III.C. Needs Assessment Update

Needs Assessment Overview

In 2019-20, RIDOH completed an extensive MCH needs assessment that incorporated feedback from a wide array of stakeholders, including community organizations, clinical providers, advocates, and families. Information was gathered from more than 1000 individuals via surveys, facilitated discussions, large community meetings, and listening sessions. The resulting data were used to develop the following MCH priorities for 2020-2025:

1. Reduce Maternal Mortality/Morbidity
2. Reduce Perinatal Health Disparities
3. Strengthen Caregiver’s Behavioral Health and Relationship with Child
4. Support School Readiness
5. Support Adolescent Mental and Behavioral Health
6. Provide Effective Care Coordination for CSHCN
7. Adopt Social Determinants of Health in MCH Planning and Practice to Improve Health Equity.

 

III.C.2.a.  Process Description

Needs Assessment Methodology

The needs assessment was a systematic process that aimed to acquire an accurate picture of the strengths and weaknesses of Rhode Island’s public health system and identify the most appropriate programs and policies to promote the health of pregnant or childbearing aged individuals, infants, children (including children with special healthcare needs), adolescents, and their families. The needs assessment team took the time to thoroughly understand the varying concerns and burdens of culturally and socio-economically diverse communities across the state using the following steps:

 

1. Planning Phase - Partnering with key internal (MIECHV) and external (SISTAFIRE and RIPIN) stakeholders to plan the needs assessment.
2. Secondary Data Analysis - Review Title V measures and population-based data to adopt a methodology for identifying key MCH problems.
3. Community & Workforce State Outreach - Collaborate and engage with key community and professional groups to understand the community perspective via surveys and focus groups.
4. Prioritization - Utilize a prioritization process that involve input from MCH leadership and RIDOH programs to select state MCH priorities.
5. Strategy Selection - Identify strategies for each selected MCH state priority with RIDOH program participation
   
   Please refer to the attachment ‘5-Year Needs Assessment Summary - Process Description’ for a detailed description of the needs assessment process and methodology.
    

III.C.2.b. Findings

 

III.C.2.b.i. MCH Population Health Status
 

Note: Beginning in 2022, NCHS has discontinued to create bridged-codes for birth, fetal death, and death race data. The change in race classification to Vital Records data may result in notable differences in outcomes by race/ethnicity.  

 

Women’s/Maternal Health (Preconception, Pregnancy, and Postpartum Health)

 

The Preconception, Pregnancy, and Postpartum Health domain section has taken into consideration that the care and outcomes of womxn, children, and families are impacted by the systemic racism, discrimination, unaddressed language barriers, and a lack of culturally responsive providers.

Preconception Health

Title X provisional data in 2022 shows that 63.1% of Title X clients were using moderate to most effective family planning methods, an improvement from 61.9% in 2021. The Black/White ratio of using moderate to most effective family planning methods were nearly similar (0.9:1).  There was a slight improving trend among women reporting that they didn't exercise or exercised little before pregnancy, from 24.3% in 2020 to 23.3% in 2021. In 2016-2021, women less than 20 years old were more likely to experience depression before pregnancy (19.1%) than women 34 years and older (13.6%).

Health During Pregnancy

In 2016-2021, there were 35.9% of unintended pregnancies in Rhode Island.  Among racial/ethnic groups, 29.0% of Non-Hispanic White women reported an unintended pregnancy, which was statistically significant compared to 42.9% of Hispanic women and 49.0% Non-Hispanic Black women.  In addition, women less than 20 years old were statistically more likely to report an unintended pregnancy than women of all older age groups.  Among RI-resident women who gave birth in 2022, 8.3% had gestational diabetes and 10.8% had gestational hypertension/preeclampsia. The overall trend of cigarette smoking during the last 3 months of pregnancy has decreased, pregnant women with disabilities had a statistically significant higher percentage (9.9%) of smoking during pregnancy than pregnant women with no disabilities (4.2%) in 2016-2021. There was also a slight increase in electronic cigarette use from 5.2% in 2020 to 5.8% in 2021. In 2022, 83.4% of pregnant women who gave birth received prenatal care beginning in the first trimester, which is a slight decrease from 84.1% in 2021.  Non-Hispanic White women (86.9%) are still more likely to start prenatal care in the first trimester than Non-Hispanic Black women (77.8%).  In addition, Non-Hispanic White women (61.2%) were significantly higher in reporting to have their teeth cleaned by a dentist or dental hygienist than Non-Hispanic Black women (42.2%), Hispanic women (49.9%) and women reporting as Other (46.3%).
 

