For the interim needs assessment update, NJ TVP compiled and synthesized statistics seeking to inform the current maternal and child health interventions that MCHBG is funding. The Team has compiled data from multiple sources, including but not limited to American Community Survey (ACS), New Jersey Pregnancy Risk Assessment Monitoring System (PRAMS), World Health Organization (WHO), Centers for Disease Control (CDC), and more.

 

Maternal/Women's/Reproductive Health & Perinatal/Infant's Health

Maternal Mortality

 

According to the World Health Organization (WHO), approximately 295,000 women died of a pregnancy-related cause, 86% of whom were women from Sub-Saharan Africa and Southern Asia. Nearly 3 out of every four maternal deaths in 2017 were due to complications such as hemorrhage, post-delivery infection, pre-eclampsia/eclampsia, unsafe abortions, and delivery complications. The remainder was due to chronic conditions such as cardiac disease and diabetes.

 

According to Pregnancy Monitoring and Surveillance System (PMSS), the 2018 pregnancy-related mortality ratio (PRMR) in the US was 17.3 deaths per 100,000 live births in the US. When stratified by race/ethnicity, evident disparities persist. Black, NH women had a PRMR of 41.4 deaths per 100,000 live births from 2016-2018, more than three times the rate for White, NH women (13.7 deaths per 100,000 live births, Figure 5). Additionally, Hispanic women had the lowest PRMR among all races/ethnicities nationally, with a rate of 11.2 deaths per 100,000 live births.

 

NJ's maternal health outcomes and disparities are among the highest in the US. Approximately 50 women die from pregnancy-related (PR) complications in NJ every three years. According to America's Health Rankings, NJ's maternal health outcomes, and disparities are known to be among the highest in the U.S. Black women experience seven times the rate of death from pregnancy-related causes compared to their white counterparts.

 

The NJ Maternal Mortality Review Committee (NJMMRC) reviews all pregnancy-related and pregnancy-associated deaths during pregnancy or within one year postpartum. Statistics shared in the recently released New Jersey Maternal Mortality Report 2016-2018 for 2016-2018 confirm persistent racial and ethnic disparities with regard to maternal mortality. The NJMMRC identified 44 pregnancy-related deaths, of which 39/43 (91%) were determined to be preventable. The state-level pregnancy-related mortality ratio (PRMR) for 2016-2018 was 14.4 deaths per 100,000 live births; however, similarly to national PMSS data, disparities are evident among race/ethnicity. The PRMR for Black, NH women was 39.2 deaths per 100,000 live births, which was 6.6 times higher than the PRMR for White, NH women, which was 5.9 deaths per 100,000 live births (Figure 11). Hispanic women had a PRMR (20.6 deaths per 100,000 live births) 3.5 times higher than White, NH women (Figure 11).

 

                        Figure 11. Pregnancy-Related Mortality Ratio by Race/Ethnicity, New Jersey, 2016-2018

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 Based on the analysis conducted by the MMRC, the leading contributing factors for pregnancy-related deaths were

1. lack of provider/patient knowledge,
2. lack of continuity of care/care coordination,
3. lack of standardized policies and procedures, substandard clinical skill/quality of care, and lack of assessment.

While the leading contributing factors for pregnancy-associated but not related cases were

1. lack of continuity of care/care coordination,
2. complications of substance use disorder,
3. complications of mental health conditions,
4. lack of provider/patient knowledge and lack of standardized policies and procedures.

The MMRC made an array of recommendations that they categorize into five themes by classes of maternal mortality, emphasizing actions that providers and facilities could take to identify and potentially address maternal mortality disparities.

1. Pregnancy-related deaths
   1. Ensure high-quality care,
   2. Build patient knowledge,
   3. Address barriers to care,
   4. Implement a holistic approach to care and
   5. Share patient records and information about care provided.
2.  Pregnancy-associated but not related deaths
   1.  Implement a holistic approach to care,
   2. Ensure high-quality care,
   3. Address barriers to care, and
   4. Share patient records and information about care provided

 

Infant Mortality

According to America's Health Rankings, as of 2021, New Jersey (NJ) has the 3rd State with the lowest overall infant mortality rate among the 50 states; however, similarly to the racial and ethnic disparities observed nationally, these disparities persist.

