NPM 14.1: Percent of Women Who Smoke During Pregnancy

Maternal tobacco use is one of the most preventable risk factors of poor birth outcomes. Smoking during pregnancy increases the maternal risks of spontaneous abortion, ectopic pregnancy, and cancers and increases fetal risks of stillbirth, premature birth, stunted growth, cleft palate, low birth weight, and sudden infant death syndrome (SIDS). Many women who are affected by nicotine addiction continue to smoke during pregnancy.

MCHS will disseminate information and education about tobacco screening and referral to health care workers and support programming to improve quality of maternal health care including screening and referral for tobacco use during and after pregnancy. 

DSHS Regional MCH staff will continue to disseminate Smoking Cessation and Reduction in Pregnancy Treatment (SCRIPT) and to develop relationships that can amplify education and referrals to the Quitline among women of childbearing age (WCBA). 

MCHS will continue to work with DSHS Tobacco Prevention and Control partners to identify additional areas of shared goals and potential collaboration.

SPM 4: Maternal Morbidity Disparities: Ratio of Black to White Severe Maternal Morbidity Rate

Racial and ethnic disparities in health outcomes between Black women and other populations must be addressed. Severe maternal morbidity (SMM) has been defined as the “unintended outcomes of the process of labor and delivery that result in significant short-term or long-term consequences to a woman’s health.”[1] Rates of SMM, while remaining relatively stable in Texas from 2009-2018[2], are increasing in the United States.[3]  Non-Hispanic Black women are disproportionality impacted by SMM with rates of SMM approximately 100 percent higher among Black than White women, with no reduction in the Black-White disparity over time.[4],[5] As with maternal mortality, SMM is often preventable. When SMM is not ameliorated, it may result in maternal death.[6] 

Based on the findings and recommendations published in the Maternal Mortality and Morbidity Task Force [now Maternal Mortality and Morbidity Review Committee, or MMMRC] and Department of State Health Services Joint Biennial Report, 2018, the MMMRC established the Subcommittee on Maternal Health Disparities. The Subcommittee’s purpose is to identify key drivers and root causes of racial disparities in maternal mortality and morbidity in Texas, with the goal of reducing or eliminating disparities in maternal health outcomes.  MCHS will continue to support the work of the Subcommittee in FY21 to continue to strengthen the health equity framework for maternal mortality case review.

The MCHS HTMB Branch will:

• integrate best practices for the reduction of peripartum racial and ethnic disparities into the programming for TexasAIM and other health care quality improvement efforts;
• implement a maternal health and safety awareness campaign to include targeted information, messaging, and strategies to address racial and ethnic health disparities and increase health equity;
• implement a High Risk Maternal Care Coordination Services (HRMCCS) Pilot in one or more geographic region of the state;
• implement staff training, conduct a program self-assessment, and develop a program action plan for increasing health equity in women’s and maternal health programming.

SPM 5: Percent of Women of Childbearing Age (WCBA) Who Self-Rate Their Health Status as Excellent, Very Good, or Good.

Self-reported health status has the capacity to account for the multiple factors that impact a woman’s preconception and interconception health. Self-reported health status is a measure of health-related quality of life and is recognized as an indicator of a population’s overall well-being. The new SPM 5 is the General Health Status measure from the Council of State and Territorial Epidemiologists (CSTE) Core State Preconception Health Indicators measure set. The measure set was developed by the Core State Preconception Health Indicators Working Group and was finalized in 2010 after incorporating stakeholder feedback. A DSHS epidemiologist and the current Healthy Texas Mothers and Babies Branch Manager served as one of seven state teams comprising the Core State Preconception Health Indicators Working Group. According to the CSTE Core State Preconception Health Indicators Detail Sheet, Self-rated Health Status (A1) (2009), this indicator is highly correlated with various adverse health outcomes, and lower self-ratings of this subjective measure have consistently been associated with “increased mortality, incident adverse health events, health care utilization and illness severity, even after medical risk factors have been accounted for.”1

A woman’s health in the preconception and interconception periods affects her health, safety and well-being throughout her life course, including outcomes of any future pregnancies and subsequent maternal, infant and child health. Women in Texas have experienced rising rates of obesity, diabetes, hypertension, and substance abuse disorder, and low rates of health insurance coverage and access to care. High rates of unintended pregnancy, preterm birth, maternal morbidity, and maternal mortality indicate a need to improve structures, quality of care, access to care, and systems to support women’s health.

