Domain: Women/Maternal Health

Planning for October 2023-September 2024

Objective

By 2025, Minnesota aims to increase the percentage of women receiving a preventative medical visit in the past year by 10% from 75% in 2020 to 83.4% in 2025.

National Performance Measure

(NPM #1) Percent of women, ages 18 through 44, with a preventive medical visit in the past year.

An annual well-woman visit provides a critical opportunity to receive recommended clinical preventive services, including screening, counseling, and immunizations, which can lead to appropriate identification, treatment, and prevention of disease to optimize the health of women before, between, and beyond potential pregnancies.[1] Minnesota’s goal for FY2024 is that 81% of all women receive a well-woman visit.

Evidence-Informed Strategy Measure

(ESM 1.2) Number of hospitals that are actively participating in Minnesota Perinatal Quality Collaborative (MNPQC) initiative focused on the Alliance for Maternal Innovation (AIM) bundle on substance use disorders.

Members of the MNPQC recognize the importance of the issues addressed by the AIM, which is a national data-driven maternal safety and quality improvement initiative. AIM’s work aligns well with the MNPQC core initiatives, and formal involvement in the AIM Program aligns Minnesota’s efforts with other states’ activities. The issues are relevant to discussions on quality improvement in Minnesota as supported by the Minnesota Maternal Mortality Review Committee (MMRC) and MNPQC Steering Committee.  The MNPQC steering committee had identified the initiative focused on opioid use disorder as a priority within the MNPQC strategic plan with intentions to model the AIM opioid / substance use disorder bundle.

The MNPQC led the state’s official enrollment in AIM in the Spring of 2022. The proposed AIM bundle for this opportunity was on Care for Pregnant and Postpartum People with Substance Use Disorder led by the MNPQC substance use disorder workgroup, Mother/Infant Opioid and Substance use Treatment and Recovery Effort (MOSTaRE).

Minnesota’s goal for FY2023 is for 10 hospitals to be actively participating in MNPQC initiative focused on the AIM bundle on substance use disorders.

Community-Identified Priority Need: Care During Pregnancy and Delivery

For more information on the impact and importance of care during pregnancy and delivery, see the Women/Maternal Health 2022 Report.

Strategies and Activities

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

1.  State Level Activities

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

Governor 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 was charged with implementing the One Minnesota priorities related to children and families (Refer to Overview of the State for more information). Children’s Cabinet activities contribute to the existing goals of ending preventable maternal and infant deaths in Minnesota and reducing infant and maternal deaths experienced by American Indians, African Americans, other communities of color, and in Greater Minnesota.  

Title V staff will remain engaged in the following activities related to One Minnesota and the Children’s Cabinet:  

• Participate on external work groups to listen to community concerns and member identified needs to inform strategies; and as subject matter experts providing technical assistance and education on best practices to reduce preventable infant and maternal deaths and improve pregnancy outcomes.   
• Work with local community leaders, schools, institutes of higher education, and community-based agencies to increase workforce diversity among birth workers and increase employment opportunity in the health sector.  
• Work with family home visitors, community partner organizations, health systems, and policy makers to support fourth trimester care to include assessing and addressing postpartum visits and increasing the utilization of Medicaid’s newly expanded postpartum coverage up to 12 months.   
• Implement a comprehensive cross-sector plan to prioritize initiatives to ensure a healthy beginning for all children. 

1.2  Champion Health Equity in the Child and Family Health (CFH) Division’s Policies, Practices, and Programming

In the spring of 2022, the CFH Division contracted with a local research and evaluation firm to strategically continue to move health equity forward within the Division, with a final strategic plan completed and submitted to CFH leadership in September 2022. Out of the learning from this strategic plan and process, a division wide Health Equity Operations Work Group was formed to identify opportunities to advance health equity using the strategic plan and staff engagement. The work of the Health Equity Operations Work Group will continue to move forward in FFY2024 – with objectives to be determined in FFY2023.

1.3  Seek Community Input to Identify Gaps and Build on Strengths in Access to Midwife and Doula Services

Minnesota Doula Workforce Survey

MDH has contracted with a research and evaluation firm to develop a survey aimed at building a more comprehensive profile of doulas and birth workers in Minnesota. For the purposes of this survey, a doula or birth worker is defined as someone who provides continuous physical, emotional, and informational support to a birthing person before, during, and after childbirth to help them achieve the healthiest, most satisfying experience possible. The goal of this work is to develop a better understanding of doulas and birth workers in the state, identify barriers to becoming or practicing as a doula and gaps in service, and opportunities to improve access by building on strengths of the doula and birth worker workforce. In FFY 2024, MDH and the contractor will compile, analyze, and create a summary report of the final survey results.

