III.E.2.b.v.c. State Action Plan Narrative by Domain

Women and Maternal Domain Plan for FY2023

Priority:

Promote mental wellness and resilience through increased access to behavioral health and other support services.

 

State Performance Measures:

Substance use during pregnancy.

Provider screening of pregnant women for depression.

 

Objective:

By September 30th, 2023, and in partnership with the Child Welfare Division at the Department of Children, Youth, and Families, Within Reach and the Washington State Hospital Association, implement the state’s new portal and policy for infants who are born substance exposed, including promotion of supports for the substance-affected mother/infant dyad.

 

Strategies:

Provide training for clinical staff providing care at birthing hospitals.

 

Support efforts to address and mitigate individual and community effects of substance use.

 

Improve the care of infants with neonatal abstinence syndrome (NAS) and neonatal opioid withdrawal syndrome (NOWS).

 

Build on efforts to identify scope of impacts of substance use, including inequities, at the local and state level.

 

Currently, Washington systems of care do not uniformly and equitably identify, and support mother/infant dyads affected by substance use. This includes a lack of streamlined child protective policies, resulting in disparities in which infants are reported to Child Protective Services (CPS) for intervention. Plans of safe care for infants and their birth parents are a requirement of federal CAPTA legislation and Washington is implementing a new online referral and notification portal to provide care coordination and wrap around services for these families.

 

DOH has been partnering with DCYF, Help Me Grow, and clinicians providing direct patient care to this population, to create clear definitions and processes in their policy.

 

Washington has created clear definitions and a notification pathway for infants who are born substance exposed but have no identified safety risks for the dyad. Additionally, there are clear definitions and a reporting pathway for dyads with identified safety risks. The services provided to infants/birth parents who meet the policy definitions for notification and wrap around services, are being provided by Within Reach which is an organization that is contracted and funded through DCYF but is not connected to CPS. The program is being piloted in a few different areas of the state with statewide implementation being planned for to begin later in 2022. 

 

Objective:

By February 1, 2023, submit a revised maternal mortality review panel report to the Washington State Legislature, covering the deaths that occurred to women during pregnancy or within one year of pregnancy, inclusive of deaths resulting from suicide, substance overdose, homicide, and deaths that occurred out of state, and covering data from 2014-2020. The report will include identification of gaps and issues contributing to preventable, pregnancy-related deaths in the maternal behavioral health system and recommendations for improvement. Recommendations will address disparities and health equity improvements to reduce maternal mortality and will include contributions from our tribal and Indigenous partners.

 

Strategies:

Support interventions to address suicide ideation among pregnant and parenting people.

 

Support efforts to address and mitigate individual and community effects of substance use.

 

Build on efforts to identify scope of impacts of substance use, including inequities at the local and state level.

 

Increase and improve reimbursement for behavioral health care from preconception through all phases of pregnancy and the first year postpartum, including screening, treatment, monitoring, and support services.

 

Take action to reduce stigma surrounding behavioral health conditions, treatment, and related challenges.

 

Implement trauma-informed services into community services, health care systems, and the public sector.

 

Explore implementation of Maternal Levels of Care in Washington state.

 

In 2016, the Washington State Legislature (in RCW 70.54.450) mandated DOH to convene a multidisciplinary review panel to conduct comprehensive reviews of deaths that occur within a year of pregnancy, regardless of cause. The goal of the maternal mortality review is to understand the root cause of maternal mortality and morbidity, and the inequities therein, so the department and partners can identify and implement strategies and activities to prevent these tragic deaths and improve perinatal care for all people and families in the state. The panel includes clinical and non-clinical professionals from all over Washington state and from diverse racial/ethnic, geographic, and professional backgrounds. The panel also includes perinatal psychiatrists and addiction medicine providers, perinatal social workers, community organizations, patients, and patient advocates.

 

To meet these goals, the department and the panel, work to identify all deaths that occur within a year of pregnancy, determine which of those deaths are preventable pregnancy-related deaths, determine underlying causes of preventable deaths, and identify the issues and factors that contributed to them. The panel and the department use analyses of data and findings to make evidenced-based recommendations for health care and systems changes. The department submits recommendations to policymakers for consideration in a legislative report every three years and works with partners – including Health Care Authority (HCA), the Washington State Hospital Association, and the Washington State Perinatal Collaborative – to implement prioritized recommendations.

