FY2019 Application

Maternal/Women’s Health

 

State Priority #1: Reduce maternal mortality and morbidity

 

2020 State Objectives:

Objective MWH-1: Reduce the maternal mortality rate in NYS by 22% to 16.1 maternal deaths per 100,000 live births in 2020.

Objective MWH-2: Increase the percentage of women enrolled in Medicaid who are screened for maternal depression during postpartum care by 5% to 6.8%.

 

Maternal mortality and morbidity are critical indictors for maternal and women’s health in NYS.  In 2016, NYS ranked 30th among 50 states in maternal mortality. According to NYS Vital Statistics, NYS’s maternal mortality rate decreased from 24.6 deaths per 100,000 live births in 2015 to 16.8 deaths per 100,000 live births in 2016. The three-year average rate decreased slightly from 20.6 deaths per 100,000 live births for 2013-2015 to 20.2 deaths per 100,000 live for 2014-2016,  and remains almost two times higher than the Healthy People 2020 objective of 11.4. Racial disparities in maternal deaths are persistent; the statewide 3-year rolling Black to White mortality ratio ranged from a high of 4.4 to 1 in 2005-2007 to a low of 3.1 to 1 in 2011-2013, with the most current ratio (2014-2016) of 3.2. The most recent data showed small geographic differences. In New York City, the Black to White ratio decreased from 3.4 in 2013-2015 to 2.8 in 2014-2016. Outside New York City, the Black to White ratio increased slightly from 3.9 in 2013-2015 to 4.1 in 2014-2016.

 

Leading causes of pregnancy-related death in NYS, based on the review of the 2012-2014 case cohort (n=96) completed this year, include: embolism (not cerebral) (23%, n=22), hemorrhage (17%, n=16), infection (17%, n=16), cardiomyopathy (11%, n=11), cardiovascular problems (7%, n=7) and hypertensive disorders (6%, n=6). Almost two-thirds of these women were obese (55%) or overweight (8%). The majority of women who died of pregnancy-related causes were affected by risk factors including hematologic issues (26%), pulmonary conditions (23%), hypertension (19%), endocrine issues (19%), cardiac problems (18%), and psychiatric disorders (17%).

 

As stated in the annual report section of this application, Severe Maternal Morbidity fundamentally affects the lives of mothers, newborns, families and health care provider teams, and can result in prolonged hospital stays, substantial medical costs, higher life-long burden of health problems, physical and emotional stress, and interference with maternal-newborn bonding, and is associated with an increased risk for maternal death, and therefore NY's Title V program will continue its focus on this important public health issue. In August 2017, NY published a manuscript summarizing the findings from the surveillance of SMM. The understanding gained from this work continues to inform Title V efforts to address women’s health before, during and beyond pregnancies. 

 

Preconception health, assessing and addressing factors impacting a woman's health, remains a Title V priority area. Improving birth outcomes for mothers and infants requires a life course perspective. Preconception and inter-conception health care – including prevention of unintended pregnancy through the use of effective contraception; identification and follow-up for medical, behavioral and psychosocial risk factors; promotion of healthy behaviors including proper nutrition, access to quality oral health services, and, optimal management of chronic disease – should be an integral component of health care for all women regardless of pregnancy intentions.  The concept of preconception health will continue to be woven into the fabric of many of NY's Title V strategies and activities. 

 

While NY’s SAP focuses on specific strategies and measures to promote well woman care and preconception health, efforts will continue to build on the extensive body of MCH public health programs and activities in place through NYS’s Title V Program, including: Comprehensive Adolescent Pregnancy Prevention Program (CAPP); Family Planning Program; SBHC; Maternal and Infant Community Health Collaboratives (MICHC); MIECHV; Perinatal Regionalization; MMR; New York State Perinatal Quality Collaborative (NYSPQC); and, the GUHH (See Section V Form 7). Additionally, this work will leverage continued collaboration with NY's extensive network of partners including OHIP which administers NY's Medicaid program, including but not limited to Medicaid Managed Care, Health Homes, Family Planning Benefit Program, Family Planning Extension Program, Medicaid Prenatal Care Programs and related 1000 Days on Medicaid initiatives. This priority is closely linked to other state priorities including: Priority #2: Reduce infant mortality and morbidity; Priority #3: Support and enhance social-emotional development and relationships for children and adolescents; and all four Life Course priorities (#5-8).  Strategies to address maternal mortality and morbidity are largely inextricable from those to address infant mortality and morbidity; thus, the strategies described for Domain 1 and Domain 2 should be considered part of the continuum of public health activities to improve both maternal and infant maternal mortality and morbidity.

