National Performance Measure #1: Percent of women, ages 18 through 44, with a past year preventive medical visit

 

Evidence Based or Informed Strategy Measure: Percentage of women who receive preconception counseling and services during an annual reproductive health (preventive) visit at family planning clinics (Title X)

 

Objectives:

 

• By July 1, 2021, increase the utilization of Long-Acting Reversible Contraception (LARC) from 18% to 22%
• By July 1, 2020, all Title X Family Planning clinics will have at least one staff member proficient in LARC insertion
• By July 1, 2021, preconception counseling and services will increase from a baseline of 25% to 40%

 

Strategies:

 

• Conduct outreach and education through community partners to inform the public on the importance of preventive care for women
• Provide the public with information and resources for obtaining access to women’s healthcare
• Provide resources and professional trainings to contracted agencies to enhance agency capacity and staff skills related to providing preventive services for women, which include contraceptive management and preconception health services
• Conduct professional trainings to contracted agencies on utilization of LARCs and LARC insertion
• Collaborate with NH Governor’s Commission on Alcohol & Drug Abuse, Perinatal Substance Exposure Task Force, to increase access to LARCs for women at risk for substance misuse

 

 

The MCH section and its sub-recipients continue to strive to provide the best possible health services to all individuals statewide, especially targeting low-income women. Through an active collaboration between primary care services and family planning, MCH has sought to improve access to these essential health services, to provide preconception counseling and access to a broad range of contraceptive methods including Long Acting Reversible Contraceptives (LARCs). MCH and the Family Planning Program (FPP) plan to continue to improve the access to these essential services.

 

The FPP has and will continue to promote the elimination of barriers to access to LARC methods among its sub-recipients. LARC methods include IUDs and implants; these methods are proven to be the most highly effective in preventing pregnancy for women of all ages.

 

In January 2018, NH Medicaid updated its reimbursement policies to permit the insertion of IUDs and implants immediately following a delivery or prior to discharge, as a separately identified and paid family planning service. Since this policy change, this benefit has been utilized but not at the anticipated rate. After examination, it was determined that there are billing challenges and a lack of knowledge of the benefit on the part of providers and hospital administrators. This has resulted in a low uptake and challenges that MCH and Medicaid did not expect. MCH and FPP plants to continue to collaborate with NH Medicaid on providing education and trainings on access to post-partum LARC methods. These collaborative efforts will help improve access to LARCs immediately after birth and remove the barrier of waiting until the first post-partum health visit for contraception.

 

In 2019 among FPP contracted sub-recipients, LARC methods had a 29.5% utilization rate among women 15-44 years old, comparable to other states in the country. A goal of the FPP is to increase the availability of LARCs and not necessarily encourage high rates of utilization. High utilization may be the result of coercive practices, according to the Office of Population Affairs.[1] The FPP monitors access to methods during site visit reviews and assesses what LARC methods are available for same-day insertion. Having LARCs available for same-day insertion decreases barriers associated with receiving this method of contraception, such as transportation and childcare.

 

Despite not aiming to increase the utilization of LARCs, the FPP plans to have the family planning medical consultant provide an educational training on the importance of providing access to LARC methods and eliminating barriers for LARC methods for adolescents. This training will take place either in-person at a mandatory sub-recipient directors’ meeting or by webinar. The FPP continues to promote and share available LARC trainings, as the National Clinical Training Center for Family Planning (NCTCFP) provides this training for free around the country annually. And by July 1, 2020, all FPP sub-recipients have at least one clinical staff member who is proficient in LARC insertion and removal.

 

In addition to provider capacity, another challenge to LARC utilization is the cost associated with the devices, as there are insufficient reimbursement mechanisms as well as administrative barriers for community health centers wanting to offer them. This poses challenges for sub-recipients who cannot pre-order devices for same-day insertions. For some FPP clients, in particular those without health insurance, these costs are prohibitive and lead to utilization of less effective methods. This consequently can result in unplanned pregnancy. The FPP promotes the use of the Liletta IUD as a cost-effective LARC method; the device cost is $100 for sub-recipients who are enrolled in the HRSA 340B Drug Pricing Program. The program plans to investigate creative means to reimburse providers fully for same-day LARC insertions.

 

MCH contracted sub-recipients will continue to provide their local communities with information and resources to access women’s preventive and preconception healthcare services. Community outreach and education will be shared with community partners and with the general public to increase knowledge of the importance of preventive and preconception health care for women. The FPP will also continue to promote awareness of family planning services and the importance of preconception health and adequate birth spacing through their social media and community tabling events.

 

The FPP program’s new health promotion advisor, along with the FPP program manager, will conduct a webinar training on outreach strategies for FPP sub-recipients. This training will include how to incorporate effective outreach and education strategies that include weaving social media into current marketing efforts and utilizing social marketing campaigns to increase reach.

