Colorado’s MCH Program
Colorado’s MCH program is housed in the Colorado Department of Public Health and Environment (CDPHE). Colorado’s MCH program collaborates with programs across CDPHE, other state agencies and statewide organizations, local public health agencies and community partners to implement strategies that have a population based impact on Colorado’s statewide MCH priorities. The 2016-2020 priorities were selected based on issues identified through the comprehensive MCH statewide needs assessment process conducted in 2015. National and/or state performance measures serve as long-term goals for each priority.
MCH Priority Implementation
Interim progress toward the performance measures is tracked through quarterly performance management reporting. Evidence-informed strategy measures and associated objectives are outlined in logic models and action plans for each priority and are posted on www.MCHColorado.org. The logic models and action plans, used to guide Colorado’s state and local MCH work, are based on best and promising practices. MCH funds are leveraged with state resources, as well as aligned with other federally-funded programs and initiatives, to support priority implementation efforts. MCH funds are also used to build the capacity of the state and local MCH workforce in the areas of health equity, community inclusion, performance management, quality improvement and evaluation. A summary of progress for each MCH priority is included below.
Women’s Mental Health Promotion
Low Risk Cesarean Reduction
Research suggests that some women are at increased risk for postnatal depression following a Cesarean. In 2017, an analysis of low-risk first birth cesarean rates among Colorado birthing hospitals was completed in partnership with the Colorado Perinatal Care Quality Collaborative. National data were also analyzed to determine a Colorado-specific target rate of 22-24%. Based on this work, 19 of Colorado’s 56 birthing hospitals were identified as having a high rate of low-risk first birth cesareans and were invited to participate in a quality improvement initiative to implement evidence-based strategies from the California Maternal Quality Care Collaborative toolkit. Hospital recruitment efforts to participate in the initiative to reduce low risk cesarean deliveries began in December 2017, with six hospitals participating in the first cohort. The cesarean rates for participating hospitals is 23.1% in 2020, down from an average baseline of 25.4% in 2018. In 2019, Colorado became an AIM (Alliance for Innovation on Maternal Health) state and selected reducing primary cesareans as the first AIM bundle to be implemented.
Pregnancy-Related Depression Screening and Referral Promotion
Depression is the most common complication of pregnancy, affecting nearly one in ten Colorado mothers. The pregnant and postpartum period is a critical time to identify and address maternal mental health concerns, for both mother and child. However, research suggests that stigma associated with mental health is a primary reason women do not seek treatment. To improve the awareness and knowledge of pregnancy-related depression among pregnant and postpartum women and to improve women’s perceptions and attitudes toward seeking help, Colorado’s MCH program supports provider education and a statewide public awareness campaign. Both efforts strive to increase understanding of the importance of screening women for depression. The campaign, developed in English and subsequently transcreated into Spanish, encourages women and their support networks to seek help via the Colorado-specific landing page of Postpartum Support International’s website. Between 2016 and 2018, the percent of women in Colorado who reported being asked by providers at their postpartum visit about depression showed a statistically significant improvement from 88.3% to 93.0%. MCH also coordinates the state’s Maternal Mortality Review Committee. The first report on maternal mortality in Colorado was published in October 2017, analyzing 145 maternal deaths from 2008 to 2013, which showed that deaths due to behavioral health conditions were increasing. Based on Colorado’s most recent review committee data for 2014-16, suicide and substance use overdose continue to be leading causes of maternal mortality.
Substance Misuse Reduction Among Pregnant and Postpartum Women
Tobacco
The percent of women who report smoking during pregnancy has been steadily dropping from 8.4% in 2009 to 5.9% in 2018. Colorado MCH funds the CDPHE Tobacco Prevention Program to support smoking cessation and promotion of smoke-free environments. Implementation strategies focus on the Colorado Quitline, provider education, and the BABY and ME Tobacco Free™ program, with sites in every county of the state. A large scale evaluation found that program participants saw a 24% to 28% reduction in the risk of preterm birth and a 24% to 55% reduction in the risk of neonatal intensive care unit admissions. Total per-person cost savings of the program compared to the birth certificate and PRAMS reference populations was $6,040 and $2,182, respectively. Total annual cost savings for Colorado associated with the intervention was $4,144,118 and $1,497,299 compared to birth certificate and PRAMS reference populations, respectively.
Marijuana
The percent of women who report using marijuana at any time during their pregnancy has increased from 5.7% in 2014 to 8.2% in 2018. To address this trend, Colorado MCH partners with CDPHE’s Marijuana Education Program to impact marijuana use amongst women of reproductive age. Since October 2017, a media campaign has been implemented to educate pregnant and breastfeeding women about the use of retail marijuana. Over the life of the campaign, there were more than 30 million media impressions via a variety of Colorado media channels throughout the state. Evaluation results from this campaign showed statistically significant increases in understanding of the health effects of marijuana on children among English-speaking women of reproductive age in the survey sample. Eighty-eight percent of women of reproductive age reported a perceived risk from using marijuana during breastfeeding. In August 2018, CDPHE launched a new marijuana education campaign that focuses on young moms, ages 15-19, which is the population that reported the lowest perception of risk of daily or near daily use of marijuana during pregnancy. Since July 1, 2018, the campaign has garnered more than 11 million paid media impressions. Perceptions of risk were assessed among women of reproductive age between two time points by an external evaluator. The perception of risk associated with a woman using marijuana once a week during pregnancy increased significantly (6 percent increase) among women of reproductive age, though not significantly among the priority population of young moms.
