Domain 1: Women’s and Maternal Health
Just over half of women who gave birth in Connecticut in 2021 were non-Hispanic White, 26.6% were Hispanic, 12.9% were non-Hispanic Black, and 5.6% were non-Hispanic Asian.
The 2017-2021 annual overall teen birth rates in Connecticut averaged 8.0 (range = 7.3 – 8.9, reported as live births per 1,000 women aged 15-19) and continued long-term declines over the previous two decades that ranged between 1.3 and 10.8% annual decline. A 2021-updated trend analysis shows an annual rate of decline for 2017-2021 of 5.2%. The lower limit for the range of teen birth rates during this five-year period of 7.3 births per 1,000 women aged 15-19 represents the lowest teen birth rate observed this century in Connecticut. Declines across all three major race-ethnicity groups are also evident for the period 2017-2021, with annual rates of declines in teen birth rates in the non-Hispanic White, non-Hispanic Black/African American, and Hispanic populations during this period averaging 11.8%, 4.9%, and 6.1% per year, respectively. In the presence of these significant declines across all three major race-ethnicity groups in Connecticut, however, disparities by race and ethnicity nonetheless exist. For the period 2017-2021, the average annual teen birth rate of Hispanic women of 22.8 births per 1,000 women aged 15-19 was 9.6 times higher than the average rate for non-Hispanic White women of 2.4. The average annual teen birth rate among non-Hispanic Black/African American women of 12.2 births per 1,000 women aged 15- 19 for 2017-2021 was 5.1 times that of non-Hispanic White women. There is a large difference in intended pregnancies by race/ethnicity, which may be due to barriers like lack of insurance, access to health care, and/or transportation. Among women delivering a live birth in CT in 2018-2020, 64.9% of women reported their pregnancies were intended, 20.7% were unintended, and 14.4% were not sure how they felt about becoming pregnant/what they wanted. Pregnancy intention varied greatly by race and ethnicity. The proportion of intended pregnancies was 74.6% among non-Hispanic White women, compared to only 47.3% among non-Hispanic Black women. For 2020, in the three months prior to becoming pregnant, diabetes and high blood pressure was most prevalent among non-Hispanic Black women (4.0% and 9.2%, respectively), depression and anxiety among non-Hispanic White (14.1% and 28.4, respectively), and poly-cystic ovarian syndrome (PCOS) among non-Hispanic Other race (6.6%). Non-Hispanic Black and Hispanic women were more likely to be overweight or obese than their non-Hispanic White or non-Hispanic Other race counterparts.
During pregnancy, 14.1% of women in Connecticut developed preeclampsia in 2020, which was highest among non-Hispanic Black women (19.6%) and lowest among non-Hispanic Other race women (11.0%). Overall, 10.0% of women in Connecticut developed gestational diabetes, which was highest among non-Hispanic Other race women (19.4%) and lowest among non-Hispanic White women (6.4%). The prevalence of gestational diabetes is increasingly common with age, 14.3% in women 35 and older. Overall, 6.0% of women had thyroid problems, with the highest prevalence’s among non-Hispanic Other race women and women 35 and older. In Connecticut, on average, there are five to six pregnancy-related related deaths per year, with a range between three and eleven deaths.
Following delivery of a live birth in 2020, 10.4% of women in Connecticut reported postpartum depressive symptoms. However, the racial/ethnic patterns shift, with lowest prevalence among non-Hispanic White women (8.1%) and highest among non-Hispanic other race women (19.2%), however, less than half sought help for their symptoms.
