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 Workgroup (RJW), 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 2021-22 activities will focus on conducting statewide focus groups with women who have experienced disrespect and abuse during their pregnancy, partners, and doulas, as well as in-depth interviews with staff working in medical settings (e.g., prenatal care sites, hospitals) who have contact with pregnant and postpartum women.

The RJW will explore and expand upon Columbia’s central research questions, a) how do women describe their experiences of mistreatment or disrespect during facility-based childbirth, and b) what are the individual, institutional, structural, and policy drivers of the treatment that women experience as disrespectful? Our focus will include prenatal care experiences as well as childbirth and immediate postpartum care. The purpose of replicating these focus groups is to: 

• Provide specific documentation and examples for CT, which may or may not vary somewhat by region, health system, provider type, or other factors; 
• Provide us with a baseline before/at time work is beginning so we can later evaluate if we’ve made an impact;
• Identify specific ways in which providers & all other facility staff, administration, health systems, and others can act and be held accountable for improvement; and
• Inform a potential CT PRAMS survey supplement in the future. 

The RJW will be working on expanding statewide efforts and developing recommendations and standards for respectful care during pre/interconception time frames as well as prenatally, during childbirth and during the postpartum period. The workgroup will focus on policy, delivery systems, advocacy, training, and public information. Through data collection and Results Based Accountability the Workgroup will report out on the impact of our efforts, which will inform our recommendations.

Internal work within EWCT will focus on updating the OKQ manual to include new data on pre and inter-conception care outcomes in Connecticut as well as exploring opportunities to build out One Key Question to become more inclusive of all persons of childbearing age. EWCT has established relationships with the Director of Real Dads Forever and the Office of Early Childhood. We 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 served with the goal of becoming all-inclusive regardless of gender, sex, or orientation.

EWCT will also be holding a One key Question training conducted by EWCT Co-Charis and a human sexuality and reproductive health trainings by Planned Parenthood of Southern New England in the second half of 2021. These trainings will be open to the community.

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

• The Women’s Services Practice Improvement Collaborative (WSPIC)

WSPIC is co-sponsored by the Department of Mental Health and Addiction Services (DMHAS) and the CT Women’s Consortium. Collaborative members are the Department’s treatment programs for women. WSPIC is a conduit for a rapid response by EWCT to needs identified WSPIC members.

• 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, COVID-19 Outreach and efforts to eliminate racism

This on-going outreach effort is collecting information about the impact on COVID-19 on underserved communities to help center health equity in Connecticut’s response and recovery efforts.

Health Equity Solutions was the lead advocate for passage SB1: An Act Equalizing Comprehensive Access to Mental, Behavioral and Physical Health Care in Response to The Pandemic. Sections of this bill: requires hospitals to offer implicit bias training for people who provide direct care during pregnancy and the postpartum period; requires the maternal mortality review committee to annually report to the Public Health Committee with recommendations on eliminating disparities in maternal health; and defines “culturally humility” and requires the Office of Higher Education to evaluate recruitment and retention of people of color in health care programs and make recommendations. EWCT will work with Health Equity Solutions and other partners in doing administrative advocating for the implementation of this legislation in the spirit it is intended.

• CSTAR (formerly known as the ACES Task Force)

This Task Force was convened by the CT Women’s Consortium and Bridgeport Prospers, a national STRIVE Initiative, to support efforts to address racism in trauma.

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.

Participation in WSPIC strengthens EWCT relationship with DMHAS, which includes the Department offering, for the past three years, EWCT-sponsored workshops on OKQ/human sexuality/reproductive health and on implicit bias as well as creating an on-line OKQ training module.

• CT 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.

• The Mom and Baby Action Network(M-BAN), an initiative of the March of Dimes

EWCT is also partnering on a national level with M-BAN, which is building cross-sector partnerships to address the root causes of inequities in maternal and infant health. This relationship provides access to national leaders in the field and opportunities to participate in the M-BAN workgroups, webinars, conferences, and legislative advocacy on the national level. M-BAN also provides EWCT and other CT efforts national visibility.

EWCT’s newly designed user-friendly website will supplement EWCTLC efforts 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 the proportion of Connecticut women who deliver a live birth and report discussing pre-/inter-conception health with a healthcare worker.

