For reporting year 2023, 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, 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 2022, there were 2.8 million persons of reproductive age (15-49 years old) who identified as female living in Pennsylvania (Pa.). The racial composition of this population is approximately 78% white, 14% Black/African American, five percent Asian/Pacific Islander and three percent multi-race. Ten 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 individuals 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.

 

Mental health problems and substance use disorders (SUD) sometimes occur together. According to Substance Abuse and Mental Health Services Administration, more than one in four adults living with serious mental health problems also has a substance use problem. Pa.’s opioid epidemic has significant and wide reaching impact. Whether it is an infant born with neonatal abstinence syndrome (NAS), children in kinship care where parental drug use was a factor, or a pregnant individual with SUD, the experiences can have lifelong impacts. SUD and mental health conditions continue to be the leading causes of pregnancy-related deaths in Pa. Understanding where individuals with SUD (or history of SUD) are receiving prenatal care and delivering their babies can help improve screening for SUD and connect more birthing individuals to treatment. In addition, educating families and support people about naloxone use when prescribed opioid pain medications and/or when there is a history of SUD can help prevent adverse maternal outcomes.

 

In the United States, about 41% of women have experienced and reported IPV during their lifetime. Of these reported cases, approximately 325,000 are pregnant during the acts of violence. For about one in six pregnant individuals, the abuse starts for the first time during pregnancy. 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 often. What is known is that IPV 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 individuals 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, it is estimated that between eight to eleven percent of pregnant individuals use illicit substances and one in seven birthing individuals experience symptoms of peripartum depression. Available data suggests a higher rate of IPV in some Black, Indigenous, and other People of Color (BIPOC) communities. However, the broader context of those statistics, including social determinants of health, systemic racism, and policing of these communities must be taken into consideration. The harm caused by IPV is compounded by the inequities survivors face in accessing health care and other social supports they need to improve the health and lives of themselves and their families.

 

An additional and critical note on this section, and throughout this report and application, the BFH acknowledges that the state of being pregnant, the act of giving birth or otherwise ending a pregnancy, and the act of parenting and caregiving are inclusive of all genders while also recognizing that data sources may not be.

 

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. 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 behavioral health of birthing individuals and families, if the providers can connect with and gain the trust of the birthing individuals they are serving.

 

In 2021, 73.3% of all birthing individuals in Pa. received prenatal care in the first trimester, with 76.8% white, 65.2% Black/African American, and 65.2% Hispanic/Latinx birthing individuals receiving prenatal care in the first trimester. Racial disparities are evident and continue to persist with 1.5% of white, 4.3% of Black/African American, and 4.1% of Hispanic/Latinx birthing individuals receiving no prenatal care.

 

Unhealthy birth outcomes, such as low birth weight and preterm birth, are influenced by many factors before, during, and in between pregnancies. Preconception care allows birthing individuals 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 individuals, 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 individuals and families served by Title V.

 

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

 

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

 

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

 

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

 

The BFH continued its partnership with the county and municipal health departments (CMHDs) to provide local services to residents in their communities. The eleven CMHDs are located in Allegheny County, Allentown City, Bethlehem City, Bucks County, Chester County, Delaware County, Erie County, Montgomery County, Philadelphia County, Wilkes-Barre City, and York City. Delaware County Health Department was established in 2022 and continues to build their infrastructure. They will be providing doula trainings and care to residents through established maternal health organizations that offer these services. 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 they serve to provide services across a wide range of physical health, behavioral 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 disproportionately affected populations served by the CMHDs. In 2023, 1,171 pregnant and birthing individuals were served through CMHD home visiting programs. Thirty-eight percent of enrolled participants successfully completed home visiting programs, exceeding the original goal of 24%. BFH staff will revise the goal for this measure in the 2024 reporting year to better reflect the program’s current accomplishments. 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, behavioral, or emotional challenges pregnant and birthing individuals may be experiencing, as well as issues within the home, such as IPV, substance use, and social or financial challenges. Feedback from program participants was collected via client satisfaction surveys to help assess and continually improve the home visiting services provided by the CMHDs. Surveys were administered on paper or electronically via text or email. Response rates have historically been low but the CMHDs helped increase participation with reminder texts, emails, phone calls, or in person reminders during a home visit.

