I. Overview of Approach to Women/Maternal Health Domain

 

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

 

The BFH identified program areas that address the BFH priority to reduce maternal morbidity and mortality. In addition to existing work, the BFH is incorporating additional programming around community-based maternal care models, such as culturally concordant doula services for low-income birthing people. The BFH is also piloting a program to link birthing people with care in the early postpartum period, to reduce mortality rates for individuals in the year following childbirth. Finally, efforts related to the state’s Maternal Mortality Review Committee (MMRC) are ongoing and will increase capacity of the MMRC to make recommendations and for the BFH to implement those recommendations.

 

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

 

The BFH conducts activities in the Women/Maternal Health domain primarily through Title V funding and does not have additional state funding to support these services. However, in the budget for state fiscal year 2023, $2.3 million in state funds were allocated to expand existing maternal health programming and prevention strategies aimed at reducing Pa.’s maternal mortality rate. Other federal funds from the Centers for Disease Control and Prevention (CDC) are used to support the MMRC. Taking into consideration the overall population needs, 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), Pregnancy Risk Associated Monitoring System (PRAMS), and COVID-19 Health Equity Response Team sponsored by the Department of Health (DOH); Moving on Maternal Depression (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 (DHS); Pregnant Women and Women with Children Inpatient Non-Hospital Programs and Pregnant Support Services Grant sponsored by the Department of Drug and Alcohol Programs (DDAP); 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 (PPC). To better streamline the state’s diverse maternal health initiatives, the BFH participates in both intra-agency collaboration with internally administered programs such as PRAMS and interagency coordination with Departments with overlapping programmatic and/or population needs such as the DHS and the DDAP.

 

Additionally, the BFH, in partnership with the University of Pennsylvania, will use Title V funding to support a targeted evaluation of the March of Dimes Supportive Pregnancy Care group prenatal care and educational programming model as delivered to pregnant persons between 15 and 24 years of age in Philadelphia in a hybrid virtual and in-person format by the Children’s Hospital of Philadelphia. The evaluation findings will be used by the BFH to help strengthen and inform decision-making regarding adolescent and maternal health programming, specifically group prenatal care, and to serve as a prototype for evaluating other group prenatal health care models utilized by the DOH.  

 

III. Priorities

 

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

 

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

 

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

 

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

 

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

 

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

 

The County Municipal Health Departments (CMHD) offer home visiting services to pregnant and birthing people, 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 may not otherwise be eligible for alternate home visiting programs. CMHD home visiting programs deliver necessary services to birthing people who have had repeat pregnancies or delayed enrollment in a home visiting program. Ideally, home visitors connect with birthing people in the prenatal period; however, not all birthing people seek assistance during this time. Many CMHD home visiting programs allow birthing people to obtain services up to a year after the birth of their children. All these factors enable home visitors to develop a relationship with and begin supporting the family exactly where they are, assist in acquiring needed services, and improve the overall health and wellbeing of Pa. families.

 

The BFH is choosing to measure the percent of pregnant and birthing people who complete home visiting programs to assess the impact on families served. By increasing the percentage of pregnant and birthing people who successfully complete these home visiting programs, the BFH aims to help birthing people 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 programs is connecting people to needed services including preventive care. While access to health care is only one factor contributing to a pregnant or postpartum person’s health, birthing people with the highest rates of severe maternal morbidity and mortality are historically less likely to receive preventive care. As such, this strategy aligns with the 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. BFH staff will continue to assess whether Title V home visiting services should be a core service by continuing to work and meet with staff from DHS. DHS oversees the Medical Assistance (MA) Managed Care Organizations (MCOs), who are required to offer home visiting services to MA eligible first-time parents, parents/caregivers of children who have been identified as having additional risk factors, or to any infant and the infant’s parent/caregiver who requests these services as well as the evidence-based Maternal, Infant and Early Childhood Home Visiting Program (MIECHV). The CMHD HV program is very small in comparison to the MIECHV or MA HV programs. BFH staff is working to determine a way to transfer HV services from the CMHD to the Medicaid program, which many participants are a part of, as to not duplicate services. However, until the MA HV program is situated and understood by DHS, the MCOs and BFH, staff is hesitant to suspend these gap filling services. If BFH staff determines that Title V home visiting services are duplicative of the other available home visiting programs, a plan will be identified for each CMHD. Further, protocols will be established to ensure participants not covered by MA continue to receive home visiting services.

