Domain: Women/Maternal Health

Reporting for October 2022-September 2023

Objective

By 2025, Minnesota (MN) aims to increase the percentage of women receiving a preventative medical visit in the past year by 10% from 75% in 2020 to 83.4% in 2025.

National Performance Measure

(NPM WWV) Percent of women, ages 18 through 44, with a preventive medical visit in the past year.  

An annual well-woman visit provides a critical opportunity to receive recommended clinical preventive services, including screening, counseling, and immunizations, which can lead to appropriate identification, treatment, and prevention of disease to optimize the health of women before, between, and beyond potential pregnancies.[1] MN’s goal for FY2023 was that 79.2% of all women receive a well-woman visit. According to data from the Behavioral Risk Factor Surveillance System, 69.3% of women had a well-woman visit in 2022. This is down from 71.9% of women reporting they received well-woman visits in 2020. This was a continuation of the decrease seen from 2019 to 2020.

This decrease can be partially attributed to the COVID-19 pandemic, a barrier that prevented women from seeking the care they need, which continued into 2021. During the pandemic, studies are reflecting that preventive health services declined due to COVID-19 mitigation activities and people avoiding possible contact with the virus. Though COVID-19 cannot fully explain the downturn in preventative medical visits among women as there was a drop in 2019 to 2020, prior to the beginning of the pandemic.

Evidence-Informed Strategy Measure

(ESM WWV.2) Number of hospitals that are actively participating in MN Perinatal Quality Collaborative (MNPQC) initiative focused on the Alliance for Maternal Innovation (AIM) bundle on substance use disorders.

Members of the MNPQC recognize the importance of the issues addressed by the AIM, which is a national data-driven maternal safety and quality improvement initiative. AIM’s work aligns well with the MNPQC core initiatives, and formal involvement in the AIM Program aligns MN’s efforts with other states’ activities. The issues are relevant to discussions on quality improvement in MN as supported by the MN Maternal Mortality Review Committee (MMRC) and MNPQC steering committee.  The MNPQC steering committee had identified the initiative focused on opioid use disorder as a priority within the MNPQC strategic plan with intentions to model the AIM opioid / substance use disorder bundle.

The MNPQC led the state’s official enrollment in AIM in the Spring of 2022. The proposed AIM bundle for this opportunity was on Care for Pregnant and Postpartum People with Substance Use Disorder led by the MNPQC substance use disorder workgroup, Mother/Infant Opioid and Substance use Treatment and Recovery Effort (MOSTaRE).

The MOSTaRE project workgroup reached out to every major health system in MN and invited them to nominate one representative hospital to participate in the project. This recruitment approach ensured that the knowledge gained could later be disseminated across the entire health system and most hospitals in MN could benefit from learnings in this initiative. Nine health systems participated in the initiative with the potential for 16 hospital touchpoints. Hospitals created their team of champions that could include obstetric and NICU clinicians and staff, Labor & Delivery managers, hospital administrators, SUD community treatment and support partners, and quality improvement experts. With guidance from faculty in monthly Zoom calls, teams at these 9 hospitals or health systems championed practice changes.

Community-Identified Priority Need: Care During Pregnancy and Delivery

MN’s five-year 2020 comprehensive needs assessment identified a significant area of need in increasing accessible, quality health care during pregnancy, making care during pregnancy and delivery the women’s health priority area for the state.

It is important for all women to have access to reliable and quality preventive care throughout the life course. Well-woman visits can address a range of physical and mental health concerns with a health care provider and may include healthy diet education, screening for chronic diseases, screening for sexually transmitted infections, vaccinations, and mental health screening. Annual well-woman visits are important to a woman’s overall health and well-being and give women the opportunity to discuss their health with their provider, as well as prevent and identify serious health concerns before they become life threatening.

