For reporting year 2021, the Bureau of Family Health (BFH) conducted activities in the Women/Maternal Health domain through Title V funding with additional federal funds from the Centers for Disease Control and Prevention (CDC) for support of maternal mortality prevention initiatives. Taking into consideration the overall population needs and current partners, the BFH has developed strategies that do not duplicate other funding sources, and that fill gaps not addressed by the existing system of care and current partners.

 

In 2019, there were over six and a half million women living in Pennsylvania (Pa.). The racial composition of this population is 81% white, 12% Black/African American, four percent Asian/Pacific Islander and two percent multi-race. Eight percent of women living in Pa. identify as Hispanic/Latinx. Several factors contribute to poor maternal outcomes and particularly disparate outcomes for Black/African American birthing people and babies. These factors include systemic racism, substandard housing, unsafe neighborhoods, stress, mental health issues, tobacco, and other substance use as well as intimate partner violence (IPV). Poor mental health, substance use (including substance use during pregnancy) and IPV have particularly negative consequences on a family.

 

In the United States, about 1.5 million women report being victims of some form of IPV every year. Of these reported cases, approximately 325,000 are pregnant during the acts of violence. The reason for this spike in IPV during pregnancy is unknown but could be due to relationship dynamic changes between partners, or that the frequency of prenatal visits yields more positive screens simply because patients are being screened more frequently. What is known is that intimate partner violence affects pregnancy more than any other common pregnancy complication. Experiencing IPV during pregnancy is associated with higher rates of depression, suicide attempts, and behavioral risk factors including the use of tobacco, alcohol, and drugs. Additionally, research has shown that birthing people abused during pregnancy are twice as likely to miss prenatal care appointments or initiate prenatal care later than recommended, supporting an association between insufficient prenatal care and adverse birth outcomes, including preterm delivery and low birth weight. Nationally, about five percent of pregnant people use illicit substances and one in seven birthing people experience symptoms of peripartum depression.

 

The COVID-19 pandemic has resulted in a host of additional challenges for birthing people in Pa. Preliminary data suggests that birthing people – particularly individuals of color – have experienced disproportionately higher rates of mental health concerns and substance use disorders, while simultaneously facing reduced access to supports for IPV and behavioral health needs in comparison to pre-pandemic life. According to the American Journal of Emergency Medicine, domestic violence cases increased by 25%-33% globally in 2020. In addition, reports from maternal health advocates have indicated that pregnant individuals have experienced reduced access to doula care and family supports before, during, and after childbirth, due to hospital policies related to COVID-19 as well as the difficulty of providing in-person care while ensuring the health and wellbeing of all parties. Finally, birthing people with children have faced challenges due to school closures, hybrid in-person/virtual school schedules, lack of childcare, job insecurity and other economic factors. Although most of these issues – behavioral health concerns, access to timely and quality supports, childcare, and employment and economic security – have historically been an issue for disproportionately affected groups, including pregnant and postpartum people, the increased prevalence of these concerns over the course of the pandemic, coupled with reduced access to services and supports, may have serious long-term consequences. For example, pregnant and postpartum people may be more likely to engage in unhealthy behaviors, such as increased drug or alcohol use, to cope with the stress of the pandemic; this uptick may be reflected in maternal and infant health outcomes over the coming months and years.

 

Priority: Reduce or improve maternal morbidity and mortality, especially where there is inequity

 

The preconception and interconception periods are times when having access to a trusted health care practitioner is valuable, and that present opportunities for important conversations to occur. Data analyzed through Pregnancy Risk Assessment Monitoring System (PRAMS) surveys suggest that when birthing people have a health care practitioner talk to them about health issues, there is recognition and value in those conversations as preventative measures or interventions. Pregnancy and the postpartum period present a window of opportunity for home visitors, obstetricians, pediatricians, and other providers to assess and take steps to improve both the physical and mental health of birthing people and families, if the providers can connect with and gain the trust of the birthing people they are serving.

 

In 2019, 74.2% of all birthing people in Pa. received prenatal care in the first trimester. Of those who received prenatal care in the first trimester, 77.9% of birthing people were white, 64.2% of birthing people were Black/African American, and 65.4% of birthing people were Hispanic/Latinx. Racial disparities are evident and continue to persist with 1.1% of white birthing people, five percent of Black/African American birthing people and 3.7% of Hispanic/Latinx birthing people receiving no prenatal care.

