The Florida Department of Health (Department) will continue to prioritize the following needs of women/maternal health during the annual reporting year, as reflected in the State Action Plan Table: 

• Improve access to health care for women, specifically women who face significant barriers to better health, to improve preconception health (National Performance Measure [NPM] 1: Percent of women, ages 18 through 44, with a preventive medical visit in the past year). 
• Promote tobacco cessation to reduce adverse birth outcomes and secondhand smoke exposure to children (NPM 14.1: Percent of women who smoke during pregnancy). 
• Reduce maternal mortality and morbidity (NPM 14.1: Percent of women who smoke during pregnancy).

The Department will address NPM 1 through state and community partnerships to develop comprehensive systems of care for women and use data to inform program development and policy change. Partnerships between the Department and other state and community agencies such as Florida’s Medicaid agency; providers; home visiting programs including Healthy Start and the Maternal, Infant, and Early Childhood Home Visiting program; local health departments; and community health centers are critical to developing and advancing comprehensive preconception health efforts at the state and local level as well as the overall system of care for women.

The Department’s universal prenatal risk screen is administered by maternal health care providers. Its purpose is to identify women at risk for delivering a low birth weight or preterm infant, or other poor birth outcomes. Women identified at risk are referred to CONNECT (coordinated intake and referral), housed at Healthy Start Coalitions (Coalitions), for information and referral to one of Florida’s home visiting programs, as selected by the woman. Currently, the universal prenatal screening process is paper driven. The maternal health care provider completes prenatal screens for pregnant women seen in their clinic and collates the screens to provide to the county health department (CHD), most typically monthly. The screening information is then manually entered into the Department’s health management system (HMS) which generates an electronic referral to CONNECT. The Department will continue to develop an electronic system that will be accessible to pregnant women and health care providers for completion of the screen. The screening results will be submitted in “real time” to generate a referral to CONNECT. The Department anticipates an increase in the number of screens completed and a decrease in the amount of time between the identification of pregnant women at-risk to provision of services, resulting in healthier pregnancies and deliveries. An educational campaign to health care providers and pregnant women will be necessary to educate on the purpose of the screen, how to use the electronic system, and the benefits of home visiting services.  

The Department’s Maternal and Child Health (MCH) Section will contract with the 32 Coalitions, non-profit organizations, for Florida’s Healthy Start program. Coalitions establish private and public partnerships that include state and local government, community organizations, and MCH providers, for the provision of coordinated community-based prenatal and infant health care. Florida’s Heathy Start program serves pregnant women and infants from birth, up to age three, who score at-risk on the universal prenatal or infant risk screen. Self-referrals and referrals provided by health care providers and other agencies are also accepted. Healthy Start services, including interconception care, are supported by state general revenue funds and Title V MCH Block Grant funds. The priorities of Florida’s Healthy Start program are:

• Reduce the occurrence of infant deaths.
• Reduce the number of low birth weight and preterm births.
• Reduce the occurrence of maternal deaths.
• Improve infant and toddler developmental outcomes.

The Department provides oversight and monitoring of the following contracts to address maternal and child health priorities:

• The Family Healthline is a statewide, toll-free hotline offering counseling information and community referrals about pregnancy, infant and toddler issues. The goal of the hotline is to improve the health status of Florida's pregnant women and their children by providing callers with information on helpful community resources and answering basic questions about pregnancy, breastfeeding, childbirth education and other pregnancy-related concerns. The Family Health Line is available in English, Spanish, and Haitian Creole. The contract is funded with Title V MCH Block Grant funds, state general revenue, and other funding sources.
• The Ounce of Prevention Fund of Florida to identifies, funds, and evaluates innovative prevention programs for at-risk children and families. They also raise awareness of MCH initiatives such as safe sleep, Reach Out and Read, and Count the Kicks campaigns throughout the state, with a focus on television and radio advertisements. This contract is funded through state general revenue funds.
• The Florida Association of Healthy Start Coalitions implements the national Nurse Family Partnership Program model in 15 counties of Florida (Hillsborough, Orange, St. Lucie, Indian River, Martin, Citrus, Hernando, Lake, Sumter, Marion, Alachua, Dixie, Gilchrist, Levy, and Miami-Dade, respectively). This contract is funded through state general revenue funds.
• A Safe Haven for Newborns promotes the Safe Haven Law through a statewide outdoor advertising and community outreach campaign. This includes the use of materials that educate and inform the public about where to obtain support and the identification of safe venues for parents considering surrendering their infants. This contract is funded through state general revenue funds.
• The Florida Pregnancy Care Network implements the Florida Pregnancy Support Services Program. The program is a network of nonprofit pregnancy support centers that provide support and assistance to women, men, and their families primarily faced with unexpected pregnancies. Services include free pregnancy tests, peer counseling, and referrals. Most of the centers offer classes on pregnancy, childbirth, parenting, and personal finance management. The centers also provide certain non-medical material assistance. The program also has a call center that operates 24/7 to provide brief consultations and directly connect callers to services withing their community. Wellness services are also provided that include, but not limited to, smoking cessation counseling, sexually transmitted disease testing, blood pressure screenings, diabetes screenings, and pap smears. The program is governed through section 381.96, Florida Statues, and funded through state general revenue funds. Beginning in FY 23-24, the program is being expanded to serve parents/guardians of children who are adopted. Services are also being expanded to include nonmedical materials assistance (e.g., clothing, car seats, cribs, formula, and diapers), counseling or mentoring, education materials, classes regarding pregnancy, parenting, adoption, life skills, and employment readiness.

