Pre/Interconception Health

 

Every Women Connecticut (EWCT) and the Every Woman Connecticut Learning Collaborative (EWCTLC) will be working toward addressing and increasing awareness around health equity, social drivers of health and social justice. A major vehicle for this work has been the recently established Reproductive Justice Alliance (RJA), which is a collaborative effort among EWCT, the MCH Coalition, PRAMS, and the March of Dimes. With guidance from Columbia University’s Averting Maternal Death and Disability (AMDD) project, The RJW’s 2022-23 activities will focus on conducting statewide focus groups with women who have experienced disrespect and abuse during their pregnancy and in-depth interviews with staff working in medical settings (e.g., prenatal care sites, hospitals) who have contact with pregnant and postpartum women.

 

The CT Reproductive Justice Alliance (RJA)

 

The Connecticut (CT) Reproductive Justice Alliance (RJA) is a group that was formed by the CT Department of Public Health, March of Dimes, EWCT, Maternal and Child Health Coalition and other organizations and individuals in 2021 to improve maternal and reproductive health in CT. The RJA is a group of community-based and state-level organizations and partners who work to address maternal health inequities in CT. The RJA is currently comprised of 30+ members who work to ensure that people who are pregnant or parenting, particularly those who are Black and/or Hispanic or Latino, receive access to quality care that is safe and respectful.

 

The goals of the RJA are to improve:

• Access to respectful, quality maternity care;

• Respectful interactions between patients, providers and staff;

• Health care systems, resources, and policies related to maternal health; and

• Accountability of health care systems by centering patients’ voices.

 

The RJA will be conducting research to better understand the experiences of individuals who are Black and/or Hispanic or Latino during pregnancy, childbirth and the postpartum period. The RJA will conduct focus group discussions with people who are pregnant and/or parenting as well as one-on-one interviews with health care providers and staff who work in health care settings to understand what opportunities and challenges exist to improve maternity care for individuals who are Black and/or Hispanic or Latino in CT. The focus group discussions will be conducted in both English and Spanish.

 

The RJA will use the research findings to help inform future programs, practices and policies to improve the health and wellbeing of people who are pregnant or parenting in CT, with particular focus on individuals who are Black and/or Hispanic or Latino. Examples of future programs could include a Know Your Rights campaign to increase public awareness about your rights during pregnancy and childbirth; support a process to improve accountability in the provision of health care; and educate health care providers on respectful maternity care.

 

RJA work has recently been elevated to a national level through the abstracts that were submitted and accepted for workshops presentations at the September CityMatCH Conference and the October Mom and Baby Action Network National Summit. The RJA will also be included in a compendium of birth equity work across the country. The compendium is a joint project between the March of Dimes and Pritzker and will aid birth equity workers, researchers and others in National projects which advance health equity for persons in their childbearing years.

 

Every Woman Connecticut & The Every Woman Connecticut Learning Collaborative (EWCTLC)

 

Preconception health counseling has been identified and endorsed by the Centers for Disease Control and Prevention as a strategy to improve maternal health and birth outcomes, as well as to reduce unplanned pregnancies. Starting in May 2016 under the auspices of the MCH Coalition and the March of Dimes, who provided the financial support, Every Women Connecticut (EWCT) and the Every Women Connecticut Learning Collaborative (EWCTLC) were established. The main goal of this initiative is to increase provider expertise and self-efficacy in implementing routine pregnancy intention screening and appropriate care, education, and services to ultimately improve birth spacing, increase pregnancy intentionality, as well as increase the proportion of Connecticut women who deliver a live birth and report discussing pre-/interconception health with a healthcare worker.

 

EWCT will be holding a One Key Question training conducted by EWCT Co-Chairs and a human sexuality and reproductive health training by Planned Parenthood of Southern New England in 2023. These trainings will be open to members of the EWCTLC.

 

In addition to these community trainings, EWCT also plans to offer e-learning Implicit Bias training with a focus on maternal health issues as well as additional e-learning opportunities on maternal mental health through the March of Dimes for EWCT and RJA members. EWCT co-chairs will hold an Implicit Bias debrief session following the e-learning rollout to facilitate conversation around implementing in their practice and/or settings.

 

Finally, EWCT will be partnering with Power to Decide to hold a OKQ train the trainer session for 3-5 EWCTLC sites implementing OKQ in 2023. Offering a train the trainer session will help address sustainability issues that many organizations in the health and human services field face due to high staff turnover. Unfortunately, COVID-19 has exacerbated this. Training key personnel who can then train others in their organizations will help to ensure OKQ  implementation is maintained and has fidelity.