 

Unhealthy birth outcomes, such as low birth weight and preterm birth, are influenced by many factors both before and during pregnancy. Preconception care allows birthing people to talk to their provider about steps to take to promote a healthy pregnancy before conception or implement strategies to delay pregnancy. It also opens the door for early entry into prenatal care. Prenatal care continues to be a crucial method in identifying health issues throughout pregnancy, allowing for early intervention and healthier birth outcomes. Additionally, pregnancy intention is associated with several health outcomes. Studies indicate that unintended pregnancies are associated with a plethora of adverse physical health, psychological, economic, and social outcomes which impact birthing people, their families and society. The BFH focuses on preconception, pregnancy, postpartum, and interconception care and uses programming to provide tools and resources to the birthing people and families served by Title V. By implementing interconception and preconception care initiatives, the BFH intends to positively influence birth outcomes.

 

NPM 1: Percent of women, ages 18 through 44, with a preventive medical visit in the past year

 

Strategy: Increase the percent of women who successfully complete evidence-based or informed home visiting programs 

 

Objective: Increase the percent of women who successfully complete an evidence-based or informed home visiting program by 2% each year

 

ESM: Percent of women who successfully complete evidence-based or informed home visiting programs

 

The BFH continued its partnership with the CMHDs to provide local services to residents in their communities. The ten CMHDs are in Allegheny County, Allentown City, Bethlehem City, Bucks County, Chester County, Erie County, Montgomery County, Philadelphia County, Wilkes-Barre City and York City. Each of these locations is affected by poverty, racial and health inequities and greatly benefit from the maternal and child health (MCH) services provided. The CMHDs have been longstanding partners for numerous reasons, one of which is direct access to Title V eligible participants at the local level. The CMHDs serve this population in many different capacities, and it is beneficial to the CMHDs as well as to the families to provide services across a wide range of physical health, mental health, and social services to improve and enrich the lives of families.

 

Various evidence-informed programs and best practices have been implemented to improve health outcomes and to reduce health inequities among disproportionally affected populations served by the CMHDs. The CMHDs provide preconception and interconception care, home visiting, and smoking cessation programs, among others, to improve the health of families. In 2021, 1,615 pregnant and birthing people were served through CMHDs home visiting programs. As of a result of COVID-19, the number of pregnant and birthing people enrolled in and served by home visiting programs decreased from previous years. This was due to discontinuation of in-person visits, adjustment to connecting virtually, and CMHDs emergency response to the pandemic. Despite the continuing challenges of the pandemic, 55% of enrolled participants successfully completed home visiting programs, exceeding the original goal of 24%. If the increased percentage continues in future years, BFH staff will consider revising the goals for this measure. Home visitors have regular contact with families, which facilitates comprehensive, family-centered care. This care puts home visitors in an ideal position to identify and address physical, mental, or emotional challenges pregnant and birthing people may be experiencing, as well as issues within the home, such as IPV, substance use, and social or financial problems.

 

Each of the 10 CMHDs home visiting programs serve prenatal and postpartum birthing people and their infants. Evidence-based or evidence-informed programming and curriculums, such as Parents as Teachers and Partners for a Healthy Baby, provide primary and preventative maternal and infant health services and education on a variety of health topics, such as substance use, healthy homes, safe sleep, fetal development, healthy nutrition for pregnancy, immunizations, birth control and family planning, parenting techniques, and breastfeeding.

 

COVID-19 continued to present challenges for the CMHDs with staffing being affected by vaccine requirements causing the CMHDs to lose home visiting nurses and other staff. Additionally, with the rise in cases, CMHDs remained flexible with home visiting protocols utilizing virtual methods to connect with participants as needed. Several of the CMHDs had waiting lists as the need for services increased due to financial challenges and employment instability affecting families. The need for infant related supplies also increased so CMHDs implemented contactless drop-offs. Other barriers to connecting with families included participants lacking adequate data and technology to access remote services that utilized Zoom or GoToMeeting as well as many participants not feeling comfortable to return to in home visits due to continued COVID-19 concerns. The CMHDs continually work to find solutions to these barriers and challenges to provide the services needed to support their communities.