Domain 2: Perinatal and Infant Health
Singleton preterm birth and low birthweight (LBW) rates show persistent racial disparities in Connecticut. In 2021 (provisional), 6.4% of non-Hispanic White women delivering singletons gave birth preterm, compared to 10.9% of non-Hispanic Black women. From 2017 to 2021, the average rate of singleton LBW infants among non-Hispanic Black/African American populations (10.3%) was 2.3 times higher than that among non-Hispanic White women (4.5%). The average rate of singleton LBW among Hispanic women (6.9%) was 1.5 times that of non-Hispanic White women. The Connecticut annual infant mortality rate (IMR, reported as deaths per 1,000 live births) averaged 4.5 (range: 4.3 - 4.7) during the period 2017-2021. All annual overall (i.e., across all race- ethnicities) IMRs for this five-year period were lower than any reported for Connecticut since 2005 and are consistent with a trend of declining IMRs for the state of 2.5% annually since that year. A 2021-updated trend analysis of IMRs also showed declines for all of the largest races and ethnicities in the state 2017-2021, at rates of 2.5% (non-Hispanic Black/African American), 2.0% (Hispanic), and 2.8% (non-Hispanic White) per year. Annual IMRs in Connecticut’s non-Hispanic White population averaged 3.1 deaths per 1,000 live births 2017-2021 and were significantly lower than those observed for the non-Hispanic Black/African American and Hispanic populations. Annual IMRs for non-Hispanic Black/African American populations averaged 9.4 deaths per 1,000 live births, and those for Hispanic populations averaged 5.4 deaths per 1,000 live births. The averages were 3.1 and 1.8 times higher, respectively, than that for Connecticut’s non-Hispanic White population. Racial disparities in infant health continue postnatally. Most women in Connecticut reported that their health care provider had recommended they place their infants to sleep on their backs during 2020. However, fewer women reported putting their infants to sleep on their backs only. Only 59.9% of Black women reported solely back sleeping compared to 92.2% of White women. Breastfeeding practices also vary by race/ethnicity. While 92.2% of women of all race/ethnicities report initiating breastfeeding postpartum, by 8 weeks, only about two-thirds of Hispanic are still breastfeeding, compared to79.7% of non-Hispanic Other race women.
An increasing concern in Connecticut is infants born with Neonatal Abstinence Syndrome (NAS) – a condition where a neonate goes through withdrawal from certain drugs that they were exposed to in the womb. Most commonly, NAS is due to chronic maternal opioid exposure. In Connecticut, the rate of CT babies with confirmed NAS per 1,000 CT hospital births increased from 6.9 (6.1, 7.8) in 2010 to 11.6 per 1,000 (10.5, 12.8) in 2016 (source: CT DPH Hospital Discharge Data). After 2016, rate of NAS in CT remained around 9-10 per 1,000 each year and ultimately declined to 7.6 (6.6, 8.5) in 2021. Collaborative partnerships have formed in Connecticut between non-governmental professional organizations, multiple state agencies, and public/private professional organizations to address NAS in the state.
Domain 3: Child Health
Overall, 90.7% of children aged 0-17 years old were reported to have excellent or very good health in Connecticut in 2020-2021. However, disparities exist in some manageable and preventable childhood conditions, indicating room for improvement. Just under 9% of children in Connecticut currently had asthma in 2021, with Non-Hispanic Black and Hispanic children disproportionately affected by asthma with higher prevalence rates of 11.3% and 13.8%, respectively. Disparities in utilization of health care have been reported, with Black non-Hispanic children visiting hospitals’ emergency departments and hospitalized for asthma at a rate nearly seven times that of non-Hispanic White children. Similarly, Hispanic children have asthma-related emergency department visits and hospitalizations 4 times that of non-Hispanic White children. Asthma is one of the leading causes of school absenteeism, putting children at risk for poor academic performance. While 8.9% of children in Connecticut had asthma in 2021, asthma disparities in utilization of health care have been reported, with Hispanic and non-Hispanic Black children visiting hospitals’ emergency departments 4.7 to 6.9 times more frequently than non-Hispanic White children (2021 CHIME data). Additionally, Hispanic and non-Hispanic Black children need to be hospitalized for asthma between 5.3 and 5 times the rate of non-Hispanic White children, suggesting greater burden in asthma severity. Children in general, but especially non-Hispanic Black and Hispanic children bear the highest burden of asthma in Connecticut.
The medical home model for children and adults is a proven approach to provide comprehensive and high-quality primary care. In 2020-2021, Connecticut (51.7%) was slightly above the U.S. average (47.7%) in the proportion of children without special health care needs who received coordinated, ongoing, and comprehensive care within a medical home. Connecticut exhibits disparities across race and ethnicity for children receiving care within a medical home, with 61.4% of non-Hispanic White children and 61.8% of non-Hispanic children of other race receiving care within a medical home, while only 31.6% of non-Hispanic Black children, and 37.7% of Hispanic children did.