 

Ten of the eleven CMHDs serve prenatal and postpartum birthing individuals and their infants through home visiting programs. 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 during pregnancy, immunizations, birth control and family planning, parenting techniques, and breastfeeding.

 

Many of the CMHDs offer home visiting services in the postpartum period, with some following families until the child is two years of age. Connecting with postpartum individuals, especially during the fourth trimester, which is defined as the twelve-week period following an infant’s birth, is essential as the body experiences physical, hormonal, and mental changes, some which may be life threatening. The CMHDs offer postpartum screenings, including depression and IPV using validated screening tools, inquire if a six-week postpartum visit has been scheduled, and assist with scheduling, as needed. Education including reviewing post-birth warning signs and when to contact a health care provider or go to the hospital is also provided. Understanding what is abnormal can empower individuals to seek care more efficiently and reduce the risk of poor health outcomes.  

 

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 are provided in collaboration with the physical health Medicaid managed care organizations (MA MCOs). Numerous CMHDs are contracting with MA MCOs to provide these services and others are considering this option. The MA MCOs or other referral sources refer the expectant or parenting individual to an evidence-based or evidence-informed home visiting program that completes an assessment and determine the needs of the family.

 

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 Department of Education and DHS 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. The BFH requires the CMHDs to collect five outcome measures also collected by the MIECHV Program to better understand the effectiveness of the CMHDs home visiting programs. The outcomes for 2023 reported by the CMHDs are as follows: 10.4% of infants were born preterm following program enrollment; 93.5% 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 98.7% of home visits; 94.5% of caregivers were screened for IPV; and 100% of caregivers with positive screens for IPV received referral information. While the data has limitations due to the small number of families served, when compared to MIECHV data, the outcome measures for the CMHDs scored higher for all measures except preterm birth. The CMHDs will continue to collect the five outcome measures, reporting on them annually.

 

BFH continues to monitor the home visiting services provided by the CMHDs to avoid the duplication of services while continuing to fill gaps for those not eligible for other programs.

 

Strategy: Increase the percent of adolescents, women and birthing individuals 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, women and birthing individuals who talked with a health care professional about birth spacing or birth control methods by 1%

 

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

 

In 2023, Centering Pregnancy programs (CPP) at Lancaster General Hospital (LGH), WellSpan Health (WSH) York, and Albert Einstein Health Network (AEHN), provided group prenatal care to 137 pregnant individuals. The CPP aims to improve birth outcomes as well as improve the knowledge base of the participants related to pregnancy and parenting.

 

Prior to June 30, 2023, the end date of the Title V-funded grant, LGH offered a group specifically for pregnant individuals with SUD in addition to the traditional CPP. Sessions were facilitated by a Licensed Social Worker certified in addictions counseling. The group followed the traditional CPP model of prenatal care, but incorporated 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. 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 continued to be successful with 91% 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 2023. 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. In-person classes on breastfeeding, infant safety, prenatal yoga, and other topics were offered so CPP participants were able to form social connections and get support from other participants. Many of the in-person classes were offered in both English and Spanish.

 

Breastfeeding/chestfeeding rates were positively affected with 91% of participants breastfeeding/chestfeeding at birth versus 79% of birthing individuals receiving traditional prenatal care in the same practice. 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 individuals that completed either the traditional CPP or SUD program were satisfied with the experience. Although their partnership with BFH has ended, LGH continues to offer CPP.

 

AEHN, located in Philadelphia, and WSH York continued their expanded CPPs. WSH York continued to serve their Spanish-speaking population with the Centering sessions being led by a Spanish-speaking coordinator and the inclusion of Spanish-speaking health care providers. To encourage attendance and participation, healthy food options, infant supplies, and transportation, which was identified as a major barrier, were provided to participants. AEHN and WSH York CPP grants will continue through September 30, 2024.