 

EWCTLC is the major vehicle to increase provider expertise and self-efficacy in implementing routine pregnancy intention screening and appropriate care, education, and services to ultimately improve birth spacing, increase pregnancy intentionality, as well as increase proportion of Connecticut women who deliver a live birth and report discussing pre-/interconception health with a healthcare worker and to support implementers of OKQ.

 

Currently there are over 350 EWCTLC members consisting of OKQ implementers and/or those who have attended an EWCT sponsored training.  EWCTLC members will receive at least quarterly Notes of Interest via e-mail. Opportunities for local networking and one-on-one meetings will also continue to be offered virtually.

 

EWCT is strategically planning to maximize its reach by establishing relationships with other organizations and entities. The specific groups are:

 

The Medicaid Strategy Group (MSG)

MSG is a coalition of health advocates working together to improve and protect the quality and reach of HUSKY/Medicaid programs in Connecticut through administrative and legislative advocacy.

 

Health Equity Solutions (HES)

HES was the lead advocate for passage of key doula legislation in the 2021 and 2022 legislative sessions: H.B. 5500, An Act Concerning the Department of Public Health's Recommendations included specific language which establishes a doula advisory committee at the Department of Public Health. A doula advisory committee will allow the profession to have autonomy in what, how, and why in building core standards to certify a doula. The Doula Advisory Committee will offer and ensure no doula be barred from this process. EWCT, in partnership with HES and other partners, will do administrative advocacy for the implementation of this legislation in the spirit it is intended.

 

The CT Help Me Grow Advisory Committee

The goal of this advisory group is to build, in partnership with families, a coordinated early childhood system that supports developmental screening, early identification and linkages to services and supports. The Advisory Committee consists of well-known and respected representatives within the early childhood field. It operates under the auspices of the Office of Early Childhood and 2-1-1 Child Development, a specialized call center of the CT United Way’s 2-1-1 system. The membership is diverse and includes both state level and community-based entities.

 

Postpartum Support International, CT

The PSI CT chapter provides direct peer support to families, trains professional, and provides a bridge to connect them. PSI Volunteer Coordinators provide support, encouragement, and local resources on the phone and email to pregnant and postpartum moms, dads, and families.

 

Connecticut Coalition Against Domestic Violence (CCADV)

CCADV has invited EWCT to introduce OKQ at staff meetings of residential staff and child and family advocates. If this introduction of OKQ leads to programs implementing this screening tool, EWCT will offer on-going training and support to support successful implementation. These programs will also be part of the EWCTLC allowing additional support from other OKQ implementers.

 

Hispanic Health Council

The Hispanic Health Council is a nationally recognized, statewide community-based organization, whose mission is to improve the health and social well-being of Latinos and other diverse communities.

 

Participation in these groups expands partnership potential as it increases EWCT’s platform for addressing pre/interconception health care, health equity and racism from a comprehensive and holistic perspective.

 

Internal work within EWCT will focus on updating the OKQ manual to reflect the impact of COVID-19 and the increased awareness around health equity, social justice, and social determinants of health as well as new data on pre and inter-conception care outcomes in Connecticut.  The revised manual will also include information and guidance on how the Child Abuse Prevention and Treatment Act (CAPTA) and the Comprehensive Addiction Recovery Act (CARA) impacts women who deliver an infant believed to have been substance exposed and/or displays withdrawal symptoms. This update will be informed by the information and resources presented in the EWCT-sponsored workshops on CAPTA and CARA that is being held on September 22, 2022.  

 

EWCT will also explore opportunities to build out One Key Question to become more inclusive of all persons of childbearing age. EWCT has established relationships with the Founder/Director of Real Dads Forever and the Office of Early Childhood and will be working with them to identify ways to expand OKQ to include men. EWCT will also work with local experts to update OKQ training language and content to better meet the needs of the LGBTQ population.

 

Consulting services will continue to be provided by Marijane Carey of Carey Consulting. Carey Consulting will be charged with managing the Advisory Committee, expanding partnerships, responding to the evaluation recommendations and engaging members of EWCTLC to increase provider knowledge and self-efficacy in delivering, promising and evidence-based education, care, and services related to pregnancy intentionality, optimal birth spacing, and pre-/interconception health.