MCHS will continue to foster collaboration with partners to increase capacity, synergy and impact of initiatives to improve women's health and healthcare delivery—including for mental and behavioral health.  Initiatives will include the HRMCCS Pilot, a maternal health and safety awareness campaign, the TexasAIM initiative, support of the work of the Texas Collaborative for Healthy Mothers and Babies (TCHMB), and other efforts. Strategic planning will continue to inform direction of women’s and maternal health programming, including a focus on the preconception, prenatal, postpartum and interconception periods.

MCHS will implement staff training, conduct a program self-assessment, and develop and implement a MCHS HTMB health equity action plan to improve programmatic culture to integrate an equity framework and reduce disparities among Texas MCH populations.

MCHS recognizes that the work of improving preconception, prenatal, postpartum and interconception health is shared with partners across DSHS and the HHS system, including those working in chronic disease prevention and behavioral health. As such, MCHS will continue to build and strengthen partnerships across and beyond the Health and Human Services (HHS) system to assess the landscape for women’s and maternal health initiatives and promote integration of women’s and maternal health into population based and health service programs.

DSHS will partner with Health and Human Services Commission to advance work described related to maternal substance use, perinatal mood and anxiety disorders, and maternal health care quality.

MCHS will continue to support population-based services and coalition- and partner-led activities throughout Texas’ regions to improve women’s and maternal health outcomes. 

MCHS will work with Healthy Texas Mothers and Babies (HTMB) Community Coalitions to align their focus on racial/ethnic disparities in birth outcomes and achieving women’s, maternal and infant health and birth equity. Coalition initiatives will be informed by ongoing community needs assessments and strategic planning. MCHS will work with HTMB Community Coalitions to develop locally relevant outreach and awareness campaigns to support their strategic objectives and align with the HTMB Framework.  HTMB Community Coalitions will work to assess opportunities for engaging Texas Historically Black Colleges and Universities (HBCUs) and other potential interested organizations and colleges with large Black student populations to expand and enhance the Preconception Peer Educators program (PPE) across the state. PPE is a national Office on Minority Health program focused on reducing infant mortality in Black communities. College-age women and men are trained to educate their peers and community members on the importance of preconception health, the impact of social determinants of health on their wellbeing, seeking regular preventive care and creating a reproductive life plan. 

MCHS will continue to work with a broad range of state and community partners to explore opportunities to expand preconception/interconception health and healthcare educational outreach efforts across DSHS and to promote integration of preconception health principles into stakeholder programming. 

MCHS will continue to promote the Texas Health Steps Online Provider Education (OPE) preconception, prenatal, and postpartum care health-focused continuing education modules. The modules are focused on equipping healthcare professionals with knowledge and resources to improve the health of Texas women before, during, and after pregnancy. The modules can be accessed at www.txhealthsteps.com. 

MCHS will continue to collaborate with CHW training programs to integrate women’s and maternal health and healthcare promotion into curricula. Promotion of healthcare provider education on women’s preventive health and healthcare will continue via DSHS Grand Rounds presentations and website resources. 

DSHS will continue to fund and coordinate with UT/TCHMB to support an Annual TCHMB Summit. The DSHS Life Course Conference has merged with the TCHMB Summit in order to increase capacity for TCHMB membership recruitment and retention while serving to engage, inform and educate health care professionals in support of improved and more equitable birth outcomes in Texas. 

Women with under- or unaddressed mental and/or behavioral health conditions prior to pregnancy are more likely to enter prenatal care late, experience pregnancy complications including preterm birth, low birth weight baby, and fetal demise. These outcomes are marked by racial and ethnic disparities. Additionally, the Texas Maternal Mortality and Morbidity Review Committee (MMMRC) has found mental and behavioral health issues contribute to severe maternal morbidity and pregnancy-related deaths in Texas. Both mental health and substance use are preconception health domains identified by the CDC as having important ramifications for birth outcomes. MCHS will continue to strengthen the HHS-system and other partnerships to identify opportunities for clinical- and population-based interventions supportive of improved mental and behavioral health among WCBA and perinatal mood and anxiety disorders, including through collaboration on a HHS Postpartum Depression Strategic Plan. MCHS will continue to look across existing programs—including quality improvement initiatives, awareness campaigns, lactation support center services, peer support programming, and coalitions—to integrate awareness and prevention strategies. MCHS will continue to use existing surveillance methods to assess mental health and substance use and disparities in WCBA. MCHS will support a TexasAIM Obstetric Care for Opioid Use Disorder Learning Collaborative as well as supportive activities at the state and regional levels to increase uptake of recommended practices for care of women with Opioid Use Disorder.