 

Strategy: Increase the percent of adolescents and women enrolled in centering pregnancy programs who talk with a health care professional about birth spacing or birth control methods

 

Objective: Annually increase the percent of adolescents and women who talked with a health care professional about birth spacing or birth control methods by 1%

 

ESM: Percent of adolescents and women enrolled in Centering Pregnancy Programs who talked with a health care professional about birth spacing and birth control methods

 

In 2021, the BFH continued its partnership with Lancaster General Hospital (LGH) in Lancaster City to provide the Centering Pregnancy Program (CPP). The CPP aims to improve birth outcomes as well as improve the knowledge base of the participants related to pregnancy and parenting.

 

LGH also administers a group specifically for pregnant people with substance use disorder (SUD). Sessions are facilitated by a Licensed Social Worker certified in addictions counseling. The group follows the traditional CPP model of prenatal care but incorporates education specifically related to SUD and pregnancy, such as how to calm an infant going through withdrawal, stress management, and what to expect if your infant must stay in the Neonatal Intensive Care Unit. In 2021, 56 pregnant people enrolled in the SUD CPP group. Challenges to participation included fear of stigma and Children and Youth Services involvement, transportation issues, and scheduling conflicts with counseling and medication dosing appointments. However, despite challenges, the program continues to be successful with 100% of participants reporting satisfaction with their care. Due to increased SUD screenings in LGH’s medical practices, the SUD CPP group continued to have an increase in referrals. The program sessions remained virtual in 2021. The virtual format was more successful for the SUD group by eliminating barriers such as transportation and childcare, allowing participants to attend more frequently, and fostering stronger connections within the group.

 

Combined, LGH’s program served 121 families with a continued emphasis on improving birth outcomes and reducing inequities among this disproportionately affected population in Lancaster City. Of those served, 59.5% were white, and 11.6% were Black/African American, with 37% of participants identifying as Hispanic/Latinx. Program outcomes were positive. LGH saw higher than expected rates for full-term births with 92.9% of their participants delivering at full term. Breastfeeding rates were also positively affected with 86% of participants breastfeeding at birth versus 81% of birthing people prior to the implementation of the CPP. CPP participants were screened for depression and referrals were made to mental health professionals as necessary. The CPP had high patient satisfaction rates, with LGH reporting that 95% of birthing people that completed either the traditional CPP or SUD program were satisfied with the experience.

 

In 2020, a Request for Application was posted for current CPPs to expand previously established programs. The two awarded applicants for the expanded CPPs were Albert Einstein Health Network located in Philadelphia, with a focus on behavioral health screenings and referrals, and WellSpan York, who expanded to serve their Spanish-speaking population by offering culturally and linguistically relevant group prenatal care. Both awardees began their programs in early Spring 2021 and served over 140 birthing persons.

 

The CPPs submitted data related to family planning and birth spacing, specifically how many adolescents and women talked with a healthcare professional about birth spacing and birth control methods. 75.6% of participants enrolled in CPPs talked with a health care professional about birth spacing and birth control methods, not meeting the goal of 85%. Delaying pregnancy allows birthing people in Pa. the opportunity to choose when they are ready to begin or expand their families. It also affords them the opportunity to improve their own health and habits prior to becoming pregnant.

 

Strategy: Implement care models that include preconception and interconception care

 

Objective: Increase the percent of women enrolled in IMPLICIT ICC program screened for risk factors during well-child visits by 1.5% each year

 

ESM: Percent of mothers served through the IMPLICIT ICC program that are screened for the 4 risk factors during a minimum of one well-child visit 

 

In 2021, the BFH partnered with the University of Pennsylvania to continue implementation of the Title V funded IMPLICIT Interconception Care (ICC) Program, wherein maternal screenings are conducted at well-child visits (WCVs). The ICC program is focused on increasing the number of birthing people who see their medical providers in the interconception period as well as changing maternal behaviors to improve overall health and birth outcomes in subsequent pregnancies. This model of care promotes utilizing scheduled WCVs to improve the health of birthing people between pregnancies. As birthing people are often more focused on their baby’s health than on their own and may not attend their scheduled postpartum visit(s), WCVs provide an opportunity to address maternal health risk factors during the interconception period. At each WCV, birthing people are screened for four behavioral risk factors to assess their health (smoking status, depression, contraception use, and multivitamin with folic acid use), and counseled and referred for services as necessary. In 2021, the grantee continued to work toward strengthening the 13 existing IMPLICIT Network (Network) sites and increasing utilization of the ICC model of care, while transitioning the IMPLICIT Network hub from Shadyside Hospital Foundation to the University of Pennsylvania.