 

Reproductive Health Services

 

Reproductive health services are funded with State and Title V funds through a five-year contract with Planned Parenthood of Southern New England (PPSNE). The program provides services in those areas of Connecticut with high concentration of low-income women of "reproductive age," and with high rates of teen pregnancy. CT’s Medicaid program offers expanded reproductive health services, which affords presumptive Medicaid eligibility for those uninsured and under 250% of the FPL to receive reproductive health and STD services at no cost. Sliding-fee scale services are also offered and pregnancy testing, counseling visits, referrals for prenatal care, contraceptive service visits, breast and cervical cancer screenings, STD and HIV screenings and counseling, and other medical services visits are also provided as appropriate. The plan for this year is to continue to offer women the Expanded Medicaid Family Planning Limited Benefit and if they qualify, with presumptive eligibility if they are eligible. Due to the impact of COVID-19 and loss of Title X funding, PPSNE closed two centers in Danielson and Old Saybrook and provided telehealth services, and completely closed their New Britain clinic, located on-sit at the Hospital of Central CT. The plan for this year is to continue to provide telehealth services or in-person visits for all clients and refer clients from Old Saybrook and Danielson to nearby centers for in-person care.   PPSNE also plans to work closely with Federally Qualified Health Centers (FQHCs) in implementing the Association of State and Territorial Health Officials (ASTHO’s) Learning Community goal of Increasing Access to Contraception for Medicaid clients. The reproductive health care services provided by PPSNE are in accordance with nationally recognized standards of care. Chlamydia and gonorrhea testing will be encouraged as a standard procedure for all patients between the ages of 15-25.

 

Planned Parenthood will continue to assure that all clients who receive a reproductive health exam participate in the development of a Reproductive Life Plan. The discussions are conducted by a licensed healthcare provider and the client.  The Program will also seek to decrease the prevalence of unintended pregnancies through health education.

 

Pregnancy Risk Assessment and Monitoring System (PRAMS)

 

PRAMS data is used by DPH and other statewide partners by providing them with data to inform their work in addressing the strategies outlined in this section. PRAMS provides statewide data on a variety of topics that are not available from any other data source, including preconception health and education, pregnancy intention, contraception methods, perinatal depression, oral health, social support, postpartum maternal and infant care, discrimination, and father involvement. Since receiving our first weighted data set in late October 2015, 91 data requests from internal and external partners have been fulfilled; numerous publications and other products have been produced; and PRAMS staff have collaborated on various efforts to address state MCH priorities, as well as statewide plans, needs assessments, and initiatives to reduce low birth weight, infant mortality, and health disparities.

 

Currently, eight years of data (2013-2020) are available for analysis, including data from the 2019 opioid supplement and a COVID-19 supplement that was implemented between October 2020-June 2021. Data collection for the 2021 surveillance year ended in June 2022 and we are awaiting our weighted data set from CDC.

 

As evidenced above, PRAMS is uniquely positioned to provide population-based data on maternal behaviors and experiences among recent postpartum women, including emerging areas of concern. In addition to core operations, PRAMS periodically implements survey supplements to collect data to address emerging needs. In June 2021, State legislation was passed legalizing adult use of cannabis products. The legislation includes the DPH’s role in surveillance and PRAMS was one of three key data sources identified by the Governor’s consultant for cannabis surveillance. CT PRAMS developed a survey supplement that included questions about marijuana use and the use of Cannabidiol (CBD) products before, during, and after pregnancy; how (e.g., smoked, dabbed, vaped, etc) and why (e.g., relieve nausea, relieve stress or anxiety, etc) women used marijuana products during pregnancy; conversations around marijuana use or recommendations during prenatal care; perceptions of how long someone should wait after using marijuana before breastfeeding or pumping milk for their baby; and if they think the use of marijuana products during pregnancy could be harmful to a baby’s health. This supplement is being implemented for the entire 2022 surveillance year which began data collection in April 2022 and will end in June 2023. In April 2023, the new PRAMS Phase 9 survey will be implemented, and we plan to retain 1-2 questions on the survey for long-term surveillance.