 

Progress toward achievement of outcomes associated with Priority #1 Reduce maternal mortality and morbidity will continue to be tracked through NPM #1: Percent of women with a past year preventive medical visit, ESM 1.14: Percentage of women enrolled in Medicaid who are screened for maternal depression during postpartum care and  two SPMs: SPM 1: The percentage of women age 18-44 years who report ever talking with a health care provider about ways to prepare for a healthy pregnancy and SPM 2: The percentage of women age 15-44 years and enrolled in Medicaid using the most effective, or moderately effective methods of contraception. These SPMs address key elements of preconception health care and leverage important investments and collaborations that NY’s Title V Program has with the DOH DCDP/BRFSS (SPM 1), DOH OHIP and OQPS.

 

Strategy MWH-1: As discussed in the Annual Report section of this application, in 2018, NYS’s Governor Cuomo announced a multi-pronged strategy to address maternal mortality and morbidity including, but not limited to:

• Implement the recommendations of the Governor’s Task Force on Maternal Mortality and Disparate Racial Outcomes;
• Establish a Maternal Mortality Review Board (MMRB) via the legislative process, building off the Title V Program’s current maternal mortlaity public health surveillance process;
• Launch a Best Practice Summit with hospitals and OB/GYNs;
• Pilot Medicaid expansion for doulas;
• Support Centering Pregnancy demonstration projects;
• Require Medical Education and curriculum development; and
• Expand the NYSPQC (further addressed in the Annual report and application sections); and
• Launch Commissioner Listening Sessions to hear from women and advocates across NYS to  better understand those factors that impact maternal mortality and morbidity. 

 

Efforts implemented to date related to these initiatives were reviewed in the Annual Report section of this application.  Title V staff are working with key stakeholders and partners on these priorities to improve health outcomes of all women, regardless of race, ethnicity and geographic location in NYS.  Governor Cuomo remains strong in his support of New York’s MCH population directly aligned with the purpose and mission of Title V. 

 

The Maternal Mortality Review Initiative will continue to conduct a complete assessment of the causes of death, factors leading to death, preventability, and opportunities for intervention. The MMR findings on recent trends and issues will be translated into action through collaboration with ACOG-NY and other key stakeholders to develop Issue Briefs, Grand Rounds, and quality improvement projects through the NYSPQC with partners (e.g., hospital associations, regional perinatal centers and affiliate obstetrical hospitals), continue maternal death case ascertainment and review process and issue reports of maternal death review findings and trends. NY has an established public health surveillance process in place to identify and review cases of maternal death through multiple sources of public health data and chart reviews. Title V plans to continue this review process while aiming to release data reports every two years to support prevention and clinical improvement strategies with partners. The next step is for NY to launch its MMRB to enhance the current process by   including variety of experts who can provide more in-depth thorough clinical reviews of each  pregnancy-related mortality  case to better understand those factors impacting these outcomes.

 

Work also continues Centering Pregnancy to improve access to and quality of prenatal care. OHIP is piloting the Centering Pregnancy projects in select high-need communities in the state and will be assessing their impact for consideration of expansion across the state. Title V staff helped inform the selection of the high priority areas for the Centering Pregnancy project and will help promote the benefits of both initiatives. Outcome measures have been developed to assess the impact of Centering Pregnancy .  A focus in the coming year will be to expand programs in clinics with already established Centering Pregnancy programs by June 2019 and then focus on clinics seeking to establish new programs.  The target communities are those with the poorest birth outcomes including communities in NYC, and Erie, Niagara, Monroe, Onondaga, Oneida, Albany, Rockland, Nassau, Suffolk and Westchester Counties. 

 

The Medicaid Doula Pilot will also continue. As discussed in the annual report section of this Domain, under the pilot, doula services are available for any Medicaid-eligible pregnant woman in fee-for-service or Medicaid Managed Care in specific geographic locations. Phase 1 of the pilot project began March 1, 2019 in Erie County. Phase 2 of the project will include selected zip codes  in Kings County once provider capacity has been achieved.  This two-year pilot includes an analysis of data including breastfeeding rates and adherence to postpartum visits.  It will also assess doulas’ and mothers’ experiences and feedback on participation in the program.  OHIP has ongoing engagement with stakeholders and has made several adjustments in order to increase participation in the pilot by both pregnant women and doulas. 

