Increase accessible, quality health care during pregnancy and delivery was a priority need identified in the 2020 MCH Five-Year Needs Assessment.

Having a healthy pregnancy and access to quality birth facilities are the best ways to promote a healthy birth and have a thriving newborn. Getting early (starting in the 1st trimester), adequate and regular prenatal care during the entire pregnancy is crucial to the health of mothers and babies. Prenatal care is the health care that women receive during their entire pregnancy. Prenatal care is more than doctor’s visits and ultrasounds; it is an opportunity to improve the overall well-being and health of the mom which directly affects the health of her baby.

Further, prenatal visits give parents a chance to ask questions, discuss concerns, treat complications in a timely manner, and ensure that mom and baby are safe during pregnancy and delivery. Receiving quality prenatal care can have positive effects long after birth for both the mother and baby. Babies of mothers who do not get prenatal care are three times more likely to be born low birth weight and five times more likely to die than those born to mothers who do get care.[1]

In 2017 in Minnesota, only 77.1% of women received prenatal care within their first trimester of pregnancy. Approximately 1 in 30 or 2,289 infants were born to a woman who received late (care that started in the 3rd trimester) or no prenatal care at all. Disparities are seen in the adequacy of prenatal care utilization across race/ethnicity (Figure 1). Less than half of births to American Indian mothers receive the recommended adequate/intensive prenatal care utilization.

Figure 1. Prenatal Care Utilization by Race/Ethnicity, Minnesota Mothers, 2017

There are many reasons why women do not get timely quality care during pregnancy. In Minnesota, the Pregnancy Risk Assessment Monitoring System (PRAMS) survey identifies barriers to care from the mother’s perspective. The leading causes women gave for not getting prenatal care as early in their pregnancy as they wanted were:

• Didn’t know I was pregnant
• Doctor/insurer wouldn’t start care earlier
• Not enough money/insurance to pay
• Couldn’t get appointment when wanted

Less common but still important barriers women mentioned included being unable to take off time from work, not having transportation to get to the care they needed, and not being able to find anyone to take care of their children (Figure 2). Barriers reported by Minnesota mothers are similar to those described across geographies and are well-documented in the literature.[2] Though some of the barriers identified are personal, many, such as the inability to get an appointment when wanted, are structural or systemic and could be modified to improve accessibility.

Figure 2. Barriers to Prenatal Care in Minnesota among Women not Receiving Care as Early as They Wanted, 2012-2017

Also important is access to care during preconception (i.e. the period of time of a woman’s life prior to getting pregnant) and peri-conception (i.e. the period of time during which a woman is actively trying to become pregnant) to ensure great health for women and a future healthy pregnancy. Altering certain habits, such as quitting smoking, achieving a healthy weight, or managing diabetes, can help a woman to become pregnant more easily and sustain a healthy pregnancy. Maintaining good health prior to getting pregnant and getting good care for any health issues can reduce the risk of early miscarriage and birth defects through genetic counseling and daily supplementation of folic acid, management of health conditions, and avoiding substance use. Women struggling with fertility issues can benefit from intensive reproductive care to improve the odds of successful conception and gestation.

Addressing substance use is a critical issue for pregnant people and families in many parts of the state, and this care should be provided alongside well-woman, pre-conception, pregnancy, and postpartum care. Maternal opiate dependency and infant neonatal abstinence syndrome (NAS) diagnoses have doubled from 2009 to 2012 according to Minnesota Medicaid claims data. Northern Minnesota endures the highest rates of prenatal maternal opiate use, specifically regions in close proximity to five tribal communities. Within these northern rural communities, the average rate of prenatal maternal opiate use is 9.8%, compared to the statewide average of 1.5% for all Medicaid-covered births.