To inform MCHS maternal safety programming, MCHS will continue to assess and monitor maternal mortality and severe maternal morbidity rates through the analysis of surveillance data. MCHS will continue to provide coordination and support to the MMMRC. MCHS will continue to contract with the University of North Texas Health Science Center to assure capacity for timely and comprehensive case review by the MMMRC. MCHS will continue to support analysis of cases, trends in maternal death and severe maternal morbidity in Texas, and development of recommendations to improve women’s and maternal care practices that reduce risk and prevent maternal and feto-infant harm.

MCHS will continue to coordinate with and partner with the DSHS’ Vital Statistics Section (VSS), Center for Health Statistics (CHS), and other partners to identify opportunities to improve the availability and quality of data for identification and review of pregnancy-associated deaths. MCHS will continue to identify and leverage resources to expand its capacity for case preparation of pregnancy-associated deaths and to support continuous quality improvement for comprehensive and timely review of pregnancy-related deaths development of recommendations by the MMMRC, dissemination of MMMRC findings, and translation of MMMRC findings into action for improvements in maternal health and safety. This work will be bolstered through MCHS’ participation in the CDC ERASE MM grant. MCHS activities will continue to address the findings and recommendations from the MMMRC Legislative Reports.

MCHS is excited to continue work implementing the TexasAIM Initiative. In January 2018, Texas’ application to become an AIM state was accepted with DSHS as the lead coordinating body. MCHS has joined the Alliance for Innovation on Maternal Health (AIM) program to implement data driven AIM maternal safety bundles. AIM is a national partnership of providers, public health, and advocacy organizations that align national, state, and hospital efforts to improve maternal health and safety. With funding from the Health Resource Services Administration (HRSA), AIM provides resources for hospitals and state teams to implement evidence-based bundles into maternal care practice. MCHS has organized their state effort into the TexasAIM initiative. The initiative, in collaboration with state level partners, engages interested Texas hospitals, provider groups, and stakeholders statewide to use tools, resources, technical assistance, and quality improvement methods to institutionalize bundles of recommended practices in maternal safety and care. As of June 2020, 97 percent of birthing hospitals in Texas are enrolled in the program, with 83 percent of enrolled hospitals participating in the TexasAIM Plus program. This represents approximately 98 percent of births in the state of Texas and 10 percent of births in the US.

TexasAIM will continue to work with hospitals in FY21 to implement and sustain improvements related to the AIM Obstetric Hemorrhage bundle while also launching learning collaboratives to support implementation of the Severe Hypertension in Pregnancy bundle and the Obstetric Care for Women with Opioid Use Disorder bundle. MCHS will also provide TexasAIM programming to selected Texas birthing centers to pilot implementation of the AIM-Supported Obstetric Hemorrhage Bundle in an out-of-hospital birthing center setting. TexasAIM will continue work begun in FY2020 to support hospital obstetric services in responding to the COVID-19 pandemic. TexasAIM will intensify a focus on racial disparities and health equity in maternal health.  

MCHS will continue to participate in the National Network of Perinatal Quality Collaboratives (NNPQC). MCHS will learn from and share lessons learned with other states and state PQCs about building an effective PQC, implementing effective quality improvement initiatives, and identifying and using tools, training, and resources necessary to foster the sharing of best practices that support a sustainable PQC infrastructure.

MCHS will continue to fund and oversee facilitation and support services for Texas Collaborative for Healthy Mothers and Babies (TCHMB), the Texas Perinatal Quality Collaborative (PQC), through a contract with the UT Health Science Center at Tyler. TCHMB aims to implement initiatives that will improve quality of care and enhance women’s, perinatal, and infant health outcomes. Support will continue for development and implementation by TCHMB of evidence-informed QI projects. Currently, there are four TCHMB Committees including the Executive, Community Health, Neonatal, and Obstetrics and Data Committees.

