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. 
• Promote tobacco cessation to reduce adverse birth outcomes and secondhand smoke exposure to children. 
• Reduce maternal mortality and morbidity. 

The Department will address National Performance Measure (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 MIECHV 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 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, for information and referral to one of Florida’s home visiting programs, as selected by the woman. Currently, the 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, most typically monthly. The screening information is then manually entered into the Department’s health management system 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 into services, resulting a heather pregnancies and deliveries. An educational campaign to health care providers and pregnant women will be necessary to educate on the purpose of the screen, the process for completion in the electronic system, and the benefits of home visiting services.  

The Department’s MCH Section will contract with the 32 non-profit community agencies, known as Healthy Start Coalitions (Coalitions), 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 (ICC), 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.
• Recue the occurrence of maternal deaths.
• Improve infant and toddler developmental outcomes.

The Department will continue to work with contracted consultants (ISF, Inc.) to finalize the assessment of provider outcome performance objectives and ongoing quality improvement processes. Completing the assessment will allow the Department’s MCH Section to better measure and report the impact of Florida’s Healthy Start program. The project plan for the final phase will identify statewide, evidence-based curricula, reporting, and recommendations; identify consistent statewide outcome performance objectives that improve birth outcomes and reduce delays for Healthy Start clients; and reinforce the importance of ensuring the Department’s efforts and decision making are data driven and factually relevant.

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

• The Family Health Line 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 identify, fund, and evaluate innovative prevention programs for at-risk children and families and raise awareness of maternal and child health 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 to implement the Nurse Family Partnership Program in four counties of Florida (Brevard, Hillsborough, Orange, and Miami-Dade, respectively). This contract is funded through state general revenue funds.
• A Safe Haven for Newborns to promote 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 abandoning their infants. This contract is funded through state general revenue funds.
• The Florida Pregnancy Care Network to implement the Florida Pregnancy Support Services Program (FPSSP). The program is a network of nonprofit pregnancy support centers that provide support and assistance to women, men, and their families primarily faced with unplanned pregnancies. Services include free pregnancy tests, peer counseling, and referrals. Most of the centers offer classes on pregnancy, childbirth, parenting, and personal finance management. 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.

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 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 Florida residents 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 tobacco users who are ready to quit will receive expanded services including 10 counseling sessions, and with a medical release, they may receive a two-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 will 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. The telephone and online services also provide another feature to help tobacco users quit, Text2Quit. Text2Quit is a new digital service that texts positive messages to tobacco users before, during, and after they quit.

The Tobacco Free Moms and Babies Collaborative brings together the Tobacco Prevention and Cessation Program (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 the 2022-2023 fiscal, through the statewide media and marketing campaign, Tobacco Free Florida will develop a strategic marketing communications plan that will include the development of marketing materials, paid media across various media channels, community outreach, and targeted Healthcare Provider outreach (OB-GYNs and Pediatricians). 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.

Reducing maternal mortality and morbidity remains a high priority for the Department. The Florida Perinatal Quality Collaborative (FPQC) and the Department will continue sustainability efforts for the momentum of the Promoting Primary Vaginal Deliveries (PROVIDE) Initiative after it ends in June 2022. The goal of the PROVIDE Initiative is to improve maternal and newborn outcomes by applying evidence-based interventions to promote primary vaginal deliveries at Florida delivery hospitals and ultimately reduce NTSV cesareans. To continue moving the needle forward in reducing primary Cesarean deliveries, the Department and FPQC will encourage sustainability strategies such as continued use of best-practice guidelines in the PROVIDE Initiative toolkit; performing chart audits on NTSV Cesarean deliveries; tracking and publishing provider-specific Cesarean rates; and educating new hospital staff and providers. There are currently over 70 Florida birthing hospitals participating.

The Department’s MCH Section will continue to collaborate with the FPQC in the effort to promote sustainability of the Maternal Opioid Recovery Effort (MORE) Initiative. The goal of the MORE Initiative is 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 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 Healthy Start Coalition to assure referral networks remain current, as well as collaborate with community partners to ensure SUD screening occurs during pregnancy.

The Department will collaborate with the Florida Hospital Association, AHCA, DCF and the Florida Society of Health System Pharmacists to expand the free naloxone program to 25 more hospitals in 2022 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 Health Management System (HMS) at CHDs to enable universal screening for SUDs at intake for women visiting CHDs for services ranging from prenatal care to WIC to 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 it the CHDs across the state. The Department is planning to support a residency training model in the state that will be incorporate into curricula so that all obstetric residents learn to incorporate recommendations for treatment of women with OUD during pregnancy into their clinical practice. 