Through the Florida Healthy Babies program, Title V MCH Block Grant funds will be provided to all 67 CHDs to provide services to women. These services can include well-woman preventative health visits; prenatal care; education for chronic disease management and prevention for pregnant women; preconception health counseling; reproductive health services; and dental care services for pregnant women as well as children (with an emphasis on children up to age six). CHDs also engage in activities that promote access to care, health literacy, and community engagement and/or establishment of policies that positively influence the broad social, economic, cultural, and environmental factors that affect a woman’s health.

The Department is committed to helping Floridians reach their fullest health potential by living tobacco free lives through prioritization of NPM 14.1. The Department will promote the Tobacco Free Florida program to bring awareness to the dangers of tobacco, while also providing free resources that help tens of thousands of Floridians to quit and Tobacco Free Florida’s Quit Your Way, that offers 24 hours a day, seven days a week, telephone counseling in English, Spanish, and other languages through a translation service. Pregnant and post-partum tobacco users who are ready to quit will receive expanded services including 10 counseling sessions, and with a medical release, they may receive a four-week starter kit of nicotine replacement therapy. Florida’s Healthy Start program will provide the Smoking Cessation Reduction in Pregnancy Treatment (SCRIPT) curriculum, an evidence-based program for smoking cessation.

Tobacco users may access resources to help them quit through Florida’s Web Coach online service. Tobacco users can plan their quit date and even receive nicotine replacement therapy through the free online service. Tobacco Free Florida also offers group quit classes available in every county, both in-person and virtual.

The Tobacco Free Moms and Babies Collaborative brings together the Tobacco Free Florida, Women, Infants and Children (WIC), Healthy Start Coalitions, and the Area Health Education Center (AHEC) to educate on the free tools and services Tobacco Free Florida has to offer to help Floridians quit smoking. Tobacco Free Florida funds 29 counties to reach pregnant women and health care providers who serve pregnant women with cessation and referral information. Tobacco Free Florida has a suite of materials to educate this population on the dangers of smoking during pregnancy and the hazards of secondhand smoke exposure. Within the 2022 General Appropriations Act, Tobacco Free Florida was allocated $2,500,000.00 (Health Communications Interventions-Pregnant Women line item) to be used for the development of a campaign to reach pregnant and post-partum women, educate them on the dangers of smoking, and to encourage quitting. During Fiscal Year (FY) 2022-2023, through the statewide media and marketing campaign, Tobacco Free Florida developed a strategic marketing communications plan that will include print and digital marketing materials, paid media across various media channels, community outreach, and targeted health care provider outreach. The Department is also working on an incentive program to help increase cessation referrals by incentivizing those who sign up into a cessation program including but not limited to: Baby and Me Tobacco Free Program, TFF Phone Quit, Group Quit, individual services and/or Healthy Start SCRIPT program.

The Florida Perinatal Quality Collaborative (FPQC) was established in 2010 to improve Florida’s maternal and infant health outcomes through the delivery of high quality, evidence-based perinatal care. To achieve this goal, the FPQC consists of statewide partnerships with perinatal-related organizations, individuals, health professionals, advocates, policymakers, hospitals, and payers. These stakeholders have been working voluntarily in data-driven, population-based, QI processes focused on some of the most critical perinatal health issues in Florida. Led by a Steering Committee and a leadership team, the FPQC engages all its stakeholders to identify the priority perinatal QI issues and to determine which initiatives are appropriate, feasible, engaging, measurable and supportable. The Department contracts with the FPQC using funds from the Title V MCH Block Grant to implement QI initiatives in Florida birthing hospitals.  