Despite the overall decline in IMR, in 2020, racial and ethnic disparities continued to persist in the US among Black, NH women, who had the highest IMR (10.38) per 1,000 live births, followed by American Indian or Alaska Native, NH (7.68), Native Hawaiian or Other Pacific Islander, NH (7.17), Hispanic (4.69), White, NH (4.40), and Asian, NH (3.14)

In 2020, NJ's Black, NH infant mortality rate (IMR) was 9.1 per 1,000 live births, while the IMR for White, NH infants was 2.5 per 1,000 live births (Figure 12). The Hispanic IMR was also 3.6 per 1,000 live births (Figure 12). The Black, NH IMR was about four times higher than the IMR for White, NH infants, and the Hispanic IMR was about two times higher than the rate among White, NH infants in NJ. Findings from the most recent 5-year needs assessment include the need to address NJ's maternal mortality crisis, especially with regard to disparities. These statistics warrant the need to continue implementing public health interventions that seek to address these racial and ethnic disparities and improve maternal and child health outcomes in NJ.

 

Birth Outcome: Preterm Birth

Preterm live births are defined as the birth of an infant before 37 weeks of gestation. Being born prematurely increases an infant’s risk of morbidity and mortality. Premature infants have a greater risk of dying in the first month of life, may require intensive care at birth, and are at higher risk of developmental disabilities and chronic illnesses throughout life.

Nationally, in 2020, disorders related to preterm birth and low birth weight accounted for about 16% of infant deaths before their first birthday. Based on statistics provided by the CDC, 1 of every 10 infants in the US was born prematurely in 2021. An increase of 4% in the preterm birth rate was observed nationally from 2020 to 2021 (10.1% to 10.5%, respectively). In 2021, while an increase was observed nationally, NJ’s preterm birth rate dropped from 9.3% to 9.2%, respectively. An 8% dropped in preterm rate is observed in NJ from 2016 to 2021, while a 7 % increase is observed nationally for the same period. These statistics warrant the need to continue implementing public health interventions that seek to address these racial and ethnic disparities and improve maternal and child health outcomes in NJ.

 

 

Formative Evaluation Projects & Results

In the past few months, NJ TVP has led multiple projects to assess the needs of the MCH population in NJ.

1. Healthy Women Healthy Families- Evaluation Project

The Healthy Women Healthy Families (HWHF) initiative is a community-based funded by the MCHBG that has been implemented in NJ since 2018. HWHF initiative focuses on improving and providing quality access to women’s preconception, prenatal, and interconception care and reducing health disparities in birth outcomes, including Black infant mortality (BIM). This is done using a two-pronged method: 1) county-level activities that focus on providing high-risk families and/or birthing individuals and caregivers of young children access to resource information and referrals to local community services that promote child and family wellness and 2) Black Infant Mortality (BIM) municipality level activities that focus on Black, NH birthing individuals and caregivers of young children by facilitating community linkages and supports, implementing specific BIM activities, and providing education and outreach to health providers, social service providers, and other community-level stakeholders. Six community-based organizations have been funded since 2018 to implement community activities for five years (July 1, 2018, through June 30, 2023).

In 2022, the NJ TVP team conducted a formative evaluation of the HWHF initiative. They utilized data from various sources, including PRAMS data, to examine some of the outcome measures that were selected by the Team that developed the HWHF initiative in 2018.

The evaluation project had multiple phases corresponding to key project activities.

• Phase 1 involved compiling maternal and child health-related statistics, formulating the evaluation questions, selecting the methodological approach, designing the surveys, and the initial recruitment for the project.
• Phase 2- involved administering online surveys through the Novisurvey platform and hosting a listening session with the grantees.
• Phase 3- involved data analysis of survey responses, hosting one listening session, and the write-up of results and recommendations.

NJ TVP Epidemiology Team designed three surveys administered via Novisurvey to grantee agency staff (Executives and Directors), community health workers (CHWs, staff), community doulas, and clients who have benefited from activities that HWHF funds fund. The TVP Epidemiology Team synthesized responses from the survey and the listening session to generate a set of comprehensive recommendations. NJ TVP utilized the recommendations to revise the HWHF Request for Proposal (RFP).

As a result of the formative evaluation project, NJ TVP Epidemiology Team generated a comprehensive list of culturally competent recommendations grouped into four categories:

1. System Level,
2. Programmatic Level,
3. Data-related, and
4. Material Development or Revision

Upon completion of the evaluation project in early 2023, NJ TVP Epidemiology Team shared recommendations with TVP leadership and RPHS staff. The recommendations made by the NJ TVP Epidemiology informed the development of new objectives and the decision to expand BIM-related activities across the State. Moreover, they assist with identifying the best pathways to adopt for implementing BIM activities throughout the State and ensure optimal staff-to-client ratio to adequately serve the population of focus.