 

Strategy: Increase the percent of adolescents, women and birthing people enrolled in centering pregnancy programs who talk with a health care professional about birth spacing or 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; this can lead to a greater engagement in one’s pregnancy and overall health, as well as to a positive learning environment. Quantitative studies have shown that birthing people 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 birthing people to actively participate in interconception care. Studies have shown that group prenatal care can positively influence birthing people’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 people with substance use disorders (SUD), as it does for other groups with higher risk of poor health outcomes.

 

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

 

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

 

Albert Einstein Healthcare Network (AEHN) and WellSpan York will continue to offer expanded CPP to better accommodate the needs of the communities they serve. AEHN CPP focuses on providing behavioral health screenings, initial counseling, and making warm handoffs to behavioral health services as needed. A social worker functions as a patient navigator to connect CPP participants to the necessary resources including behavioral health services. WellSpan York will continue to help meet the needs of their community by providing a culturally and linguistically competent CPP to Spanish-speaking birthing people in York County. This group is led by a program coordinator, who is also a certified bilingual medical interpreter, with a Spanish speaking physician responsible for oversight of the CPP cohorts. This dynamic builds trust and helps facilitate productive discussions during the group sessions.

 

Pregnant and birthing people 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 birthing people that seek care between pregnancies and the percent of birthing people that talk to a healthcare professional about birth control and birth spacing. Therefore, the BFH has chosen to document and track the number of birthing people who speak with a health care professional about birth spacing and birth control methods. Since the service areas of the two CPP locations are limited, the total number of persons served by the CPP is small. Additionally, the programs are working to address a specific need in the communities where the programs reside.  These factors make it difficult to measure whether this strategy is addressing the disparities identified in the statewide data. However, the populations identified and served by AEHN and WellSpan York stand to benefit from the focused services provided. Barriers and access to care are considered when developing strategies to increase positive health and birth outcomes.  Transportation to and from medical appointments, culturally appropriate care, providing behavioral health screenings and warm referrals, including in-home therapy may positively impact the patients served by these programs.

 

Strategy: Implement care models that include preconception and interconception care

 

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

 

ESM: Percent of women and birthing people 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, and a healthy pregnancy begins long before conception. Preconception and interconception care improve the health of women and birthing people before and between pregnancies. When birthing people 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 CDC and Health Resources and Services Administration (HRSA). Although some adverse outcomes of pregnancy cannot be prevented, optimizing a birthing person’s health before and between pregnancies can reduce the risks of poor birth outcomes for both the birthing person and their infant.

 

Individuals who are impacted by mental health, substance use, and chronic health conditions, and who experience an unintended pregnancy, are at higher risk of experiencing adverse pregnancy outcomes. Studies indicate that unintended pregnancies are associated with adverse physical health, psychological, economic, and social outcomes, particularly for individuals with pre-existing behavioral and physical health concerns. Screening and intervention for family planning, depression, tobacco use, and multivitamin with folic acid use can address these risk factors prior to pregnancy. In addition, ICC that includes contraceptive counseling can reduce rates of unintended pregnancies.

 

As birthing people who receive ICC tend to have healthier pregnancies and lower-risk births, this strategy may help lower rates of maternal morbidity and mortality, particularly where there are disparities. ICC is particularly critical for Black/African American birthing people, who have the highest infant and maternal mortality rates of any racial group in the United States, including in Pa. Due largely to the nation’s history of racism and marginalization, Black/African American pregnant people are significantly more likely to have pre-existing health conditions than their white counterparts. The rate of maternal mortality is at least twice as high for non-Hispanic Black/African American birthing people than for non-Hispanic white birthing people. In addition, the rate of severe maternal morbidity is 2.3 times higher among Black/African American birthing people than among their white counterparts, affecting over 1,000 births per year in Pa. ICC has the capacity to reduce these persistent racial disparities in birth outcomes by reducing unintended pregnancies and by helping birthing people enter pregnancy in optimum health.