Adequate and regular prenatal care early on in and during the entire pregnancy is equally crucial to the health of mothers and babies. Data from MN birth records shows that babies of mothers who do not get prenatal care are three times more likely to be born low birth weight and five times more likely to die than those born to mothers who do get care. Receiving quality prenatal care can have positive effects long after birth for both individuals.  Prenatal care is more than practitioner visits and ultrasounds; it is an opportunity to improve the overall well-being and health of the pregnant person which directly affects the health outcomes of the baby. Further, prenatal visits give parents a chance to ask questions, discuss concerns, identify and treat complications in a timely manner, and ensure that the pregnant person and baby are safe during pregnancy, delivery, and postpartum. Having a healthy pregnancy and access to quality prenatal, delivery, and postpartum care facilities are one of the best ways to promote a healthy birth and have a thriving mother and baby.

In 2022, 79% of pregnant people in MN received prenatal care within their first trimester of pregnancy. Additionally, approximately 75.5% of pregnant people received adequate or adequate plus prenatal care (based on the Adequacy of Prenatal Care Utilization Index). There are many reasons why people do not get timely and/or quality care during pregnancy; however, MN recognizes that systemic racism is a root cause for creating and continuing to create barriers to accessing quality care before, during, and after pregnancy and delivery. We know from conversations with our community and healthcare systems partners, as well as from community members themselves, that unfair and unjust treatment of women and pregnant people of color and their families in the MN healthcare system is an ongoing reality. As a result, disparities are seen in the adequacy of prenatal care utilization across race/ethnicity (Figure 1). For example, births to American Indian mothers are the most likely to receive inadequate or no prenatal care (PNC) and least likely to receive adequate and adequate plus care.

Figure 1. Prenatal Care (PNC) Utilization by Race/Ethnicity, MN Residents, 2022

In MN, the Pregnancy Risk Assessment Monitoring System (PRAMS) survey identifies barriers to care from the mother’s perspective. The leading causes respondents gave for not getting prenatal care as early in their pregnancy as they wanted were:

• The doctor or my health plan would not start care as early as I wanted (29%)
• I couldn’t get an appointment when I wanted one (28%)
• I didn’t know I was pregnant (21%)
• Too many things going on (21%)
• Didn’t have enough money or insurance to pay for my visits (19%)

Other barriers mentioned by PRAMS survey respondents included being unable to take off time from work, not having transportation to get to the care they needed, and not being able to find anyone to take care of their children. These barriers attest to the impact of systemic racism on accessing quality and dependable healthcare services from an intersectional systems lens. Healthcare services do not occur in a bubble; the ability to access and the quality of healthcare services is interrelated with other factors such as transportation, finances and employment, insurance, childcare, and others. The COVID-19 pandemic has illuminated these impacts and disparities for women and pregnant people of color and their families in MN uplifting the need that access to care during pregnancy and delivery must be considered within a broader context of interrelated systems.

Implementation of the following strategies and activities, in partnership with statewide stakeholders, supported access to holistic, family focused, whole person care and services, equips providers with the resources and skills needed to work with diverse communities, and shifts policy priorities to reduce systemic barriers impacting birthing people.

Strategies and Activities

Strategy A: Expand Family-Focused, Community-Based Policy and Funding

State Level Activities

Key leaders have demonstrated an investment in perinatal health through state priorities to address maternal health disparities. One partner opportunity occurred during the National Maternal Health Innovation Symposium in August 2023. States and their key partners attended to hear multiple perspectives and experiences in perinatal health. A plenary led by indigenous leaders spoke on "moving forward with improved outcomes for indigenous maternal health". This plenary was followed by our MN Lieutenant Governor Peggy Flanagan that expressed authentic support, recognition, and need to address of the critical work led by maternal health programs. Her top leadership represented MN's values and priorities within Indigenous, Black and communities of color in maternal health at a national event. Lieutenant Governor Flanagan shared the different investments statewide tied to improving maternal and child health outcomes. This opportunity to hear from leadership voice and passion at an event with local, state, and national demonstrated our state possibilities to make policy and system changes that impacts our communities.