Reducing maternal mortality and morbidity remains a high priority for the Department. House Bill 5, passed during the 2022 legislative session, requiring hospitals that provide birthing services to participate in a minimum of two FPQC initiatives at all times. The FPQC is working with the Department, the Agency for Health Care Administration (AHCA), and the Florida Hospital Association (FHA) to ensure hospitals are aware of this legislation and the process to enroll. The Department will maintain contracts with the FPQC to implement QI initiatives in Florida hospitals. To continue moving the needle forward in reducing primary cesarean deliveries, the Department and the FPQC will encourage sustainability strategies such as continued use of best-practice guidelines learned from the Promoting Primary Vaginal Deliveries Initiative that was implemented in Florida birthing hospitals. The Department and AHCA will continue to recognize hospitals that achieve the Healthy People 2030 goal of low-risk, primary C-section rates at or below 23.6 percent.  

The Department’s MCH Section will continue to collaborate with the FPQC in the effort to improve identification, clinical care, and coordination of treatment and support for pregnant women and their infants with any exposure to opioids. Hospitals will be given strategies for continued implementation of the best practice guidelines established by the FPQC. Strategies include the continuation of universal substance use disorder (SUD) screening for all pregnant women; the provision of naloxone to patients at risk of overdose; and continued education of hospital staff and providers. Hospitals will be encouraged to continue working with their local Coalition to assure referral networks remain current, as well as collaborate with community partners to ensure SUD screening occurs during pregnancy. Health care providers and hospitals will also be encouraged to participate in the Coordinated Opioid Recovery Network that was created to disrupt the opioid epidemic in several Florida counties.

The Department will collaborate with the FHA, AHCA, the Department of Children and Families, and the Florida Society of Health System Pharmacists to expand the free naloxone program to hospitals that have high rates of overdose. Other ongoing efforts to improve screening and access to care for women in the perinatal period include efforts to update the Department’s HMS at CHDs to enable universal screening for SUDs at intake for women visiting CHDs for services (i.e., prenatal care, WIC, family planning, and HIV clinics). That work is in the exploratory stage and will be implemented in a pilot during the application year. If successful, the goal is to expand to CHDs across the state.

The Department will continue implementation of the Perinatal Mental Health grant received from Health Resources and Services Administration (HRSA) in collaboration with the Florida State University College of Medicine and Florida Maternal Mental Health Collaborative. The initiative, Improving Maternal and Pediatric Access, Care and Treatment for Behavioral Health (BH IMPACT), provides:

• Access for patients and clinicians to comprehensive referral resources and services in the region for mental health and substance use.
• Clinician access to telephone consultation with a psychiatrist during normal business hours.
• The use of brief, valid screening tools for depression, anxiety, and substance use.
• Tracking and reporting of information and measures related to the programs processes and outcomes.
• Training of Obstetric providers in best practice maternal behavioral health screening, treatment, and risk issues.

Based on the successful establishment of the program, the Florida BH IMPACT program is poised for statewide expansion and program enhancement which includes:

• Statewide implementation of psychiatric consultation for obstetrics and behavioral health providers.
• Expansion of program enrollment access to all prenatal care points-of-contact including midwives, doulas, CHDs, and statewide community agencies that encounter pregnant and postpartum women.
• Training for home visitors on substance use interventions to increase the capacity of home visitors on substance use interventions.
• Enhancements to the statewide resource directory to include substance use, social, and other medical care services, enhanced monitoring, and analytics of the directory for continuous quality improvement.
• Promotion of Florida’s toll-free Family Health line that provides perinatal mental health information.
• Increase capacity to collect data from enrolled obstetrics sites to include information for electronic medical records related to mental health and substance use screening results; documentation of substance use or mental health diagnoses, treatments, referrals; labor, delivery, and birth complications, as well as infant outcomes such as NICU admission and outcomes.
• Expand ability to collect advanced analytics from web-based resources, including the statewide behavioral health resource directory. This will allow tracking, reporting, and enhancing the reach of the database. 
• Enhance ability to track and evaluate the outcomes of provider trainings. 

The Department will promote the National Maternal Mental Health Hotline that provides 24/7, free, confidential support before, during, and after pregnancy; and the materials developed by the HRSA. The hotline offers callers:

• Phone or text access to professional counselors.
• Real-time support and information.
• Response within a few minutes, 24 hours a day, 7 days a week.
• Resources.
• Referrals to local and telehealth providers and support groups.
• Culturally sensitive support.
• Counselors who speak English and Spanish.
• Interpreter services in 60 languages.