The proportion of children with a mental/behavioral health condition who received treatment or counseling declined in Connecticut from 2016-2017 to 2020-2021. In Connecticut, the proportion declined from 57.4% to 56.4%. Between 2012 and 2020, the proportion of children under three years-old who received a developmental screening rose consistently from 16.2% to 61.7%. However, this is just over half of the population, indicating that improvement is still needed, but appears promising, given the current trend lines.
Adverse Childhood Experiences (ACEs) are stressful or traumatic events, including abuse, neglect and household dysfunction that occur during childhood. Adverse childhood experiences and trauma are risk factors for depression, anxiety, and post-traumatic stress disorder. In their most extreme form, ACEs can result in death. In 2020-2021, 19.9% of Connecticut’s youngest residents between 0-17 years of age experienced one adverse childhood experience and 15.9% had experienced two or more, with 24.3%, Hispanic children experiencing two or more adverse childhood experiences compared to 9.7% of non-Hispanic white children. To address the immediate threat of violence, as well as long terms health consequences, the State of Connecticut is engaged in several public health and policy initiatives.
Domain 4: Children with Special Healthcare Needs
Children and youth with special health care needs (CYSHCN) have or are at increased risk for chronic, physical, developmental, behavioral, or emotional conditions. In addition, they often require more health-related services beyond what is required by children generally. There is a well-documented benefit for children in having health insurance. According to the National Survey of Children’s Health, in 2001, nearly three-quarters of CYSHCN had private insurance (73%). In 2020-2021, 98% of CYSCHN were covered by health insurance or a health coverage plan. Of those, 39.9% reported that the insurance was not adequate for the child’s health needs. The proportion of CYSHCN who had either private or public insurance was 26.3% and 67.5%, respectively; 4.1% had a combination of both.
Among CYSHCN, Connecticut (44.9%) was slightly above the U.S. average (42.0%) in the proportion of children who received coordinated, ongoing, and comprehensive care within a medical home in 2020-2021. Among CYSHCN in Connecticut that needed effective care coordination, 58.8%were reported receiving needed and effective care coordination, compared to 57.8% of CYSHCN in the U.S. on average, in the same time period. In 2020-2021, Connecticut dropped to 14.4% (down from 19.6% in 2019-2020) which was lower than the National average of 17.2%in the proportion of 12-17-year-old CYSHCN who received the services needed to transition to adult health care. Families of CYSHCN reporting receiving care in a well-functioning system varied greatly by age. In 2020-2021, the proportion was 26.4% for 0-11-year-olds, and 4.1% for 12-17-year-olds. Overall, 4.6% of parents of CYSHCN reported they were usually or always frustrated getting services for their child, compared to only 1.5% of parents of children without special health care needs.
The prevalence of mental/behavioral health conditions has been increasing among children and has been found to vary by geographic and sociodemographic factors. Further, the receipt of treatment is also generally dependent on sociodemographic and health-related factors. Adequate insurance and access to a patient-centered medical home may improve mental health treatment. In Connecticut, among children aged 3-17, a slightly higher proportion of White non-Hispanic children with a mental/behavioral condition received treatment or counseling, compared to Hispanic children with a mental/ behavioral condition (16.5% and 13.0%, respectively). Conversely, 2.7% of Hispanic children and 4.7% of Black non-Hispanic children did not receive treatment or counseling but needed to see a mental health professional. In 2020-2021, 3.0% of children (aged 3-17) in Connecticut had ever been diagnosed with autism spectrum disorder (ASD), which is equivalent to the national percentage (2.9%).