 

To date, the panel has reviewed maternal deaths from 2014-2020. This includes deaths from substance overdose, suicide, and domestic violence. The forthcoming report will include findings from deaths through 2020. The findings from the most recent report, published in 2019, include:

 

From 2014-2016, 100 people died within one year of pregnancy in Washington state; a quarter of these deaths were related to behavioral health conditions.

 

• 15 deaths were from accidental overdose: most related to opioid use.
• 13 deaths were from mental health conditions resulting in suicide.
• 11 of the deaths from behavioral health conditions were found by the panel to be directly related to pregnancy.
• Most people whose deaths were related to behavioral health conditions had Medicaid insurance coverage at the time of death.
• The majority of these deaths occurred six weeks to a year after the end of pregnancy; many occurred six months or more after pregnancy ended.
• Deaths from substance overdose affected a disproportionate number of people who were American Indian/Alaska Native.
• Most of these deaths impact people living in urban areas.

 

Some of the factors identified by the Maternal Mortality Review Panel (MMRP) to have contributed to preventable deaths from behavioral health conditions included:

 

• Gaps in knowledge among patients and their families about behavioral health conditions and care during pregnancy, and the resources that are available.
• Gaps in clinical skill and quality of care among perinatal providers and facilities about screening, assessment, management, and resources for behavioral health conditions that result in suicide and substance overdose.
• Lack of access to behavioral health care and services–including inpatient and outpatient services that accommodate people with children–throughout Washington state, including in urban areas.
• Persistent stigma and bias among patients, families, providers, and communities about behavioral health conditions and care during pregnancy.
• Lack of universal support structures (like home visiting and doulas) and care coordination (like perinatal patient navigators and community health workers) for parents and families who struggle with behavioral health conditions during pregnancy.

 

Work has already begun to implement recommendations based on these findings; however, there is still more to be done. The panel found that at least 60% of pregnancy-related deaths in 2014-2016 were preventable, and that most of the preventable factors occurred at the systems level. Additionally, more information is needed to understand the nature of racial/ethnic, geographic, and economic disparities in maternal mortality. To continue efforts to understand the root causes of maternal deaths from behavioral health conditions and determine where interventions are needed most, it is essential to continue to conduct comprehensive maternal mortality reviews of these types of deaths.

 

In the next year, the MMRP will continue to center health equity in the maternal mortality review process and work. Some of the strategies we will implement over the next year include:

• Prioritize health equity expertise and lived experience, along with other expertise areas and affiliations, as we recruit for new members of the MMRP as part of our empanelment process every three years.
• Provide access to health equity learning and other education opportunities for the MMRP.
• Work with the CDC to align practices of identifying discrimination, racism, bias, and stigma in the deaths we review so we can make recommendations for change using data from the maternal mortality review work. This includes participating in monthly workgroups/meetings, and collaboration with other states on successful strategies and practices that meet these goals.
• Work with the health equity and social justice experts on the MMRP to help us better identify evidence in the information we review and present it to the MMRP so they can make informed decisions.
• Consult with agency health equity experts to create a more formal health equity training/learning plan for all of the MMRP.
• Move forward with and support the listening sessions with the American Indian Health Commission (AIHC) and hope to learn more about how to better collaborate with these partners. DOH will ensure that the recommendations developed by the AIHC are included as an appendix in the next report and that other recommendations included in the report reflect input from the AIHC as well as feedback gathered from other partners in the state.
   

Following the report’s release in early 2023, DOH staff will share the findings widely with partners and community members around the state. DOH will also include applying lessons learned from the AIHC listening sessions in work to implement the report’s recommendations.

 

Plan to review the CDC LOCATeSM (Levels of Care Assessment ToolSM) survey results for Washington birthing hospitals with a committee representing people interested in Maternal Levels of Care as well as Neonatal Levels of Care. The committee will make decisions for Washington state regarding next steps for Maternal Levels of Care. DOH already has an established certificate of need for Neonatal Levels of Care.