In Minnesota, there are eight Emergency Medical Services (EMS) regions (Appendix III). The highest rate of NAS was found in the Northwest EMS region of the state (202 per 10,000 live births) with 173 NAS cases between 2012 and 2016 (Figure 3). The lowest rate was found in the Southwest region of the state (18 per 10,000 live births) with 23 cases between 2012 and 2016. However, a large portion (47%) of the total number of NAS cases occurred in the Metro region (873 of the total 1,839 cases), while the rate for the Metro region was the fifth highest among the EMS regions (Figure 3).

Figure 3. Neonatal Abstinence Syndrome Rate, Varied by Minnesota EMS Region

Efforts to address care during pregnancy and delivery is imperative to improve health for Minnesotan women over the next five years. For women of child bearing age, having access to age and culturally appropriate, quality health care is imperative for themselves and for their families. Maternal health is a cornerstone to population health. Enhancing prenatal and postnatal care for this population will elevate the chance of healthy birth outcomes for women and infants.

Determined strategies to address care during pregnancy and delivery were: (1) expand family-focused, community-based policy and funding, (2) integrate services and optimize cross-sector collaboration, (3) strengthen and expand culturally responsive, trauma-informed care. Implementation of these strategies in partnership with statewide stakeholders support access to holistic care and services, equip providers with the resources and skill needed to work with diverse communities, and shift policy priorities to reduce systemic barriers impacting women of child bearing age.

Five-Year Strategies and Activities Moving Forward

As with other priority areas, a Strategy Team was assembled to identify a set of strategies and activities for the Minnesota Title V program to help ensure women have accessible, quality health care during pregnancy and delivery. This Strategy Team was comprised of a diverse group of statewide stakeholders and included recipients and providers of women services, such as pregnancy and postpartum support, birth doula services; representatives from local public health (LPH) from regions across Minnesota (representing large, small, rural and urban communities), Title V staff, professionals serving Minnesota’s American Indian populations, and other communities of color and academia.

A logic model has been developed to visualize our planned work and intended results (see Figure 3). A larger version of the logic model is included with the supporting documents for this application. This logic model, along with the five-year action plan table, provide a broad picture of Minnesota’s strategies aimed at improving care for women during pregnancy and delivery. The discussion below includes Minnesota’s plans for implementing the strategies during FY2021 specifically.

Figure 3. Minnesota Care during Pregnancy and Delivery Logic Model

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

Addressing care during pregnancy and delivery from a population health lens focuses on expanding the immediate family’s role in care and the birthing process. This also involves the evolution of funding and policy to be reflective of the communities they are intended to serve. Over the next five years, statewide initiatives will focus on addressing foundational changes to delivery structure for maternal health and improving/expanding workforce to reflect our communities.

Collaborate across Government Agencies, including Participating on the Children’s Cabinet Healthy Beginnings Work Group

Governor Tim Walz is committed to a vision that everyone in our state has an opportunity to thrive. The governor instituted a plan to build One Minnesota, where state agencies collaborate to create a state that works for everyone. Under One Minnesota, the Children’s Cabinet is charged with implementing the One Minnesota priorities related to children and families (See Overview of the State for more information).

One of the priorities of the Children’s Cabinet is to end preventable maternal and infant deaths in Minnesota through the work of the Healthy Beginnings work group. The draft goal for this area is to reduce infant and maternal deaths experienced by American Indians, African Americans, other communities of color, and in Greater Minnesota.

Minnesota will explore collaborative efforts to:

1. Participate on other external work groups as subject matter experts providing technical assistance and education on best practices to reduce preventable infant deaths and improve maternal and infant health outcomes.
2. Work with universities and agencies to increase workforce diversity and increase employment opportunity in the health sector.
3. Work with Family Home Visitors, community partner organizations, and health systems to embolden fourth trimester care to include assessing and addressing postpartum visits and expanding coverage past 6 weeks.
4. Develop a plan to prioritize initiatives to ensure a healthy beginning for all children.