 

Despite broad consensus on the importance of ICC, this care is still not routinely provided, and there is not widely accepted, evidence-based model for delivering ICC. To help address this gap, the Interventions to Minimize Preterm and Low Birthweight Infants using Continuous Improvement Techniques (IMPLICIT) Network developed, piloted, and implemented a model for ICC in Pennsylvania in 2012.

 

The IMPLICIT Network is a multi-state, family medicine, maternal-child health learning collaborative focused on improving birth outcomes and promoting the health of women, birthing people, infants, and families through evidence-based interventions, innovative models of care, quality improvement, and professional development for current and future physicians. Through the IMPLICIT Network participating providers have the ability to establish evidence for ICC. It is also a forum for professional collaboration, development, and continuing education.

 

Often, due to lack of transportation, paid time off, or childcare, parents do not attend routine provider visits for themselves, but instead prioritize attendance at well-child visits (WCVs) for their infant or child. By offering biomedical, psychosocial, and behavioral interventions for risk factors prior to pregnancy the risk of adverse pregnancy outcomes, such as preterm birth, can be minimized. The IMPLICIT ICC model works to change maternal behaviors and improve birth outcomes by screening birthing people for four behavioral risk factors at their child’s WCVs: smoking status, depression, contraception, and multivitamin with folic acid use. Individuals with positive screens are provided with brief interventions or referrals. This model of care has been shown to effectively identify modifiable maternal risks and show maternal behavior change that are associated with improved health outcomes.

 

The IMPLICIT ICC model is adaptable to a variety of settings, including family medicine practices, pediatric care, health departments, community health centers, and public health programs. Because no two clinical sites are identical, each practice can tailor this innovative model to meet its needs and those of the population it serves. Providers may utilize this model even if they do not wish to participate in the IMPLICIT Network’s collaborative processes (such as data collection and quality improvement efforts).

 

The IMPLICIT Network has been working to advance principles of health equity within its programs and operations, to better address racial disparities in maternal health. Disaggregating data by race/ethnicity and meaningful community engagement are two priority areas of focus for the IMPLICIT Network in the coming year. The Network is actively building community partnerships, through partnership agreements, on the local, state, and national level, and is establishing a community advisory board to generate feedback and suggestions for improvement. In addition, the IMPLICIT Network will begin providing ICC program data regarding screening and intervention rates, disaggregated by race/ethnicity, in its regular reports. This will help the BFH to better understand how well this strategy is serving Black/African American birthing people and other priority populations during the interconception period.

 

In 2024, the IMPLICIT Network will continue to work with family medicine providers in Pa. to strengthen existing ICC programs and expand this model of care to new sites. Through continued implementation of the IMPLICIT ICC model of care at participating IMPLICIT Network sites, the BFH seeks to demonstrate that the model can effectively identify modifiable maternal risks and result in maternal behavior change that may lead to improved birth outcomes.

 

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

 

Objective: Increase the number of community-based doulas providing services in priority 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 due to historical marginalization, doula support has the potential to reduce health disparities and improve health equity. Unfortunately, culturally and racially concordant doula care is inaccessible for many pregnant people, due to financial constraints and the limited availability of doulas in communities where the majority of people live below the poverty threshold.

 

Community-based doula programs provide perinatal 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 inequities. 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.

 

If implemented with a focus on equitable access, community-based doula support can reduce persistent and pervasive racial disparities in maternal health outcomes. Within local communities, doulas often serve as trusted sources of information, advocacy and navigation throughout the perinatal period. By providing culturally concordant, continuous support and evidence-based information across the entire pregnancy, doulas can contribute to improved maternal and infant outcomes and experiences by reducing stress, anxiety, and pain, and by promoting self-efficacy and confidence. According to a U.S. Department of Health and Human Services Assistant Secretary for Planning and Evaluation (ASPE) Issue Brief, individuals’ labor and delivery that were supported by doula care had lower cesarean and preterm birth rates and improved rates of breastfeeding initiation. By supporting clients in advocating for their personal care preferences, doulas can help reduce the detrimental effects of racism and implicit bias and prevent unwarranted and undesired clinical interventions.