 

Objective:

By March 31, 2026, ensure 80% of birthing hospitals in Washington state have established processes to universally screen everyone giving birth for substance use disorders and perinatal mood and anxiety disorders as part of the Alliance for Innovation on Maternal Health (AIM) patient safety maternal mental health protocols.

 

Strategies:

Promote standardized depression, anxiety, and substance use screening across the life course.

 

Promote verbal screening for substance use for every person giving birth, using validated tools.

 

Improve the care of infants with neonatal abstinence syndrome (NAS) and neonatal opioid withdrawal syndrome (NOWS).

 

Support interventions to address suicide ideation among pregnant and parenting people.

 

Maternal morbidity and mortality rates have been on the rise in the United States for the past 40 years, with marked disparities in the rates for women of color, women from low-income backgrounds, and women from rural areas.[1],[2] It is estimated that for every maternal death, 50 or more women are affected by severe maternal morbidities each year, nationally.[3] The CDC estimates that one in eight women experience a depressive episode after pregnancy.[4] Untreated maternal depression or other more extreme mood disorders can lead to significant morbidity, and in extreme situations, maternal suicide and infanticide.

 

In Washington state, all maternal deaths are reviewed by a panel of clinical and nonclinical perinatal experts and assessed for cause of death and underlying contributing factors. The panel found that in review of maternal deaths from 2014-2016, at least 60% of pregnancy-related deaths were preventable, and that the leading causes of pregnancy-related deaths were associated with behavioral health conditions, including suicide and accidental overdose. According to our Pregnancy Risk Assessment Monitoring System (PRAMS) data, in 2018, 11 percent of women interviewed expressed experiencing postpartum depression symptoms.

 

DOH has partnered with Washington State Hospital Association (WSHA) to join the Alliance for Innovation on Maternal Health (AIM), which is a national organization run in partnership with the American College of Obstetricians and Gynecologists (ACOG) to improve maternal outcomes through the implementation of hospital-wide quality improvement protocols called “safety bundles.” In the next five years, MCHBG-funded staff will collaborate with WSHA to roll out the Maternal Substance Use safety bundle. In alliance with recommendations from the American Academy of Pediatrics, ACOG, and the United States Preventive Services Task Force, the bundle promotes routine and standardized screening of pregnant and postpartum women for substance use. Recommendations include mother/birth parent and infant rooming in together and non-pharmacologic interventions as first-line treatment for signs and symptoms of withdrawal in the infant. The bundle is being piloted by 13 birthing hospitals during 2021 and a second cohort of hospitals will begin implementing the bundle beginning January of 2022. We are also looking at the feasibility of beginning implementation of the Maternal Mental Health: Depression and Anxiety bundle before March 2026.

 

To support the implementation of the Maternal Substance Use safety bundle, DOH, HCA, and WSHA will promote the Centers of Excellence for Perinatal Substance Use certificate program. This program will certify birthing hospitals that meet a specific set of criteria for care of people giving birth with a substance use disorder. These criteria will include verbally screening every person giving birth for substance use disorders and perinatal mood and anxiety disorders, as well as implementation of hospital policies and support for pregnant and parenting individuals who screen positive for a substance use disorder. Additionally, WSHA and DOH launched a Perinatal Substance Use Learning Collaborative that offers monthly learning sessions and a toolkit of resources to support hospitals in implementing bundle components and become a Center of Excellence for Perinatal Substance Use.

 

Priority:

Optimize the health and well-being of adolescent girls and adult women, using holistic approaches that empower self-advocacy and engagement with health systems.

 

National Performance Measure:

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

 

 

 

Objective:

By Sept 2023, maintain communications and guidance documents for COVID and pregnancy/birth/postpartum/children to reflect up-to-date COVID data and understanding, to include racial disparity considerations.

 

Strategies:

Integrate MCH COVID communications into the DOH COVID team communications and maintain current guidance documents and communications.

 

Support the “One Vax Two Lives” campaign to dispel misinformation, and address fears some expecting families may have about COVID vaccines. This campaign is a partnership with The University of Washington‘s Center for an Informed Public and the UW Medicine‘s Department of OB-GYN.