 

The CPPs submitted data related to family planning and birth spacing, specifically how many adolescents, women, and birthing individuals talked with a health care professional about birth spacing and birth control methods. Eighty-eight percent of participants enrolled in CPPs talked with a health care professional about birth spacing and birth control methods, exceeding the goal of 86.8%. Delaying pregnancy allows birthing individuals 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 and birthing individuals enrolled in IMPLICIT ICC program screened for risk factors during well-child visits (WCV) by 1.5% each year

 

ESM: Percent of women and birthing individuals served through the IMPLICIT ICC program that are screened for the 4 risk factors during a minimum of one WCV 

 

Interconception care (ICC) is the use of medical and psychological interventions to address individuals’ risk factors between pregnancies, with the aim of improving future maternal and infant health outcomes. ICC has the capacity to reduce the persistent racial disparities in maternal and infant birth outcomes. The leading underlying causes of infant mortality, particularly among Black/African American babies, are low birth weight and preterm birth (factors which are often connected). By offering biomedical, psychosocial, and behavioral interventions prior to pregnancy, the influence of risk factors for adverse pregnancy outcomes, such as preterm birth, can be minimized.

 

The setting of ICC has taken multiple forms, with most birthing individuals being provided this care only during annual well-woman visits or at their postpartum checkup(s). However, in a system where most people do not routinely receive early postpartum care, birthing individuals may not see their maternal care provider until at least six weeks postpartum, if at all; many do not, or cannot, attend the six-week postpartum visit, due to time, childcare, work, or transportation constraints. Often, the first appointment a birthing individual has with a provider after their baby’s birth is with their infant’s doctor – not their own, when they take their newborn or child to their routine WCV.

 

Family physicians are ideally positioned to lead health care system change related to ICC; even parents that lack providers of their own are likely to take their infants to their WCV. WCVs in the first two years of life occur frequently (at one and two weeks and at one, two, four, six, nine, 12, 15, 18 and 24 months), presenting family health providers with regular opportunities to screen for and address maternal risk factors. Working within the WCV framework provides an opportunity for family health providers to address maternal health during the interconception period.

 

In 2023, the BFH continued to partner with the University of Pennsylvania and the IMPLICIT Network (IMPLICIT) to strengthen and expand the Title V-funded IMPLICIT ICC Program, wherein maternal screenings are conducted at WCVs. IMPLICIT developed, piloted, and implemented a model for ICC in Pennsylvania in 2012. Since that time, the IMPLICIT ICC model of care has been successfully implemented in a variety of sites in several states and is showing promising results in reducing unintended pregnancies and improving preconception health.

 

The IMPLICIT ICC model promotes utilizing scheduled WCVs to improve the health of birthing individuals between pregnancies. At each WCV, birthing individuals 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. The IMPLICIT ICC model is focused on increasing the number of birthing individuals 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.

 

The effectiveness of the ICC model of care is measured by how many birthing individuals are screened for modifiable maternal risk behaviors, and how many of those with positive screens receive either an intervention or a referral to services. In 2023, IMPLICIT’s 15 active sites reached 3,410 unique parent-baby dyads who may not have received care otherwise. Of the individuals that received ICC screening, 14.2% screened positive for tobacco use, 7.6% for depression, 21.1% for lack of contraception use, and 39.5% for lack of multivitamin with folic acid use. Approximately 22% of the individuals who were served last year identify as Black/African American; continued efforts to expand the reach of this model is critical if it is to significantly impact statewide maternal racial health disparities.

 

IMPLICIT continued to experience staffing challenges and transitions that impeded its ability to meet all grant goals regarding screening and intervention rates for 2023. In 2023, ICC screening was performed at 8,731 well-child visits, resulting in an overall screening rate of 81.1%; this was lower than the target of 83.6%. IMPLICIT met grant goals for smoking, depression, and multivitamin interventions, but fell shy of meeting the targeted intervention rate for contraception. Interventions for positive screens were documented at the following rates: 87.6% for tobacco use, 92.9% for depression, 76% for contraception use, and 66.1% for multivitamin with folic acid use.

