I. Overview of Approach to Women/Maternal Health Domain

 

The health and well-being of women, infants, and children determine the health of the next generation. The effects of maternal mortality and morbidity are devastating for families, communities and society as a whole. Further complicating circumstances are the racial disparities surrounding maternal mortality and morbidity. African American women are significantly more likely than white women to die or suffer from pregnancy complications. The Bureau of Family Health (BFH) offers programming around, and is committed to reducing, this disparity in an effort to achieve health equity among all women for a healthier Pennsylvania (PA).

   

The BFH identified program areas that address the new BFH priority on reducing maternal morbidity and mortality. In addition to existing work, the BFH is incorporating additional programming around community-based maternal care models, such as doula services, and models of care that promote male involvement and father engagement into its action plan. BFH staff are also exploring what medical services home visitors can provide to women in the prenatal and early postpartum periods, in hopes of reducing maternal morbidity and mortality in PA.

 

II. Other Federal Funding and State-Funded Activities/Future Efforts

 

The BFH conducts activities in the Women/Maternal Health domain through Title V funding only and does not have additional federal or state funding to support these services. Taking into consideration the overall population needs and current partners, the BFH has developed strategies that do not duplicate those of other funding sources outside of the BFH, and that fill gaps that are not addressed by the existing system of care and current partners. Through this effort, staff identified initiatives aimed at improving maternal health outcomes, including the: Title V MCHSBG, MMRC, Special Supplemental Nutrition Program for Women, Infants and Children (WIC), Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM), PRAMS, and COVID-19 Health Equity Response Team sponsored by the DOH; MOMD, Value-Based Payment Model/Maternity Care Bundle, Plans of Safe Care, and Opioid Use Disorder Centers of Excellence sponsored by the Department of Human Services; Pregnant Women and Women with Children Inpatient Non-Hospital Programs and Pregnant Support Services Grant sponsored by the Department of Drug and Alcohol Programs; Pennsylvania Perinatal Quality Collaborative (PQC) and Doula Services Workgroup sponsored by the Jewish Healthcare Foundation; and Pritzker Children’s Initiative sponsored by the Pennsylvania Partnerships for Children. To better coordinate the various maternal health initiatives, the DOH is exploring whether there is a need for a Maternal Health Task Force to function as the convener of maternal health work across the Commonwealth. If deemed necessary, the task force will be responsible for assessing and evaluating the current work, identifying gaps, identifying emerging needs and providing recommendations to address maternal mortality and morbidity.

 

III. Priorities

 

Priority: Reduce or improve maternal morbidity and mortality, especially where

there is inequity

 

NPM 1: Percent of women, ages 18 through 44, with a preventive medical visit in the past year

 

Strategy: Increase the percent of women who successfully complete evidence-based or informed home visiting programs 

 

Objective: Increase the percent of women who successfully complete an evidence-based or informed home visiting program by 2% each year

ESM: Percent of women who successfully complete evidence-based or informed home visiting programs

Home visiting can have positive effects on women, infants, children and children with special health care needs (CSHCN) as well as on the family as a whole. Home visiting programs support families by providing health check-ups, screenings, referrals, parenting advice, and guidance in navigating other programs and services in their community. Additionally, home visiting programs monitor progress on children’s developmental milestones and help parents to provide a safe and supportive environment for their children to grow. This support and education aim to improve the overall health and well-being of the families served, improve birth outcomes and increase birth spacing.

 

The County Municipal Health Departments (CMHD) offer home visiting services to women, infants, children and CSHCN. CMHD home visiting programs have the flexibility to utilize the program that best fits the population being served. Due to PA’s diverse population, what works in one location may not be appropriate or practical in another. Evidence-based models such as Nurse Family Partnership, Parents as Teachers and Healthy Families America are used in some areas. Other areas utilize evidence-informed curriculums such as Partners for a Healthy Baby or Bright Futures. All provide both clinical and social services to the families they support. The flexibility inherent in these home visiting programs facilitate participation from those who would not otherwise be eligible for alternate home visiting programs. CMHD home visiting programs deliver necessary services to women who have had repeat pregnancies or delayed enrollment in a home visiting program. Ideally, home visitors connect with women in the prenatal period; however, not all women seek assistance during this time. Many CMHD home visiting programs allow women to obtain services up to a year after the birth of their child. This enables home visitors to develop a relationship with and begin supporting the family as well as provide assistance in acquiring needed services.