Establish a Learning Collaborative to Build a Culture of Health Equity as a Foundation for our Work across Disciplines

In 2021, Title V staff will recruit mothers, educational institutions, providers, community advocates and staff from MDH’s Office of Rural Health to participate in the Culture of Health Equity learning collaborative, which implores organizations to revisit past policies and structures to reframe the vision of population health. This process will work with stakeholders in women’s health to re-assess recruitment and group processes, allowing community to lead community programming. MDH also will work with partners to cultivate meeting spaces and learning collaborations over the next five years to bring medical providers, community advocates, and policy makers together to address and invest in evidence-based interventions for trauma informed and culturally appropriate care. The learning collaborative will include mothers with lived experience on maternal health topics at the forefront of decision-making.

Over the next five years, MDH will partner and promote programs focusing on work force development including implicit bias, cultural competency, and trauma-informed care as a foundation. This work must occur in collaboration with educational institutions such as: medical, physician assistant, nursing (entry to higher education), midwifery, and public health schools to diversify programming. Furthermore, MDH strives to elevate birth workers, doulas, and community health workers as a critical role in population health infrastructure. This work begins with addressing critical gaps in the health workforce pipeline by engaging with high schools, post-secondary, and trade schools to offer affordable classes with internships, fellowships or other opportunities to help students find work after completion of degrees. This work must be matched by on-going mentorship of new professionals in these fields to diversify workforce in Minnesota.

Strategy B. Integrate Services and Optimize Cross-Sector Collaboration

The second strategy for improving care during pregnancy and delivery, is to integrate health and social services and optimize cross- sector collaboration to benefit mother and infant. Care services for expectant mothers is often delivered by health specialties, not holistically. By integrating existing services, promotion of preventative health becomes an option for mom and baby and allows families to work with a care team. Connecting families with health resources and groups is the core of the work over the next five years.

The IMPLICIT Network will be piloting work to address the 4th trimester in IMPLICIT model, and are eager to work with MDH over the coming years on this addition to the model planning. Over the next five years, MDH will work in collaboration with a quality improvement grantee to recruit five clinics to implement and evaluate this model, adapt to practice, and develop sustainability plans for once the grant cycle is over.

Furthermore, MDH will collaborate with providers, health systems, and community partners on quality improvement interventions through MNPQC. As a primary improvement activity, MNPQC will work to address critical cross-sector collaboration, like the urgent need to seamless address maternal opioid misuse alongside pregnancy, postpartum and pediatric care.

Implement the IMPLICIT Model in Well-Child Visits

For many years, the CYSHN and MCH sections collaborated on a birth defects prevention grant. The new round of this grant was re-envisioned to address community input and allow optimization of cross-sector collaboration. The new prevention grant focus is on interconception care and optimizing postpartum mothers’ point of contact with providers through well-child visits.

This will be the first time the evidence-based Interventions to Minimize Preterm and Low birth weight Infants using Continuous Improvement Techniques (IMPLICIT) will be adopted in Minnesota. The IMPLICIT model utilizes time in the well-child visit, to incorporate maternal risk assessments for mother to improve birth outcomes. The model includes foci on four behavioral risks affecting future birth outcomes: smoking, depression, family planning and birth spacing, and multivitamin with folic acid use. Not only does this promising practice allow collaboration to integrate services, provide needed services and education to care givers, it also encourages providers to improve their understanding of quality improvement, implementing and evaluating evidenced based practice in their role.

The IMPLICIT Network developed, assessed and integrated this evidenced based model for the past 10 years, and are working in partnership with MDH and the March of Dimes to disseminate this interconception model.

Strengthen and Expand the Minnesota Perinatal Quality Collaborative

The Minnesota Perinatal Quality Collaborative (MNPQC) is a multidisciplinary approach that uses quality improvement (QI) principles to improve maternal and infant health outcomes and reduce health disparities. Established January 2018, the MNPQC seeks to strive for a composition of membership that is representative of the communities across our state as well as engaging our key experts in perinatal health. MDH leads this work in partnership with the Minnesota Perinatal Organization (MPO). Provider champions across health systems and state member organizations have been constantly engaged in the development of the MNPQC and the upcoming initiatives, with the goal to actively seek to engage community voices and family perspectives on perinatal care with a more thoughtful approach to ensure all members have equitable contributions. The focal point of the MNPQC is the steering committee, representing statewide hospitals, advocacy groups, and community members whom advise on potential strategic opportunities to support MNPQC initiatives and involvement in other statewide initiatives.