In 2022, the CFH Division contracted with a local research and evaluation firm to develop a strategic plan to continue to move health equity forward within the Division. Project goals included:

• Build off past/current CFH energy and effort related to equity and health equity
• Generate buy-in across the Division for its initial vision for advancing health equity within CFH – including intellectual understanding, feeling the importance of this work, and the readiness to engage in this work
• Identify high-level action steps the Division can take to achieve its vision
• Understand existing strengths and capacity within the Division to achieve high-level action steps and identify additional resources needed
• Determine how the Division will know that the high-level action steps achieve the Division’s vision - i.e., what “success” looks like.

The final strategic plan was completed and submitted to CFH leadership in September 2022, and implementation of the strategic plan began in October 2022. CFH leadership created the Health Equity Operations Workgroup, made up of CFH staff volunteers, to guide the implementation of the CFH Health Equity Strategic Plan. The workgroup began meeting monthly since December 2022 to move the strategic plan into action by determining and implementing tasks, deadlines, and staff involvement. In August 2023, the CFH Division hired its first Health Equity Strategist and part of their role is leading the Division through the continued implementation of the CFH Health Equity Strategic Plan.

Request for Proposals for a Community of Assessment of Strengths and Barriers to Accessing Midwife and Doula Services

MDH recognizes the community-informed solutions are needed to identify opportunities and gaps connecting individuals to birthing services and resources that support optimal health outcomes. In FFY2022 MDH released a request for proposals seeking a community assessment of strengths and barriers to accessing midwife and doula services in MN with a requirement that the awardee engage the communities experiencing the greatest disparities in maternal and infant pregnancy outcomes, to ensure the voices and input of the communities are aligned with recommendations and future work. The overall goal of the community assessment was to improve maternal and infant health outcomes in groups with the most significant disparities, including Black, Indigenous and other communities of color, new immigrants, families with lower incomes, and/or rural communities by increasing the availability of midwife and doula services. The contract, and related activities, was set to occur February 1, 2023, through June 30, 2023.

Maternal Care Access Coordinator

The Dignity in Pregnancy and Childbirth Act (144.1461) was passed by the Legislature in 2021 to address inequities in maternal health care, calls on the state to increase the availability of, and access to, doula and midwifery services by removing barriers to communities disproportionately affected by maternal and infant morbidity and mortality. To help improve health equity in pregnancy and postpartum outcomes, MDH hired a Maternal Care Access Coordinator to develop a strategic plan and to develop and implement policies, activities, and programs, with community input, aimed at expanding access to prenatal care, doula, and midwifery services by working with internal and external partners and stakeholders. The work of the Maternal Care Access Coordinator will inform cross-sector collaborations with internal and external stakeholders working to advance policies and systems changes to remove barriers to access for doula and midwife services such as trainings, certification, and reimbursement.

Strategy B: Integrate Health and Social Services to Optimize Cross-Sector Collaboration

State Level Activities

MN had an active landscape prioritizing improved perinatal outcomes across our communities. In July 2023, Healthy Beginnings, Healthy Families Act passed the MN legislation to ensure the health and well-being of young children and their families. This 18-million-dollar investment in over 4 years includes advancing perinatal health and wellbeing through advancing community and partner strategies.

One key investment in partnership as a leading solution have been demonstrated in supporting programs and/or organizations such as a state perinatal quality collaborative. MN legislation identified the need of a nonprofit organization to support efforts that improve maternal and infant health outcomes. MN Perinatal Organization (MPO) is the nonprofit organization that leads the MNPQC. This MNPQC grant is to create or sustain a multidisciplinary network of representatives of health care systems, health care providers, academic institutions, local and state agencies, and community partners that will collaboratively improve pregnancy and infant outcomes through evidence-based, population-level quality improvement initiatives. The grant program started early fall 2023 with a program timeline through June 2026.