Maternal Care Access Coordinator

To help improve health equity in pregnancy and postpartum outcomes, MDH hired a Maternal Care Access Coordinator to develop a strategic plan and to develop and implement policies, activities, and programs, with community input, aimed at expanding access to prenatal care, doula, and midwifery services by working with internal and external partners and stakeholders. In FFY2024, the Maternal Care Access Coordinator will finalize the review of frameworks created by community doulas involved with Ramsey County’s Birth Equity Community Council’s (BECC) policy committee that aims to improve the doula certification process and reimbursement, which was recently increased by Medical Assistance in Minnesota. Community input and assessment will be developed and implemented to reflect the suggestions outlined by the community doulas and other partners for improving the process and expand organizations for required training for birth doulas. Additionally, the Maternal Care Access Coordinator will assess the access to midwife services for communities experiencing the highest rates of disparate pregnancy outcomes. This information will be used to inform cross-sector collaborations with internal and external stakeholders working to advance policies and systems changes to remove barriers to access for doula and midwife services such as trainings, certification, and reimbursement.

B.  Strategy B: Integrate Health and Social Services to Optimize Cross-Sector Collaboration

1.  State Level Activities

1.1  Implement and Evaluate the IMPLICIT Model to Screen for Maternal Risk Factors During Well Child Visits

For many years, the CYSHN and MCH sections in the CFH Division have collaborated on birth defects prevention grants and continue to focus on interconception care and optimizing postpartum mothers’ point of contact with providers through well-child visits. MDH plans to continue and expand the evidence-based IMPLICIT model (Interventions to Minimize Preterm and Low Birth Weight Infants using Continuous Quality Improvement Techniques) in Minnesota. The IMPLICIT model utilizes time in the well-child visit to incorporate maternal risk assessments for mothers and birthing persons 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 and implementing and evaluating evidenced-based practice in their role.  

The national IMPLICIT Network developed, assessed, and integrated this evidence-based model for the past 10 years, and are working in partnership with MDH and the March of Dimes to disseminate this interconception model. In FFY2024, MDH will be engaging in the following activities: 

• Continue implementation and data collection at the three sites recruited to implement the IMPLICIT model in the state, with mentorship from cohort one and two sites.  
• Analyze and evaluate data collected in the REDCap database with the assistance of IMPICIT Network partners to integrate continuous quality improvement practices tailored to the needs of each site. 
• Work in collaboration with the national IMPLICIT Network to host webinars and meetings to create a collaborative environment for grantees to network.
• Present opportunities for grantees to attend national IMPLICIT webinars and conferences.  

1.2  Strengthen and expand the Minnesota Perinatal Quality Collaborative (MNPQC)

Minnesota became an AIM state in Spring of 2022 and the MNPQC, co-led by MDH, is eager to take the next step in statewide quality improvement efforts for maternal health outcomes. The MNPQC is primarily responsible for coordinating AIM implementation and is undergoing exploratory opportunities to develop the data platform to increase efficiency and reduce burden with hospital partners. This grant program will provide five-year funding support to the MNPQC to lead the establishment of an AIM data infrastructure, including data collection portals, reporting, engagement of hospitals/providers, and expand AIM bundles being implemented in Minnesota. MNPQC is especially eager to engage with the AIM community to learn, build and grow this work. Objectives supporting this in FFY2024 are to: 

• Identify and implement AIM bundles and support data collection and sharing. 
• Provide AIM technical assistance, training, and sharing QI project success to promote participation.
• Identify the next AIM bundle, incorporating the Innovations for Maternal Health Outcomes in Minnesota (I-MOM) project work, including the MCH Task Force Perinatal Sub-Committee, the Perinatal Health Strategic Plan, and community recommendations. 
• Work to address, as a primary improvement activity, critical cross-sector collaboration, like the urgent need to seamlessly address maternal opioid misuse alongside pregnancy, postpartum and pediatric care.

1.3  Address Maternal Opioid Misuse

MOSTaRE Initiative

A key recommendation from the MMRC was “to support statewide improvements for birthing people who have substance use disorders, including adequate identification of substance use in the birthing population, referral to services and support groups, and increased funding to expand treatment and access to treatment throughout the state”. The MNPQC created a pressing priority to address the opioid crisis and impact of substance use disorders (SUDs) on pregnant people and infants.

MNPQC identified the MOSTaRE QI initiative. The purpose of the MOSTaRE initiative is to work with providers, hospitals, and other stakeholders to improve identification, clinical care, and coordinated treatment/support for pregnant and parenting people with substance use disorder and their infants through a family-centered approach to care.  The MOSTaRE initiative launched the AIM bundle, ‘Care for Pregnant and Postpartum People with Substance Use Disorders’ in September 2022 with rolling recruitment.

Overall benefits of the MOSTaRE initiative for pregnant people with substance use disorders include:

• Improved screening for SUD
• Improved patient, caregiver, and public education about SUD
• Provision of trauma-informed care
• Fostering of collaboration among healthcare providers and across healthcare systems
• Increased patient access to additional support services and medication-assisted treatment (MAT).

