Priority: Strengthen the capacity of the health system to promote mental health and emotional well-being.

 

Objective 1. Increase to 92% from baseline (89.2%, PRAMS 2018) the percent of birthing people who have moderate or high social support following the birth of their baby. 

In 2021, 88% of PRAMS respondents indicated having moderate or high social support, compared to 86% in 2020 and 87% in 2019. MDPH will examine the changes in moderate or high social support comparing 2016-2019 (88%) and 2020-2021 (87%) with a difference-in-differences analysis for pre-COVID-19 and COVID-19 periods. PRAMS staff will examine the characteristics of people with a lower score of social/emotional connectedness, and the association of frequent postpartum depressive symptoms with this social connectedness question. This analysis will help to identify vulnerable populations and guide efforts to promote mental health and emotional well-being, especially in times of public health emergencies. MA PRAMS will be continuing the Social Determinants of Health (SDoH) supplemental survey through 2024 and will analyze the SDoH data in conjunction with social support questions to assess relationships with postpartum depression and maternal and infant outcomes.

 

In April 2023, DMCHRA completed an initial linkage of PRAMS to the PELL (Pregnancy to Early Life Longitudinal) data system. This linkage will allow for analyses that include the birthing parent’s beliefs, attitudes, and experiences before, during and shortly after pregnancy from PRAMS with the longitudinal case mix data for hospital-based medical care from PELL. The linked data will enable exploration of the effects of the birthing parent’s experiences of social support, racism, partner’s support, and life stressors on severe maternal mortality (SMM) events during delivery hospitalization and in the postpartum. An analytic plan is being developed and will be underway in FY24.

 

Perinatal Mental Health Training and Technical Assistance 

MDPH will continue to provide training and technical assistance (TA) on perinatal mental health (including maternal mental health and co-morbidities such as substance use and interpersonal violence) to state agencies (such as the Departments of Children and Families and Early Education and Care), providers (including home visiting programs and community health centers), and health plans.  

 

Doula Initiative

BFHN will continue to host monthly Doula Partner Advisory Group meetings with the goal of drafting recommendations for doula certification. The Advisory Group includes doulas, a certified nurse midwife, and representatives from the American College of Obstetricians and Gynecologists, MassHealth, MA Hospital Association, the MA Health Plan Association, and the Commonwealth Care Alliance. MDPH provides monthly consultant fees to 8 doulas for their participation.

 

MA MIECHV

Home visitors will continue to screen participants for depression prenatally and postpartum and provide education, brief intervention, and referrals to mental health supports to people identified with depression. Additional FY24 activities include data collection and analysis on completed participant depression screens to assess progress on a MIECHV performance measure assessing the percent of primary caregivers enrolled in home visiting who are screened for depression using a validated tool. Data will also be collected and analyzed to report on an outcome measure assessing the percent of primary caregivers referred to services for a positive screen for depression who receive one or more service contacts. MA MIECHV will analyze these data by race, ethnicity, gender, and language to identify and address inequities in depression screening and referrals to services. Programs will continue to support families in accessing mental health services as needed and offer ongoing social connections in the form of group services. MA MIECHV will continue to support innovative staff positions within home visiting programs – such as case workers or outreach coordinators – who can liaise with mental health and other services and facilitate successful connections to supports.

 

Welcome Family

Welcome Family nurses will continue screening for depression and social connectedness and offering referrals for diagnosis and support as needed. The program will use a family-driven and culturally appropriate approach when considering the types of referrals being made, recognizing that many families find value in informal supports, such as doulas and peer-to-peer support groups, compared to mental health counseling or medication.

 

FOR (Follow-up Outreach Referral) Families

Since September 2022, the Commonwealth has managed a spike in the number of families experiencing homelessness who reside in Emergency Assistance shelter. Due to the increasing number of families in shelter, FOR Families requested and was approved additional funding from the MA Department of Housing and Community Development to support five additional home visitors and one additional supervisor. Increased staffing capacity allow more families in shelter to have specific and individualized support to address barriers to achieving permanent and stable housing and health and well-being for their families. In hiring new staff, the program would look to recruit more Spanish and Haitian language speakers to reduce the need for interpreters and delays.

 

FOR Families will continue engaging families transitioning from homelessness to stable housing who are at high risk for stress, depression, violence, and substance use. Home visitors will monitor clients for symptoms of depression and provide education, supportive counseling, and referrals to mental health services. Home visitors will assess families’ needs, define goals, develop plans, and connect with community support services. They will use staff meetings and case conferences with shelter providers as a method of technical support and education to their shelter colleagues about symptoms of depression and tips on family engagement.

 

Priority: Prevent the use of substances, including alcohol, tobacco, marijuana and opioids, among youth and pregnant people.

 

Objective 1 (NPM 14). By 2025, reduce the percentage of people who report smoking during pregnancy from the baseline of 4.3% in 2018 RVRS) to 2.0%.