Additionally, MN became an AIM state in Spring of 2022 and the MNPQC, co-led by MDH, is eager to take the next step in statewide quality improvement efforts for maternal health outcomes.  The state maternal health innovation team – Maternal Health Outcomes in MN (I-MOM), in partnership with MNPQC, is primarily responsible for coordinating AIM implementation and is undergoing exploratory opportunities to develop the data platform to increase efficiency and reduce burden with hospital partners. This grant program provided five-year funding support to the MNPQC to lead the establishment of an AIM data infrastructure, including data collection portals, reporting, engagement of hospitals/providers, and expand AIM bundles being implemented in MN. MNPQC is especially eager to engage with the AIM community to learn, build and grow this work. Objectives accomplished were to:

• Identify and implement AIM bundles and support data collection and sharing.
• Provide AIM technical assistance, training, and sharing QI project success to promote participation.
• Identify the next AIM bundle, incorporating the Innovations for I-MOM project work, including the MCH Advisory Task Force Perinatal Sub-Committee, the Perinatal Health Strategic Plan, and community recommendations.
• Work to address, as a primary improvement activity, critical cross-sector collaboration, like the urgent need to seamlessly address maternal opioid misuse alongside pregnancy, postpartum and pediatric care.
• The active AIM bundle was focused on the Care for Pregnant and Postpartum People with Substance Use Disorder – detailed in the activity 3 below – is focused on maternal opioid use.

Notably, a key member of the MNPQC proposed a QI initiative to address early hearing detection in newborns. This project convened MNPQC steering committee members and interested content experts, identified members in collaboration with MDH, to develop a project in alignment with outcomes mentioned in the Improving Hearing Loss Diagnosis by Three Months of Age project. The project timeline was a short six months, focused on improving the percentage of newborns with referrals, i.e., did not pass newborn hearing screening, from birthing facilities and received a complete audiological hearing evaluation by 3 months of age. This initiative ended in September 2023.

MOSTaRE Initiative – Title V Supported

In 2023, the state’s mandatory reporting laws for pregnant people using substances changed, and providers are exempt from the mandatory reporting of people who use a controlled substance during pregnancy. These significant policy changes in MN reduce systemic barriers to addiction services and care-seeking support for birthing people by addressing these on-going health needs.

The MNPQC chair presented on “Statewide Perinatal Substance Use Disorder Improvements: Bringing it all together” at a national platform via the virtual maternal innovations symposium. In this presentation, the MNPQC chair highlighted multiple collaborative partnerships occurring on the state level across MNPQC members and partners. Key SUD topics were 1) to understand requirements in perinatal toxicology testing and child protection services reporting, 2) the importance of decoupling reporting and resourcing to support culture of treatment and not punishment to optimize perinatal outcomes, and 3) lastly, how a state perinatal quality collaborative is a key mechanism to align broad partner engagement on SUD perinatal work.

The MN Perinatal Quality Collaborative (MNPQC) has also provided several opportunities to engage birthing hospitals to apply clinical practices in alignment to this new policy change.

AIM Bundle – Care for Pregnant and Postpartum People with Substance Use Disorders – Title V Supported

In 2022, MN became officially enrolled in the Alliance for Innovation on Maternal Health (AIM) program led by the MN Perinatal Organization (MPO) who hosts the MNPQC. The state maternal health innovation team – Maternal Health Outcomes in MN (I-MOM) - works in partnership with MPO to lead the establishment of data infrastructure to support the implementation of the AIM program, including data collection and reporting portals. Through this partnership, MNPQC’s first AIM bundle is on Care for Pregnant and Postpartum People with Substance Use Disorder led by their substance use disorder (SUD) workgroup. To implement this AIM bundle, MNPQC uses the innovation strategy through a hybrid quality improvement model to reach all areas of the state and improve direct clinical care and workforce training. The MNPQC initiative focuses on perinatal SUD emphasizing family-centered care and addressing prevention and treatment of substance exposure during and after pregnancy for both birthing people and their infants. The MOSTaRE initiative launched in September 2022 with rolling recruitment. The goals of the AIM bundle are to:

• Improve patient and caregiver education.
• Provide trauma-informed care.
• Foster collaboration among healthcare providers and across healthcare systems.