 

The effectiveness of the IMPLICIT ICC model of care is measured by how many birthing persons are screened and how many individuals with high-risk behaviors receive an intervention. Two thousand eight hundred sixty-five unique birthing person-baby dyads were served in 2021. Of these, 78.3%, or 2,243 birthing persons, were screened for all four risk factors at a minimum of one WCV. ICC screening was performed at 5,161 WCVs in 2021. This is lower than the 2020 overall screening rate of 78.8% across all sites and did not meet the objective of increasing the percent of women screened for risk factors during WCVs to 81.2%. Of the individuals that received ICC screening, 17.6% screened positive for tobacco use, 14.7% for depression, 18.4% for lack of contraception use, and 42.1% for lack of multivitamin with folic acid use. Interventions for positive screens were documented at the following rates: 88.7% for tobacco use, 86.6% for depression, 75% for contraception use, and 59.6% for multivitamin with folic acid use.

 

The grantee reported that the ongoing strains of COVID-19 on participating providers and the IMPLICIT Network hub, in addition to key staff turnover, contributed to the lower-than-anticipated screening rates. The Network will continue to provide support to ICC sites to improve screening and intervention rates in 2022.

 

Strategy: Implement community-based, culturally relevant maternal care models

 

Objective: Increase the number of community-based doulas providing services in targeted neighborhoods

 

ESM: Number of community-based doulas trained in communities served by the program

 

Doulas are trained to provide non-clinical emotional, physical, and informational support, education, and advocacy during pregnancy, labor, and in the early postpartum period. In addition, doulas help empower pregnant people to establish and maintain positive communications with care providers, resulting in increased engagement in healthcare decision-making. Doulas spend up to 11 times longer with clients than other health care providers and encourage pregnant or postpartum people experiencing warning signs to seek medical attention prior to experiencing a life-threatening emergency. Doula care also improves maternal health outcomes by reducing unnecessary medical procedures that can result in serious short- and long-term complications.

 

Community-based doulas provide pregnant people and their partners with low-cost or free education, support, and counseling during pregnancy, birth, and the postpartum period; focus on eliminating health barriers and disparities; and promote healthy bonding between pregnant people and their babies. In contrast to conventional doulas, community-based doulas share the same background, culture, and language as the pregnant people they support. They also have additional training in social determinants of health, trauma, and racial equity that supplements the traditional doula education curriculum.

 

The Philadelphia Department of Public Health (PDPH) provides care through the Doula Support Program (DSP) to Philadelphia residents. The DSP focuses on prenatal and postpartum people with a history of a SUD, including opioid use disorder (OUD). The program utilizes a community-based doula model to offer support to enrolled individuals up until one year postpartum. Due to a rise in cases of infants born with neonatal abstinence syndrome (NAS), PDPH saw a need to design this program to specifically serve pregnant people with substance use issues. Due to COVID-19, in person visits with doulas was changed to virtual connections with program participants; however, the program was still able to serve 30 people in 2021. Of these participants, 66% identified as Black/African American with 10% identifying as Hispanic/Latinx. Almost 100% of program participants were covered by Medicaid. To foster a sense of community among program participants, the DSP started a virtual parent group that meets twice a month to offer support and facilitate connections among program participants. In 2021, PDPH trained three community-based doulas, meeting the goal, to provide services through this program.

 

Objective: Increase the number of behavioral health providers trained in pregnancy intention assessment

 

ESM: Number of behavioral health providers trained in pregnancy intention

 

The unintended pregnancy rate for birthing people with opioid use disorder (OUD) is 84.9%, significantly more than the national average of 45%. Further, according to the DOH’s “Neonatal Abstinence Syndrome: 2019 Report”, 1,608 Pa. infants were diagnosed with opioid-related NAS after birth, compared to 2,140 the year before. In 2021, the BFH continued its partnership with the Alliance of Pennsylvania Councils, Inc. (Alliance) in an initiative to reduce the rate of unplanned pregnancies in birthing people with OUD. The Alliance is currently comprised of three family planning councils, each serving a region within Pa; a family planning council representing Western Pa. ceased participation in the Alliance since beginning this project.