Delivery and Postpartum Health

In 2022, 30.2% of women had a cesarean delivery in a Rhode Island facility with a low-risk birth, a steady increase since 2018 (27.5%).  Rhode Island has one of the highest low-risk cesarean birth rates in the nation.  The 2022 severe maternal morbidity rate was 86.5 per 10,000 delivery hospitalizations, which is a slight increase from 85.4 per 10,000 in 2021. Racial disparities continue to be seen between Black women (124.0 per 10,000 delivery hospitalizations) than White women (72.9 per 10,000) in 2018-2022. These disparities can also be seen among delivery hospitalizations regarding postpartum hemorrhages (Hispanic women: 1,044.1 per 10,000 delivery hospitalizations; Black women: 1,028.4 per 10,000; White women: 796.6 per 10,000) and severe hypertension (Black women: 510.6 per 10,000; Hispanic women: 351.9 per 10,000; White women: 296.1 per 10,000). Provisional data from the Pregnancy and Postpartum Death Review show that in 2018-2021, there were 24 pregnancy-associated deaths in Rhode Island.  The pregnancy-associated mortality ratio (PAMR) in Rhode Island for 2018-2021 is 58.2 per 100,000 live births.  The number of pregnancy-related deaths in 2018-2021 for RI is less than 10.  The percentage of women reporting symptoms of postpartum depression was 12.7% in 2020, an increase from 11.5% in 2019. In 2016-2021, 17.8% of women identifying Other as their race/ethnicity group reported postpartum depressive symptoms compared to Non-Hispanic White women with 11.3%, a statistically significant difference. An even larger and significant disparity in reporting postpartum depression exists between women with disabilities (30.9%) and women with no disabilities (10.9%).

 

Perinatal/Infant Health

 

Poor Birth Outcomes

In 2022, 7.9% RI-resident infants were born with low birth weight (< 2,500 grams), 9.0% infants were born preterm (< 37 weeks gestation), and 26.4% were born early term (37-38 weeks gestation). Racial disparities are observed among low-birth-weight infants (Non-Hispanic Black infants: 10.8%; Non-Hispanic White infants: 6.4%) and preterm births (Non-Hispanic Black infants: 11.5%; Non-Hispanic White infants: 8.0%) for 2002. The infant mortality rate in RI is 3.6 deaths per 1,000 live births in 2022, a slight decrease from 3.7 per 1,000 in 2021. There is a large disparity between the Non-Hispanic Black IMR (9.1 per 1,000 live births) and the Non-Hispanic White IMR (2.9 per 1,000) for 2018-2022, with a Black-White infant mortality ratio of 5.0:1. Birth defects program data in 2021 show that 76 newborns were discharged with neonatal abstinence syndrome. This represents a rate of 72.7 per 10,000 live births.

Mental/Behavioral Health of Caregiver

In 2021-22, home visitors observed 66.8% of caregivers interacting with their children, a further increase from 65.4% in 2020-21.  In 2020-21, caregivers who were single and never married (14.5%) were far less likely to be observed interacting with their children than caregivers who were married (76.1%).  Furthermore, 58.0% of caregivers are able to handle the day-to-day demands of raising children very well in 2020-21, which is a slight decrease from 58.7% in 2019-20.  In 2020-21, the percentage of mothers who reported having excellent or very good mental and emotional health was 70.4%, which is a further decrease from 71.3% in 2020-21. In 2020-21, 63.6% of mothers with a household income of 100-199% Federal Poverty Level (FPL) reported having excellent or very good mental and emotional health compared to 78.3% of mothers with a household income of 400% FPL or greater. 