 

In addition to improving prenatal care in high need communities, it is imperative to ensure quality inpatient perinatal care.  NYS has demonstrated a long-standing commitment to a regionalized system of perinatal care.   The DOH oversees a perinatal regionalized system in which every birthing hospital in NYS is designated at a specific level based upon its ability to provide perinatal care to women and newborns. Hospitals are designated as one of four levels of perinatal care based upon the types of patients that are treated, sub-specialty consultation available, qualifications of staff, types of equipment available and volume of high-risk perinatal patients treated.  Basic or Level I hospitals provide care to normal or low-risk pregnant women and newborns, and they do not operate neonatal intensive care units (NICUs). Level II hospitals provide care to women and newborns at moderate risk, and Level III hospitals care for patients requiring increasingly complex care.  Level II and III hospitals must operate NICUs. The highest level hospital, the Regional Perinatal Center (RPC), is a tertiary care hospital capable of providing all the services and expertise required by the most acutely sick or at-risk pregnant women and newborns.  The concentration of high-risk patients makes it possible to maintain the substantial expertise and expense required for the care of high-risk women and newborns and attending level sub-specialty consultation in maternal-fetal medicine and neonatology.  Due to the changing landscape of the health care system as well as standards of perinatal care, the DOH is fully supporting efforts to update perinatal hospital standards in NYS.  Details regarding this process are contained in the Perinatal and Infant Health Domain.  Through these efforts, the DOH will ensure high quality care to improve health and birth outcomes for women and newborns throughout NYS. 

 

Through the updates to NYS’s perinatal regionalization system and standards of care (see Priority #2) and the work of the Taskforce on Maternal Mortality and Disparate Racial Outcomes, NY’s Title V Program will continue to explore opportunities to streamline data analysis processes, and share lessons learned to improve maternity care practices. 

 

Strategy MWH-2: Expand surveillance and reporting activities to include severe maternal morbidity. Studying SMM is critical both to preventing maternal morbidity and to strengthening Title V understanding of maternal death. Because SMM captures the most serious cases of maternal morbidity, analysis of SMM improves the opportunity to identify factors that are relevant to preventing future cases from progressing to the most serious stages of illness, disability or death. Building on the initial SMM data analysis work described above and in the 2017 annual report, Title V is working toward incorporating SMM case identification and analysis in surveillance reports to inform clinical and community prevention activities led by both Title V and partners.

 

NY's Title V program recognizes the importance of data access for all key partners and stakeholders.  To that end, Title V staff are working with the NYSDOH's OPHP to maintain the MCH dashboard developed and launched in 2018, mirroring the objectives and outcomes reflected in NY's SAP.  The MCH dashboard, closely aligned with the dashboard for NY's Prevention Agenda (PA) provides easy access to key data points reflected in NY's SAP and clearly show NY's progress in these priority outcomes, while also allowing partners to identify and address priority MCH issues on the local level.

https://webbi1.health.ny.gov/SASStoredProcess/guest?_program=/EBI/PHIG/apps/mch_dashboard/mch_dashboard&p=sh

 

Strategy MWH-3: In collaboration with key partners, continue to co-convene work with community stakeholders to advance a comprehensive maternal health agenda that includes policy, community prevention and clinical quality improvement strategies.  In NYS, heightened attention to the public health priority of maternal mortality – in particular the striking racial and economic disparities – has prompted significant work across several key organizations and settings, including the DOH Title V Program, ACOG-NY, state hospital associations including both the Health Care Association of New York State (HANYS) and Greater New York Hospital Association (GNYHA), the NYCDHMH, the New York Academy of Medicine (NYAM) and March of Dimes.  Partners from the PMH will be involved in several initiatives discussed throughout this application all with a goal of advancing a comprehensive and collaborative agenda for improving maternal health across the life course and ensuring the quality and safety of maternity care in NYS, with a particular focus on health equity.