Support toward achieving these goals was through provision of ongoing technical assistance and support for data collection through action period calls with participants, including nine hospital teams from seven health systems statewide. Seven of the hospitals were located outside of the Twin Cities metro area. Of the total health systems involved, there was potential reach across sixteen hospitals. As part of the AIM SUD initiative was able to coincide with a Project ECHO series focused on perinatal substance use that ended in March 2023. This twice-monthly ECHO webinar series on the intersection of perinatal opioid use disorder and mental health, led by an addiction medicine provider and a perinatal psychiatrist – MNPQC members at a large health system. Topics aligned well with the different issues encountered by the hospitals, such as legal implications of perinatal substance use, infant toxicology. This ECHO series also included program outcome opportunities for the recent MMRC report to be presented in the February 2023 session, and the MNPQC SUD faculty presented on the SUD quality improvement initiative in the March 2023 session. Other technical assistance has included team monthly status reports that allows one-on-one coaching support to strengthen ability to meet AIM data reporting within health systems teams.

Task Force on Pregnancy Health and Substance Use Disorder – Title V Connected

The 2023 MN Legislature activated the Task Force on Pregnancy Health and Substance Use Disorder by statute to begin July 1, 2023.  The Task Force must complete their work by December 1, 2024, with a report recommending protocols for both testing and reporting for prenatal exposure to controlled substances. Beginning July 1, 2023, the MN Department of Health has contracted facilitators to assist with the appointment process and meeting requirements outlined by the legislature. The Task Force held their first meeting in October of 2023.

Comprehensive Drug Overdose and Morbidity Prevention – Title V Connected

Established in July 2023, the Comprehensive Drug Overdose and Morbidity Prevention Act (MN Statues 144.0528) created comprehensive drug overdose and morbidity prevention activities, epidemiologic investigations and surveillance, and evaluation, to monitor, address, and prevent drug overdoses statewide through integrated strategies conducted by MDH. With the goal to address the drug overdose epidemic by implementing eight comprehensive strategies for substance use disorder education and intervention. Two of these strategies specifically address drug overdose and morbidity in those who are pregnant or have just given birth and their infants. This new work is a collaborative approach with the MCH and CYSHN sections in the CFH Division to address substance use during pregnancy and in the postpartum period and improve referral for infants impacted by NAS/NOWS. Over the next few years, the design of a system to assess, address, and prevent the impacts of drug overdose and morbidity on those who are pregnant, their infants, and children. Funding to create statewide grants to implement recommendations from the maternal mortality review focusing individuals who maybe using substances during pregnancy and in the postpartum period.

The MNPQC led a maintenance period with their “Hypertension during Pregnancy and Postpartum Period” initiative that ended in September 2022. Initially, MNPQC explored an opportunity to upload AIM Bundle metrics on a quarterly basis. Due to the initial structure of the data entry within quality improvement platform, it was difficult to adapt the metrics without greatly altering the measures provided during while the Hypertension initiative was active. The MNPQC Progress Report on Hypertension in Pregnancy and Postpartum Period Initiative was shared by their co-chairs at the Program Advisory Committee meeting in August 2023 and available on their webpage.

In FFY2023, MDH was awarded a new HRSA grant from the State Maternal Innovation and Data Capacity Program. The purpose of the award is to support state capacity to improve maternal health and address maternal health disparities through quality services, a skilled workforce, enhanced data quality and capacity, and innovative programming that aims to reduce maternal mortality and severe maternal morbidity. MDH created the “Innovations for Maternal Health Outcomes in MN (I-MOM)” program. The purpose of the I-MOM program is focused on alignment and strengthening of the implementation of innovative, data-driven, community-informed and supported perinatal health programs to improve perinatal health outcomes for communities experiencing the highest rates of disparities in MN (Black, American Indian, other populations of color, new immigrants, refugees, and rural).

I-MOM activities include innovative programing, increased data capacity, implementation of AIM statewide quality improvement care initiatives, and support for building a skilled perinatal health workforce to reduce perinatal morbidity and mortality, and goals include:

1. Build a shared vision for perinatal health: Bring together perinatal health partners, specifically engaging community partners, to create alignment among goals, priorities, and actions to enhance access to a skilled workforce, decrease disparities and improve outcomes.
2. Improve data access and expand surveillance: Increase timely, high-quality state perinatal health data to support surveillance and inform the development of innovative perinatal health programs.
3. Improve the collection, reporting and analysis of AIM data: Identify and implement quality improvement bundles (through AIM) and provide training to support quality improvement initiatives designed to improve maternal health outcomes.