 

Support access to and communication clarity around emerging guidance for COVID-19 vaccination during pregnancy and lactation.

 

The next maternal mortality review report scheduled for release in early 2023 will include data and findings from reviews of deaths that occurred within a year of pregnancy in 2020. We anticipate 2020 deaths will include some related to COVID-19, either directly or indirectly, and as such, we anticipate related recommendations COVID-19 around vaccine and pregnancy.

 

Objective:

By December 2022, distribute health promotion materials in relation to Senate Bill 6128 passed by the Washington State Legislature to expand Medicaid coverage to one year postpartum.

Strategies:

Support women during the “fourth trimester”; enhance postpartum care to allow providers to check in with mothers about their mental health and other medical issues.

Promote standardized depression, anxiety, and substance use screening across the life course.

Address the need for more services, support, providers, and insurance coverage, particularly in rural communities and remote areas.

 

Staff will collaborate with HCA to conduct outreach through local health jurisdictions (LHJs) regarding Medicaid expansion to 1 year postpartum.  This will include presentations and materials distribution at the Washington Public Health Association conference and through routine LHJ and Accountable Community of Health collaborative meetings.

 

Objective:

By September 2023, collaborate with community birth experts from the doula, home visiting, nursing and community health worker workforce, to identify a process for birth equity priorities and funds distribution and program development in line with anti-racist values.

 

Strategies:

Support active engagement by birthing hospitals, licensed birth centers, and perinatal providers in quality improvement efforts that reduce the leading causes of maternal mortality and morbidity.

 

Support healthy pregnancies, births, and maternal recovery; address inequities and prevent maternal mortality and morbidity.

 

Support women during the “fourth trimester”; enhance postpartum care to allow providers to check in with mothers about their mental health and other medical issues.

 

To address disparities in birth outcomes among communities of color, particularly the Black and African American community, DOH has committed to creating space to learn from community perinatal and birth leaders about their equity priorities to help inform ongoing funding and program areas of focus.

 

As part of these community engagement efforts, DOH developed a survey for people serving birthing families, primarily Black and African American birthing families. The purpose of the survey was to gather feedback on how best to distribute the remaining birth equity project funds (which will be focused on Black and African American birthing families of greater King County), explore development of a community advisory committee, and discuss best practices for recognizing community-rooted organizations and programs. There were 51 unique respondents to the survey, with the majority of respondents representing King, Pierce, and Snohomish counties. DOH staff hosted two virtual community meetings to share key themes from the survey and discuss next steps.

 

Key themes of survey feedback regarding potential community advisory committee formation included:

 

• Strong support for the development of a community advisory committee that will guide the allocation of the remaining birth equity project funds and share expertise with DOH.
• The importance of including birth workers, doulas, and other people who work closely with the community on the community advisory committee. These committee members can share community concerns and insights about the impact of programs and policies.
• Investing time in the community advisory committee and grantee selection to get the process and the outcome right.

 

Guidance about best practices when recognizing community-rooted organizations and programs included:

 

“A community led program is a program where the leaders have shared the same experiences as those they serve. They then take those experiences and use them as a driving force to improve the community.”

 

DOH can better engage with community by asking the community what they want, what has and hasn't worked in the past, what they view as barriers to successful, culturally relevant programs in their community, and how sustainability can be created or ensured.

 

“Ask community members. Not just the ones that seem to be in spokesperson positions, not just the most adept at navigating DOH culture, not just the code-shifters. Ask the broadest range of community members possible. Meet them where they are, support their needs in participating in meetings, and listen.”

 

DOH should ask applicants “What proportion of your membership/leadership reflects the communities we are focused on? What proportion of your membership/leadership includes birth workers who are members of those communities? What work have you been doing to increase/expand equity in birthing experiences?”

 

Based on this feedback, DOH has partnered with two facilitators to conduct ongoing community engagement around birth equity in Washington state. These two facilitators represent and are rooted in the Black/African American, Pacific Islander, and Indigenous community. Their work will include key informant interviews and listening session around the state. A community advisory committee is also in development and will continue to provide insight into birth equity work during this time period. During this reporting period, the findings from this work will be used to adapt programing and continue to shift the power of decision making to those impacted by programs and health disparities.