The mental/behavioral health of a woman may impact the ability to care for their infants.  Timely and validated screening for behavioral health outcomes among pregnant and postpartum women will help improve the well-being of the caregivers and their infant.  MomsPRN clinic cohort data from 2022 show that 66.3% of perinatal patients (pregnant up to 1 year postpartum) were screened for depression, a decrease from 2021 of 71.1%. Groups that have the highest depression screening rates are patients who are Hispanic (81.2%) and have no insurance (83.9%), compared to groups who report their race/ethnicity as Other (48.7%) and have private or other insurance (55.7%).  Variation in screening prevalence by demographics may result from the use of different screening protocols of individual practices. Using the family visiting model, depression screening for the caregiver is much higher overall in 2022 (92.2%).  MomsPRN clinic cohort data in 2022 also show that 55.4% of their patients have been screened for anxiety during the same perinatal period, a drop from 66.3% in 2021.  Similarly, groups that have the highest anxiety screening rates are patients who are Hispanic (80.5%) and have no insurance (90.3%), compared to groups who report their race/ethnicity as Other (48.7%) and have private or no insurance (55.7%). 
 

 

Child Health
 

Children’s Health Data

In 2020-21, 24.7% of children ages 6-11 were physically active every day, a decrease from 28.4% in 2019-20.  NSCH 2012-21 data show that 74.0% of children were continuously and adequately insured in the past year. Interestingly, children with private health insurance (70.4%) were significantly less adequate than children with public health insurance (91.4%). According to the 2020-21 National Immunization Survey (NIS), Among the 2019 cohort, 85.3% of RI children by the age of 24 months have completed the combined 7-vaccine series, an increase from the 2018 birth cohort of 78.6%. RI remains the highest ranked in the nation for influenza coverage among children ages 19 to 35 months.  In 2020-21, 53.3% of children without special healthcare needs meet the criteria of having a medical home, a slight drop from 54.5% in 2019-20.
 

Child Literacy

Early literacy is an important precursor for developing a foundation to school readiness. The percentage of postpartum women reporting currently reading or looking at a book with their baby in the past week in 2021 is 85.9%. Statistically significant differences continue to exist among racial/ethnic groups in 2016-2021, where 76.5% of Hispanic postpartum women reported currently reading to their infant compared to 87.5% of Non-Hispanic White postpartum women. In 2020-21, 39.8% of family members were reading to their child ages 0-5 every day, a slight increase from 36.5% in 2019-20.  This outcome becomes more evident in the significant disparity between Hispanic family members reading to their child ages 0- 5 every day (17.5%) compared to Non-Hispanic White family members (51.7%). The Reach Out and Read RI Program show that 40.1% of pediatric practices participated in book sharing in 2022, an increase from 34.1% in 2021. Overall, 98.7% of books were distributed among well child visits.
 

 

Adolescent Health

Healthcare and Immunization

According to the 2020-21 NSCH data, 71.5% of adolescents ages 12 to 17 received a past year preventive medical visit, a decrease from 79.5% in 2019-20.  The 2020-21 NIS reports that 90.1% of teens ages 13 through 17 have received at least one dose of the HPV vaccine, a drop from 93.0% in the previous year.  RI has the highest rates of HPV vaccination coverage in the US. Other adolescent immunizations were also high in 2021 with 92.8% receiving at least one dose of the meningococcal conjugate vaccine and 93.8% receiving at least one dose of the Tdap vaccine.  However, both meningococcal conjugate and Tdap immunization rates among adolescents were slightly lower than 2020.  Nevertheless, seasonal influenza (76.5%), meningococcal, and Tdap immunization rates in RI exceed U.S. rates among adolescents.
 

Behavioral/Mental Health

There was a decrease in bullying in school property among high school students from 16.4% in 2019 to 10.3% in 2021, the lowest prevalence since the question was first asked in 2009. LGB high school students continue to be more likely to be bullied on school property (20.1%) than heterosexual high school students (7.6%), as well as more likely to be electronically bullied (LGB HS students: 20.1%; heterosexual HS students: 9.3%). Suicide ideation is of an important issue concerning the MCH Program. YRBS shows an increase among high school teens who seriously considered committing suicide from 13.3% in 2019 to 17.1% in 2021. Disparities exist between 19.8% of Hispanic teens who seriously considered committing suicide compared to 15.4% of Non-Hispanic White teens. The prevalence of having attempted suicide was higher among gay, lesbian, and bisexual students (41.8%) than heterosexual (10.1%) students. The Suicide Prevention Initiative reports in 2022 that 76.6% of RI students were screened and referred for support services using Kids’ Link, a behavioral health triage service and referral network. This is an increase from 63.6% reported in 2021.  In 2020-21, 56.6% of adolescents ages 12-17 received treatment or counseling by a mental health professional.