 

In addition to improving clinical care practices, community-based doulas can help address social determinants of health that impact maternal health, such as transportation issues, language and cultural gaps, food and housing insecurity, and maternal mental health conditions. Depending on the situation, doulas may provide screening, referral, and navigation assistance for necessary services. This may be particularly helpful for Black/African American women and birthing people, as generations of structural racism has resulted in inequities. The BFH is invested in helping to ensure that birthing people in Pa. have access to culturally and racially concordant doula care during the perinatal period. The BFH is interested in helping to grow the MCH workforce at the local level and increase access to sustainable employment opportunities for community-based doulas. As such, the BFH is supporting the development of community-based doula programs that are primarily focused on addressing racial maternal health disparities; increasing the number of community-based doulas that are certified through the Pennsylvania Certification Board; and providing community-based doula support to priority communities. By connecting more pregnant people with higher risk of poor birth outcomes to doula support, the BFH aims to improve health outcomes for birthing people and their babies.

 

Currently, the BFH supports two community-based doula program grants using Title V funds: one serving individuals affected by opioid use disorder (OUD), through the Philadelphia Department of Public Health (PDPH), and one providing doula care to individuals within the Healthy Start Pittsburgh service area.

 

The PDPH developed a Doula Support Program tailored to the needs of birthing people with SUD. The program uses trained doulas and provides additional trainings to support the SUD population. Training topics include trauma-informed care and doula support; how to support birthing people with SUD or opioid use disorder (OUD) throughout pregnancy, birth, and in the postpartum period; mandated reporting, and how to navigate the DHS’ systems and make referrals; NAS education; and harm and stigma reduction for birthing people with SUD/OUD.

 

Healthy Start Pittsburgh (Allegheny and Westmoreland counties) is implementing a community-based doula program in areas with high rates of racial disparities in preterm birth and infant mortality. The program is utilizing the HealthConnect One model. The BFH looks forward to working with Healthy Start over the coming year as they continue to implement this program.

 

Additionally, Delaware County Health Department (DCHD), which was established in 2022, intends to implement a doula program. DCHD will partner with established community-based doula programs to hire and train new doulas as well as provide doula services to the community. Doulas serving birthing people with SUD/OUD and mental health concerns will be given additional training on substance use, NAS, trauma‑informed care, and mental health. Montgomery County Health Department (MCHD) will continue to support the training of community-based doulas through a partnership with Maternity Care Coalition. MCHD’s Perinatal Periods of Risk (PPOR) study indicated that, to reduce infant mortality rates and increase birth equity, doulas are needed in communities to serve Black/African American and brown birthing people.  

 

The state has made significant strides in recent years to make quality doula care more accessible and affordable for all birthing people. Over the past few years, the Pennsylvania Doula Commission, PA Department of Human Services, and the Pennsylvania Certification Board (PCB) developed and began implementing a state-level Certified Perinatal Doula (CPD) credentialing process. In addition, the state has begun taking steps toward making doula services reimbursable under Pa.’s MA program, to provide a pathway for low-income individuals to access doula care, and for those doulas to receive compensation for their services. However, MA reimbursement will not begin until sufficient doulas have been certified by the PCB in all regions of the state. Unfortunately, there have not been concerted efforts to recruit, train, and certify community-based doulas, and, as a result, there are fewer than 10 doulas certified through the PCB.  

 

The BFH is invested in helping to grow the perinatal doula workforce throughout Pa. and helping to ensure that pregnant and birthing people – particularly those who identify as Black, Indigenous, and People of Color (BIPOC) -- have access to culturally and racially concordant doula care. The four community-based doula programs mentioned in this section are, by the nature of their limited-service areas, incapable of significantly impacting statewide rates of maternal mortality and related health disparities. The BFH is currently exploring ways to partner with community-based maternal health organizations throughout Pa. to train, certify, and mentor community-based doulas and increase public and provider awareness of both the doula credential and service.

 

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

 

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

 

ESM: Percent of women and birthing people 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 birthing person and infant. When used in the postpartum period, screening tools provide home visitors with the opportunity to assess birthing people’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 continue, a discussion about birth spacing and birth control methods. The BFH continues its work with Title V partners to ensure screening among pregnant and postpartum people for risk factors related to behavioral health.

 

Many of the CMHDs use the Institute for Health and Recovery’s Integrated 5Ps (parents, peers, partner, pregnancy, past) Screening Tool (5Ps) to screen pregnant, birthing, and postpartum people during home visits. Online trainings on the use of the 5Ps tool are available if training is needed. This screening tool assists with identifying pregnant, birthing, and postpartum people in need of support and referral for mental health services, SUD assessment, and intimate partner (IPV) counseling.