 

The CMHD home visiting programs aim to support women in the prenatal and postpartum period who may not be eligible for traditional home visiting programming. The BFH is choosing to measure the percent of women who complete home visiting programs to assess the impact on families served. By increasing the percentage of women who successfully complete these home visiting programs, the BFH aims to help women address risk factors that may be associated with severe morbidity and mortality such as co-morbidities and receipt of care in the postpartum period. Additionally, an important component of home-visiting is connecting the client to needed services including preventive care. While access to health care is only one factor contributing to a woman’s health, women with the highest rates of severe maternal morbidity and mortality are also among the women who are less likely to receive preventive care. As such, this strategy aligns with the new priority and may drive improvement in the National Performance Measure (NPM). In the coming year the BFH will continue to partner with the CMHD to provide home visiting services to the Title V population.

 

Strategy: Increase the percent of adolescents and women enrolled in centering pregnancy programs who talk with a health care professional about birth spacing or birth control methods

 

Objective: Annually increase the percent of adolescents and women who talked with a health care professional about birth spacing or birth control methods by 1%

 

ESM: Percent of adolescents and women enrolled in Centering Pregnancy Programs who talked with a health care professional about birth spacing and birth control methods

 

Centering Pregnancy is a patient-centered model of group prenatal care. The curriculum offers the flexibility and time to engage in conversations around important health topics dependent on the needs of the group, which can lead to a greater engagement in one’s pregnancy and overall health as well as a positive environment for learning. Quantitative studies have shown that women who receive prenatal care through the Centering Pregnancy Program (CPP) model have: a reduced number of low birthweight babies; a reduced number of preterm births; a higher number of prenatal visits; and increased breastfeeding rates compared to traditional prenatal care. The CPP curriculum covers birth control and birth spacing at numerous points throughout the pregnancy and postpartum periods to encourage women to actively participate in interconception care. Studies have shown that group prenatal care can positively influence women’s health outcomes after pregnancy and improve the utilization rate of preventive health services such as family planning. Additionally, evidence suggests that group prenatal care supports successful outcomes in pregnant women with substance use disorders (SUD), as it does for other vulnerable groups.

 

The BFH will continue its partnership with Lancaster General Hospital (LGH) to provide CPP in the next year. Additionally, the BFH will continue to assess the pilot program created specifically for women with SUD. This group follows the original CPP model with the addition of education focused on pain management without opioids, soothing techniques for babies diagnosed with neonatal abstinence syndrome (NAS), as well as other topics specific to this population. The opioid crisis has caused an immediate need for this group as the number of infants born exposed to substances continues to grow across the nation as well as in PA. Incidence of NAS in the United States has been increasing substantially since 2004. Recent reports suggest that incidence increased 433 percent from 1.5 per 1,000 live births in 2004 to 8.0 per 1,000 live births in 2014. According to the PA Department of Health’s Neonatal Abstinence Syndrome: 2018 Annual Report, among infants born in PA on or after January 10, 2018, through December 31, 2018, a total of 2,140 cases of NAS have been reported. Further, there were 67 cases of NAS in infants born at Lancaster County hospitals and birthing facilities. Sixty-one of those cases were to Lancaster County residents. SUD also negatively impact maternal health, putting pregnant women at risk for interpersonal violence and other unsafe situations, failure to obtain prenatal care, as well as apprehensiveness to seek help for SUD due to a fear of custody issues or legal consequences.

 

The BFH is preparing to announce a Request for Application (RFA) for existing CPP to provide additional services through the CPP model. Awarded applicants will have an established CPP with the intent to expand their program to accommodate the unmet needs of the communities they serve. These initiatives may include tailoring CPP groups to women with SUD or other populations in need of focused services or incorporating additional services - such as dental or behavioral health services - into their program.

 

Women enrolled in CPP have pre-established relationships with their providers that foster trust in the medical system and encourage future visits with healthcare professionals. These relationships help to increase both the number of women that seek care between pregnancies and the percent of women that talk to a healthcare professional about birth control and birth spacing. Therefore, the BFH has chosen to document and track the number of women who talk with a health care professional about birth spacing and birth control methods. This strategy may help to reduce maternal health risks and complications associated with unintended pregnancies and short birth spacing, thereby aiming to reduce the incidence of maternal mortality and morbidity.