 

Children with Special Health Care Needs

 

According to 2016-20 NSCH data, 21.4% of RI children ages 0-17 years have at least one special health care need, a significant difference with the nationwide estimate of 19.4%. In 2020-21, 69.0% of CSHCN are continuously and adequately insured in RI. There are 18.7% of CSCHN who are uninsured.

 

Medical Home/Care Coordination

To be considered a medical home a practice must be accessible, family centered, continuous, comprehensive, coordinated, compassionate, and culturally effective. In 2020-21, 53.3% of children with special healthcare needs (CSHCN) had a medical home, compared to 54.3% of CSHCN in 2019-20. This measure nearly meets the Healthy People 2030 target objective of 53.6%.  The Medical Home Portal in RI, a website offering resources and links to families with CSHCN, reported the site receiving 53,403 web hits in FY22, a 39.5% increase from 38,276 web hits in FY21. Another metric from FY22 shows that 21.7% of unique users clicked on at least one resource link from Medical Home Portal.  A satisfaction survey was sent out to registered users of the Medical Home Portal, and 86.2% responded that the site was helpful. In 2019-20, 41.3% of CSHCN received effective care coordination, an increase from 35.1% in 2019-20.
 

Impact on Families

RI continues to study and monitor the financial impact that many families with CSCHN experience. NSCH 2020-21 reports that 9.0% of families with CSHCN have had problems paying for any of the child’s medical or health care bills in RI compared to 4.7% of children without special healthcare needs.  NSCH data also shows that 14.2% of RI families of CSHCN had a family member stop working or cut down hours of work because of the child’s health or health conditions, which is statistically significant compared to 2.8% families of children without special health care needs. The number of caregivers able to handle the demands of raising children ages 0-17 with special healthcare needs very well is statistically lower (44.4%) than caregivers raising children without special healthcare needs ages 0-17 (61.8%).

 

Cross/Cutting Systems Building

Social Determinants of Health

The Title V Program has a long-standing interest to address social determinants of health among MCH populations by monitoring and reporting these conditions from various population-based data. In PRAMS 2016-2020, 7.8% of postpartum mothers reported thinking back to their childhood and very often finding it hard for their family to pay for basic needs like food or housing.  According to 2021 YRBS data, 70.9% of HS students reported they will probably or definitely complete a post high school program, a drop from 75.4 in 2019%.  Compared to 89.0% of White HS students who most of the time or always feel safe and secure in their neighborhood, only 72.6% of Black HS students felt safe and secure in their neighborhood. In 2021, 3.3% of students who have ever slept away from their parents or guardians did so because they were kicked out, ran away, or abandoned, a decrease from 7.5% in 2019. The National Survey of Children’s Health also collects data on social determinants of health.  In 2020-21, 63.1% of households among Hispanic families could always afford to eat good and nutritious meals, which is significantly different compared to 82.5% of households among White Non-Hispanic families. Furthermore, 52.3% of Hispanic parents definitely agree that their child lives in a safe neighborhood compared to the same response from 74.7% of White Non-Hispanic parents.

 

Health Equity Indicators

RI has adopted 15 Health Equity Indicators as statewide measures to assess health equity in the state. These indicators span across five domains (integrated healthcare, community, physical environment, socioeconomics, and community trauma), which are further broken down in measuring key determinants of health that are reported at the city/town level and by race/ethnicity.  Housing burden, a socioeconomic indicator, is calculated by identifying the percentage of cost-burdened renters and owners for RI cities and towns.  This composite metric from 2022 HousingWorks RI Factbook’s data showed that Black household owners (37%) and Hispanic household owners (40%) had a higher total cost burden than White household owners (26%) The graduation rate among high school students who completed 4 years in the 2019-20 freshman class was 85.4%, which is nearly similar to the 2018-19 freshmen class with a graduation rate of 85.7%.  In 2018, the core cities of Central Falls (11%) and Woonsocket (14%) were two of three RI municipalities that had the lowest turnout among registered party-affiliated voters for the general elections.