Overall benefits of the MOSTaRE initiative for infants exposed to substances include:

• Improved screening for substance exposure
• Increased adoption of nonpharmacologic methods of treating Neonatal Abstinence Syndrome or Neonatal Opioid Withdrawal Syndrome (NAS/NOWS), such as the “Eat, Sleep, Console” model
• Increased emphasis on “rooming in” to promote maintenance of the maternal-infant dyad.

By December 2023, the MOSTaRE initiative aims to:

• Increase the identification and treatment of SUDs in pregnant people and substance exposure in infants by 50% or more in order to improve pregnancy and postpartum outcomes
• Increase the use of non-pharmacologic methods for treating infants exposed to opioids
• Reduce the average length of hospital stay for infants exposed to opioids.

Support toward achieving these goals is through provision of ongoing technical assistance and support for data collection through action period calls with participants, including ten hospital teams from six health systems statewide – with seven of the hospitals outside of the Twin Cities metro area.

Prior to the launch of the AIM MOSTARE initiative, MNPQC faculty hosted a town hall session called “Chat with CPS: Response to changes in reporting of prenatal exposure to controlled substances”. This townhall featured county health departments (three metro and one rural) with over 90 registrants. MNPQC invested in collaborative partnerships to streamline the educational components for the SUD initiative to leverage resources and minimize duplication. Additionally, these collaborations identified emerging issues, gaps, and other needs expressed by communities and partners.

A result of this strategy was to elevate a twice-monthly ECHO webinar series on the intersection of perinatal opioid use disorder and mental health, led by an addiction medicine provider and a perinatal psychiatrist – MNPQC members at a large health system. Project ECHO is an existing web module series hosted by Hennepin Health, with key content supportive to the MOSTaRE initiative. The series focuses on the intersection of perinatal opioid use disorder and mental health, led by key perinatal clinical leadership. MDH will continue to elevate the ECHO webinar series in FFY2024.

In 2023, the Minnesota Legislature passed the Comprehensive Drug Overdose and Morbidity Prevention Act.  As a part of this legislation, Title V staff will partner with MDH staff to identify, address, and respond to drug overdose and morbidity in those who are pregnant or have just given birth through multitiered approaches including NAS monitoring efforts; implement substance use disorder-related recommendations from the maternal mortality review committee; collaborate with interdisciplinary and professional organizations that focus on quality improvement initiatives related to substance use disorder; promote medication-assisted treatment options, and support programs that provide services in accord with evidence-based care models for mental health and substance abuse disorder.

1.4  Strengthen State Capacity to Improve Maternal Health Outcomes and Address Maternal Health Disparities

In FFY2023, MDH was awarded a new HRSA grant on the State Maternal Innovation and Data Capacity Program – creating the I-MOM project. The purpose of the I-MOM project is to support state capacity to improve maternal health and address maternal health disparities through quality services, a skilled workforce, enhanced data quality and capacity, and innovative programming that aims to reduce maternal mortality and severe maternal morbidity. As a part of the I-MOM project, MDH will establish a Perinatal Sub-Committee under the existing Maternal and Child Health Advisory Task Force which will support development of Minnesota’s first Perinatal Health Strategic Plan. The I-MOM Project Planner will lead project management and implementation of the I-MOM project in FFY2024 until the end of the grant period, including collaboration with Title V staff and the MCH Advisory Task Force Perinatal Sub-Committee.

C.  Strategy C: Strengthen and Expand Culturally Responsive, Trauma-Informed Care for Women of Childbearing Age

1.  State Level Activities

1.1  Expand and Improve the Minnesota Maternal Mortality Review Project (MMRP)

The goal of the MMRP is to improve the health outcomes of pregnant people through maternal mortality and morbidity reviews. The MMMRP houses the MMRC, which reviews maternal death cases and develops recommendations to prevent future deaths. With new legislative changes in July 2021, the MMRC formally became recognized as a State Advisory Committee to be appointed by the commissioner of health and sits within MDH.

The MMMRP activities for FFY2024 are many and include the following: 

• Analyze multi-year data and 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 of death, and document findings and decisions in the Maternal Mortality Review Information Application (MMRIA) to assist with ongoing analysis. 
• Continue to review maternal deaths associated with COVID-19 infections.  
• Expand community members and/or those with lived experience representation on the MMRC.  
• Disseminate committee findings, analysis, and recommendations to internal and external stakeholders annually.  
• Collaborate with partners to strategically develop statewide actionable interventions to reduce contributing factors identified by the case reviews.  
• Develop a community action team to identify strategies and resources needed for the community to implement recommendations and mitigate barriers to improved pregnancy outcomes. 
• Train, and cross-train, internal staff on data management and system processes to improve timely access to case information, abstraction, and data entry. 
• Invest in community driven interventions to address maternal mortality and build upon communities working in culturally tailored approaches in maternal health. 
• Improve case identification and completion of record collection in partnership with Department of Human Services, other divisions within MDH, the Minnesota Hospital Association, State Medical Examiners, and Law Enforcement entities.  
• Develop feasible processes and systems to collect and analyze maternal morbidity data to identify leading causes of morbidity in the state.  
• Tailor quality improvement interventions, in conjunction with the MNPQC, to target and address maternal mortality and morbidity.  