Opioid
The rate of emergency department visits for prescription opioid poisoning per 100,00 women ages 15-44 rose from 20.6 in 2016 to 22.9 in 2018. At the same time, the rate of hospitalizations has gone down from 13.3 in 2016 to 8.7 in 2018. To decrease opioid poisoning, MCH and the Opioid Overdose Prevention Program collaborate with state and local members of the Colorado Consortium for Prescription Drug Abuse Prevention, housed at the University of Colorado Denver School of Pharmacy. Public awareness, safe disposal, provider education, and public health surveillance strategies are being implemented to address this priority.
Reduction of Infant Mortality among the African American Population
The majority of MCH-funded infant mortality prevention work in Colorado is implemented by Denver Public Health and TriCounty Health Department, as the agencies that serve the three counties with both the highest rates of African American residents and the highest rates of African American infant mortality in the state. The aggregated infant mortality rate in Denver, Adams and Arapahoe counties has been steadily declining from 12.3 in 2014 to 5.5 in 2018. Efforts to address infant mortality have focused on the promotion of Colorado’s Preterm Birth Reduction Strategies. These prevention strategies include a campaign to increase awareness of the risks of prematurity, training on toxic stress as a contributing factor, child and family screening and connection to community-based resources, as well as the advancement of family-friendly employment policies, including paid family leave.
Early Childhood Obesity Prevention
Breastfeeding Promotion
Breastfeeding initiation rates in Colorado have consistently hovered at or above 90% in Colorado. This is, in part, due to hospitals achieving and maintaining the Baby-Friendly designation. According to 2016 birth certificate data, breastfeeding initiation rates amongst Baby-Friendly hospitals in Colorado was 94.1% vs 90.7% in other hospitals. In 2019, approximately 37% of all live births in Colorado occurred at one of the 14 Baby-Friendly designated hospitals. To recruit and retain hospitals as Baby-Friendly, MCH-funded staff coordinate the statewide Baby-Friendly Collaborative. Members of the Collaborative share strategies for how to engage hospital leadership in Baby-Friendly, educate about the Hospital Quality Incentive Payment Program within Colorado Medicaid and use incentives to implement changes that advance their hospital towards Baby-Friendly designation. Rates of exclusive breastfeeding through six months of age continue to be significantly lower than initiation rates. They have also been quite variable, with a low of 21.2% in 2010, a high of 30.3% in 2012, and the most recent rate of 27.3% in 2016. To support continued breastfeeding, MCH-funded staff, in partnership with the Breastfeeding in Child Care Advisory Committee and the Colorado Department of Human Services, developed an interactive online training module for child care professionals to align with the recently developed Breastfeeding in Child Care Toolkits. These tools were created to address knowledge gaps and to positively influence the behaviors, attitudes and practices of child care providers to support breastfeeding.
Physical Activity Promotion
Development of basic motor skills of children in early learning settings is linked to later levels of physical activity. To set the trajectory for healthy weight in school age children, MCH-funded staff promote policies, systems and environments that early learning settings, primary care, public health providers, community partners, parents and caregivers can implement to support young children in establishing healthy habits in both home and early learning environments. MCH-funded staff work with child care facilities to support attainment of an activity point on their child care quality rating assessment. Data from the Colorado Department of Human Services indicates that the number of facilities that receive the rating point for physical activity has increased since 2015 from 41 to 406 in 2019, indicating a positive trend in implementing the recommended and best practices for physical activity.
Developmental Screening and Referral Promotion
Colorado remains in the top tier amongst states for developmental screening rates, with rates higher than the national average (50.5% v. 33.5%, respectively). However, Early Intervention Colorado data showed that in 2016, there was no statistically significant difference in the rate of Colorado children, ages 0-3, and children nationally, who received early intervention services through Part C of the Individuals with Disabilities Education Act. This may be an indicator of barriers to evaluation and intervention services after screening. An MCH-supported interagency council was created to reduce policy barriers, with a current focus on increasing data systems integration from screening to the delivery of services. In addition, local public health agencies are working with their partners to strengthen community-based screening and referral processes. To date, over 110 local partners have implemented quality standards that support community-based early childhood screening, referral and treatment services for developmental needs.
Bullying and Youth Suicide Prevention
According to research, different types of violence are interconnected and often share the same root causes. An effective strategy to prevent multiple forms of violence is based upon a shared risk and protective factor approach. This recognizes the overlapping causes of violence, as well as the factors that protect against the experience of violence. Strategies funded by MCH to prevent bullying and youth suicide include building school connectedness, community connectedness, and economic stability for youth. Current local efforts to support this priority are focused on implementation of Sources of Strength, a best practice bullying and suicide prevention curriculum. To date, 77 schools statewide are implementing Sources of Strength.
Medical Home Promotion for Children and Youth with Special Health Care Needs
Having a medical home is fundamental to delivering high-quality and cost-effective health care. In 2017-2018, 40.9% percent of Colorado children and youth with special needs have a medical home, which has had a downward trend from 45.6% in 2016. Strategies funded by MCH to address this trend include community-based care coordination, expanding the use of telehealth to increase access to pediatric specialty care, including behavioral health, and strengthening referral systems to services and supports.
2021-2025 MCH Priorities
The new MCH Framework for the next five-year block grant cycle is based on the statewide MCH needs assessment conducted throughout 2019. Some of MCH’s existing efforts will continue, along with new strategies to address the following seven priorities:
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