In a continued effort to support implementers of OKQ, EWCT will be conducting a survey of the EWCTLC on their current implementation efforts of One Key Question, identifying strengths and areas of need, and potential implementation opportunities moving forward.

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 be offered virtually until it is safe to resume in person meetings.

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 250FPL 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. 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.

The Personal Responsibility Education Program (PREP), funded by the Administration on Children and Families, Family and Youth Services Bureau, will continue to deliver evidence-based programming to high-risk youth in Bridgeport middle and high schools, East Hartford high schools. CREC alternative high schools, and in community-based and residential programs serving youth with child welfare involvement. The New London school district was recruited during COVID and the program will be delivered this school year by health teachers. The Be Proud! Be Responsible! and Reducing the Risk programs will be delivered to high school youth in the health class, as well as community youth, and Making Proud Choices will be delivered to middle school youth. In the late Spring of 2020, due to COVID-19, the CT PREP program developed virtual programming and trained facilitators in the delivery. This year the plan is to resume in-person education, but COVID data and Governor mandates will determine the need to revert to virtual learning. Entry and exit surveys will be collected from all participants and will be used to evaluate behavior change and reduction in risk-taking behavior.

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, 71 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. Data collection for the 2020 surveillance year ended in June 2021 and we received our weighted data by mid-July since we were the first state weighted this year. We not only achieved our highest weighted response rate ever (63.2%), but response rates among all strata (including lower responding groups) also increased. The 2020 data includes COVID-19 supplement data that we will analyze and disseminate to our statewide partners. These supplemental questions were an effort to begin collecting population-based data on how the lives of mothers were being impacted by COVID-19 infection and the COVID-19 pandemic. PRAMS data will complement other CDC COVID-19 surveillance efforts by filling gaps in data, including measuring the proportion of women and/or someone in their household infected with COVID-19 during their pregnancy, and also examining interactions with health care providers in person and by telemedicine, barriers to seeking or getting care (prenatal, postpartum and well-baby visits), precautions taken and other experiences related to COVID-19 exposure/infection, hospital experiences during labor and delivery and postpartum, and economic/emotional hardship. We will also be able to divide women into groups that were not at all affected, somewhat affected, or greatly affected by the societal effects of the pandemic. Taken in conjunction with the rich information that PRAMS already gathers on the lives of women around pregnancy, we may be able to quantify the degree of disruption across many different life domains. For example, are planning on looking at outcomes and health care usage in 2019 vs. 2020. We anticipate potentially seeing an increase in the frequency of maternal anxiety and depression as well as interpersonal violence based on anecdotal reports from our statewide partners who serve pregnant and postpartum women. We’ll also examine if there are changes in usage and timing of prenatal care, dental care (which is already a challenge to get people to go because of the misconception it is not safe during pregnancy), postpartum visits, postpartum contraceptive use, and more.

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. Internal partners from the Tobacco Control Program and Office of Injury Prevention had had a conference call in May 2021 with a national consultant hired to assist the Governor’s Office with the legalization process in CT. PRAMS was one of three key data sources identified by the contractor for cannabis surveillance. Subsequently, internal partners convened a meeting to discuss existing data (if available) and how data can be collected moving forward. PRAMS staff have been in discussions with their CDC PRAMS Project Manager and other PRAMS states who are collecting or have collected data on perinatal marijuana use to help identify the best approach for moving forward. Data collected as part of opioid survey supplement in 2019 can provide an initial baseline estimate for marijuana use during pregnancy as there was one question asking about a variety of substances used during pregnancy. CT PRAMS is in the process of finalizing questions for a survey supplement around 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 will be implemented beginning in Fall 2021 and will continue through the end of the 2022 surveillance year. In 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 also anticipate adding a social determinants of health (SDOH) survey supplement. Currently, it’s estimated that this questionnaire will be available from CDC and ready for implementation in October 2021. We plan on implementing both the marijuana and SDOH supplements at the same time to minimize disruptions to operations and maximize efficiency as new survey booklets will need to be printed.