 

Individuals from the Listening Sessions universally shared that community health workers were tremendous support during and after their pregnancies.  Expanding access to Community Health Worker (CHW) services was therefore a top recommendation made by the Taskforce on Maternal Mortality and Disparate Racial Outcomes.  Governor Cuomo’s 2019 Justice Agenda recommends the expansion of the Community Health Worker programs in key communities across the state to provide needed social support, information, and advocacy. CHWs are a trusted and valued community resource as individuals navigate the healthcare system. This proposal will expand CHW activities to address key disparities, including providing more childbirth education and support, assisting in the development of collaborative child care and social support networks, assisting with the development of a birth plan and supporting increased health literacy among communities around the state. Implementation of CHW expansion will be through the MICHC program. It is anticipated that with additional funds from Medicaid, beginning later this year, NY’s MICHC program will add approximately 50-60 CHWs and serve an additional 2,400 prenatal and postpartum women.

 

Title V staff have also been meeting with DOH DCDP staff to connect their prevention and treatment efforts with Title V initiatives to improve pre/interconception health. The DCDP implements evidence-based, evidenced-informed, and innovative public health strategies in high need areas of the state to support New Yorkers to live healthier lives and eliminate health disparities by reducing the incidence and burden of chronic diseases and conditions (e.g., heart disease, stroke, cancer, obesity, diabetes, asthma, arthritis) and their associated risk factors (poor nutrition, tobacco use, and lack of physical activity).  There is a tremendous overlap between the priorities and areas served by DCDP and the Title V program.  This cross-division relationship allows greater reach of these efforts by increasing awareness of and collaboration around both divisions’ priorities among local-level Title V and chronic disease prevention partners working in the same communities. 

 

Title V will also continue its efforts through the NYSPQC, a partnership with NYS RPCs and RPC-affiliate birthing hospitals, which seeks to provide the best and safest care to NYS’ women and infants through the translation of evidence-based guidelines to clinical practice.  The NYSPQC, ACOG-NY, HANYS, GNYHA and NICHQ, will continue to lead the NYS Obstetric Hemorrhage Project to assist birthing hospitals across NYS with improving the assessment and management of maternal hemorrhage, one of the leading causes of maternal morbidity and mortality in NYS.  The project will continue to focus on: team sharing and learning to promote collaborative learning; implementation of the Safe Motherhood Initiative (SMI) obstetric hemorrhage bundle; tailored clinical and quality improvement education (in-person and virtual, webinars, grand rounds, etc.) and technical assistance; and ongoing data collection, analysis and feedback to track relevant measures. This initiative aligns with the goals and measurement strategy of the national ACOG Alliance for Innovation on Maternal Health (AIM).  The purpose of the AIM program is to equip, empower and embolden every state, perinatal quality collaborative, hospital network/system, birth facility and maternity care provider in the U.S to significantly reduce severe maternal morbidity and maternal mortality through proven implementation of consistent maternity care practices that are outlined in maternal safety bundles.

 

Further, the NYSPQC also in collaboration with ACOG District-NY, HANYS, GNYHA, and NICHQ, is leading the NYS Opioid Une Disorder (OUD) in Pregnancy/NAS Project.  This learning collaborative, which kicked-off in September 2018, and is currently being piloted in 19 birthing hospitals, seeks to identify and manage women with OUD during pregnancy, and improve the identification, standardization of therapy, and coordination of aftercare of infants with NAS. NYS fully participates in the national AIM through this project.

 

Strategy MWH-4: Collaborate with Medicaid to institute reimbursement for immediate postpartum insertion of LARC.  As stated previously, over half of pregnancies in NYS are unintended. Pregnancy planning and prevention are greatly influenced by use of effective contraception. Despite the effectiveness of LARC, it is not widely used by most women due to concerns regarding coercion, safety, misunderstanding that devices may cause sexually transmitted diseases, and a general lack of knowledge regarding LARC. Additionally, because of the decreasing popularity of Intrauterine Devices (IUDs) in the past, health care providers may not have had been trained on placing IUDs. In addition, the high acquisition cost, lack of insurance reimbursement and inadequate supplies of LARCs in provider offices may pose challenges for the use of LARC in cost-effective and time-efficient ways.

 

Building on the extensive work summarized in the 2017 Annual Report, including NY’s IM CoIIN initiative and CDC-led 6|18 initiative, NY’s Title V Program will continue to collaborate with NY’s State Medicaid Program and other partners to educate providers on the policy change that provides reimbursement for immediate postpartum insertion of LARC and to address misconceptions about LARC among providers and women of reproductive age.

