of young children and work on positive parenting and family self-sufficiency skills using a strengths-based curriculum. These protective factors build resilience and positive outcomes for both the child and parents. Previous outcomes studies report the infant mortality rate was 74% less likely among HANDS participants than statewide.
KY was a recipient of formula and competitive grant funds through the Maternal Infant Early Childhood Home Visiting (MIECHV) Program. At full implementation, 78 counties received expanded services (in addition to the core HANDS program, which is in every county). Due to changes in the federal MIECHV, currently only 29 of KY’s highest at-risk counties receive support by MIECHV Formula funds. The benchmark results from this program found improvements in maternal and newborn health; school readiness and achievement; increased screening for domestic violence and referrals for victims of domestic violence; family economic self-sufficiency; referrals for other community resources; decreased mother and child visits to the Emergency Room; and decreased incidence of child injuries requiring medical attention.
During 2018, the state workforce for HANDS was dramatically reduced as veteran staff retired or found other state promotional opportunities. Regardless of this workforce transition, HANDS continued to meet federal standards of programming with local field representatives’ assistance and serve the women and children of KY. In 2020, MCH was able to onboard and fill many of the vacant positions. As previously stated, HANDS work targeting reaching at risk families using multiple virtual platforms, telephone care coordination, and addressing other barriers for virtual engagement such as lack of internet connectivity services and more.
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