 

Maternal behavioral change after intervention for each of the four behavioral risk factors continued to be tracked in 2023; a cohort of 1,636 dyads who gave birth in 2020 were followed longitudinally to evaluate the effectiveness of the IMPLICIT ICC model of care. Of the 8,296 WCVs conducted for the babies in this cohort, 7,124 WCVs included the presence of the mother/birthing individual. The analysis of the data from this cohort showed that over time, many birthing individuals that received ICC interventions for positive risks experienced long-lasting behavioral change. Specifically, of those that received interventions for smoking, 16.8% demonstrated behavioral change. Of those treated for depression, 47.4% experienced improvement. Individuals that were identified as not utilizing contraception were 54.9% more likely to use contraception following intervention. Finally, 36.9% of individuals that were found to not be using multivitamins with folic acid, continued to take multivitamins following intervention. The results of the cohort indicate that the IMPLICIT ICC model has the capacity to result in long-lasting behavioral change for individuals with maternal health risks.

 

In 2022, IMPLICIT established a Health Equity Committee (HEC) to improve the quality of care for all, through a more inclusive health equity lens. The HEC’s priority focus in 2023 was on creating opportunities to collect feedback from, and collaborate with, the communities IMPLICIT serves; assessing ICC sites’ understanding of patient needs; rebranding IMPLICIT in a way that better reflects the diversity of the communities served; and educating IMPLICIT providers on topics related to health equity.  

 

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

 

Objective: Increase the number of community-based doulas providing services in priority 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 individuals to establish and maintain positive communications with care providers, resulting in increased engagement in health care decision-making. Doulas spend up to 11 times longer with clients than other health care providers. This provides opportunities to educate on what to expect during pregnancy, labor, and delivery and in the postpartum period as well as encourage pregnant or postpartum individuals 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 individuals 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 individuals and their babies. In contrast to conventional doulas, community-based doulas share the same background, culture, and language as the pregnant individuals they support. They also have 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 individuals 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 or parenting individuals with substance use issues. The doulas address social determinants of health by discussing housing, employment, and mental health. In 2023, the program served 125 pregnant or parenting individuals. Of these participants, 60% identified as Black/African American, and almost five percent identified as Hispanic/Latinx. 84% 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. Additionally, in 2023, ten new individuals were trained as community-based doulas.

 

In July 2022, through the RFA process, the BFH awarded a grant to Pittsburgh’s Healthy Start program, to implement a community-based doula program using the HealthConnect One (HC One) model. Healthy Start operates in Allegheny and Westmoreland counties, in areas with high rates of racial disparities in preterm birth and infant mortality. The HC One program model has been identified as an AMCHP “best practice”. The HC One model has been shown to decrease medical interventions during labor and delivery, improve birth experiences, and increase breastfeeding rates, among other positive outcomes.

 

Due to the length of required core and associated doula trainings, the Healthy Start program did not begin serving doula clients until 2023. In 2023, ten individuals from priority populations in the Healthy Start service area completed community-based doula training. Following their training, these doulas cumulatively received a combined total of 91 individuals during 187 doula-client visits in the prenatal and postpartum periods, including 34 births. Of clients served, 89.9% were Black/African American, the priority population for this program. One hundred percent of doula clients were assessed for service needs related to SDOH; those who were not already receiving services from other Healthy Start programs were referred to social supports. Eleven of the 12 clients who reported that that they were diagnosed with hypertensive disorder were supported with blood pressure management support. Of the doula-supported births, 21% of clients received at least two in-person home visits within the first two weeks postpartum. As the program was still in early stages of implementation, there have been some challenges related to client acceptance of the immediate postpartum home visit.  Those challenges will continue to be addressed to increase the percentage of clients who receive home visits. Of the 34 births, 35% were via caesarean section; 3% had a birthweight of under 2500 grams; and 12% were at less than 37 weeks gestation. In addition, 88% of the infant/parent dyads-initiated breastfeeding.