The adolescent health data relies on the results from the CT School Health Survey (CSHS). It is important to note that the 2021 CSHS prevalence estimates and trends have likely been impacted by some significant factors unique to the 2021 CSHS administration For example, the CSHS has always been administered in the Spring semester of the school year. Due to COVID-19 impact on in-person learning, the CDC allowed for the survey to be delayed to the fall semester later in 2021. Some questions on the CSHS ask students about their behavior in the prior 12 months. In the fall of 2021 that time period would have included when COVID-19 precautions limited opportunities for social interaction both at school and extracurricular. While non-response bias analysis indicated that 2021 CSHS data was representative, the overall sample size has reduced the ability to provide prevalence estimates by subgroups for certain indicators. Estimates with Coefficient of Variation (CV) higher than 30 or denominator less than N=30 have been suppressed. Due to this, comparison to previous years is not advised. Use and misuse of illicit drugs (e.g., heroin, fentanyl, cocaine), prescription opioid medications and alcohol are major issues nationally and in Connecticut. In recent years illicit drug use among Connecticut high school students has declined. Nonetheless, 8.5% of high school students reported ever taking prescription pain medication for non-medical reasons. Prevalence was highest among Hispanic (12.5%) and lowest among White (6.3%) students. Only 1.3% of Connecticut high school students currently smoke cigarettes. In contrast, 24.9% report ever using an electronic vaping product, 10.6% report current use, and 4.0% report frequent use.
Bullying is considered a traumatic event, and fighting may be considered either a traumatizing experience or a consequence/outcome of having repeated exposure to trauma. Bullying also indicates disruption in the school setting that impacts school connectedness, which is an important protective factor for substance use, sexual behavior, mental health, and academic success. In recent years, Connecticut females were more likely than Connecticut males to be bullied on school property. In 2021, 13.8% of females and 10.6% of males reported being bullied on school property in the past 12 months. Bullying was more common among non-Hispanic White, compared to Hispanic students. The percentage of females being cyberbullied is also consistently higher than the percentage of males in recent years, with 18.2% of females and 9.4% of males reporting the experience in the past 12 months. Youth who identify as lesbian, gay, bisexual, transgender, or queer (LGBTQ) are more likely to be bullied, both on school property and electronically, when compared to students who identify as heterosexual. The percentage of LGBTQ youth who reported cyberbullying was more than double the percentage of heterosexual youth who reported cyberbullying, 23.2% versus 10.6%.
In the 2021, the prevalence of physical dating violence was 5.9% among students who reported only opposite sex partners, compared to 8.4% among students with partners of the same sex or both sexes. Prevalence of sexual dating violence varied dramatically among high school students, with 9.8% of heterosexual students reporting it, compared to 19.6% of those identified as being gay/lesbian/bisexual, and 34.1% of those “unsure” of their sexual identity. Among Connecticut high school students, 6.2% report being forced to have sexual intercourse in their lifetimes. Prevalence was 4.4% of heterosexual students, compared to 13.3% of gay/lesbian/bisexual students.
According to the 2021 Adolescent Behaviors and Experiences Survey, more than one in three high school students (37.1%) experienced poor mental health during the COVID-19 pandemic. Nationally, suicide contemplation by high school students in the last 12 months was 17.2%. By comparison, Connecticut is below the national average. In 2019, 15.9% of females and 9.3% of males reported considering suicide in the past 12 months. In 2019, 8.3% of females and 5.2% of males attempted suicide. Significantly more Hispanic students (10.1%) attempted suicide compared to non-Hispanic Black/African American (5.8%) and non-Hispanic White (5.7%) students. In 2018, the rate of Connecticut youths who died by suicide was 2.8 per 100,000. The rate of death by suicide for 0–19-year-olds for 2020 was 1.8 per 100,000 CT population. For 2021(estimates for that age-group) was 2.3 per 100,000 CT population.
Title V Agency
The mission of the DPH is to protect and improve the health and safety of the people of CT by: assuring the conditions in which people can be healthy; promoting physical and mental health, and preventing disease, injury, and disability.
Dr. Manisha Juthani serves as Commissioner of DPH. Dr. Juthani is an infectious diseases physician at Yale School of Medicine in New Haven, where she specializes in the diagnosis, management, and prevention of infections in older adults. Dr. Juthani assumed the role as Commissioner on September 20, 2021.
Leadership:
Rosa M. Biaggi, MPH, MPA and Mark Keenan, RN, MBA are Chiefs of the Community, Family Health, and Prevention Section (CFHPS) and previously served as the Title V Maternal and Child Health Director. Marc Camardo, MPH, is the Title V Director and SSDI Director and reports to Mark Keenan. Ann Gionet is the Children with Special Health Care Needs Director and reports to Mark Keenan. Selma Alves, MPH, is the MCHBG Family Advocate and reports to Ann Gionet.