 

At the beginning of this project, each council was tasked with developing a pilot program to identify and address the specific needs of their region. Projects selected for implementation included training behavioral health providers on assessing their clients’ pregnancy intention and contraceptive needs; facilitating access to family planning services for people in treatment facilities; conducting screenings in schools to identify youth in need of services; and educating communities about substance use disorders (SUDs).

 

The Alliance provided services to improve the preconception health of and reduce unintended pregnancy rates for 3,120 individuals in 2021, 77.3% of whom were diagnosed with a SUD and 63.1% with an OUD. One thousand four hundred seventy-five women (including 747 with an OUD) and 1,642 men with an SUD received services, such as limited scope contraceptive care and sexual and reproductive health education, as a result of this initiative. Unfortunately, due to the continuing impact of the COVID-19 pandemic on the Alliance’s ability to provide in-person services, counseling, education, and training at behavioral health providers and in schools, fewer individuals were served in 2021 than initially anticipated.

 

It is critical that initiatives intended to improve birth outcomes prioritize groups that have been historically economically and socially marginalized, such as populations of color. Although efforts have been made throughout this initiative to better engage individuals that identify as Black/African American, Indigenous, and people of color (BIPOC), the majority (78.3%) of clients served by this program in 2021 were white; however, the percentage of white clients ranges between the pilot projects, from a minimum of 56% to a maximum of 83.1%. Overall, the program population is slightly less majority-white than the state of Pa. (78.3% compared to 81.6%). The program also serves more Hispanic/Latinx clients than the state population (15.9% compared to 7.8%). The overall racial and ethnic composition of the clients served did not shift substantially from 2020 to 2021, despite the COVID-19 pandemic and its disproportionate burden on people of color and the agencies that serve them.

 

In 2021, the Alliance trained two behavioral health providers to assess for pregnancy intention as part of their routine intake and counseling. This is significantly less than the number of providers trained in this area in 2020 – 36 – and does not meet the objective of increasing the number of behavioral health providers trained in pregnancy intention assessment. The decrease in provider trainings is reflective of a lack of new partnerships with SUD treatment sites, as a result of COVID-19 pandemic-related barriers, competing priorities, and the natural project trajectory. In addition, as the Alliance has received feedback from the councils and their partner sites, they have identified other critical training needs, such as in trauma-informed care, and have pivoted to develop and implement trainings to address these gaps. In 2021, the Alliance provided an additional 18 providers with professional development in how to address trauma and sexual health in SUD treatment settings.

 

The current initiative ends in 2022; if the BFH selects to replicate elements of the pilot projects in future partnerships, a focus on serving communities of color will be key. By increasing access to integrated sexual and reproductive health services for groups that are disproportionately affected by SUD, the BFH hopes to reduce the incidence of unintended pregnancy and improve health outcomes for birthing people with OUD and their babies.

 

Strategy: Implement care models that include maternal behavioral health screenings and referral to services

 

Objective: Increase the percent of women enrolled in Title V home visiting, Centering Pregnancy, and IMPLICIT programs that are referred for services by 1% annually, following a positive screening

 

ESM: Percent of women enrolled in home visiting, Centering Pregnancy and IMPLICIT that are referred for behavioral health services, following a positive screening 

 

The BFH understands the strong connection between physical health and behavioral health and has worked to ensure that birthing people are screened for behavioral health issues when receiving care through Title V funded programs. The BFH requires all Title V funded CMHDs home visiting programs to utilize evidence-based/informed screening tools to assess behavioral health issues during the perinatal period. By doing so, the BFH aims to identify and address potentially risky behaviors or circumstances to improve pregnancy outcomes, as well as improve health for children and families in the same household. Many of the CMHDs and the CPPs use the Edinburgh Depression Scale, a validated tool comprised of ten questions that can be used in both the prenatal and postpartum periods. In 2020, the BFH made the decision to no longer require the use of the 5Ps tool, a quick, non-threatening tool that assesses risk for alcohol dependency, substance misuse, interpersonal violence, and depression base on five domains (Parents, Peers, Partner, Pregnancy, and Past). To remain consistent, BFH staff have allowed the CMHDs to discontinue use of the 5Ps if it was not working for their organization. As of 2021, seven CMHDs continue to use the 5Ps screening tool. Going forward, the BFH is asking partners to utilize evidence-based tools for screening in lieu of the 5Ps tool which is not considered an evidence-based tool as it lacks published, peer-reviewed research studies.