 

In addition, Title V will work with providers on the equity concerns that surround the use of LARC.  The New York State Family Planning Training Center has provided training to family planning providers to emphasize equity and reinforce reproductive justice principles in the delivery of family planning services.  Webinars were conducted in mid-2018 to promote use of patient-centered methods to assess reproductive intention, and to introduce a shared decision-making model for contraceptive counseling.  In addition, the annual New York State Family Planning Program provider meeting featured a keynote address to discuss the role of client-centered care in reducing disparate health outcomes.    In 2019, the New York State Family Planning Training Center will conduct a series of in-person regional trainings for family planning providers across the state that will focus on developing individual and organizational strategies to reduce implicit bias in family planning settings and promote health equity.

 

Strategy MWH-5: Collaborate with partners to increase screening and follow-up support for maternal depression. As highlighted in the NA, maternal depression is the most common morbidity among postpartum women, affecting 10-20% of women during or within 12 months of pregnancy. Maternal depression is a priority concern of many stakeholder groups and organizations in NYS. The Title V Program is uniquely positioned to provide leadership in facilitating connections among partners and advancing collaborative strategies that span health insurance, health care and community-based settings.

 

There is solid evidence that maternal depression can be accurately identified using brief validated depression screening instruments, and that treatment improves the prognosis for the woman and her family. Screening can be incorporated in routine prenatal, postpartum and well-baby visits, and must be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. Despite widespread acknowledgement of the prevalence and impact of maternal depression, previous studies suggest that screening for maternal depression is not standard practice, and especially that few providers use validated screening tools.

 

For the past few years, Title V staff have participated in a Prenatal Care workgroup with the OQPS to support implementation of Medicaid Prenatal Care standards and other related collaborative efforts. Part of the focus of this workgroup has been the development and implementation of a study on the quality of prenatal care provided through the Medicaid Prenatal Care Program. From January 2017 – December 2018, OQPS conducted a Perinatal Care Performance Improvement Project with 15 NYS Medicaid Managed Care plans.  The focused on four areas:

• Improving Access to 17-alpha hydroxyprogesterone caproate (17P) to reduce the risk of recurrent preterm birth
• Behavioral Health risk assessment and follow-up – depression
• Behavioral Health risk assessment and follow-up – tobacco use
• Improving utilization of LARC to support birth spacing that is optimal for maternal-fetal outcomes and patient choice.  

 

The study ended December 31, 2018.  Data will be available in July 2019.

 

Title V staff will continue to participate in quarterly Prenatal Care Workgroup meetings to provide input into quality improvement activities and provide updates on the NYSPQC (http://www.nyspqc.org).

Several new initiatives began in 2016 and continued into 2018 that include a focus on maternal depression.  Title V staff partner with the CCF on the implementation of a community-led project through the Early Childhood Comprehensive Systems (ECCS) Impact grant (August 1, 2016 - July 31, 2021) that supports collaborative quality improvement projects in three high need counties (Erie, Niagara and Nassau) to improve maternal depression screening and follow-up as well as developmental screening and follow-up for young children. CCF is working closely with DOH on this grant.  With leadership from Dr. Kuo, Associate Professor and Division Chief for General Pediatrics at the University at Buffalo, the Erie/Niagara team organized a learning collaborative focused on improving developmental screening at six pediatrics practices, including: Niagara Street Pediatrics, Towne Gardens Pediatrics, Main Street Pediatrics, Neighborhood Health Center, Jericho Road Community Health Center, and Tonawanda Pediatrics. The team credits the changes and improvements they have made to the importance of creating run charts of ASQ data. In the upcoming year the team will be designing a referral algorithm for families with young children.

 

At the other end of the state, under the leadership of Dr. Isakson, the Nassau team has used ECCS activities to support the implementation of Help Me Grow Long Island. Help Me Grow Long Island offers free developmental and social emotional screens and provides free, virtual, ongoing support to families with young children on Long Island who have concerns such as their child's development or behavior, navigating service systems, or locating baby items. Nearly 800 screens have been completed in the last year alone. The Nassau team is working with partners on creative ways to spread information about developmental health among families and increase the number of sites providing developmental screens. In the upcoming year, Nassau County ECCS will continue to build their HMG Long Island infrastructure to help achieve the 5-year ECCS aim and meet ECCS reporting requirements.