 

Depression is a common complication during pregnancy and in the postpartum period, affecting nearly one in seven birthing people, and has negative consequences for both birthing people and infants when untreated. In the prenatal period, maternal depression has been associated with preterm birth, low birthweight, and fetal growth restriction. In the postpartum period, maternal depression may result in issues with breastfeeding/chestfeeding, difficulties in relationships, or increased substance use. The risk of maternal depression is 1.6 times higher for Black/African American individuals than their white counterparts; unfortunately, mental health symptoms are often overlooked and under addressed among Black/African American pregnant and birthing people.

 

Screening for depression in both the prenatal and postpartum periods is necessary to identify birthing people in need of services and to improve the health of birthing people and their families. Some evidence suggests that although screening without follow-up care can have benefits, referral and treatment offer the most benefit. With the implementation of new grant agreements in 2023, the CMHDs are required to use a validated screening tool to screen participants for depression. The majority have chosen either the Edinburgh Depression Scale or Patient Health Questionnaire-9 as their preferred screening tools. Participants are screened, at minimum, once in both prenatal and postpartum periods. CMHDs are encouraged to make warm referrals to behavioral health services following a positive screen. Race and ethnicity data are not collected as part of this measure, making it difficult to gauge whether it is addressing the disparities found in referral rates for behavioral health services.

 

With BFH and Title V support, the IMPLICIT Network continues to implement the IMPLICIT ICC model of care throughout Pa. The ICC program screens birthing people for depression and three other behavioral risk factors at well-child visits. Positive screens are addressed through brief intervention or referrals to treatment. The IMPLICIT ICC model of care has been shown to effectively identify modifiable maternal risks and result in maternal behavior change that may lead to improved health outcomes. Over the next year, the IMPLICIT Network will work to increase ICC screening rates across Pa., maintain or increase intervention rates for positive screens, and expand the IMPLICIT ICC model of care to new sites in Pa.

 

Although screenings of this kind are completed irrespective of participants’ race or ethnicity, efforts of this nature enable more birthing people to be assessed and connected to treatment or resources when necessary. This has the potential to impact racial disparities in rates of maternal depression in the service area of participating providers. Replication and expansion of this model of care throughout the state could result in a statewide reduction of maternal morbidity and mortality due to unidentified and untreated behavioral health concerns, particularly where there are disparities.

 

Changing the picture of IPV necessitates recognizing all its characteristics and focusing on changing attitudes, particularly among key population groups that experience higher rates of such violence. The BFH program assesses pregnant and birthing people for indicators of IPV and provides vulnerable individuals with resources to reduce the risk of 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 birthing person or child by removing the stigma associated with violent relationships. Title V partners will be required to use evidence based IPV screening tools. The selected tools include the Hurt, Insult, Threaten, Scream (HITS) and the Humiliation, Afraid, Rape, Kick (HARK) screenings which address both emotional and physical abuse. Title V partners 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.

 

The BFH continues its work to increase the percent of birthing people enrolled in Title V programs that are screened and referred for services, to ensure continuity of care and the best outcomes for birthing people and their families. As such, the home visiting, Centering Pregnancy, and IMPLICIT programs will track the percentage of behavioral health services referrals made because of the positive screens.

 

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

 

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

 

ESM: Percent of women and birthing people who attend a postpartum visit within 28 days of delivery through the 4th trimester pilot program

 

Early postpartum care decreases mortality risk, particularly among birthing people who have chronic medical conditions like hypertensive disorders. Following 2018 recommendations from the American College of Obstetricians and Gynecologists, the IMPLICIT Network developed a 4th trimester (4TM) model of care initiative to address gaps in postpartum care and decrease rates of maternal mortality in the early postpartum period. With this model, biomedical and psychosocial risk factors associated with maternal morbidity and mortality, such as cardiovascular health, mental health, substance use, and trauma, are being identified and addressed. Title V funds are supporting the development and implementation of the IMPLICIT 4TM model of postpartum care in Pa.