 

The IMPLICIT Interconception Care (ICC) Program, mentioned earlier in this report, includes maternal depression screenings at well-child visits (WCVs). Birthing people are counseled and referred for services as necessary. This initiative is focused on increasing the number of birthing people who see their medical providers in the interconception period and changing maternal behaviors to improve overall health and birth outcomes in subsequent pregnancies. In 2021, 1,940 birthing people received a depression screening at their child’s WCV; of the 285 positive screenings, intervention was documented for 247, or 86.6%, of these individuals.

 

Given the importance of providing follow-up services for behavioral health issues, the BFH chose to measure the percent of women enrolled in home visiting, CPP or IMPLICIT programs that are referred for behavioral health services, following a positive screening. Warm handoff referrals, where the home visitor or healthcare provider assists the participant in setting up a behavioral health appointment, help to increase the likelihood that they will follow through with the appointment. In 2021, 87.9% of pregnant and birthing people enrolled in the home visiting, CPP, or IMPLICIT programs were referred for behavioral health issues, following a positive screening. The focus on providing referrals for behavioral health services following a positive screen helped to exceed the first year goal of 80% of participants that received referrals. Reasons pregnant and birthing people may not be screened include refusal or early withdrawal from the program. Additionally, with many programs still holding virtual sessions due to COVID-19, participants are not always comfortable discussing mental health issues through a virtual platform.

 

Pennsylvania, through the Pennsylvania Partnership for Children, was awarded the Pritzker Children’s Initiative Prenatal-to-Age-Three Implementation grant. The overall goal of the project is to increase the number of children and families receiving high-quality services by 25% by 2023, and by 50% by 2025. BFH staff sit on the Maternal Health Subgroup, which is focusing on extending Medicaid access to postpartum services, ideally for 12 months; advancing behavioral health screenings for prenatal and postpartum people; ensuring that those with a positive screen receive needed services; and advancing reimbursement for doulas in the Medicaid program.

 

Strategy: Implement care models that encourage women to receive care in the early postpartum period

 

Objective: Increase the percent of women that receive early postpartum care through a 4th trimester pilot program, compared to the year 1 baseline data, by at least 3% annually, starting with reporting year 2022

 

The “fourth (4th) trimester” generally refers to the first three months postpartum. The mainstream maternal health framework does not provide routine care for birthing people until six weeks after childbirth, halfway through this period. However, birthing people experience significant biological, psychological, and social changes during this period that that can lead to poor outcomes if not promptly and adequately addressed. In the weeks following childbirth, pre-existing conditions and new health concerns that go unaddressed can result in the exacerbation of these health issues and, in some cases, maternal death. By ensuring individuals receive a postpartum visit in the early fourth trimester – before 28 days have elapsed – birthing people can be connected to the care they need, and rates of maternal mortality and morbidity will decrease. 

 

In May 2018, the American College of Obstetricians and Gynecologists (ACOG) called for a new paradigm for postpartum care that addresses the current needs for birthing people and protects against morbidity and mortality for birthing people after pregnancy. Improved 4th trimester care was also recognized as a high priority area by the National Institute of Child Health and Human Development in its strategic planning for 2020.

 

ESM: Percent of women who receive a maternal health assessment within 28 days of delivery through the 4th trimester pilot program

 

As a result of the ACOG recommendations, the IMPLICIT Network began planning a new initiative, the 4th Trimester, or 4TM, model of care, to address gaps in postpartum care and decrease rates of maternal morbidity and mortality in the early postpartum period. This care model enables providers to identify birthing people who are at increased risk of postpartum health problems, develop tailored care recommendations for families, and increase the number of birthing people receiving maternal health care within 28 days of delivery.