Work on the Phase 9 survey has begun at CDC and CT PRAMS staff have already contributed input, including convening an ad hoc New England PRAMS meeting to discuss what we may want to recommend for changes, as well as the possibility of including one or more questions as a region to look at common areas of interest. The group expressed interest in continuing to meet and the CT PRAMS Director/SSDI Coordinator will serve as the informal convener of the group. As decisions about the Phase 9 Core survey continue at the federal level, CT PRAMS has already begun looking at what changes it might want to make for the other portions of the survey (Standard and state-developed questions). Work on survey content with internal and external partners to ensure Title V MCH data needs are met to the best of our ability will continue into the upcoming year. The Phase 9 survey is currently slated for deployment with the 2023 surveillance year.

In 2021, the CT PRAMS Director along with key partners at Carey Consulting and the March of Dimes Connecticut Chapter formed a new Reproductive Justice Workgroup that had evolved out of a 2020 PRAMS Data to Action project around discrimination before and during pregnancy. The workgroup currently consists of 24 members including persons with lived experiences, local and State government agencies, and community organizations. In the upcoming year, activities will include conducting qualitative research in the form of community focus groups with women, partners and doulas, as well as in-depth interviews with staff working in medical settings (e.g., prenatal care sites, hospitals) who have contact with pregnant and postpartum women to measure experiences of disrespect and mistreatment while receiving these services. We are seeking to replicate this exploratory and formative research that was performed by Columbia University’s Averting Maternal Death and Disability (AMDD) project which supported birth justice efforts in NYC. We will explore and expand upon their central research questions, a) how do women describe their experiences of mistreatment or disrespect during facility-based childbirth, and b) what are the individual, institutional, structural, and policy drivers of the treatment that women experience as disrespectful? Our focus will include prenatal care experiences as well as childbirth and immediate postpartum care; in the future, we would like to expand our qualitative research into preconception and interconception care. The purpose of replicating this research is to:

1) Provide specific documentation and examples for CT, which may or may not vary somewhat by region, health system, provider type, or other factors;

2) Provide us with a baseline before/at time work is beginning so we can later evaluate if we’ve made an impact;

3) Identify specific ways in which providers and all other facility staff, administration, health systems, and others can act and be held accountable for improvement; and

4) Inform a CT PRAMS survey supplement in the future.

NYC PRAMS had also developed and implemented a birth justice survey supplement and they presented the results alongside Columbia’s research at a CDC PRAMS webinar in August 2020. Their supplement had explored a) how common is it for women to experience mistreatment or disrespect during childbirth, and b) if it is more common among some communities or some social/ethnic/racial groups than others. Because NYC PRAMS is in the process of refining their tool, we will connect with them in the future about the possibility of using their supplement in CT to further expand our data capacity around this critical area.

In addition to the qualitative research, the Reproductive Justice Workgroup will be working on expanding and unifying statewide efforts and developing recommendations and standards for respectful care with the intent to reduce maternal morbidity and mortality. The workgroup will focus on policy, delivery systems, advocacy, training, and public information.  Our partner at the March of Dimes also will be leading the group through data collection, monitoring and reporting on the impact of our efforts along the lines of RBA.

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 2020-2021, 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 17 wellness days across the state, reaching over 316 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 initiate addressing oral health workforce gaps in dental health professional shortage areas (DHPSAs) and other underserved areas in Connecticut and coordinating a continuum of oral health education services for CT residents, with an emphasis on underserved populations. Community based prevention efforts continues with the 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 CT water operators and local health departments to comply with the current CT state water fluoridation statute. Activities will include a water fluoridation principles and practice training, maintaining optimally fluoridated water levels in public water systems, conducting a community water fluoridation aging equipment survey, and continuing to provide data to CDC.

The CT Dental Health Partners (CTDHP), the state’s Medicaid/CHIP 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 conduct the Every Smiles Counts (ESC) oral health surveillance survey for kindergarten and third graders students across the CT in the 2021-2022 academic year. Schools are selected randomly to capture a cross section of state demographics. In-person screening will be conducted with a goal to screen 8,000 students.

The OOH will continue to implement the Medical-Dental Integration Pilot (MDIP) at five of the Community Health Center, Inc, federally qualified health centers.

Pilot efforts to screen for risk factors for childhood obesity and dental caries through nutritional screening, counseling, referral, and care coordination will continue between medical and dental staff. Evaluative tools continue to be utilized at all levels of the pilot. The MDIP Advisory, established in 2021 will meet quarterly to provide guidance and establish best practices. Train the trainer model will continue to be applied for increased sustainability.

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