 

In the upcoming year, we be finalizing our Phase 9 survey content. Beginning in 2021, CDC engaged PRAMS sites and other key internal and external partners to begin crafting the Core survey content of the new Phase 9 survey. That multi-stage process culminated with the release of the final Phase 9 Core survey in July 2021. CT PRAMS has already started comparing the Phase 9 content to the Phase 8 to assess what key content was added or dropped before we begin developing the remaining portion of the survey (Standard and state-developed questions). This step is critical because numerous partners depend on PRAMS for informing their programs and/or grant reporting, so any potential changes will have to be carefully considered to ensure Title V and other MCH data needs are met to the best of our ability. Fortunately, many of the priority areas we had voted on earlier in the Core survey development process made the final Core survey, which allows us additional opportunities to add other content we may not have had room for to maximize fulfilling our data needs.

 

Some of the new Core content will allow us to measure several social determinants of health (SDOH) and expand our ability to measure and address disparities and equity in CT. Some of the new questions include content around a) discrimination while getting health care during pregnancy, at delivery, or at postpartum care based on 13 different dimensions (e.g., including race, ethnicity, or skin color; disability status; immigration status; age; weight; sex or gender; sexual orientation; religion). This question is similar to an existing question on our Phase 8 survey that we had planned to expand, but now will likely drop to avoid duplication; b) being treated unfairly due to race, ethnicity, or skin color in any of the following situations: job, housing, police, courts, school (self/child’s), getting medical care; c) different types of disabilities before pregnancy; d) other SDOHs (transportation to medical appts, work, errands; not enough food); e) addition of same-sex couple options to certain questions (e.g., why not taking birth control); and f) management of high blood pressure during pregnancy (among those who had this) and receipt of information (and how) of “warning signs” to watch out for during and after pregnancy that require immediate medical attention (e.g., fever, frequent or severe headaches, or severe stomach pain).

 

Also of note is that CT PRAMS’s three state-developed fatherhood and partner support questions were officially adopted as CDC Standard questions for other states to select from! The Phase 9 survey will begin with the 2023 surveillance year next April.

 

Additional work that began as Data to Action projects that will continue in the coming year include:

 

Leading the RJA: CT PRAMS will continue to provide data to support the efforts of the RJA, which the CT PRAMS Director helped cofound in 2021. The CT PRAMS Director is also co-PI with CT’s CDC MCH Epidemiology Assignee leading the qualitative research project discussed elsewhere in this application (see State Systems Development Initiative update). The quantitative data from PRAMS coupled with the qualitative RJA research will help drive the work of the RJA.

 

Finishing the CAPTA Evaluation Effort: In March 2019, CT implemented a statewide Child Abuse Prevention and Treatment Act (CAPTA) response that requires hospitals to identify infants exposed in utero to a range of legal and illegal substances (including alcohol), infants showing withdrawal symptoms, or those diagnosed with FASD and notify the CT Department of Children and Family’s (DCF) new CAPTA portal. In Fall 2021, an evaluator for DCF approached CT PRAMS to see if data from the 2019 PRAMS opioid supplement could be used to help evaluate data captured in the newly implemented CAPTA notification system. Our results suggest that CAPTA is accurately identifying certain types of substance use for certain individuals, but there are areas should be examined further to better understand hospital practices and implement quality improvement efforts. For example, despite State policy guidance that any alcohol use in pregnancy should result in a notification, CAPTA appears to be capturing more frequent alcohol use only. In addition, it appears that the current screening/testing practices may be under-identifying substance use and/or resulting in differential CAPTA notifications in pregnancy among all race/ethnic groups except non-Hispanic Black individuals. However, it’s important to note that one limitation in CAPTA is that the data was missing race/ethnicity data for 10% of records which may have influenced the rates of detected substance use across racial/ethnic groups. This highlights an opportunity for training with hospitals to improve data quality and completeness.

 

Partnering with DSS on their Maternity Care Bundle Project: In Fall 2021, CT PRAMS met with the DSS Medical Director and other DSS staff involved in the new maternity care bundle program to discuss how PRAMS could inform the development phase of the bundle and provided them with a PRAMS Medicaid report using 2019-2020 data, as well as a subsequent expanded set of analyses. They shared select data with the Maternity Bundle Stakeholder Advisory Council as part of the bundle planning process. CT PRAMS recently met with these same partners to discuss how PRAMS can help measure certain outcomes in the post-implementation evaluation phase of the overall program; these discussions will continue during the coming year.