 

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

 

Objective: Increase the percent of women and birthing individuals 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 and birthing individuals 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 and behavioral health and has worked to ensure that birthing individuals are screened for behavioral health issues when receiving care through Title V funded programs. The BFH requires all Title V funded CMHD 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.

 

The IMPLICIT ICC Program, mentioned earlier in this report, includes maternal depression screenings at their child’s WCVs. Birthing individuals are screened, counseled, and referred for services as necessary. This initiative is focused on increasing the number of birthing individuals who see their medical providers in the interconception period and changing maternal behaviors to improve overall health and birth outcomes in subsequent pregnancies. In 2023, 3,410 birthing parent/baby dyads attended a total of 8,731 WCVs through the IMPLICIT ICC Program. Birthing individuals were present at 92.5% of their children’s WCVs during this time period. Although the IMPLICIT ICC Program provides a method of screening birthing parents for four risk factors, not all parents are screened for all four risk factors at every visit they are attend, due to time constraints and/or needing to focus on other areas of importance. In 2023,IMPLICIT Network ICC providers completed depression screens at 4,977 (57%) of the WCVs in which birthing parents were in attendance; 7.6% of these screens indicated a positive risk, and interventions were provided 92.9% of the time. This met the 2023 grant goal of maintaining the rate of depression intervention at 80% or greater.

 

Given the importance of providing follow-up services for behavioral health issues, the BFH chose to measure the percent of women and birthing individuals 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 health care provider assists the participant in setting up a behavioral health appointment, help to increase the likelihood that the participant will follow through with the appointment. In 2023, 89.6% of pregnant and birthing individuals 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 2023 goal of 81.6% of participants that received referrals. Reasons pregnant and postpartum individuals may not be screened include refusal or early withdrawal from the program.

 

Pa., 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 originally focused on extending Medicaid access to postpartum services, accomplished in October 2022, and advancing reimbursement for doulas in the Medicaid program. Infrastructure for doulas to become Medicaid providers to make doula services more accessible to pregnant and postpartum individuals covered by Medicaid is being built. The group is developing a comprehensive and coordinated system of care and support for Pa. birthing individuals by establishing a perinatal psychiatric access pilot program; ensuring every birthing individual has access to coverage during pregnancy, supporting campaigns that advocate for universal paid leave and an earned income tax credit at the state level, and increasing the state’s capacity to collect, report, and analyze stratified data.

 

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

 

Objective: Increase the percent of women and birthing individuals 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

 

ESM: Percent of women and birthing individuals who attend a postpartum visit within 28 days of delivery, through the 4th trimester pilot program

 

Maternal mortality (MM), or mortality occurring during pregnancy or within 42 days following the end of pregnancy, and morbidity, and the pervasive disparities between racial and ethnic groups, continues to be a strong area of focus. According to the CDC, nationwide MM rates (during pregnancy or in the 42 days following the end of pregnancy) increased by 40% in 2021, with a rate of 32.9 deaths per 100,000 live births, compared with a rate of 23.8 in 2020 and 20.1 in 2019. This is 1,205 U.S. deaths due to pregnancy-related causes in 2021, compared to 861 in 2020 and 754 in 2019.

 

Racial disparities in health outcomes persist. In 2021, non-Hispanic Black/African American birthing individuals experienced a MM rate 2.6 times higher than that of white birthing individuals during pregnancy or in the first 42 days postpartum; 69.9 Black/African American women and birthing individuals per 100,000 live births died from maternal causes in 2021, versus 26.6 of their white counterparts. The MM rate continued to climb for Black/African American individuals; the rate for this population was 55.3 per 100,000 live births in 2020, 44.0 in 2019 and 37.3 in 2018.