The Title V Program resides within the CFHPS. The CFHPS works to improve the health of the overall population across the lifespan, especially mothers, infants, children, adolescents, and other vulnerable groups, by establishing opportunities that support healthy living habits through education, early detection, access to care and chronic disease prevention. The CFHPS is comprised of the following units: 1) Reproductive and Perinatal Health Unit; 2) Adolescent and Child Health; 3) Maternal and Child Health Epidemiology; 4) Chronic Diseases; 5) Women, Infants and Children (WIC); 6) Epidemiology; and 7) Nutrition, Physical Activity and Obesity. The CFHPS also includes the: 1) Genomics Office; 2) Health Access, Early Hearing, Repayment, Oral Health and Primary Care Office; and 3) Office of Injury and Violence Prevention. Staff work collaboratively across units and offices to coordinate resources and maximize program capacity.
The Title V Program is responsible for the direct or indirect administration of programs carried out with funds from the MCHBG. The majority of CT's activities serving mothers, infants, children, adolescents, and children and youth with special health care needs reside within the CFHPS, including: Autism Spectrum Disorder; Children and Youth with Special Health Care Needs including Respite and Extended Services; Family Advocacy; School Based Health Centers; Sickle Cell Disease; Maternal Mortality Review; Case Management for Pregnant Women; Family Planning; Healthy Choices for Women and Children; Supplemental Nutrition Assistance Program; Birth Defects Registry; Early Hearing Detection and Intervention; State Systems Development Initiative; Pregnancy Risk Assessment Monitoring System; Primary Care Office: Family Wellness Healthy Start; Provide Supplemental Nutritious Foods; Breastfeeding promotion and support; and Nutrition education. These programs either receive Title V funds or work in collaboration with the Title V Program.
The CFHPS employs 110 permanent staff with expertise and skills in various areas of public health having graduate degrees or have experience in nursing, social work, allied health, health education, research, evaluation, epidemiology, law, planning, administration, and management. Most CT's Title V program activities reside organizationally within the CFHPS. The proposed FFY 2024 plan will maintain overall staff support at 22.0 FTE positions.
The MCHBG supports a full time equivalent in the Health Information Systems and Reporting Section to maintain vital record databases containing information on births, deaths, hospitalizations, and risk factors related to maternal and child health. Epidemiologists use vital record information to help direct and evaluate Title V program activity. Funding from the MCHBG also provides support for staff in the Newborn Screening Program, the Fiscal Office, Public Health Systems Improvement, and Grants and Contracts.
Staff from other programs across the DPH collaborate and/or provide support to the Title V staff. These programs include Obesity, Asthma, WIC, Environmental Health, STD, HIV, Vital Records, State Laboratory (Newborn Screening) and Tracking Units, Oral Health, Tobacco, Nutrition, Facility Licensing, and Injury and Violence Prevention.
Number, location, and full-time equivalents of staff who work on behalf of the Title V Program
The State of Connecticut is highly invested in supporting efforts to implement the core public health functions (assessment, policy development, and assurance) and to achieve increased accountability through ongoing performance measurement and supporting an adequately sized and skilled workforce.
Current Initiatives
DPH is on track to submit its reaccreditation application to the Public Health Accreditation Board (PHAB) in the summer of 2023. The preparation for the application began in 2022, as soon as DPH obtained an extension approval from the Public Health Accreditation Board (PHAB) to apply for reaccreditation under their revised standards and measures version 2022. Towards this goal, the Commissioner launched an agency-wide kickoff meeting and identified section champions to work on the various domains pertaining to reaccreditation. The section champions met monthly until the end of the year and thereafter switched to one-on-one meetings with the Public Health Systems Improvement (PHSI) staff, who lead the reaccreditation coordination efforts within DPH.