 

Breast and Cervical Cancer

 

The CT Breast and Cervical Cancer Early Detection Program (CBCCEDP) is funded through the Centers for Disease Control & Prevention (CDC) and state of CT funds. The program provides comprehensive screening to Connecticut women ages 21 to 64 that are medically underserved, uninsured, and low income, all factors that are barriers to healthcare access. The primary objective of the program is to increase the number of women screened for breast and cervical cancer and referred for diagnostic testing and treatment. For the program year of 2021-2022, the WISEWOMAN Program (WWP) received CDC funding to provide cardiovascular screening services to women receiving breast and cervical cancer services. The WWP serves the same target population as CBCCEDP, specifically women between the ages of 40-64; Wellness checks are provided in the form of Body Mass Index (BMI), waist circumference, blood pressure monitoring, along with Cholesterol and Blood glucose monitoring for participants. Those found with at risk values in need of improvement can be supported by Health Coaching and specific Lifestyle Programs to better assist the participant in reaching their health and wellness goals. The Colorectal Cancer Program (CRC) received CDC funding to provide colorectal cancer screening, diagnostic, and treatment referral services for persons who qualify over the age of 45. Together the CBCCEDP, WWP, and CRC programs create the Connecticut Early Detection & Prevention Program (CEDPP), providing a whole-body approach to improving the health of CT Women. During this program period, CEDPP continued to provide services at 6 health care systems, consisting of 21 hospitals to reach more CT women. These hospitals sub-contracted with 14 FQHCs, 14 clinics and 15 Planned Parenthood clinics. CEDPP contracted health systems partnered with several organizations to provide Community Wellness Day events for women and families where services were provided where they live and work and appointments were given for further follow-up visits. CEDPP collaborated with area CT Walmart Stores, CT Cosmetologists Association, and CT Physicians for Women to conduct outreach and 10 wellness days across the state, reaching over 3200 women.  CEDPP Wellness days provides, at a minimum, patient education, health assessment, clinical screening and clinical referral. CEDPP continued to collaborate with Knox Garden, Snap-Ed program, Sardili’s Produce, Joan Dauber Food Bank, and Women’s Empowerment Center to provide community garden opportunities to program participants and improve food security, healthy nutrition, and physical activities to reduce the risk of cancer and heart diseases to participants in the Hartford Community.

 

Oral Health

 

The Office of Oral Health (OOH) and its partners will continue to implement the State Oral Health Improvement Plan 2019 - 2024 (SOHIP). Focusing on prevention, access/utilization, medical and dental integration, and data collection and analyses.  The OOH is dedicated to ensuring access to oral health services for all residents regardless of race ethnicity, education, or class background. The SOHIP aims to decrease oral health disparities; promote a culturally competent oral health workforce, continue and increase community engagement of partners to establish practices; and improve the oral health literacy of CT residents.

 

The OOH program activities will continue to address oral health workforce gaps in dental health professional shortage areas (DHPSAs) and other underserved areas in CT and coordinate a continuum of oral health care for CT residents, with an emphasis on underserved populations. Community based prevention efforts continue with community water fluoridation and dental sealant programs. Action steps over the next year will include activities around increasing inter-professional collaboration across disciplines, including dental and primary medical care to develop best practices to improve service coordination and delivery.

 

The OOH and CT DPH Drinking Water Section (DWS) will continue to support certified water operators and public water systems to comply with the CT water fluoridation statute. Activities will include a water fluoridation principles and practice training, maintaining optimally fluoridated water levels in public water systems, and continuing to submit data to CDC WFRS on a timely basis.

 

The CT Dental Health Partnership (CTDHP), the state’s Medicaid Husky dental Administrative Service Organization (ASO), will continue to focus on intensive outreach to underserved residents with efforts to secure a dental home. Outreach efforts will continue to pregnancy and post pregnancy. In 2020 the CTDHP established an evaluation workgroup (The Affinity Group) which seeks to explore the potential for an initiative allowing the application of dental sealants in pediatric settings by a crossed trained medical-oral health staff. This is to encourage early child oral health screening, improve partnership between medical and dental providers, and establish early dental homes. The OOH is a member of this working group and efforts are ongoing.

 

The OOH will continue to implement the SEAL CT! Program and facilitate the CT Dental Sealant Advisory. OOH will finalize the Every Smiles Counts for Children final report and continue to implement the Every Smile Counts for Older Adults survey, which is taking place April – November 2022. The OOH will continue to implement the MDIP in partnership with CHCI and facilitate the Medical Dental Integration Advisory.

 

The OOH continues to promote and share bi-lingual oral health educational information, resources, social media postings, and public services announcements for the general public and MCH population. This is conducted via DPH’s social media, the OOH webpages, and through community partners.