 

In addition to racial disparities in MM rates, birthing individuals continue to experience disparities in MM based on age. In 2021, MM rates for individuals aged 40 and older were 6.8 times higher than the rate for women under 25. There were 20.4 deaths per 100,000 live births for birthing individuals under age 25, versus 31.3 for individuals aged 25-39, and 138.5 for individuals aged 40 and older.

 

Nationwide, the leading underlying causes of MM are cardiovascular conditions (26.6%), infection (14.3%), and obstetric hemorrhage (12.1%). Based on CDC Maternal Mortality Review Committee (MMRC) data from 44 states, over 80% of all pregnancy-related deaths are preventable. The leading underlying causes of pregnancy-related death among Black/African American birthing individuals are cardiac and coronary conditions, and over 50% of postpartum strokes occur within 10 days of delivery. Early postpartum care decreases mortality risk for people with hypertensive disorders and other chronic conditions.

 

Pregnancy care has traditionally been organized into three trimesters, with a single postpartum visit at approximately six weeks postpartum. The timing of this visit contradicts the evidence that shows over 50% of pregnancy-related deaths occur after the birth of the infant, and 40% of these deaths occur by six weeks postpartum. In addition, as many as 40% of individuals do not see their maternity provider at all after discharge from the hospital or birth center, with rates even lower among Black/African American individuals.

 

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

 

In 2018, the American College of Obstetricians and Gynecologists (ACOG) called for a new paradigm for postpartum care that addresses the current needs for birthing individuals and protects against morbidity and mortality in the postpartum period. As a result of the ACOG recommendations, IMPLICIT, with support from BFH, developed and began implementation of an innovative 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 individuals who are at increased risk of postpartum health problems, develop tailored care recommendations for families, and increase the number of birthing individuals receiving maternal health care within 28 days of delivery.

 

The IMPLICIT 4TM model aims to identify high risk patients, who may have mood concerns, obesity or wound concerns, thyroid disorders, hypertensive disorders, endocrine disorders, renal disease, or substance use disorders. 4TM providers create a postpartum registry of anyone who received prenatal care at the practice, or delivered with providers in the practice, and prioritizes getting patients back into the office to see their providers between seven and 21 days after delivery. Ideally, 4TM providers develop a plan for the early postpartum visit when the patient is between 28 weeks gestation and delivery.

 

4TM providers collect patient data from multiple encounters, including prenatal visits, immediately after delivery, and during the early postpartum visit. At the early postpartum visit, 4TM providers connect patients with any needed psychosocial, biomedical, and other wraparound services or referrals. 4TM screenings assess for biomedical risk (hypertension, preeclampsia, cardiovascular, diabetes, and postpartum hemorrhage) and psychosocial risk (depression, tobacco use, and substance use). In order to reduce fragmentation of care across providers and settings, providers establish a care team, which may include a primary care provider, specialty physician, lactation consultant, mental and behavioral health providers, and a case manager.

 

In 2023, IMPLICIT supported continued implementation of the 4TM model at four sites (Lancaster General Family Medicine Residency (FMR), UPMC Williamsport FMR, UPMC McKeesport FMR, and University of Pennsylvania Philadelphia-FMR). By the end of 2023, three of these sites were actively sharing data, and one was collecting data and working towards being able to share. The baseline data for this ESM was established in 2022, with 58.2% (336) of 577 eligible birthing individuals having received an early postpartum visit through the 4TM program. In 2023, of the 541 eligible birthing individuals at active 4TM sites, 81.1% (368) attended a visit within 21 days postpartum, meeting the objective of increasing the percent of individuals that receive 4TM care by at least three percent annually.

 

IMPLICIT has continued to experience challenges in collecting, sharing, and analyzing data from the 4TM project. The data sharing process continues to rely largely on manual data entry, a labor-intensive and time-consuming process. In addition, unforeseen complications with utilizing and updating electronic health records and creating common workflows delayed progress of this initiative. In 2024, IMPLICIT will continue to support 4TM 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

 

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

 

In an effort to improve programming and processes, the Maternal Mortality Review Program (MMRP) surveyed MMRC members after each meeting. Consistently, the review committee found the presented cases to be unbiased and fair and were pleased with the context of case review, the manner in which cases were presented, and the overall MMRC meeting. The MMRP also sought suggestions from the review committee to improve future meetings.