 

At the state level the ECCS initiative is connected to various TA initiatives and statewide workgroups and committees such as OHIP’s First 1000 Days on Medicaid Initiative, the New York Strengthening Infant/Toddler Policies and Practices, the NYS Infant and Early Childhood Mental Health TA initiative, the NYS Parenting Education Partnership, and workgroups on the NYS Governor’s Early Childhood Advisory Council and the Governor's Child Care Availability Task Force. In addition to maintaining and growing state partnerships, the state ECCS impact grantee plans to further develop a Community Readiness Scale for New York State Communities to help them assess their readiness and capacity of using collective action to improve their early childhood systems, engage in peer-to-peer support, prepare for project sustainability and inform NYS policy decisions.

To support this initiative, Title V staff participate on a workgroup charged with implementation of developmental health promotion by increasing monitoring, screening, and follow up. The ECCS Impact grant is a community-led program that identifies community leaders to participate in local teams to identify ways to improve services including screening and services. As discussed in the annual report, both projects have made progress in convening partners and starting work on improving screening and referrals into services.  Title V staff will continue to participate in the leadership team and support engagement of DOH-funded partners in the communities.  Relevant lessons learned will also be shared with partners working in these and other areas.

Through Governor Andrew Cuomo’s Report on the Status of New York Women and Girls, 2018 Outlook, additional efforts to address maternal depression and reduce maternal mortality were launched and progress was made.  Of the efforts initiated, Title V staff will continue to work on the following:  assisting OMH in increasing awareness and use of the Project TEACH expansion for maternal mental health consultations and training; developing and disseminating social media posts addressing stigma and awareness; and coordinating WIC and home visiting screening and referrals where possible. 

As discussed in the Annual Report, Title V staff are participating in the Center on Law and Social Policy’s Moving on Maternal Depression learning collaborative.  Staff participate on the core and data teams and will help with dissemination of lessons learned and promising strategies arising from the collaborative.

 

Similar to the ECCS Impact initiative, Title V staff working in Home Visiting are supporting a community-led Coordinated Intake and Referral System pilot designed to increase referrals into home visiting programs. This project complements NYS OMH’s funding of the expansion of HealthySteps model to 17 additional pediatric health care practice settings as discussed in the annual report in the Perinatal and Infant Health Priority. Title V staff participate on a workgroup to support the HealthySteps initiative to engage both the child and family during routine early-life medical visits and provide screening services for the entire family, including screenings for maternal depression. These enhanced early-life visits offer an opportunity for families to find support in an accessible and non-stigmatizing environment.  

 

Additionally, the state’s ECAC identified early identification, prevention and intervention for maternal depression as a current priority and has convened a workgroup to develop and help advance relevant strategies.  As mentioned in the annual report, members of the ECAC subgroup working on this issue were active in the development of priorities in NYS’s First 1000 Days on Medicaid initiative.  Members will help with implementation and spread, as they are able, of the initiatives that address maternal depression:  allowing providers to bill for the provision of evidence–based parent/caregiver–child therapy (also called dyadic therapy) based solely on the parent/caregiver being diagnosed with a mood, anxiety, or substance use disorder; and piloting home visiting in up to three communities and an identification of common programmatic elements that could be paid for through Medicaid funding. Title V staff will continue to participate on the leadership team for the home visiting workgroup and will help with the pilot implementation and dissemination of payment levers as they are identified and established.

 

NY’s Title V program will continue to partner with OHIP regarding tracking screening codes to learn about current billing practices.  The Title V program will continue to collaborate and provide relevant data on maternal depression screenings conducted for clients receiving home visiting services by the evidence-based models and MICHC CHWs.  Other areas discussed for possible attention are screening tools, referral practices and follow-up care.  The Title V Program will continue to collaborate with partners including OHIP, OASAS, OQPS, DFS, OMH, CCF and the ECAC to advance this work. Implementation of this strategy will be tracked by ESM MWH-5: Percentage of women enrolled in Medicaid who are screened for maternal depression during postpartum care, revised this year to include women enrolled in Medicaid.

 

Strategy MWH-6: Participate in intra- and interagency groups developing response to increased opioid use to ensure maternal and child health perspectives and populations are addressed. The increase of opioid use among MCH population is a key concern of many stakeholders in NY.  The age-adjusted rate of all opioid overdose deaths per 100,000 population in NYS tripled between 2010 (5.4) and 2016 (15.1). However, the age-adjusted rate of heroin deaths increased by over six times from 1.0/100,000 in 2010 to 6.5/100,000 in 2016, whereas the age-adjusted rate of opioid pain reliever deaths per 100,000 increased 2.7 times between 2010 (4.3) and 2016 (11.7).  During the same time period, the age-adjusted rates of overdose among women also increased reaching 8.1 per 100,000 population in 2016. 