 

PRAMS

MA PRAMS will launch Phase 9 survey in June 2023, starting with January 2023 births. Phase 9 questions include cigarettes/e-cigarettes (vaping) in all trimesters of pregnancy; the current Phase 8 survey asks about smoking during the three months before pregnancy and the third trimester of pregnancy. MDPH will examine PRAMS data from 2023 in FY25. MDPH will use PRAMS data to report on nicotine use during pregnancy and validate reporting of cigarette smoking on the birth certificate.

 

Perinatal-Neonatal Quality Improvement Network (PNQIN)

MDPH will continue to share PRAMS data at PNQIN statewide summits to foster collaboration and support quality improvement cycles to reduce nicotine, marijuana, and alcohol use during pregnancy (also tied to Objective 2 below). PNQIN will support hospital teams that have strong screening and referral processes in place and work to engage additional hospitals, with the goal of increasing screening and referral to existing statewide support services such as the MDPH Tobacco Cessation and Prevention Program.

 

MA Tobacco Cessation and Prevention Program (MTCP)

MTCP will use findings from surveys, key informant interviews of family support providers and substance use treatment facility providers, and focus groups with birthing people to inform and implement trainings to build knowledge and confidence among providers when addressing tobacco/nicotine use among pregnant and parenting people. MTCP will also use the findings to promote the Quitline services, especially the pregnant and postpartum protocol, as a resource for providers to use with their clients.

 

MTCP will continue to engage with Market Decisions Research to finalize a report of findings, a communication plan, a dissemination plan, and a plan to work with tobacco/nicotine treatment TA providers to incorporate lived experience perspectives into trainings for providers. MTCP will implement messaging and trainings as well as develop an evaluation plan to assess feedback and progress towards increasing quality of existing programs and more effective promotion of tobacco/nicotine recovery resources using trauma-informed racial equity and intersectionality frameworks.

 

MA MIECHV

MA MIECHV will continue to provide training on substance use, NAS, substance use screening, and trauma-informed practice, and home visitors will routinely screen participants for substance use. Data on tobacco cessation referrals will be collected and analyzed to assess progress on a MIECHV performance measure assessing percent of primary caregivers enrolled in home visiting who reported using tobacco or cigarettes at enrollment and were referred to tobacco cessation counseling or services within three months of enrollment. MA MIECHV will analyze these data by race, ethnicity, gender, and language to identify and address inequities in depression screening and referrals to services. In addition, MA MIECHV will explore the use of a validated substance use screen to support home visitors in assessing risk for substance use and identification of appropriate referrals to treatment services.

 

Objective 2. By 2022, improve measurement of marijuana use among pregnant people by adding specific questions to the PRAMS survey.

Objective 3. By 2023, improve measurement of alcohol consumption among pregnant people by adding specific questions to the PRAMS survey. 

 

PRAMS

MA PRAMS used the opioid supplement to collect marijuana use during pregnancy for births through December 2022 and will launch the Marijuana supplement with the initiation of PRAMS Phase 9 in June 2023, starting with January 2023 births. These findings will be used in a data brief on perinatal substance use which will be drafted in FY24 and posted on the MDPH and PNQIN websites.

 

The Phase 9 survey will be launched in June 2023, and MA PRAMS will add questions about alcohol consumption in all three trimesters of pregnancy; the current Phase 8 survey asks about alcohol consumption in the past two years and during the three months before pregnancy. MDPH will examine data from 2023 in FY25.

 

Center for Birth Defects Research and Prevention

In FY23, CBDRP will continue the Birth Defects Study to Evaluate Pregnancy exposures (BD-STEPS) and the Stillbirth Study. Data from these studies are released on a regular basis and CBDRP anticipates having MA data available by late 2023. This population-level data will allow MDPH to better understand the prevalence of marijuana use in pregnancy, as well as the frequency of use, route of use (e.g., smoke, vape, eat, consume drinks, dab) and reason for use (e.g., recreationally or to relieve nausea, anxiety, pain, symptoms of a chronic condition).

 

Fetal Alcohol Spectrum Disorder (FASD) Task Force

The FASD Task Force will increase training opportunities geared towards services for families caring for individuals with FASD (such as school systems, direct therapy and social work agencies, DCF Foster/Adoptive Care, and Children’s Behavioral Health Initiative providers), and research further opportunities to directly support families caring for individuals with FASD.

 

 

Additional activities to prevent the use of substances among youth and pregnant people

Additional efforts to address this priority that do not directly relate to the performance measure or other objectives are described below.

 

PNQIN

Title V will continue to support PNQIN initiatives and statewide summits, which convene almost all birth hospitals in the state to share best practices for the care of substance exposed newborns and their families. PNQIN will continue to focus on addressing perinatal opioid use during pregnancy, at delivery, and during the first year of life.