Additionally, in FFY2024, staff will work with MNPQC members, community partners, and clinic systems to develop protocols and processes for a maternal morbidity review team. Maternal morbidities are considered “near miss” incidents related to pregnancy or childbirth that did not result in death. The protocols and processes will assist implementing case reviews to expand identification of opportunities to improve care as well as requesting records from newly acquired data sources for case narratives.

1.2  Address Violent Maternal Deaths through Surveillance and Evidence-Based Intervention

Title V staff partnered with MDH’s Injury and Violence Prevention Section (IVPS) on a maternal violent death project funded by the Office on Women’s Health. This five-year grant (2021-2026) is designed to reduce deaths among pregnant and postpartum women due to violence with specific interventions around suicide, homicide, and domestic violence. This project aims to 1) enhance surveillance of violent maternal deaths and 2) expand the evidence-based Confidentiality, Universal Education and Empowerment, Support (CUES) intervention.

The project team will continue working closely with the MMRC, MNPQC, and other local organizations toward achieving these goals, and will engage in the following activities in FFY2024: 

• Continue Violent Death Reviews using an updated review protocol.
• Pilot the implementation of an internal maternal violent death database and quality improvement of reporting forms.
• Continue partnership with the MNPQC and intervention partners to develop and disseminate resources on maternal violence in Minnesota.
• Focus reporting for violent maternal deaths to be shared with MMRC members and partners.
• Pilot an informant interview protocol through a contract with external partners – which reflects a recommendation from the CDC for MMRC partners to use informant interviews for comprehensive case reviews.
• Develop a dissemination and information sharing plan for data connected to this grant.
• Reimburse MMRC members for participation in this the small sub-working group.
• Form meaningful connections with medical examiners, including relationship-building through visits to county medical examiners’ offices.

1.3  Partner to Implement Requirement for Birthing Facilities to Provide Anti-Racism and Implicit Bias Training to Staff

MDH staff will work to provide ongoing implementation support to birthing facilities required, through the Dignity in Pregnancy and Childbirth Act, to provide staff with anti-racism and implicit bias training annually beginning in January 2023. With our partners at the U of M’s Center for Anti-Racist Research for Health Equity and Diversity Science, MDH looks forward to supporting health systems, birthing hospitals, and clinics to ensure that training is provided. The first two modules launched in December 2022 and April 2023.

D.  Additional Related Activities

1.  State Level Activities

1.1  Provide Holistic Health and Well-Being Support to Women, Pregnant People, and Their Families Through Family Home Visiting (FHV)

FHV is an effective upstream intervention that serves as a key link to other interventions and community supports and is a notable contributor to improved maternal and infant health outcomes. FHV services in Minnesota are supported by several funding streams including state, federal and local resources. At the state level, MDH oversees and distributes funding for home visiting services provided under Temporary Assistance to Needy Families (TANF) funding, the federal Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program, Minnesota Evidence-based Home Visiting, and Minnesota's Nurse-Family Partnership legislation. Together, these funding streams provide approximately $33 million annually to support home visiting programs across the state that serves upwards of 7,200 families.

In FFY2024, Title V Staff will partner with and support MDH’s FHV staff to:

• Implement activities that provide culturally and linguistically appropriate services to priority populations, including home visitors attending implicit bias training or other trainings that promote culturally responsive, trauma-informed care, and using funding to support the American Indian specific FHV Curriculum – Family Spirit. 
• Connect families to needed community services.
• Promote the importance of well-women visits, prenatal and postpartum care, and strive to assure that the women served have health insurance and are connected to a primary care provider.
• Work closely with primary care providers to encourage cross-sector collaboration to provide a more holistic approach to caring for families during pregnancy and after the birth of their child.
• Provide screening, using validated tools, for: depression during the postpartum period; intimate partner violence, parent-child interactions, and developmental and social emotional concerns for children – and, subsequently, make appropriate referrals.
• Provide health information and encouragement to families including, but not limited to, family planning, breastfeeding and child nutrition, and child growth and development.

[1] Committee on Gynecologic Practice. ACOG Committee Opinion Number 755: Well-woman Visit. Obstet Gynecol. 2018 Oct 132(4):e181-e186. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/10/well-womanvisit