State Health Improvement Plan: CT’s State Health Improvement Plan (SHIP) provides a roadmap for statewide health improvement efforts. The SHIP framework includes an Advisory Council, Four priority area Action Teams, a statewide SHIP Coalition, and a Data Committee. Several sub-committees also exist within this framework on an as-needed basis. DPH provides leadership and coordination to this statewide initiative to improve collective impact across the state. The Advisory Council, an 18-member body, provides leadership and overall strategic guidance to the statewide effort. Members include a consumer, state agencies, healthcare professionals, a former legislator, and representatives from educational institutions, charitable foundations, and non-profit community-based organizations. The Action Teams are organized by priority focus areas – Access to Healthcare, Economic Stability, Healthy Food and Housing, and Community Strength and Resilience.
The CT Maternal and Child Health (MCH) Coalition advocates for health equity and the elimination of racial and ethnic health disparities. Through the establishment of Initiatives, operating under the auspices of the MCH Coalition, Connecticut is supporting efforts to improve pre and interconception health care/pregnancy intentionally through the establishment of Every Woman Connecticut and the MCH Coalition convened the Reproductive Justice Alliance designed to improve the state’s maternal mortality and morbidity statistics, especially for Black and Brown birthing people. These Initiatives welcome MCH Coalition members as well as those who are limiting their involvement to a working group and their scope of focus and work.
The Maternal Mortality Review Committee (MMRC) in CT works to identify factors that may have contributed to the death and to make recommendations to reduce pregnancy-related morbidity, mortality, and disparities. The MMRC is committed to a multipronged approach to avoid all preventable maternal deaths and improve maternal health and health equity. Through equitable partnerships with communities, the MMRC work to understand the severity and complexity of maternal health disparities, advocate for policy solutions, and support innovative approaches and interventions to eliminate inequities that threaten the health and well-being of all birthing persons.
Preventive interventions to address teen pregnancy through CT's Title V programs include those to delay the onset of sexual activity, promote abstinence as the social norm, reduce the number of adolescents who have sex at young ages, and increase the number of sexually active adolescents who use contraceptives effectively. Healthy Choices for Women and Children, a case management program serving Waterbury, and the Family Wellness Healthy Start (FWHS) program serve pregnant and parenting teens and include interconception services. The FWHS program works to eliminate disparities in infant mortality and adverse perinatal outcomes especially among the target population of African American and Hispanic women in Hartford and New Britain.
The Personal Responsibility Education Program targets teens ages 13-19 in Bridgeport, Hartford, Meriden, Waterbury, and New Britain to provide evidence-based HIV, STD, and pregnancy prevention activities that have been found through rigorous research and evaluation to be effective in reducing sexual activity, increase contraceptive use in already sexually active youth, and delay unplanned pregnancy through both abstinence and contraception.
The Reproductive Health Program is administered by Planned Parenthood of Southern New England, Inc. (PPSNE) and is funded with state and Title V funds through a five-year contract. The program provides services in those areas of Connecticut with a high concentration of low-income women of reproductive age, and with high rates of teen pregnancy.
The Children and Youth with Special Health Care Needs Program’s CT Medical Home Initiative provides community-based medical home care coordination networks and collaboratives to support children with special health care needs. Services include: a statewide point of intake, information and referral; provider and family outreach; and parent-to-parent support. Care coordination services include linkage to specialists and to community resources, coordination with school-based services, and assistance with transition to adult health care and other services.
United Way of Connecticut’s 2-1-1 Infoline is an integral part of the CT Medical Home Initiative, providing a statewide point of entry as well as information and referral. DPH has dedicated MCHBG as well as other federal funding towards improving the United Way resource database and website, thus enhancing access to information for providers and consumers. The improvements include the ability to access information in numerous languages. United Way has also provided outreach and training to family and community-based organizations regarding how to effectively use the 2-1-1 website.
In addressing the needs of adolescents, the CT Title V program strategies emphasize supporting adolescent wellness (including comprehensive well child visits) and process improvement for the transition to adult life. School Based Health Centers were utilized in promoting comprehensive adolescent well visits, inclusive of developmental assessment, risk assessment and behavioral health screening, anticipatory guidance, and body mass index (BMI) screening and intervention.
The DPH Immunization Program oversees the provision of all recommended childhood vaccines to over 680 providers statewide including private physician offices, community health centers, School Based Health Centers, and local health departments. All nationally recommended childhood vaccines are provided to School Based Health Centers for children up through 18 years of age free of charge.
Partnership and Collaborations by Domain
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