TVP staff revised the RFP and released a new version that focuses on implementing breastfeeding education and postpartum support. The goal of HWHF continues to be to improve maternal and infant health outcomes for women of childbearing age (as defined by CDC as 15-44 years of age) and their families, especially Black and Hispanic women, through a collaborative and coordinated community-driven approach by implementing:

1. County-level activities that will focus on providing families and/or women of childbearing age access to resource information and referrals to local community services that promote child and family wellness, and
2. Black, NH, and Hispanic Infant Mortality (BHIM) municipality activities will focus on Black NH and Hispanic women of childbearing age by facilitating community linkages and supports, implementing specific BHIM programs, and providing education and outreach to health and social service providers and other community-level stakeholders.

Through this RFA the NJDOH seeks to increase access to comprehensive and culturally sensitive postpartum care by implementing breastfeeding education, postpartum doula care, and case management through community health workers. HWHF grantees will implement postpartum doula care and evidence-based breastfeeding education programs in all 21 NJ Counties. However, due to high Black, NH, and Hispanic mortality rates, grantees will be expected to provide additional services to support selected municipalities further. Moreover, due to the revision made, all grantees are now required to address specific county-level outcome measures on preconception care, pregnancy, and birth outcomes, interconception care, and long-term outcomes. TVP will monitor the outcome measures by race/ethnicity over time to evaluate the effectiveness of the HWHF initiative in the future.

Additionally, in response to the recommendations that surfaced through the HWHF evaluation project, NJ TVP, in collaboration with key stakeholders and CHW instructors who have designed the CHW core curriculum, will add a case management component to the CHW course curriculum. This case management component will equip CHWs with the skill needed to better case manage their clients. The added sessions will offer the following:

1. Care management and the key responsibilities of care managers
2. Identifying community resources
3. Providing effective referrals
4. Role Play: Client-Centered Referrals
5. Gender Identity
6. Case Study
7. Elements of an Effective Care Management Plan
8. Establishing Client Priorities and Developing Action Plans
9. Activity: Developing a Care Management Plan
10. Care coordination – what it is, why it is essential, and how it is done effectively.

 

 

2. Community Health Worker Evaluation

 

In collaboration with the Rutgers School of Public Health, NJ TVP developed an evaluation project that focuses on examining the adopted strategies used to train, deploy, and engage CHWs. The populations of focus include racial and ethnic populations, immigrants, those with limited English proficiency, the homebound, seniors, the homeless, disabled populations, migrant workers, pregnant and nursing mothers, the underinsured and uninsured, undocumented workers, and substance abusers.

The evaluation project aid NJ TVP in assessing the effectiveness of the CLG and Rutgers Project ECHO training on increasing CHW competencies and improving curricula materials and instruction to address gaps in training. Based on the evaluation project results, NJ TVP is working on further updating the curricula and assessment materials to better equip CHWs with the skill needed to serve their clients adequately. NJ TVP and evaluation partners are also using results to assess progress and improve strategies for recruitment and deployment to optimize CHW integration into community organizations and to address and support the integration of CHWs within diverse organizations.

 

 

3. Fetal Alcohol Syndrome Prevention and Postpartum Depression and Mood Disorders- Evaluation Project

In 2001 the Fetal Alcohol Syndrome (FAS) Taskforce comprised representatives from the NJ Department of Health and Senior Services (DHSS) recommended steps to expand prevention programs and strengthen systems to alleviate the effects of prenatal alcohol exposure in NJ. The NJ DOH funded multiple grantees to implement FAS- related activities that seek to reduce the impact of prenatal exposure to substances in NJ communities.

The NJ Postpartum Depression and Mood Disorders (PPD-MD) Initiative was established by Governor Codey in July 2005 to raise awareness about postpartum depression and to increase access to appropriate clinical services. Through this initiative, NJ TVP, through the grantees it funds, seeks to provide information about symptoms, screening, diagnosis, and treatment of postpartum depression to healthcare providers and New Jerseyans. PPD- MD Grantees outreach to women and their families via a toll-free hotline, brochures, online resources, and State-

In 2023, over 20 years after the implementation of the FAS program and over 15 years after the implementation of the PPD-MD program NJ TVP Epidemiology Team designed and conducted an informative evaluation project to inform future programmatic and policy decisions of the program. The evaluation projects had multiple phases corresponding to key project activities.