The Department will continue to use Title V funding for four regional part-time nurse abstractors, an epidemiology staff person for data analysis, and additional staff as needed to support the statewide Florida Maternal Mortality Review Committee (Florida MMRC). Reduction and prevention of maternal deaths is a national and state priority. The Florida MMRC is an ongoing system that collects and analyzes information related to maternal deaths to promote system improvements through evidence-based actions aimed at preventing future untimely deaths. The multi-disciplinary Florida MMRC meets quarterly to review cases of maternal mortality and identify issues and make recommendations for improvements in care at the individual, provider, and community levels. Actions of the committee include reports covering multiple years of review, which are beneficial for evaluating trends and proposing recommendations for change. In addition to monitoring annual data and trends, select topics are chosen for further analysis to obtain a more complete understanding of a particular issue or condition and promote the development of targeted actions that may prevent future deaths. The Florida MMRC will continue to promote and develop timely messages and action items to support initiatives related to preventing maternal deaths in Florida. The Department will develop briefs and reports based on Florida MMRC findings to distribute to professional organizations through the Florida MMRC representatives and post the messages on the Department website.

Funding from the Centers for Disease Control and Prevention’s Preventing Maternal Deaths: Supporting Maternal Mortality grant will continue to be used in the expansion of the scope of the Florida MMRC to include the review of mental health related causes of death. The Florida MMRC Mental Health Subcommittee will continue to review cases involving substance use and suicide in order to identify contributing factors and to make care improvement recommendations. The Department will continue to contract with a staffing agency for the necessary resources, nurse abstractors, social worker, and data analyst, needed for the Mental Health Subcommittee. The Florida MMRC will start to include informant interviews as part of the case review process. The purpose of the informant interview is to gain insight into factors related to potential bias or discrimination that may have contributed to the maternal death. The informant interview will give the Florida MMRC insight into the decedent’s life that is not available in medical records. This information will be used to identify opportunities to improve healthcare quality and systems of care. The Department will create a report based on the findings from the Mental Health Subcommittee and disseminate the report to the Florida MMRC members so they can share it with their affiliated organizations and peers.

The FPQC, in collaboration with the Department will continue the implementation of the Postpartum Access and Continuity of Care (PACC) QI initiative that aims to improve postpartum systems of care beginning at the time of discharge from a birthing facility. Findings from the Florida MMRC identified that the larger portion of maternal deaths occur after but within 60 days of discharge. The PACC Initiative seeks to improve maternal health through hospital-facilitated continuum of postpartum care by coordinating and providing respectful, timely, and risk-appropriate coordinated care and services. The PACC Initiative’s primary aim is by June 2024, participating hospitals will increase the percentage of patients with a two-week postpartum appointment scheduled prior to being discharged home, by 20 percent. A secondary aim is to increase patient postpartum education which includes the benefits of early postpartum appointments, warning signs, and birth spacing, by 20 percent. The FPQC will recommend and assist hospitals to develop a comprehensive process workflow for safe discharge including scheduling the early postpartum appointment or Post-Birth Health Check, that includes:

• Establishing a policy/standard operating procedure (SOP) to include a Maternal Discharge Risk Assessment to determine appropriate discharge timing and follow-up plan.
• Establishing a policy/SOP to perform the Postpartum Discharge Assessment to ensure all health parameters are within normal limits just prior to discharge.
• Establishing a policy/SOP to schedule a Post-Birth Health Check: a follow-up encounter within two weeks (may be needed sooner if high risk factors) prior to discharge from hospital.

The Department will collaborate with the FPQC to develop a QI initiative to address the broad social, economic, cultural, and environmental conditions that may affect birth outcomes. This new initiative will offer participating hospitals the opportunity to delve into data about their patients to discover unwanted variations, develop approaches to enhancing respectful maternity care, improve screening and linkage to resources for patients in need, and improve efforts at engaging families and community members in hospital QI. Core initiative components include standardization of care practices related to individualized screening; making appropriate referrals to support individualized needs prior to discharge; adopting appropriate and respectful care practices to best serve the identified needs in their communities; providing respectful maternity care training for providers and staff; educating patients on the importance of screening and respectful maternity care practices adopted by the hospital; developing and implementing the hospital’s written action plan; implementing a survey within hospitals; and developing a supportive environment that is respectful of each patient and their individualized needs.