 

The PA MMRC reviews all pregnancy-associated deaths, defined as a death during pregnancy or one year following the end of pregnancy regardless of the cause of death or outcome of the pregnancy in Pa. with the exception of pregnancy-associated deaths that occur in Philadelphia County. Philadelphia has administered a local MMRC since 2010. PA MMRC and Philadelphia MMRC collaborate to collectively review all deaths in Pa.

 

The PA MMRC’s most recent report highlighting pregnancy-associated death cases from 2020 was completed in January 2024. Recommendations were provided for patient/family, provider, facility, system, and community levels. The MMRP and MMRC collaborate to prioritize and consolidate the recommendations. The most common recommendations for all deaths and those which should be prioritized for intervention, specifically in pregnancy-related deaths, defined as a death during pregnancy or within one year of the end of pregnancy from a pregnancy complication, a chain of events initiated by pregnancy, or the aggravation of an unrelated condition by the physiologic effects of pregnancy, were included in the report.

 

In 2023, the PA MMRC reviewed pregnancy-associated deaths that occurred in 2020. In 2020, there were 107 cases verified as pregnancy-associated by Pa. and Philadelphia MMRCs. Of those cases reviewed, the leading cause of death was mental health conditions, making up 45% of cases. Within the broader category of mental health conditions, overdose and substance use disorder were most prevalent. When combined with injury, which encompassed events like accidental deaths, suicides, and homicides, these two causes of death made up 74% of all pregnancy-associated deaths.

 

The committee determined that 29% of the cases reviewed were pregnancy-related. Mental health conditions accounted for 45% of pregnancy-related deaths, while embolism accounted for 16%, and cardiac/coronary conditions for 13%.

 

The MMRP provides training opportunities during regular MMRC meetings at least once annually. In September 2023, the PA MMRC met for a Diversity, Equity, and Inclusion training for MMRC members to address bias, discrimination, and cultural competence.

 

MMRP staff strengthened partnerships with internal and external stakeholders and engaged family and community partnerships to address pregnancy-associated deaths. Staff from the MMRP joined more than 250 women, birthing individuals, governmental agencies, health care professionals, insurance providers, maternal support organizations, policy advocates, social determinants of health professionals, and support networks for the inaugural Birth Justice Philly Summit. The summit highlighted the efforts to create an equitable space during childbirth. Attendees engaged in meaningful discussions on topics such as how local communities are uniquely positioned to effectively address their specific challenges; promotion for the use of data collection and evaluation to guide progress and adaptation, how to positively impact maternal and postpartum health outcomes; and identification of methods to leverage public policy to promote and improve maternal health.

 

The Pennsylvania Perinatal Quality Collaborative (PA PQC) is the action arm for clinical MMRC recommendations. In 2023, the PA PQC worked with 63 hospitals representing 82.5% of live births in Pa. This work included an initiative with 48 hospitals to expand the focus on maternal SUD/OUD. Statistics from the Maternal Substance Use initiatives survey identified that 89% of participating hospitals reported they are using a validated screening tool for substance use in pregnancy; 83% reported they have protocols in place to provide brief interventions (with an additional 9% in progress); and 79% reported they are providing medications for OUD to pregnant individuals with OUD.

 

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)

 

Effective collaboration and coordination are important to create a high-quality system of support for birthing people individuals and families in Pa. Collaboration across agencies and programs ensures better coordinated services and reduces the duplication of services across agencies. BFH staff met the goal of convening with DHS and MIECHV quarterly in the 2023 calendar year. The intent of these meetings is collaboration among agencies to understand the programs and initiatives offered through the systems of care for pregnant and postpartum individuals in Pa. This knowledge and understanding aids in the development of gap filling programs offered through Title V.