As a part of the I-MOM program, MDH established a Perinatal Sub-Committee under the existing Maternal and Child Health Advisory Task Force which will support development of MN’s first Perinatal Health Strategic Plan. The I-MOM Project Planner leads project management, as well as implementation of the I-MOM project in FFY2024 until the end of the grant period, which includes collaboration with Title V staff and the MCH Advisory Task Force Perinatal Sub-Committee. The I-MOM program submitted their first Maternal Health Annual Report (MHAR) to HRSA that will guide MDH ability to access data to analyze in a timely reporting leading to a formalized data structure central in our division.

MDH has a long-term goal that was echoed by the MNPQC and community partners, to develop an outward facing, equity-focused, maternal health dashboard to serve as the foundation for improvements in health for birthing families in MN. Preliminary planning efforts have been informed by the Perinatal Sub-Committee, MNPQC Data Committee and associated networks, to provide a key platform to engage experts to guide development and use of the dashboard.

The MNPQC is a critical partner for goal three of the I-MOM program to identify and implement AIM patient safety bundles by providing training to support quality improvement initiatives designed to improve perinatal health outcomes. The MNPQC began their first AIM bundle focused on the care for pregnant and postpartum people with substance use disorder. Goal three, the quality improvement model is reported in the activities two and three above.

Local Public Health and Community Spotlight

FHV is an effective upstream intervention that serves as a key link to other interventions and community supports and is a notable contributor to improved maternal and infant health outcomes. FHV services in MN are supported by several funding streams including state, federal and local resources that provide approximately $39 million annually to support home visiting programs across the state to serve upwards of 6,500 families. Additionally, two-thirds of MN’s Title V dollars are distributed to 51 community health boards who often use these Title V funds to provide and/or supplement FHV services.

In FFY2023, with support from Title V Staff, community health boards, tribal nations, and nonprofits engaged in the following activities:

• Implement activities that provide culturally and linguistically appropriate services to priority populations, including home visitors attending implicit bias training or other trainings that promote culturally responsive, trauma-informed care, and using funding to support the American Indian specific evidence-based FHV Curriculum – Family Spirit. 
• MDH FHV began providing funding in July 2023 to grantees implementing promising practices and evidence-informed strategies to specifically reach priority populations including families experiencing incarceration, high-risk pregnancies, substance use disorder, serious persistent mental illness, housing insecurity or homelessness, intimate partner violence or living in a domestic violence shelter, and culturally diverse underserved communities with limited access to family home visiting services.
• Connect families to needed community services.
• Promote the importance of well-women visits, prenatal and postpartum care, and strive to assure that the women served have health insurance and are connected to a primary care provider.
• Work closely with primary care providers to encourage cross-sector collaboration to provide a more holistic approach to caring for families during pregnancy and after the birth of their child.
• Support parents early in their role as a child’s first teacher and foster parenting skills that decrease the risk of child abuse.
• Help parents develop safe, stable, and nurturing environments that support healthy development.
• Provide screening, using validated tools, for: depression during the postpartum period; intimate partner violence, parent-child interactions, and developmental and social emotional concerns for children – and, subsequently, make appropriate referrals.
• Provide health information and encouragement to families including, but not limited to, family planning, breastfeeding and child nutrition, and child growth and development.

Strategy C: Strengthen and Expand Culturally Responsive, Trauma-Informed Care for Women of Childbearing Age

State Level Activities

The MMMRP’s goal is to improve the health outcomes of pregnant people through maternal mortality and morbidity reviews. The MMMRP houses the Maternal Mortality Review Committee (MMRC), which reviews maternal death cases and develops recommendations to prevent future deaths.   The MMRC is a state advisory committee with members appointed by the commissioner of health. In 2022, appointments were finalized, and orientation was offered for members of the newly formed MMRC. Included in this new membership were annual plan agreements to support members representing communities disproportionately impacted by maternal mortality ($2,500 per member).  Between October 2022-May 2023, the MMRC reviewed maternal deaths occurring from 2019-2020, including deaths associated to COVID-19. Additionally, during this reporting period, the MMRC had 7 meetings.