MCHS will coordinate with the DSHS’ EMS-Trauma Systems Program, Regional Advisory Council Perinatal Care Regions (PCRs), and with other partners and stakeholders to identify opportunities to support uptake of recommended practices among hospitals to support their achievement of maternal and neonatal levels of care designation. DSHS Maternal and Child Health Epidemiology will continue to provide program support for risk-appropriate levels of maternal care by calculating maternal health outcome measures for ongoing program evaluation, monitoring, and re-designation of hospitals’ levels of care every three years by DSHS Consumer Protection.

MCHS will continue to leverage partnerships with community-based, professional and governmental organizations across the state and at a national level, including the HTMB Coalitions, TCHMB, the Texas Perinatal Advisory Council (PAC), the AIM, the NNPQC, the National Preconception Health and Health Care Initiative, and others to keep abreast of, promote and implement evidence-based practices that promote women’s and maternal health and safety. 

MCHS will continue to assess, build, and leverage partnerships to increase dissemination and implementation of recommended maternal and women's health best practices. In collaboration with partners, MCHS will continue to work to establish a strong Texas Perinatal Quality Improvement Network (TPQIN) to support quality improvement efforts in clinical and community settings related to women’s and maternal health. Key partners and stakeholders for a successful TPQIN include relevant state agencies and their advisory councils, membership associations and professional groups, public and consumer groups, regional and local health- and health-care structure, and academic institutions and centers (see Figure 1).

Figure 1 Texas Perinatal Quality Improvement Network Partners and Stakeholders (adapted from the CDC Perinatal Quality Collaborative Guide Working Group’s Resource Guide for States:

 Developing and Sustaining Perinatal Quality Collaboratives)

Figure 2 outlines steps to effectively develop, launch, and implement a statewide, large scale quality improvement initiative, including steps required for use of public health knowledge to select an appropriate quality improvement topic; mobilization of partners to successfully launch a large-scale quality improvement project; and consideration of elements needed to support effective implementation, sustainability, and impact of the initiative.

Figure 2 Key Steps in Launching a State Wide TPQIN Initiative. (adapted from the CDC Perinatal Quality Collaborative Guide Working Group’s Resource Guide for States:

 Developing and Sustaining Perinatal Quality Collaboratives)

[1] American College of Obstetricians and Gynecologists and the Society for Maternal–Fetal Medicine, Kilpatrick, S. K., & Ecker, J. L. (2016). Severe maternal morbidity: screening and review. American journal of obstetrics and gynecology, 215(3), B17–B22. https://doi.org/10.1016/j.ajog.2016.07.050

[2] DSHS. (2019). 2019 Healthy Texas Mothers and Babies Data Book. [Online]. Available:https://www.dshs.texas.gov/healthytexasbabies/data.aspx. [Accessed June 2020].

[3] Centers for Disease Control and Prevention (CDC), "Severe Maternal Morbidity in the United States," Last Reviewed January 31, 2020. [Online]. Available: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/severematernalmorbidity.html#anchor_trends. [Accessed June 2020].

[4] DSHS. (2019). 2019 Healthy Texas Mothers and Babies Data Book. [Online]. Available:https://www.dshs.texas.gov/healthytexasbabies/data.aspx. [Accessed June 2020].

[5] Fingar, K. R., Hambrick, M. M., Heslin, K. C., & Moore, J. E. (2006). Trends and Disparities in Delivery Hospitalizations Involving Severe Maternal Morbidity, 2006–2015: Statistical Brief #243. In Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Agency for Healthcare Research and Quality (US). Available: https://www.hcup-us.ahrq.gov/reports/statbriefs/sb243-Severe-Maternal-Morbidity-Delivery-Trends-Disparities.pdf. [Accessed June 2020].

[6]American College of Obstetricians and Gynecologists and the Society for Maternal–Fetal Medicine, Kilpatrick, S. K., & Ecker, J. L. (2016). Severe maternal morbidity: screening and review. American journal of obstetrics and gynecology, 215(3), B17–B22. https://doi.org/10.1016/j.ajog.2016.07.050