 

Health Equity Indices

The MCH Program continues to incorporate equity indices as part of Title V reporting to better understand how social determinants affect specific MCH populations.  The Child Opportunity Index (COI) has developed a second version of its equity index calculated using education, health and environment, and social and economic indicators for the child population (ages 0-17).  For state-normed data in 2015, there is a large variation in the overall COI of census tracts in Providence and Pawtucket (labeled ‘Very Low’) compared to census tracts of suburban municipalities such as East Greenwich and Barrington (labeled ‘Very High’).

 

Emerging Public Health Issues

 

Covid Pandemic

 

The Covid-19 pandemic has affected health systems and services to the MCH population in Rhode Island, as well as highlighted inequities among vulnerable populations and communities.  There were declines in childhood vaccination (with greater declines among children ages 7 or older and Black children) and lead screening. The pandemic also disrupted survey response rates from routine population-based surveys such as RI PRAMS, as well as the data collection of various RIDOH programs and external collaborative data partners such as the Reach Out and Read Program.

To protect their clients and workers, RIDOH programs such as Family Visiting and WIC offered telehealth services to pregnant women, postpartum women, and their families. The Health Equity Zones (HEZs) offered a ready-made infrastructure to support immediate and longer-term efforts in High Density Communities (HDCs) most affected by the Covid-19 crisis.  To improve reporting of Covid-19 cases among newborns and pregnant women, the Office of Vital Records began collecting questions on Covid-19 beginning in 2021.

Early research showed that pregnant women were more likely to have severe illness from Covid than non-pregnant women.  Evidence from CDC studies demonstrate that the Covid vaccine was just as safe and effective to pregnant women as it was to non-pregnant women. All people ages 6 months and older are eligible for Covid-19 vaccination.  The Pediatric Advisory Council oversees and provides clinical guidance for the reach and distribution of Covid-19 vaccines among the pediatric population in Rhode Island. As of August 10, 2022, 0.4% of ages 0-4, 40.3% of ages 5-9, 61.5% of ages 10-14, and 71.0% ages 15-18 completed the primary vaccine series for Covid-19. Vaccines for Covid-19 are monitored through the Rhode Island Child and Adult Immunization Registry (RICAIR).   One of the health issues to monitor post-Covid vaccination are adolescent sexually transmitted infection rates, which already had increasing trends for chlamydia and gonorrhea before the pandemic.

 

Drug Overdoses

The goal is to reduce opioid overdose deaths by one-third within three years by addressing four key strategies: treatment, overdose rescue, prevention, and recovery.  Accidental drug overdose deaths increased by 35% from 308 in 2019 to 384 in 2020. Although full 2021 calendar data isn’t available yet, it is projected to report a higher accidental drug overdose death count than 2020. For more updated data on the opioid epidemic and local resources see PreventOverdoseRI.org.  In 2019, the Rhode Island Governor’s Prevention and Intervention Task Force updated its strategic action plan. The new plan keeps the strategic pillars (prevention, rescue, treatment, and recovery) and renews focus on data use to inform response, engage diverse communities, change negative public attitudes on addiction and recovery, incorporate harm-reduction principles, and address its social determinants of health. RIDOH has emphasized the importance of a community-driven response to the opioid epidemic.   The Pregnancy and Postpartum Death Review Committee (PPDRC) reviews pregnancy-associated deaths to determine whether a drug-related cause of death affected the pregnancy and provides recommendations to prevent these drug-related deaths.

 

 

III.C.2.b.ii. Title V Program Capacity

 

III.C.2.b.ii.a. Organizational Structure

 

RIDOH is the lead RI agency responsible for addressing maternal and child health needs throughout the state. Section 23-13 of the RI General Laws gives RIDOH broad authority for administering and overseeing Title V MCH services. RIDOH is located within the state's Executive Office of Health and Human Services (EOHHS), a cabinet agency that reports directly to the Governor. Because RIDOH is the only health agency in the state (there are no local or county health departments), it has the unique ability to build capacity and coordinate direct partnerships with other state agencies, institutions, organizations, and communities. The Title V Program is part of the Health Equity Institute (HEI). The HEI is strategically located in the Office of the Director.
 