 

DOH will also be launching a new Birth Equity RFA in 2022, with new projects starting in early 2023. These projects will be informed by the community facilitator’s findings as well as guidance from the community advisory group. Funded projects are expected to serve the Black/African American, Pacific Islander, and Indigenous community and other communities as funding allows.

 

Once a cohort of birth equity project partners have been selected, they will work with DOH contract staff to develop scopes of work, implement their projects, and connect with the other grantees to ensure partnership and shared learning between organizations.

 

Objective:

By September 30, 2022, create training opportunities for perinatal care providers on mood disorders and suicide risk during and after pregnancy, and determine feasibility of modifying existing legislation requiring mandatory provider suicide training to include content on maternal suicide, risk factors, and interventions.

 

Strategies:

Take action to reduce stigma surrounding behavioral health conditions, treatment, and related challenges.

 

Implement trauma-informed services into community services, health care systems, and the public sector.

 

Promote standardized depression, anxiety, and substance use screening across the life course.

 

In the most recently published report on maternal deaths from 2014-2016, the Maternal Mortality Review Panel found that 30% of pregnancy-related deaths were caused by behavioral health conditions resulting in suicide. The majority of these deaths occurred in urban areas, and most of these women had Medicaid health insurance coverage. The panel identified a number of gaps in the perinatal health and service system that contributed to these deaths, including lack of knowledge among perinatal health care and service providers around screening, assessment, and management of suicide during pregnancy and through the first year; lack of knowledge of postpartum mood disorders and the treatment and resources that are available; and lack of access to inpatient and outpatient services when they were needed most.

 

To increase awareness and knowledge of suicide risk and pregnancy, DOH explored the feasibility of amending the law that outlines suicide training requirements for health care professionals in the state, RCW 43.70.442. There are significant barriers that made this amendment unfeasible. The minimum standards are general at this time, and this amendment would open the door for a change in the scope of the standards towards more specialized standards. Furthermore, it could take years to progress and have minimal impact on reach of training materials. However, we developed a collaborative partnership with the DOH Injury and Violence Prevention team to increase awareness and educational opportunities for health care providers and other key partners on suicide risk during and after pregnancy. Planned activities include presentations to behavioral health groups, resources included in the injury prevention listserv, and sharing of data between the MMRP and Injury Prevention units.

 

DOH staff are pursuing various methods of creating and distributing training opportunities on perinatal mental health to the Washington provider community.

 

In spring 2021, DOH released a request for applications to fund projects that meet the MMRP’s recommendation to “increase knowledge and skill of providers, patients, and families about behavioral health conditions during and after pregnancy, and the treatment and resources that are available for support.” These projects aim to support maternal Medication Assisted Treatment (MAT) programs; increase perinatal peer support groups and services; and offer provider trainings to improve skill in addressing perinatal behavioral health.

 

DOH will also partner with the University of Washington to develop a program to train and support members of primary care clinics to address perinatal suicide risk. Aspects of this suicide risk reduction care include screening for suicide risk (including identifying risk factors and the use of screening tools), evaluating the severity of any identified risk, preparing a risk mitigation plan, and initiating a team-based care approach within the care setting or in conjunction with community resources to address this risk.

 

The Perinatal Health unit will continue to partner with the DOH Injury and Violence Prevention unit to promote training opportunities and data regarding suicide in the pregnant and parenting population to the behavioral health community. Furthermore, the revised Washington State Suicide Prevention Plan, scheduled for release by the end of 2022, will include an appendix with information on suicide among the pregnant and parenting population. This partnership provides new audiences and venues to disperse findings from the Maternal Mortality Review Report, as well as partnerships in the behavioral health field.

 

Objective:

By December 2022, collaborate with tribal partners to hold a listening session that includes plans to better understand maternal mortality in tribal and Indigenous communities, and content to be included in the next Maternal Mortality Review Panel report that includes recommendations centered on the tribal context, with added consideration of unique challenges and opportunities of tribal members and nations in relation to quality improvement.

 

Strategies:

Support interventions to address suicide ideation among pregnant and parenting people.