 

Strategy: Implement care models that include preconception and interconception care

 

Objective: Increase the percent of women enrolled in IMPLICIT ICC program screened for risk factors during well-child visits by 1.5% each year

 

ESM: Percent of mothers served through the IMPLICIT ICC program that are screened for the 4 risk factors during a minimum of one well-child visit

 

Poor maternal health contributes to excess rates of preterm birth and infant mortality.

When women are provided with preconception interventions, or interconception care (ICC), they are more likely to enter pregnancy in optimal health. ICC is designed to identify and potentially modify risks to improve future birth outcomes and is recommended by the Centers for Disease Control and the Health Resources and Services Administration. Although some adverse outcomes of pregnancy cannot be prevented, optimizing a woman’s health before and between pregnancies can eliminate or reduce the risks of poor birth outcomes for both mother and infant. As women that receive interconception care tend to have healthier pregnancies and lower-risk births, this strategy may help lower rates of maternal morbidity and mortality among women that receive this care.

 

Since there is no widely accepted model for delivering ICC, the IMPLICIT Network developed and implemented an innovative, inter-professional, evidence-based approach to ICC. The BFH will work with the University of Pennsylvania and the IMPLICIT Network on the IMPLICIT ICC program. The ICC program works to change maternal behaviors and improve birth outcomes by screening women for four behavioral risk factors at well-child visits. The factors are: (1) smoking status, (2) depression, (3) contraception, and (4) multivitamin with folic acid use. Through continued implementation of this innovative model, the BFH seeks to identify whether women receiving screening and advice from a medical professional during their children’s well-visits will increase the likelihood that they will participate in regular and ongoing consultation with their own providers. At least 1,500 mothers will be screened during well-child visits each year as part of this initiative. A cohort of 700 women who give birth in 2020 will be followed for three years to evaluate the effectiveness of the ICC model of care. To date, maternal behavioral change after intervention for each of the four behavioral risk factors has been identified and continues to be tracked.

 

Strategy: Implement community-based, culturally relevant maternal care models

 

Objective: Increase the number of community-based doulas providing services in targeted neighborhoods

 

ESM: Number of community-based doulas trained in communities served by the program

 

Doulas are trained to provide non-clinical emotional, physical and informational support for people before, during, and after labor and birth. Doulas can facilitate positive communication between the birthing person and their care providers by helping people articulate their questions, preferences and values. Benefits to continuous labor support include a significant reduction in cesarean deliveries, shorter labors, reduced use of medication, lowered risk of birth trauma, improved birth outcomes, higher rates of breastfeeding initiation, and reduced risk of postpartum depression. Because these benefits are particularly important for those most at risk of poor outcomes, doula support has the potential to reduce health disparities and improve health equity. Unfortunately, doula care is often out of reach for high-risk women due to financial constraints and the limited availability of doulas in low-income communities.

 

Community-based doula programs include services tailored to the specific needs of the community they serve at no or very low cost. In addition to birthing support, community-based doulas usually offer prenatal and postpartum home visits, childbirth and breastfeeding education, and referrals for needed health or social services. Most community-based doulas are members of the community they serve, sharing the same background, culture, and/or language with their clients, and conduct their work with an understanding of intergenerational trauma, implicit bias, and maternal health disparities. Community-based doulas lead with the understanding that choice, access and informed, shared decision-making in pregnancy, childbirth, and reproductive care are central to improving outcomes. In addition, community-based doula programs are the only home visiting program models in the U.S. in which a home visitor is present at the birth.

 

The Philadelphia Department of Public Health (PDPH) has developed a Doula Support Program (DSP) aimed toward women with SUD. The program will utilize trained doulas and provide additional trainings to support the SUD population. Training topics include: trauma informed care and doula support; how to support women with SUD or opioid use disorder (OUD) throughout pregnancy, birth, and in the postpartum period; mandated reporting, and how to navigate the Department of Human Services (DHS) system and make referrals; NAS education; and harm and stigma reduction for women with SUD/OUD.

 

To address this need, community-based doulas are being trained in communities at high risk for maternal and infant morbidity and mortality. By connecting more high-risk women to doula support, the BFH aims to improve health outcomes for women and their babies. 