It is the responsibility of the RI MCH Program to ensure that MCH initiatives, within RIDOH and throughout the state, are coordinated and family-centered for mothers, children, CSHCN, and families. The Title V program is managed by the State MCH/CSHCN Director, the MCH Program Manager, a MCH leadership team, and a MCH policy team. The MCH policy team meets monthly to discuss progress on Title V strategies, share relevant information and resources, and improve alignment and collaboration across RIDOH programs. Various RIDOH programs take the lead on different MCH strategies as indicated in the organizational chart.

 

III.C.2.b.ii.b. Agency Capacity

 

The RI Title V Program works closely with RIDOH programs, other state agencies and community partners to promote and protect MCH populations, including ensuring a statewide system of comprehensive, community-based and family- centered care. RIDOH is the sole public health entity in RI. There are no local health departments. As such, RIDOH relies heavily on partnerships to advance its work throughout the community. These partnerships include advocacy groups, colleges and universities, community-based organizations, federally qualified health centers, health plans, Medicaid, professional organizations (RIAAP, RIACOG, etc.), committee and coalitions, and other state agencies. RIDOH MCH staff convene and participate in over 70 committees or advisory boards. Recent efforts have been focused on building infrastructure at the community level through the Health Equity Zone initiative. This effort promotes collaboration to support public health at the community level.

 

(i) Capacity to provide and assure services within each of the five population health domains

The needs assessment survey of community professionals showed good collaboration among the organizations that serve the MCH populations in each domain. However, about a third of professionals indicated that additional collaboration was needed with various types of organizations in order to better support families. Limited staffing and time were cited as barriers to collaboration, and 40% indicated that limited availability of services in the area was a barrier. Transportation, system navigation, childcare, and waitlists were identified as leading barriers to services. The priorities identified by the professionals mirrored those of community members. Mental health was the leading priority, followed by culturally responsive pregnancy/postpartum education and care. Money/employment and housing, affordable high quality childcare and safe, healthy, quality schools also were identified as priorities.
 

(ii) Capacity for serving CSHCN

RI Title V does not provide direct services to CYSHCN. RI’s Title V CSHCN program enjoys a collaborative working relationship with RI Medicaid and RI Office of Rehabilitation Services. Title V CSHCN participates on advisory committees with consumers and state leaders to ensure Medicaid services and supports are organized and comprehensive. Title V CSHCN leadership sits on the Medicaid Managed Care Advisory Committee for CSHCN.
 

III.C.2.bii.c MCH Workforce Capacity

 

There are over 100 FTEs employed by RIDOH who are working on MCH related programs and services. This includes staff that provide planning, implementation, evaluation, and data analysis. RIDOH also directly supports the MCH workforce through many community contracts including family visitors, peer resource mental health specialists, parent consultants (12 work at RIDOH and 27 work in community settings), community health workers, safety-net clinical providers, youth advisory groups, sexual health counselors, breastfeeding lactation consultants, and prevention educators.  For a more detailed description of the MCH Workforce see III.E.2.b.i MCH Workforce Development.

 

III.C.2.b.iii. Title V Program Partnerships, Collaboration, and Coordination

 

The RI MCH program is a consistent leader in maternal and child health policy and programs. RIDOH staff champion the interests of mothers and children statewide in over 70 committees and boards in which they participate in or convene. A full list of these committees can be found in the supporting documentation section of the report and is called “2020 RIDOH MCH Partnerships and Collaborations”.
 

III.C.2.c. Identifying Priority Needs and Linking to Performance Measures

Below is the summary table with the top two MCH priorities by MCH domains conducted by the internal prioritization sessions:

The highest MCH state priorities were selected based on scoring from five criteria: (1) racial/ethnic disparities; (2) community support/political will; (3) availability of resources/agency capacity; (4) potential for public health influence; and (5) the matrix score (composite score from information about magnitude, trend, and racial/ethnic disparities). These priorities were selected based on the input from various professional and community voices that stressed the importance of addressing racial/ethnic disparities. The ability to drive change based on current workforce capacity resources guided the selection process. MCH leadership also decided to potentially include the second highest priority for each domain based on consensus. In this case, the Title V Program included improving prenatal health as an additional state MCH priority because of the importance of the inter-related work among RIDOH programs that focus on prenatal health issues such as oral health, substance use, and behavioral/mental health.

 

Below is a table of the seven MCH state priorities linked to Title V performance measures.