With feedback from community members and stakeholders, the MNPQC is working on three quality improvement initiatives over the coming years to improve maternal and infant outcomes statewide. Current quality improvement initiatives focus on addressing preterm birth prevention, maternal hypertension in pregnancy, and maternal opioid misuse disorders.

In the coming years, the MNPQC will focus on a newly formed Community Advisory Committee, comprised of community members and stakeholders, who provide insight into each initiative to inform a tailored approach for intervention in Minnesota’s diverse communities.

Evidence-Based Strategy Measure

A key area of focus for the MNPQC is to address health equity in maternal and infant care and identify opportunities to improve patient-provider trust. Moving health equity to a core measure of the MNPQC will allow providers and community members to collaborate on dismantling areas of health that for too long built barriers. A first step to dismantling preconceived or taught thoughts is for the MNPQC steering committee to complete an implicit bias training, with continual opportunities for training throughout the year. This training will be paired with an evaluation tool to allow a tailored approach to improving future trainings with community advocates leading this work.

Because of the reasons stated above, Minnesota will measure the proportion of MNPQC membership that completed implicit bias training as our evidence-based strategy measure (ESM) for the next five-year block grant cycle. More information on the measure, data sources, and potential limitations are included on the ESM detail sheet.

Address Maternal Opioid Misuse

The MNPQC neonatal abstinence syndrome/opioid use disorder (NAS/OUD) work group will implement collaborative interventions to improve health outcomes for pregnant and postpartum moms and babies with an emphasis of capacity building across greater Minnesota. A major barrier is availability of providers offering medical treatment for pregnant and postpartum people with opioid substance use disorders, especially in certain regions of the state.

In concert with the Minnesota Hospital Association, American Society of Addiction Medicine, and key stakeholders in opioid prevention work, the MNPQC will provide statewide certification training online to increase capacity of providers to gain waivers to treat pregnant and postpartum people. The MNPQC will engage content matter experts members who have to meet the supplement deliverables (i.e., provider trainings; protocol implementation; linkage to resources) in this online format, allowing rural and urban providers to interact, and engaging partnerships in the work across the state. With the completion of the Buprenorphine waiver training, participants will also examine stigma around women with substance use disorders and breaking down barriers to care for this at risk population.

In addition, the MNPQC will work on a set of activities to increase provider understanding of NAS/OUD overall in the state. Activities provided by health organizations and experts from the NAS/OUD work group will be delivered via interactive tools through the MNPQC.

These activities include:

• Create web series based on core interventions and technical assistance led by content experts;
• Develop and disseminate tools and resources to support NAS/OUD activities
• Engage broader MNPQC membership to strengthen dissemination of NAS/OUD tools and resources
• Support plan with MNPQC to determine sustainable NAS/OUD activities following the end of funding in September 2021.

Strategy C. Strengthen and Expand Culturally-Responsive, Trauma-Informed Care

The third strategy is to work with partners and decision makers to strengthen and expand culturally responsive, trauma-informed care, among women of childbearing age. In discussions with partners, it is evident that changes need to occur in training, locations of delivery services, and funding sources for this population. Increasing access to respectful care, will allow mothers to have more autonomy while seeking services with the intention to build a trusting relationship with their health provider. Using public health surveillance programs such as evaluating maternal mortality, has allowed collaboration across sectors to identify where population health can be improved to allow mother to thrive during and after their pregnancies.