 

Support efforts to address and mitigate individual and community effects of substance use.

 

Promote standardized depression, anxiety and substance use screening across the life course.

 

Build on efforts to identify scope of impacts of substance use, including inequities at the local and state levels.

 

Increase and improve reimbursement for behavioral health care from preconception through all phases of pregnancy and the first year postpartum, including screening, treatment, monitoring, and support services.

 

Take action to reduce stigma surrounding behavioral health conditions, treatment, and related challenges.

 

Implement trauma-informed services into community services, health care systems, and the public sector.

 

The MMRP includes clinical and nonclinical professionals from all over Washington state and from diverse racial/ethnic, geographic, and professional backgrounds. To reaffirm our state’s commitment to improving systems that serve families to be more equitable, the maternal mortality review law now ensures the panel will always include people who are American Indian/Alaska Native and people who serve tribal and urban Indian communities in the state. These members do not need to apply and there is never a capacity on the number of members to represent these communities.

 

Representatives from tribal and urban Indian communities have participated in the maternal mortality review proceedings since 2017, and contributed to the report published by DOH in 2019 outlining data and findings on maternal deaths from 2014-2016, including total counts of pregnancy related deaths, causes of death, and demographic descriptions.

 

Data analyses of the three years indicate American Indian/Alaska Native women had the highest maternal mortality rate of all racial/ethnic groups in 2014-2016. These data, combined with gaps in care and services identified by the panel, as well as history of medical care and treatment of American Indian/Alaska Native people throughout the country, indicate a persistent and historically rooted disparity that has impacted these communities for over a hundred years. To understand the nature and root causes of this and other disparities, DOH and the MMRP will continue to review maternal deaths in the state, as well as identify strategies to better collaborate with tribal and Indigenous partners to reduce maternal mortality in those communities.

 

DOH is committed to working with tribal and urban Indian partners to begin learning how to improve collaborative relationships in public health care systems, so all communities can thrive and achieve their highest level of health and well-being. In December 2019, the American Indian Health Commission (AIHC)’s representative on the MMRP invited DOH staff to present data and findings from the report released that same year. After the presentation concluded, members of the Commission provided invaluable feedback and posed a number of relevant and challenging questions. In response to the commission (and to feedback from American Indian/Alaska Native representatives on the panel), DOH has been collaborating with the commission to fund and coordinate one or more listening sessions. The purpose is to learn more about maternal mortality in tribal/Indigenous communities and how these communities want to engage with panel efforts to reduce maternal mortality; identify opportunities for creating additional tribal/Indigenous-led MMRP recommendations and quality improvement activities centered on the tribal context; and outline next steps. Planning for the listening session will take place over the rest of 2021, with the actual listening session(s) scheduled to occur sometime in 2022.

 

[1] Centers for Disease Control and Prevention. (2019). Pregnancy Mortality Surveillance System. Reproductive Health. Found at:
https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-mortality-surveillance-system.htm?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Freproductivehealth%2Fmaternalinfanthealth%2Fpmss.html

[2] Singh GK. Maternal Mortality in the United States, 1935-2007: Substantial Racial/Ethnic, Socioeconomic, and Geographic Disparities Persist. A 75th Anniversary Publication. Health Resources and Services Administration, Maternal and Child Health Bureau. Rockville, Maryland: U.S. Department of Health and Human Services; 2010. Found at: https://www.hrsa.gov/sites/default/files/ourstories/mchb75th/mchb75maternalmortality.pdf

[3] Callaghan, W. M., MacKay, A. P., & Berg, C. J. (2008). Identification of severe maternal morbidity during delivery hospitalizations, United States, 1991-2003. American Journal of Obstetrics and Gynecology, 199(2), 133. Found at https://www.sciencedirect.com/science/article/abs/pii/S0002937807023320

[4] Centers for Disease Control (2020). Vital Signs: Postpartum Depressive Symptoms and Provider Discussions About Perinatal Depression – United States, 2018. Morbidity and Mortality Weekly Report, May 15, 2020/69(19);575-581. Found at: https://www.cdc.gov/mmwr/volumes/69/wr/mm6919a2.htm?s_cid=mm6919a2_w