Data abstraction for the MMRC is completed through annual plan agreements and contracts. Contractors were trained to use a CDC developed data base for maternal mortality, and abstracted cases for the committee to review.  A professional technical contract for a key abstractor for the maternal mortality review and awarded in September 2022. This Key Abstractor was contracted to work with MDH for 2 years. MDH also has continued agreements with additional abstractors due to an increased case load.

Additionally, MDH staff, including Title V staff, engaged in the following activities in FFY2023:

• Attended the Maternal Mortality Review Information Application (MMRIA) User Meeting, hosted by the CDC, connecting with other states to learn about improved processes and best practices in case reviews.
• Updated and continued to implement a retention plan for maternal mortality review documents using internal processes and procedures at MDH.
• Executed a data sharing agreement with the MN DHS to identify service locations for maternal deaths that have received Medicaid during pregnancy or the first year postpartum.
• Delivered presentations on maternal mortality data with partners at various gatherings.
• Partnered with MDH’s Office on Women’s Health to develop and implement interventions to reduce maternal deaths due to violence – specifically homicide and suicide – including adding a MMRC work group to focus on violent death reviews. 

In May 2023, MDH applied and was awarded CDC funding to support MMRC work to begin October 1, 2023. Planning occurred in September 2023 to include the following activities in the grant:

• Improving timeliness & accuracy of data entry into the CDC database (MMRIA).
• Future implementation of the Hear Her media campaign.
• Supporting three community-based organizations that represent and serve communities most impacted by disparities in maternal mortality.
• Supporting the MN Perinatal Quality Collaborative.
• Providing debriefing support to MMRC committee members.

MDH staff partnered with MDH’s Injury and Violence Prevention Section (IVPS) on a maternal violent death project funded by the Office on Women’s Health (OWH). This five-year grant (2021-2026) is designed to reduce deaths among pregnant and postpartum women due to violence with specific interventions around suicide, homicide, and domestic violence. This project aims to 1) enhance surveillance of violent maternal deaths, and 2) expand the evidence-based Confidentiality, Universal Education and Empowerment, Support (CUES) intervention. The project team worked closely with the MMRC, MNPQC, and local violence-prevention organizations toward achieving these goals.

In FFY2023, the project team completed the following activities:

• Formed a MMRC maternal violent death review workgroup to pilot a review protocol focused on reviewing violent deaths including homicide and suicide.
• Planned a gathering between MMRC workgroup members and subject matter expert partners who are also part of the grant’s Intervention Leadership Team. The goal of the gathering was to introduce the workgroup members and subject matter expert partners to the maternal violent death review protocol (as mentioned in bullet one) and identify their roles. The meeting occurred on Nov. 4th, 2022.
• Developed a crosswalk of the mortality surveillance systems MMRIA MNVDRS (MN National Violent Death Reporting System) used by the Maternal and Child Health and Injury and Violence Prevention sections of MDH. The purpose of the crosswalk was to help create an internal maternal violent deaths database to improve maternal death case ascertainment.
• Title V staff involved this project joined staff from IVPS on a trip to the Hennepin County Medical Examiner’s Office. The purpose of this trip was to build meaningful connections with medical examiners.
• With carryover funding available through this OWH funding, MDH contracted with the National Association for Retrospective Fatality Analysts (NARFA) to pilot an informant interview protocol with a Retrospective Fatality Analysis approach.

In FFY2022 MDH staff worked to implement the Dignity in Pregnancy and Childbirth Act, part of which requires all birthing facilities to provide staff with anti-racism and implicit bias training with curriculum to be updated annually. The University of MN’s Center for Anti-Racist Research for Health Equity was the lead in this work, contracting with Diversity Science to create learning modules to be released to the public to meet these criteria. Modules were not released until 2023.

[1] Committee on Gynecologic Practice. ACOG Committee Opinion Number 755: Well-woman Visit. Obstet Gynecol. 2018 Oct 132(4):e181-e186. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/10/well-womanvisit