 

Moms Do Care (MDC)

MDC will continue to implement peer led, seamlessly integrated, trauma informed continuums of wraparound care for pregnant, postpartum, and parenting people with opioid use disorders. The MDC TA team will provide support and training in implementing the program and assist the MDC health care systems to plan for ways to sustain the wraparound services as well as collaborative, multidisciplinary networks of support established by the program. MDC will also continue to work with the health care systems and their regional partners to build and maintain the organizational system change initiatives and collaborate with Medicaid and public health stakeholders to bring this direct service and system change model to a statewide reimbursable scale.

 

Plans of Safe Care/Family Care Plans/Infants with Prenatal Substance Exposure

MDPH in partnership with the Department of Children and Families, will receive In-Depth Technical Assistance (IDTA) from the National Center on Substance Abuse and Child Welfare to further efforts to support families impacted by parental substance use and infants affected by prenatal exposure to substances. Goals for the IDTA include: 1) Develop a statewide governance structure for supporting families impacted by parental substance use and infants affected by prenatal exposure to substances. 2) Develop a shared language, vision, and mission to govern our cross-systems work. 3) Ensure MA maintains compliance with current Child Abuse Prevention and Treatment Act (CAPTA) regulations. 4) Implement a public health approach to the identification, engagement, and initiation of the Plan of Safe Care with families. An online video-based training will also be developed and made available through a MDPH learning management system.

 

FIRST Steps Together

In addition to direct service provision, the program will continue to create mechanisms to implement Plans of Safe Care, expand and refine the perinatal and parenting peer recovery and clinical workforce, improve systems of care for families impacted by parental substance use, and develop and disseminate best practices.

 

FIRST Steps Together will continue to build capacity to implement Mothering from the Inside Out, an evidence-based intervention to increase reflective capacity among parents with substance use disorders, through the training of two new cohorts of clinicians, and, if funding is secured, the development of a training curriculum for peer staff. MDPH will disseminate an extensive FIRST Steps Together implementation toolkit and create online training modules related to a range of relevant topics.

 

FIRST Steps Together will partner with the Executive Office of the Trial Courts to develop a pilot to provide services to participants in one Family Treatment Court.

 

There will be a continued expansion of the Group Peer Support model throughout the substance use treatment system. This is a trauma-responsive support group model based on evidence-informed modalities that was developed initially to combat perinatal mood disorders. 

 

MA MIECHV

MA MIECHV will continue to pilot an overlay of a Peer Recovery Coach within the Parents as Teachers (PAT) program. MA MIECHV will continue to use the MIECHV American Rescue Plan award to support a full-time peer recovery coach and expand the Berkshire Recovery Coach Pilot. Through this pilot, home visitors attend the Recovery Coaching and Ethical Considerations trainings required for Recovery Coach Certification. Supervisors attend the Recovery Coach Supervisor training to build their capacity to supervise recovery coaches. The home visitor/recovery coach positions will also have access to specialized training provided through FIRST Steps Together and to the peer learning collaborative, thus integrating State Opioid Response and MA MIECHV resources.  

 

Priority: Reduce rates of and eliminate inequities in maternal morbidity and mortality.

 

Objective 1 (SPM 1). By 2025, the MMMRC will increase the percent of pregnancy-associated deaths that are reviewed within two years of occurrence from 0% to 50%.

Objective 2. By 2025, develop a structure for community input to the review process that is authentic and addresses the power dynamics between medical providers and community stakeholders. 

 

Maternal Mortality and Morbidity Review Committee (MMMRC) 

In FY24 MDPH will continue efforts to increase the percentage of pregnancy-associated deaths reviewed within two years of the death. MDPH has used a quality improvement approach to identify ways to streamline and improve the efficiency of the MMMRC process. MDPH is enhancing efforts to reduce abstraction time and improve efficiency of data collection. This includes the transition from manual entry of vital records into MMRIA to an electronic upload on a quarterly basis. With CDC grant funding, MDPH was able to hire four new part time medical record abstractors, bringing the total number of abstractors to five. In addition, the frequency of MMMRC meetings is being increased to reduce the backlog and timely review of new cases as they get reported and entered in MMRIA.

 

MDPH is also working to establish a structure for authentic community engagement in the MMMRC review process. MDPH has contracted with the Tufts Interdisciplinary Evaluation Team (TIER) to provide training and on-going TA to the MDPH Community Engagement Specialist/Maternal Health Coordinator working to interface with a wide array of community members and promote bi-directional communication on a consistent basis within the Committee review process. Training is scheduled to end in August and recruitment of at least five community members will begin in September 2023. In the meantime, the Community Engagement Specialist and MDPH MMR leadership is working with current committee members to transition to the use of plain language (instead of clinical terminology) during each review and to adopt a debrief session after each review that promotes continued understanding and commitment to the tenets of authentic community engagement. 