 

Strategy: Implement community-based, culturally relevant maternal care models

 

Objective: Increase the number of behavioral health providers trained in pregnancy intention assessment

 

ESM: Number of behavioral health providers trained in pregnancy intention assessment

 

Unhealthy birth outcomes, such as low birth weight and preterm birth, are influenced by many factors, including pregnancy intention. Studies indicate that unintended pregnancies are associated with adverse physical and mental health, economic and social outcomes; these impact women, their families and society. The unintended pregnancy rate for women with OUD, is 86 percent, compared to the national unintended pregnancy rate of 45 percent. Unfortunately, due to the rise of unintended pregnancies in women with OUD, the number of infants diagnosed with opioid-related neonatal abstinence syndrome after birth has also increased.

 

To address this need, behavioral health providers are being trained to assess pregnancy intention and contraceptive needs so that they may facilitate access to family planning services for women in SUD treatment facilities. The BFH formed partnerships with the Alliance of Pennsylvania Councils, INC. (Alliance) to address unintended pregnancy rates among individuals with OUD. Each of the three councils within the Alliance has implemented a pilot project to build linkages between family planning agencies and behavioral health and substance abuse treatment centers, leveraging the partnerships and experience to find the right fit for the communities served. In the next year, the Alliance will focus their efforts on continued development and implementation of their individual regional programs. Through this initiative, the BFH aims to reduce the incidence of unintended pregnancy and improve birth outcomes for women with SUD and their babies.

 

Strategy: Implement care models that include maternal behavioral health screenings and referral to services

 

Objective: Increase the percent of women enrolled in Title V home visiting, Centering Pregnancy, and IMPLICIT programs that are referred for behavioral health services by 1% annually, following a positive screening

 

ESM: Percent of women enrolled in home visiting, Centering Pregnancy and IMPLICIT programs that are referred for behavioral health services following a positive screening

 

Screening is an important tool to maximize the services provided to families. When used in the prenatal period, screening tools can identify the need for additional services and improve birth outcomes for both mother and infant. When used in the postpartum period, screening tools provide home visitors with the opportunity to assess women’s behavioral health status and provide referrals, as necessary, to improve health in the critical interconception period. They also present an opportunity to introduce, or to continue, a discussion about birth spacing and birth control methods. The BFH continues its work with the CMHD to ensure screening among pregnant and postpartum women for risk factors related to behavioral health.

 

Many of the CMHDs utilize the Institute for Health and Recovery’s Integrated 5Ps Screening Tool (5Ps) to screen women during home visits. Online trainings on the use of the 5Ps tool are available, if training is needed. This screening tool assists with the identification of women in need of support and referral for mental health services, SUD assessment and interpersonal violence (IPV) counseling.

 

Depression is a common complication during pregnancy and in the postpartum period, affecting nearly one in seven women, and has negative consequences for both mothers and infants. In the prenatal period, maternal depression has been associated with preterm birth, low birth weight and fetal growth restriction. In the postpartum period, maternal depression could result in issues with breastfeeding, difficulties in relationships or increased substance use. Screening for depression in both the prenatal and postpartum periods is necessary to identify women in need of services and to improve the health of women and their families. Some evidence suggests that although screening without follow-up care can have benefits, referral and treatment offer the most benefit. Moving forward, the CMHD will be required to utilize a validated screening tool to assess clients for depression. The CMHD will track the number of behavioral health services referrals made as a result of the positive screens.

 

Changing the picture of IPV necessitates recognizing all of its characteristics and focusing on changing attitudes, particularly among key population groups that experience higher rates of such violence. The BFH program assesses women for indicators of IPV and assists vulnerable individuals with resources to avoid being harmed in their relationships. Home visitors are in an ideal position to address IPV and begin a conversation with their clients. A simple conversation could save or improve the life and health of a woman or child by removing the stigma associated with violent relationships. Home visitors will continue to talk with clients about IPV and the impact it can have on a family if left unaddressed. Public health strategies that promote healthy behaviors in relationships are important in stopping the cycle of IPV. Moving forward, the CMHD will be required to utilize a validated screening tool to assess clients for IPV.

 

The BFH is working to increase the percent of women enrolled in Title V programs that are screened and referred for services, to ensure continuity of care and the best outcomes for women and their families.