Over the next five years, MDH will partner across sectors to encourage providers and maternal health partners to participate, complete, and continue education on implicit bias and trauma-informed care in maternal health. Building on the maternal mortality review committee, MDH will disseminate committee findings, analysis, and recommendation to internal and external stakeholders annually. Title V staff will work with the maternal mortality review committee and partners to strategically develop actionable interventions to be applied statewide.

Expand and Improve the Minnesota Maternal Mortality Review Project

The Maternal Mortality Review Project’s (MMMRP) goal is to improve the health outcomes of pregnant people through maternal mortality and morbidity reviews. The MMMRP houses the committee, which reviews maternal deaths cases and develops recommendations to prevent future deaths. As the review committee continues to review cases, translating to action will be key in programming.

In 2020, the CDC updated reporting forms for maternal deaths to include discrimination, interpersonal racism, and structural racism to contributing factors to maternal deaths. With these additions to the review committee analysis as potential contributing factors of maternal death, it is imperative to train the full committee on implicit bias, and how these factors may present in maternal deaths reviewed. The committee will complete training, and annually have re-education on implicit bias, allowing members to share experiences and learn from each other on dismantling structural racism in the medical system.

In the next five years, MDH plans to expand analysis of maternal morbidity in Minnesota. This process would necessitate expanding statewide partnerships, with the MNPQC leading quality improvement projects on leading causes of maternal morbidity in the state. On a national level addressing maternal mortality and morbidity are a priority, this will also allow Minnesota to work alongside other states on identifying and addressing the ‘near misses’ that impact more than 50,000 mothers nationwide. The MMMRP activities during FY2021 are as follows:

• Analyze multi-year data, provide demographics, geographic burden, distribution of death, and cause of death, to inform change of practice or policies.
• Review all pregnancy- associated maternal deaths within 18 months of date, and document findings and decisions in the Maternal Mortality Review Information Application (MMRIA)
• Disseminate committee findings, analysis, and recommendation to internal and external stakeholders annually.
• Work with committee and partners to strategically develop actionable interventions to be applied statewide.
• Invest in community driven interventions to address maternal mortality, build upon communities working in culturally tailored approaches in maternal health
• In partnership with Department of Human Services, Divisions within MDH, the Minnesota Hospital Association, State Medical Examiners and Law Enforcement entities, improve case identification and completion of record collection.
• Develop feasible systems to collect and analyze maternal morbidity data to identify leading causes of morbidity in the state. In conjunction with the MNPQC, tailor quality improvement interventions to target and address maternal morbidity.

National Performance Measure and Five-Year Objective

Minnesota has chosen to continue to focus on NPM 1, the percent of women, ages 18 through 44, with a preventive medical visit in the past year for the next five-year cycle beginning with FY2021. It is important for women to have access to reliable preventative care throughout the life course. Well-woman visits address a range of physical and mental health concerns with their health care provider and may include healthy diet education, screening for chronic diseases, screening for sexually transmitted infections, vaccinations, and mental health screening.[3] The fragmented nature of women’s preventive care includes care during pregnancy and delivery. Women often see many preventive providers during preconception, interconception, and pregnancy.

The 2018 Behavioral Risk Factor Surveillance System (BRFSS) found that 75.8% of women, ages 18 through 44, had a preventive medical visit in the past year. By 2025, Minnesota aims to increase the percentage of women receiving a preventative medical visit in the past year by 10%.

[1]Wymelenberg S. (1990). Science and Babies: Private Decisions, Public Dilemmas. Washington (DC): National Academies Press (US); Chapter 5, Prenatal Care: Having Healthy Babies. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK235274/.

[2] Phillippi JC. (2009). Women’s Perceptions of Access to Prenatal Care in the United States: A Literature Review. Journal of Midwifery & Women’s Health. Volume 54 No. 3 May/June, 219-225.

[3] Garcia, S, Martino K, Lai Y-H, Minkovitz C, Strobino D. Strengthen the Evidence Base for Maternal and Child Health Programs. NPM 1: Well-Women Visit. Women’s and Children’s Health Policy Center Johns Hopkins University, June 2017.