 

In 2021, the BFH began working with the University of Pennsylvania and the Network to develop a plan for piloting the 4TM model of care with the goals of addressing gaps in postpartum care and decreasing rates of maternal mortality in the early postpartum period. The Network developed the 4th trimester (4TM) model and began piloting the program at eight sites in February 2021. Unfortunately, due to COVID-19-related staffing limitations, the 4TM pilot project experienced significant barriers to establishing timely, consistent, and accurate data collection, reporting, and analysis. Consequently, the Network was unable to provide baseline data for all sites regarding the individuals who received a maternal health assessment within 28 days of delivery through this initiative. Due to this limitation, the Network’s reports in 2021 instead focused on the progress that was being made with regards to pilot readiness and implementation. The Network continues to support 4th Trimester sites’ efforts to implement the new care model and standardize, collect, share, and analyze data.

 

Strategy: Use Maternal Mortality Review Committee (MMRC) recommendations to inform programming

 

Objective: Implement a minimum of 1 MMRC recommendation annually

 

ESM: Number of MMRC recommendations implemented

 

Maternal mortality (MM) and morbidity, and the pervasive disparities between racial and ethnic groups, continues to be a strong area of focus. In 2020, the overall rate of MM in the United States was 23.8 deaths per 100,000 births. Further, the rate for non-Hispanic/Latinx Black/African American birthing people was 55.3 deaths per 100,000 live births compared to 44.0 deaths per 100,000 live births in 2019.   

 

In addition to racial and ethnic disparities in MM rates, birthing people experience disparities in MM based on age; MM rates for individuals aged 40+ were 7.8 times higher than the rate for women under 25 with 13.8 deaths per 100,000 live births for those under age 25, 22.8 for those aged 25–39, and 107.9 for those aged 40 and over.

 

To reduce risk factors associated with maternal deaths, particularly where there are racial/ethnic inequities, data regarding the incidence/causes of MM and prevention recommendations must be shared with health providers and the public. The Maternal Mortality Review Committee (MMRC), a requirement of Pennsylvania’s 2018 Maternal Mortality Review Act, serves as the formal process to investigate the causes of pregnancy-associated deaths and develop prevention strategies. Per legislative requirement, MMRC membership includes obstetricians, maternal fetal medicine specialists, a certified nurse-midwife, an addictions medicine specialist, specialized gynecologic psychiatrists, social workers, coroners, an emergency medicine physician, and community voices. In addition to clinical guidance, MMRC members consider the impacts of social determinants of health, with a goal of reducing racial bias and health inequity. This initiative is dually funded through the CDC and Title V.

 

Since its inception in 2018, the committee has only reviewed 44 maternal death cases (52% of the 2018 deaths). Due to the difficulties experienced by the MMRC in reviewing all Pa. maternal deaths in a timely fashion, the committee underwent several modifications in 2021. These resulted in the MMRC’s first public-facing report, a reorganization of the committee itself, and the establishment and strengthening of new partnerships.

 

The MMRC’s first report was published in January 2022. Recommendations were provided for system, provider, and community levels related to four primary themes: build infrastructure to identify and support pregnant and postpartum individuals with mental health concerns; build infrastructure to identify and support pregnant and postpartum individuals who use substances; build infrastructure to provide more comprehensive medical care for all pregnant and postpartum individuals; and build infrastructure to identify and support pregnant and postpartum individuals with history of intimate partner violence. These themes were presented to the Pennsylvania Perinatal Quality Collaborative (PA PQC), the action arm of the MMRC, for potential implementation of specific recommendations within these themes.

 

As part of a reorganization effort, all existing MMRC members were asked to reapply, if interested in continuing their service. In addition, an attempt was made to recruit new partners and community members who represent Pennsylvania’s diverse geographic regions, clinical and community specialties, and racial and ethnic backgrounds. For purposes of consistency, clear processes for case review and the development of recommendations were also established.

 

In addition to these reorganization efforts, MMRC program staff worked to strengthen partnerships with external stakeholders. Staff attended the Pennsylvania Coroner’s Association Annual Meeting to convey the critical role coroners’ and medical examiners’ records play in the work of the MMRC. To better understand and address MM throughout Pa., program staff also worked to develop a formal relationship, through the implementation of new data and grant agreements, with the decade-old Philadelphia MMRC. With these documents in place, Philadelphia MMRC was able to implement four recommendations: educating community-based home-visiting and family support programs on early warning signs of maternal morbidity to ensure timely referral for clinical treatment; establishing a cardiology task force to make city-wide recommendations on enhanced care for women identified to be at high risk of cardiomyopathy or infarction; establishing grants for Intimate Partner Violence/MMR groups; and increasing community investment, beginning with focus groups to ensure an understanding of what the community wants and needs.