 

Through implementation of the IMPLICIT 4TM model, birthing people identified as high risk for postpartum complications are scheduled for a postpartum visit between 7 and 21 days after birth. At this early visit, participating sites provide counseling, interventions, and/or referrals for birthing people that screen positive for one or more risk factors. By helping patients recognize warning signs, get an accurate and timely diagnosis, and have access to quality care, the 4TM model of postpartum care decreases their risk of maternal morbidity and mortality.

 

The 4TM model is currently being implemented at four sites in Pa., with plans for further replication. In the next year, the IMPLICIT Network will continue to support, strengthen, and expand the 4TM program in Pa. and to standardize, collect, share, and analyze data regarding the people that receive screening, referrals, and follow-up care in the first month postpartum. By implementing this model of care, the BFH seeks to decrease rates of maternal morbidity and mortality in the early postpartum period, particularly where there are disparities. Although the 4TM model has the potential for reducing racial disparities in maternal mortality rates by addressing cardiovascular health earlier in the postpartum period, it is too early in the model’s implementation to understand its true reach or impact on the overall maternal population or on the Black/African American maternal population. However, this strategy aims to directly address the priority need and, if successful, could drive improvement for the National Outcome Measures on maternal morbidity and mortality, and decrease racial health disparities for birthing people in Pa.

 

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

 

Maternal death during pregnancy, childbirth, or in the postpartum period is a tragedy with a catastrophic impact on families. MMRCs thoroughly review cases of pregnancy-associated death, which is any death during pregnancy or within one year of the end of pregnancy, and develop recommendations. These reviews allow state level data and trends to be identified and focused interventions to be implemented to decrease the number of preventable deaths. Data from MMRCs from 2017-2019 determined that the underlying causes of pregnancy-related deaths, or deaths that would not have occurred if the person was not pregnant, vary by race. Cardiac and coronary conditions were the leading underlying cause of death among non-Hispanic Black persons. Mental health conditions were the leading underlying cause of death among Hispanic and non-Hispanic white persons.

 

In January 2022, the MMRC published a legislative report documenting findings and recommendations resulting from the cases reviewed to date. Through this report, the MMRC recommended that Pa. builds infrastructure to identify and support pregnant and postpartum individuals who have mental health concerns, use substances, and/or have a history of IPV. In addition, the MMRC recommended that Pa. provide more comprehensive medical care for all pregnant and postpartum individuals.

 

Healthcare-related recommendations were shared with the Pennsylvania Perinatal Quality Collaborative (PA PQC). The PA PQC is implementing quality improvement initiatives related to severe hypertension in pregnancy, maternal OUD, NAS, contraceptive care and depression. The PA PQC works with 63 hospitals across the state representing 82.5% of live births in Pa. Implementing recommendations through the PA PQC has the potential to positively impact the health of birthing people in Pa. Further, BFH staff are working with the Jewish Healthcare Foundation to implement programming to expand the reach of existing e-consults or telephonic/video consultation for SUD and MH perinatal follow-up/treatment. Other recommendations will require support from, and coordination with, other internal and external stakeholders.

 

Review of pregnancy-associated deaths from 2020 will be completed in 2023. Once all data has been analyzed, program staff will work to publish a second legislative report identifying and addressing disparities among this population. In 2024, the BFH will work to identify partners to assist with implementing MMRC recommendations; address barriers associated with implementation; and implement a minimum of one recommendation.

 

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 birthing people and families in Pa. Collaboration can increase service utilization through effective referral processes. Further, agencies that communicate with one another and share information can provide their service recipients with consistent messaging. As a result, families may be less overwhelmed by information and less frequently 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 focused outreach, and development of cross‑sector plans for improving health outcomes. Cross-collaboration also provides public health programs and professionals with opportunities 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, the Pa. Medicaid program has expanded home visiting services for first-time birthing people and those that are at higher risk of poor outcomes. 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.

 

Convening quarterly with other state agencies and programs helps strengthen a shared understanding of initiatives for families, with the goal of reducing silos across agencies and better serving pregnant and parenting people in Pa. With continued meetings, the BFH will be able to determine what gap filling services are needed to improve the health of Pa. residents and address the disparities identified in the data. In the next year, the BFH will continue quarterly meetings with the DOH, DHS, and the MIECHV Program to promote collaboration and better serve Pa. residents.