• Phase 1 involved compiling maternal and child health-related statistics, formulating the evaluation questions, selecting the methodological approach, designing the surveys, and the initial recruitment for the project.
• Phase 2- involved administering online surveys through the Novisurvey platform and hosting a listening session with the grantees.
• Phase 3- involved data analysis of survey responses, hosting one listening session, and the write-up of results and recommendations

As a result of the formative evaluation project, NJ TVP Epidemiology Team generated a comprehensive list of culturally competent recommendations grouped into four categories:

1. System Level,
2. Programmatic Level,
3. Data-related, and
4. Material Development or Revision

Based on the recommendations, TVP staff revised the FAS and PPD-MD RFPs and released a new version in FY24. The goals and objectives of the upcoming FAS and PPD-MD RFPs will be informed by the evaluation results and recommendations.

 

 

Adolescent Health

The CAHP collects pre- and post-survey data for all students who participate in our programs (with parental consent). The following is data collected in the prior program year related to social-emotional learning and bullying prevention.

After completing a Personal Responsibility Education Program (PREP) EBM, students reported the following:

• 74% indicated they were more or much more able to manage their emotions in healthy ways
• 73% indicated they were more or much more able to resist or say no to peer pressure
• 76% indicated they were more or much more likely to talk with a parent or caregiver about things going on in their life

After completing a Sexual Risk Avoidance Education (SRAE) EBM, students reported the following:

• 66% indicated they were more or much more able to manage their emotions in healthy ways
• 70% indicated they were more or much more able to resist or say no to peer pressure
• 69% indicated they were more or much more likely to work together to find a solution to a conflict
• 67% indicated they were more or much more likely to speak up or ask for help if they were being bullied

 

After completing the Teen Outreach Program (TOP) (specifically), students reported the following:

• 93% indicated they were able to make decisions to keep themselves healthy and safe (4% increase)
• 86% indicated they were able to come up with ways to solve problems (9% increase)
• 89% indicated they were able to understand how other people feel (4% increase)
• 81% indicated they were able to help make their community a better place (11% increase)
• 88% indicated they could handle the challenges that came their way (6% increase)

Students receive a pre- and post-survey provided by the funder (Family Youth Services Bureau) that covers all EBMs implemented. Students who participate in TOP specifically receive an additional pre- and post-survey developed by the model developer. The above data shows how students who participated in our programs had increased skills and protective factors related to social-emotional learning and bullying prevention.

After reviewing pre- and post-assessment survey data (referenced above), CAHP noted a difference in the response rate between middle and high school youth on the FYSB survey. This may be in part due to the wording of the questions on the FYSB survey versus the wording of the TOP survey. It is important to note that 80% of the youth who completed TOP were part of the SRAE program, and therefore the gap between the rate of responses is concerning. CAHP staff will investigate this and reach out to FYSB for support regarding the wording of the middle school survey questions that may be causing this differentiation in response. Due to the statistically significant change rate for protective factors on the TOP survey, CAHP is confident that the program is being administered successfully and that any issue would be specific to the FYSB survey. Unfortunately, CAHP is not able to change the wording of either of the surveys administered. CAHP can advocate for changes in question wording annually and will address questions at that time.

 

 

Children and Youth with Special Health Care Needs (CYSHCN)

During the calendar year 2022, the Specialized Pediatric Services Program collaborated with Family Centered Care Services staff to analyze how many children utilizing grant-funded Child Evaluation Center services are known to Case Management. Results showed that approximately 15% of children were known to Case Management. Given the results, the SPSP will educate the grant-funded Child Evaluation Center grantees on available case management services, provide the contact information for each county case management unit, and encourage the grantees to work directly with SCHSCM and share the information with the families they serve.

 

In 2022, FCCS conducted a pilot satisfaction survey of families registered with SCHSCM for continuous quality improvement. The results showed that 79% of responders felt their SCHS case manager supports their family, and 77% said their CM meets the needs of their family. Additionally, over 65% of responders ranked the overall value of SCHSCM services as either excellent or very good. The pilot response rate was lower than expected, but through the redesign of the electronic data system (CMRS), FCCS will be able to enhance communication with the families served by SCHSCM and conduct annual and exit satisfaction surveys. The data will help to continuously identify areas of improvement and guide policy and implementation of SCHSCM services across the State.

FCCS utilizes the Case Management Reporting System as its primary hub to document all case management activities. These include communication with affected families, individual service plans, case management actions, service delivery, deactivations, and more. Currently, CMRS is undergoing a major redesign that will enable the capturing of data to monitor and evaluate the services provided to CYSCHN populations. The redesign encompasses several modules of the system, including Individual Service Plan, Exceptional Events, Child Information, custom reports at the CMU level, the ability to conduct family surveys, and features that will better facilitate communication with families.