 

On October 1, 2020, Pennsylvania became the 38th state to join the Alliance for Innovation on Maternal Health (AIM). AIM is a national data-driven maternal safety and quality improvement initiative which provides implementation support and data tracking

assistance to participating states to support the adoption of AIM’s patient safety bundles. AIM also enables states to track their success on improving maternal outcomes through AIM’s national data center. The PA PQC had three initiatives in 2021: an expanded focus on maternal OUD, NAS, and contraceptive care, including access to immediate postpartum long-acting reversible contraception (LARC); Moving on Maternal Depression (MOMD) to improve prenatal and postpartum depression screening and follow-up rates and reduce associated racial/ethnic disparities; and the PA AIM initiative to adopt the PA AIM Bundle to improve severe hypertension in pregnancy treatment and reduce associated racial/ethnic disparities. Each of these initiatives have made considerable progress in improving the safety of pregnant and parenting people in Pa.

 

Strategy: Initiate regular meetings and collaboration between DOH, DHS, and MIECHV

 

Objective: Convene quarterly meetings between agencies that provide services related to maternal health

 

ESM: Number of meetings held between DOH, DHS and MIECHV annually (maternal health)

 

Home visiting programs have achieved positive outcomes in reducing the incidence of low birthweight babies and repeat pregnancies. These programs have also resulted in improved child development and increased immunization rates. Beginning in July 2020, the Department of Human Services (DHS) expanded home visiting services for all first-time parents, parents of children with additional risk factors and families who wish to be enrolled covered by Medicaid. These services will be provided in collaboration with the physical health Medicaid managed care organizations (MCOs). Numerous County Municipal Health Departments (CMHD) are contracting with MCOs to provide these services and others are considering this option. The MCOs or other referral source refer the expectant or parenting person to an evidence-based or evidence-informed home visiting program who will complete an assessment and determine the needs of the family. DHS is still working to evaluate the data from the first year of this program. BFH staff will continue to work with DHS to collaborate and ensure services are not duplicated between agencies.

 

In Pa., the Office of Child Development and Early Learning (OCDEL) is the lead agency for the Maternal, Infant and Early Childhood Home Visiting Program (MIECHV). OCDEL is a collaborative effort between the Pennsylvania Departments of Education and Human Services focused on improving systems so all children can reach their full potential. Many of the home visiting models offered through MIECHV have specific requirements beyond poverty level and need, such as prenatal enrollment and first pregnancy, unlike the flexible enrollment requirements of the CMHDs. Many of the CMHDs have MIECHV home visiting programs administered out of the same office, which allows for collaboration and referral. In 2019, the BFH made it a requirement that the CMHDs collect five outcome measures also collected by the MIECHV Program. This initiative was implemented to have a better idea of the effectiveness of the CMHDs home visiting programs as compared to the MIECHV Program. The outcomes for the first full year of data collection reported by the CMHDs were as follows: 10.5% of infants were born preterm following program enrollment; 81.1% of primary caregivers enrolled in home visiting were screened for depression; caregivers were asked if they had concerns with their child’s development, behavior, and learning at 72.5% of home visits; 63.6% of caregivers were screened for IPV; and 80% of caregivers with positive screens for IPV received referral information. When compared to MIECHV data, the outcome measures for the CMHDs scored higher for four out of the five measures. The only measure to score lower was the percent of caregivers that were asked if they had concerns with their child’s development, behavior, and learning. The CMHDs will continue to collect the five outcome measures, reporting them on a yearly basis.

 

BFH staff met with DHS and MIECHV twice in the past year, not meeting the goal of quarterly meetings. The intent of these meetings is to collaborate between agencies and programs to provide care to the people in Pa. Initial attempts at this collaboration were not as successful as hoped but BFH staff continue to pursue common goals to align work and improve the system of care available to the families served. To foster more productive collaboration, BFH staff will focus on specific MCH topics at each meeting to aid in shaping conversations going forward.