 

Strategy: Implement care models that encourage women to receive care in the early postpartum period

 

Objective: Increase the percent of women that receive early postpartum care through a 4th trimester pilot program, compared to the year 1 baseline data, by at least 3% annually, starting with reporting year 2022

 

ESM: Percent of women who receive a maternal health assessment within 28 days of delivery through the 4th trimester pilot program

 

The “4th trimester” generally refers to the first 28 days postpartum. During this time, women experience significant biological, psychological, and social changes that may not be sufficiently addressed by the mainstream maternal health framework, which does not provide routine care for women until six weeks postpartum. Concerns regarding maternal mental health, contraception and birth spacing, physical recovery from childbirth, substance use, and other issues often go unrecognized in these early weeks. As a result, physical and behavioral health problems may go untreated and exacerbate one another, increasing the risks of maternal morbidity and mortality, particularly among women who are low-income, African American, or who have chronic medical conditions. In order to improve the health of all women, and reduce health disparities, health providers and systems are increasingly seeking to provide routine maternal health care during the 4th trimester.

 

In 2019, the IMPLICIT Network designed a new initiative to address maternal morbidity and mortality in the postpartum period. This project, called “4th Trimester,” is based on 2018 recommendations from the American College of Obstetricians and Gynecologists to address maternity care needs in the weeks and months following childbirth. Improved 4th Trimester care was also recognized as a high priority area by the National Institute of Child Health and Human Development in its strategic planning for 2020.

 

The IMPLICIT 4th Trimester initiative will allow providers to identify high-risk mothers, develop tailored care recommendations for families and increase the number of women receiving maternal health care within 28 days of delivery. Through this initiative, biomedical and psychosocial risk factors associated with maternal morbidity and mortality, such as cardiovascular health, mental health, substance use, and trauma, will be identified and addressed. Participating sites will provide counseling, interventions, or referrals for women that screen positive for one or more of the risk factor areas, within 28 days of delivery. Through this initiative, the BFH seeks to decrease rates of maternal morbidity and mortality in the early postpartum period. As such, this strategy aims to directly address the priority need and, if successful, could drive improvement for the NOMs on maternal morbidity and mortality. A minimum of 500 women annually are expected to be served by this project after the care model is implemented. Of these individuals, a cohort of 250 mothers that give birth from 2021-2022 will be followed in order to evaluate the effectiveness of the 4th Trimester model of care.

 

Strategy: Use Maternal Mortality Review Committee (MMRC) recommendations to inform programming

 

Objective: Implement a minimum of 1 MMRC recommendation annually

 

ESM: Number of MMRC recommendations implemented

 

During this grant cycle the BFH will continue to participate on the Maternal Mortality Review Committee (MMRC), reviewing maternal death cases and assisting in developing and implementing recommendations regarding the prevention of maternal deaths in PA. The MMRC is made up of a diverse group of professionals in an attempt to take into consideration each aspect of a woman’s life and death, with a focus on social determinants of health, when possible. The MMRC continues to review cases and, once a full year of cases has been reviewed, the MMRC will recommend action steps to reduce PA’s maternal mortality rate. BFH will aim to implement a minimum of one of these recommendations annually.

 

Strategy: Initiate regular meetings and collaboration between DOH, DHS, and MIECHV

 

Objective: Convene quarterly meetings between agencies that provide services related to maternal health

 

ESM: Number of meetings held between the DOH, DHS and MIECHV annually

 

Effective collaboration and coordination are important to create a high-quality system of support for women, mothers and families in PA. Collaboration can increase service utilization through effective referral processes. Further, agencies that communicate with one another and share information are able to provide their service recipients with consistent messaging. As a result, families may be less overwhelmed by information and they will not be faced with competing demands by multiple agencies. Consistent messaging may also increase utilization of services due to destigmatizing the receipt of those services. Additionally, collaboration across sectors, agencies and programs ensures better-coordinated services and facilitates the creation of shared care plans, identification of individuals and families for targeted outreach and development of cross-sector plans for improving health outcomes. Cross-collaboration also provides public health programs and professionals with an opportunity to address critical social determinants of health, including education, environment, lifestyle, and socioeconomic factors, thereby providing more holistic services to PA residents. As mentioned in the report narrative, in 2019 the PA Medicaid Program expanded home visiting services for first-time and at-risk mothers. With this expansion, it is beneficial to Title V programming to stay up to date on changes to ensure BFH continues to fill gaps not met by existing programming.

 

In the next year, the BFH will organize quarterly meetings with the Department of Health (DOH), DHS, and the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program in order to promote collaboration and better serve PA residents.