The Florida MMRC has identified quality of health care as one of the major contributors to the rates of maternal mortality and morbidity in the state. To address this finding, the Department has started a Levels of Maternal Care (LOMC) verification pilot project for Florida hospitals. LOMC designations were developed at the national level to enable women to receive risk-appropriate maternal care, a key strategy to reduce maternal mortality and morbidity. The LOMC is a voluntary process that allows hospitals to self-designate as one of the four following designations:

• Level I - Basic Care: Care for low to moderate-risk pregnancies, demonstrating the ability to detect, stabilize, and initiate management of unanticipated maternal-fetal or neonatal problems that occur during the antepartum, intrapartum, or postpartum period until the patient can be transferred to a facility at which the specialty maternal care is available.
• Level II – Specialty Care: Level I, plus moderate to high-risk antepartum, intrapartum, and postpartum conditions.
• Level III – Subspeciality Care: Levels I and II, plus care for more complex maternal medical conditions, obstetric complications, and fetal conditions.
• Level IV – Regional Perinatal Health Care Centers: Levels I, II, III, plus on-site medical and surgical care of the most complex maternal conditions and critically ill pregnant women and fetuses throughout antepartum, intrapartum, and postpartum care.  

The Department will continue collaborative efforts with the FPQC and The Joint Commission to implement the LOMC verification pilot project. The FPQC will use funding from the Department to pay the initial site visit cost and first full year annual fee for any Florida maternity hospital willing to apply for and participate in the LOMC project; this will cover nearly half of the cost of a hospital’s three-year participation. The FPQC will complete a needs assessment to propose an implementation plan for future years.

With year three on the horizon, the University of Florida Gator MOMitor™ team is developing system expansion supported by the Title V MCH Block Grant. Expansion will include providing additional survey assessments for postpartum participants to identify and treat SUDs as well as adding a prenatal component. Prenatal participants will be screened for early diagnosis and surveillance of mood disorders, SUDs, hypertensive disorders, and gestational diabetes during pregnancy. In additional to recruiting another 500 postpartum participants in year 3, the team plans to also recruit 200 pregnant women for antenatal monitoring. The smartphone application will also be expanded to provide educational resources regarding mental health in the perinatal period through mental health resources within Gator MOMitor™ and statewide through BH IMPACT Maternal Mental Health Resource Directory.

The Department has numerous goals set forth for the improvement of maternal mortality outcomes through various projects, programs, and initiatives across Florida. These are each overseen in some way by a core group of personnel within the Maternal and Child Health Section. This leads the Department to recognize the need for strategic planning services related to the coordination, planning, development, and implementation of improvements to the maternal mortality system of care. The development of a project charter, strategic plan, and implementation plan will connect three key areas for maternal mortality, mission, vision, and achievement of goals.

Section 383.2163, Florida Statutes, required the Department to establish telehealth minority maternity care pilot programs in Duval and Orange counties. The purpose of the pilots is to use telehealth to expand the capacity for positive maternal health outcomes in racial and ethnic minority populations. During the 2023 Florida legislative session, the project was expanded to 18 additional counties with the highest ranking of severe maternal morbidity rates per 1,000 deliveries in hospitals for calendar year 2020. The additional counties include Miami-Dade, Hillsborough, Palm Beach, Broward, Pinellas, Polk, Pasco, Brevard, Volusia, Manatee, Sarasota, Collier, Escambia, Lake, Seminole, Leon, Marion, and Lee. Each county will have a coordinating program to use telehealth to assess the service needs and gaps of pregnant and postpartum women who were at high-risk for severe maternal morbidities. This includes screening and treatment of common pregnancy-related complications, including, but not limited to, anxiety, depression, substance use disorder, hemorrhage, infection, amniotic fluid embolism, thrombotic pulmonary or other embolism, hypertensive disorders relating to pregnancy, diabetes, cerebrovascular accidents, cardiomyopathy, and other cardiovascular conditions. Additionally, the programs used telehealth, or coordinated with prenatal home visiting programs, for the following services:

• Referrals to Healthy Start's coordinated intake and referral program to offer families prenatal home visiting services.
• Services and education addressing social determinants of health, including, but not limited to:
  • Housing placement options.
  • Transportation services or information on how to access such services.
  • Nutrition counseling.
  • Access to healthy foods.
  • Lactation support.
  • Lead abatement and other efforts to improve air and water quality.
  • Childcare options.
  • Car seat installation and training.
  • Wellness and stress management programs.
  • Coordination across safety net and social support services and programs.
  • Evidence-based health literacy and pregnancy, childbirth, and parenting education for women in the prenatal and postpartum periods.
  • Connection to support from doulas and other perinatal health workers.
  • Tools for prenatal women to conduct key components of maternal wellness checks (e.g., scales, blood pressure devices with verbal readers, blood glucose tests).

The Department received $12,663,856 in General Revenue Funds to implement the program in FY 23-24. Funds will support the telehealth services, an external evaluation, and data management system and dashboard.