 

Addressing the opioid epidemic in NYS is a priority.  DOH is focusing on statewide prevention activities to build a coordinated approach to fight addiction.  Efforts include:

• Identifying and sharing data between agencies and affected communities:
• Developing training for health care providers on addiction, pain management and treatment;
• Making the prescription drug monitoring program easier for providers to access and use;
• Providing resources to assist communities in combating the opioid epidemic at the local level; and,
• Coordinating statewide and community programs to improve the effectiveness of opioid prevention efforts. 

 

For the MCH population specifically, the impact of this crisis is visible in the dramatic increase in rates of drug-related discharges for newborns over the last several years. While rates have increased across the state and among all racial/ethnic groups, the trend is especially pronounced outside of New York City, where the rate of NAS has doubled since 2008.  In response to this rapidly emerging issue, Title V staff have been engaging with several key partners to assess needs, identify existing resources and participate in the development of additional strategies. Title V staff  participated on an interagency work group, led by the NYS OASAS, with support from an in-depth technical assistance grant from the National Center for Substance Abuse and Child Welfare, to address women with substance use disorders and their substance exposed infants in Onondaga, Warren and Washington counties.  Title V staff was on the core team of state and local agency partners.  The initiative’s priorities were screening, peer services, access to treatment, and NY’s response to the CARA amendment to CAPTA.  The grant ended in February 2019, however efforts to develop systems for implementing plans of safe care continue as roles for local providers are worked out in pilot communities.  Many partners need to be engaged to ensure pregnant and parenting women using opioids receive appropriate care and support for themselves and their infants. 

 

Title V staff are engaged in several efforts to contribute to and benefit from work related to surveillance and data for opioid use.  The Title V Program will continue its collaboration across NYSDOH sister programs on a study of maternal opioid use and NAS.  Study questions addressed for 2010 - 2015: 

• Among women in the Medicaid program who delivered an infant, how many filled prescriptions for opioids or received opioid dependence treatment during pregnancy?
• Did patterns vary by geographical area, provider or type of drug? 
• Among infants born with NAS in NYS, how many had mothers who filled prescriptions for opioids or received opioid dependence treatment? 
• How did this impact the infant’s length of stay and inpatient costs? 

 

The data analyses will continue to determine the counties or regions with the highest burden.  A clearer understanding of the epidemic will help determine the most effective intervention tactics. The data analysis planning team, comprised of Title V staff and other state agency representatives, will continue monthly meetings to address questions or concerns that arise throughout the study period. 

 

The opioid surveillance workgroup will continue to monitor opioid overdose deaths in the state and will report these deaths to counties.  They will also continue to update the DOH website with the most recent data and trends on opioid prevalence, healthcare utilization and mortality in NYS.

 

Additionally, the Women Who Use Drugs Workgroup is comprised of various stakeholders, including the Title V Program, AIDS Institute Office of Drug User Health, ACOG District II, healthcare providers, midwives, doulas, county health departments, universities and community-based organizations. The workgroup focuses on substance use disorders in women and perinatal substance abuse. The workgroup is focused on educating providers on substance use disorder in women, promoting treatment for substance use disorder, reducing the stigma around addiction, supporting trauma informed care, encouraging breastfeeding and promoting ethical care for women with substance use disorder. The group continues to meet monthly.

 

Staff from the NYSPQC are also working collaboratively with the NYS Breastfeeding Coalition to develop topic ideas for a Grand Rounds event that will take place in August 2019 and focus on breastfeeding for women who use opioids.

 

As more information about this significant public health issue becomes available, the Title V Program will incorporate the information within relevant community-based prevention programs. Governor Cuomo’s statewide task force to combat heroin and opioid abuse, comprised of experts in health care, drug policy, advocacy, education, parents and New Yorkers in recovery, will continue to build on the state’s previous efforts and use members’ expertise and experience to develop a comprehensive action plan. Title V staff will continue to identify opportunities to assure the needs of NYS’s MCH population are included in statewide efforts to address this issue and make recommendations regarding opportunities to intervene.