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, county health departments, and statewide community agencies that encounter pregnant and postpartum women.
• Training to home visitors on substance abuse 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 Family Health toll-free hotline that provides perinatal mental health information.
• Increase capacity to collect data from enrolled obstetrics sites to include information for the electronic medical record related to mental health and substance use screening results; documentation of substance uses or mental health diagnoses, treatments, referrals; labor, delivery and birth complications, as well as infant outcomes such as Neonatal Intensive Care Unit admission and outcomes.
• Expand ability to collect advanced analytics from web-based resources, especially the statewide behavioral health resource directory. This will allow for 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 of surveillance 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 throughout the year 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 and develop briefs 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 CDC Preventing Maternal Deaths: Supporting Maternal Mortality grant will be used to assist with the expansion of the current scope of the Florida MMRC to include mental health related causes of death. Contracted nurse medical records analysts will abstract cases of suicide and overdose related deaths. A contracted social worker will develop and oversee the process of obtaining informant interviews from family members and friends of the deceased mother. The social worker will also serve as a subject matter expert to enhance the inclusion of the social determinants of health into the case narrative and case review process as well as identify possible areas of bias and discrimination in the health care service delivery. A mental health subcommittee will review the abstracted cases quarterly to determine pregnancy relatedness, identify contributing factors, assess preventability, and create care improvement recommendations.

The FPQC, in collaboration with the Department and other partners from Agency for Health Care Administration, Alliance for innovation on Maternal Health, University of South Florida Health, The American College of Obstetricians and Gynecologists, AWHONN, American College of Nurse-Midwives, Florida Association of Healthy Start, Florida Society of Neonatologists, Florida Academy of Family Physicians, March of Dimes, Florida Blue, Florida Hospital Association, Preeclampsia Foundation, Florida Alliance for Healthcare Value is working on the development of a new initiative called Postpartum Access and Continuity of Care (PACC) to improve postpartum systems of care and interconception 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 and within 60 days of discharge. The project 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. This initiative will be offered across the state of Florida to all facilities that offer birthing services. Special attention is paid to the design of the evaluation component.

The Florida MMRC has identified quality of health care as one of the major contributors to high rates of maternal mortality and morbidity in the state. To address this finding, the Department is implementing Maternal Levels of Care designations in Florida hospitals during the application year. Maternal Levels of Care (MLC) 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 MLC 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 the Power of Mom campaign to promote maternal health and to raise awareness of the issues of maternal mortality and morbidity throughout the state. The campaign will include messages that promote optimal health in women of childbearing age, including preconception and postpartum health. The outreach activities and messages will be targeted to underserved communities as well as the general public and address racial disparities and other inequities that contribute to maternal mortality. Educational materials will be provided to partners across the state. Billboards and a Public Service announcement will also be a part of this campaign to bring public awareness to maternal mortality to a broader scale and to empower mothers and their support teams to listen to their bodies, speak up when something does not feel right, as well as to build a stronger collaborative relationship between a mom and her care team. A website will also be developed to assist moms and their support team by providing access to electronic versions of the developed educational materials for download and printing. It will also conveniently provide a single location of other resources available to Florida moms. The resources will highlight partners and programs across the state that aim to improve the health of moms and babies.

With year two on the horizon, the UF Gator MOMitor™ team is developing system expansion supported by the Title V MCH Block Grant. Expansion will include providing additional survey assessments for participants that are identified with cardiovascular disease and are lactating. They will provide portable pulse oximeters and scales to women diagnosed with cardiovascular disease to enable them to monitor for symptoms at home. The team plans to increase their participant goal from 400 to 500 postpartum women. Going forward, the team plans to utilize additional technologies to begin testing feasibility of use on a larger scale. This would allow the application to be used by other hospitals and health systems therefore, monitoring and assessing more women in this fragile population across the state of Florida.

Section 383.2163, Florida Statutes, requires the Department establish telehealth minority care pilot programs in Duval and Orange counties. The purpose of the pilots is to include the use of telehealth to expand the capacity for positive maternal health outcomes in racial and ethnic minority populations. Through a procurement process, the Department has identified an organization in each respective county to implement the project. Each pilot program uses telehealth to assess the needs of pregnant and postpartum women who are at high-risk for severe maternal morbidities (unintended outcomes of the process of labor and delivery that result in significant short-term or long-term consequences to a woman’s health). The pilot programs will link pregnant and postpartum women to social services and education, coordinate care, and provide for services not covered by insurance. The outcomes of the pilot programs will be evaluated to identify the results of the pregnant and postpartum women who participate. Recommendations will also be identified, including technology and costs, for potential regional and/or statewide implementation of the program.