Objective 3. By 2025, leverage collaborative partnerships to inform practice and policy changes and disseminate findings including MMMRC recommendations.

 

Maternal Mortality and Morbidity Review Committee

MDPH epidemiologists will analyze the data from MMRIA to document the number and rate of pregnancy-related and pregnancy-associated deaths in MA. Data will be examined to determine the burden, causes, and distribution by age, race, ethnicity, and geographic area of maternal deaths. Additionally, qualitative analysis of data will be conducted using information from medical reports, social worker notes, prenatal care records, police reports, public records, media, and key informant interviews (once legislative authority is granted) and focus groups within communities disproportionately experiencing high rates of poor maternal health. To contextualize these data, we will also compile community level indicators and reports from multiple sources to create community profiles. We will use the MA Racial Equity Data Road Map as a guide to better contextualize the data in the setting of the broader historical and current policy and system factors that affect the health.

 

PNQIN

PNQIN will continue to support the implementation of the Alliance for Innovation on Maternal Health (AIM) collaborative QI project and serve as a liaison between the AIM national office and participating hospitals, providing guidance, education, and TA to hospitals. The Equity bundle was launched in September 2022 and will continue through September 2024. PNQIN will continue to conduct SMM webinars with hospitals to review their data reports, answer questions, solve coding issues, and encourage participation in the AIM Initiative.

 

PNQIN will also explore the implementation of on-site assessments of hospitals for designation of levels of care, explore linkage of Levels of Care Assessment Tool (LOCATe) results with process and outcome indicators, and operationalize the levels of care designations, ensuring equity and access to the appropriate level of care centers. PNQIN anticipates weaving the Levels of Maternal Care (LoMC) concept into ongoing PNQIN initiatives to not only ensure its longevity but to safeguard the quality improvement-oriented approach. In addition, PNQIN and partners from the Betsy Lehman Center will participate in a site visit that will be facilitated by ASTHO with the objectives to (1) compare and contrast two states that have implemented LoMC through a voluntary versus regulatory framework; and (2) review best practices for hospital quality improvement site visits regarding LoMC.

 

Objective 4. By 2025, reduce inequities in rates of COVID-19 infection among birthing and lactating people of color by improving their vaccination coverage during pregnancy from 21.6% for Hispanic individuals, 21.5% for non-Hispanic Black individuals and 14.0% for non-Hispanic American Indian/Alaska Native/Other individuals to above 50.0% for these groups.

 

Surveillance for Emerging Threats to Pregnant People and Infants Network (SET-NET)

CBDRP will continue to routinely share COVID-19 surveillance data on pregnant people and their infants as part of SET-NET. While the cohort is restricted to pregnant people with infections during 2020-2021 and, thus, has been completely ascertained, data from medical record abstraction continue to be updated and shared. In addition, CBDRP will continue to assist in the hepatitis C surveillance arm of SET-NET, by linking hepatitis C data to vital records and conducting medical record abstractions for identified cases. CBDRP will build upon their established collaboration with the Bureau of Infectious Diseases and Laboratory Sciences by having quarterly meetings to discuss the intersection of MCH populations and infectious diseases. Through this partnership, both will work to bolster preparedness efforts to ensure that the public health response to emerging infections meets the needs of MCH populations.

 

In addition, MA SET-NET will continue contributing to national-level studies and analyze their state-level data, carrying out their multistate study examining the risk of stillbirth associated with SARS-CoV-2 infection during pregnancy and an analysis examining the association between newborn hearing loss and SARS-CoV-2 infection during pregnancy. All analyses, both currently underway and yet to be designed, will center racial equity, stratifying analyses by race/ethnicity and exploring structural factors that contribute to any observed inequities.

 

MA SET-NET will continue to link birth certificate data with COVID-19 vaccination data from the Massachusetts Immunization Information System (MIIS) to examine COVID-19 vaccination uptake among pregnant and recently postpartum people. Findings from the descriptive, disaggregated analysis of COVID-19 vaccine uptake among pregnant people by race/ethnicity have been summarized in a MMWR Weekly Report currently under review and scheduled for publication in September 2024.   

 

Community Evaluators

The first cohort of Community Evaluator projects will be wrapped up and findings will be translated into a report with recommendations for MDPH. The second cohort of projects will be executed and, together, both cohorts of projects will help MDPH better understand the effects of COVID-19 on MA residents disproportionately impacted by the pandemic. (See MCH Data Capacity Efforts section for information on Cohort 2 projects)

 

PRAMS

Both COVID-19 and COVID-19 vaccine supplemental data collection and analysis is ongoing, and a fact sheet is planned. Findings will be shared with community stakeholders, and clinicians through PNQIN to inform vaccination promotion for COVID-19 and future emerging threats.