 

The PREP program will continue to promote the availability of family planning services and continue to provide education on the importance of reproductive and sexual health services. The program will utilize the federal Performance Monitoring Dashboard as a resource for assessing ongoing trends and program improvement needs. The NH six month follow-up survey will be analyzed to provide further program-specific evaluation information. A Tableau (data visualization) dashboard may be designed to streamline interactive utilization of the data. Additionally, due to COVID-19, the PREP program’s cohorts have gone online. The program will run its cohorts on a virtual platform, as meeting in groups and/or meeting in schools is prohibited at this time, to maintain social distancing. The pre and post surveys will be completed online, eliminating barriers that exist with mailing which may partly account for poor response rates on previous surveys. The program anticipates continuing to offer virtual cohorts as PREP coordinators have cited transportation challenges for many adolescents. This will also allow the sub-recipient who serves rural youth to have cohorts of adolescents from different towns participate together. The program anticipates that this may increase the number of youth who participate in the program. The PREP manager will continuously evaluate this new way of delivering the program.

 

*   *   *   *   *   *   *

 

National Performance Measure #14.1: Percent of women who smoke during pregnancy

 

Evidence Based or Informed Strategy Measure: Number of calls received by the New Hampshire Quitline in the past year

 

Objectives:

 

• By July 1, 2021, decrease the percentage of women who smoke during pregnancy to 22% or less among deliveries paid by NH Medicaid.
• By July 1, 2021, decrease the percentage of women who smoke during pregnancy to 3.5% or less among deliveries not paid by NH Medicaid.
• By July 1, 2021, all of the MCH-funded CHCs will have referral sources documented along with follow-up for patients who smoke, in their electronic medical records.

 

Strategies:

 

• Increase the utilization of QuitWorksNH and QuitNow-NH through education of health care providers and citizens.
• Facilitate enrollment into tobacco treatment programs by making referrals for both providers and clients easier (e.g. electronic two-way system).
• Professional education on best practices in tobacco treatment through online e-learning modules.

 

 

Screening and Counseling for Pregnant Women in the Community Health Centers (CHCs)

 

The collaboration between MCH and the NH Tobacco Prevention and Cessation Program (TPCP) will continue through the coming year. The majority of the prenatal clinics associated with the Community Health Centers (CHCs) are successfully screening for smoking in pregnant women during each of the three trimesters and referring as appropriate. Those who are not achieving targets for this measure are required to research the barriers to achieving success and determine what changes may lead to improvement. As part of the effort to assist in overcoming barriers, the Perinatal Nurse Coordinator will continue to provide educational materials for providers (Module 5, discussed below) and for patients (in collaboration with the TPCP).

 

MCH Specific Activities

 

MCH and TPCP will continue to provide information to women who are pregnant or parenting about the short- and long-term effects of smoking. The focus on educating mothers will be through the DPHS social media platform. NH DPHS currently has an active presence on Facebook, Twitter and Instagram. Social media provides the opportunity to share information regularly and provides an opportunity to reach a specific audience. Data from the NH Pregnancy Risk Assessment Monitoring System (PRAMS) reveals the potential impact for education with this technology. The 2018 NH PRAMS data show that when seeking information on pregnancy issues, over 50% of women use social media such as Facebook or Twitter, 59% use cell phone applications and some 96% use internet searches. This mode of dissemination of information carries the potential for information to be “shared” from viewer to viewer and therefore the ability to reach a larger audience is enhanced.

 

In order to encourage patients to think about quitting smoking, providers must be motivated to give the necessary information to patients. NH PRAMS data from 2018 show that 98% of women report that healthcare worker asked them during a prenatal visit if they were a smoker. The 2018 data on healthcare workers’ assistance to quit smoking during a prenatal visit shows that 66% of women reported that there was discussion on how to quit, an increase from 47% in 2016. In addition, 32% received a referral to a national or state Quitline in 2018, an increase from 18% in 2016. Provider recommendations for the use of a nicotine patch increased from 18% in 2016 to 39% in 2018 while recommendations for the use of nicotine gum increased from 12% in 2016 to 27% in 2018. While these are significant increases there is still considerable opportunity for improvement in the area of healthcare workers’ addressing patients’ opportunities and aids for quitting tobacco use.

 

Module 5

 

The provider education module developed by the TPCP through funds from MCH and the March of Dimes will continue to be available to providers through the NH Quitline. Module 5 covers the negative impacts of smoking before, during, and after pregnancy. The module also addresses smoking around the subject of breastfeeding. The goal of this pregnancy module is for the viewer to understand the health and economic challenges of low-income women who smoke while pregnant, and to help tailor strategies to meet their specific needs and circumstances. Additionally, the viewer will understand the high prevalence of postpartum relapse among those who quit during pregnancy, and the effect this may have on continuation of breastfeeding. The module promotes the use of motivational interviewing to discuss smoking and teaches providers how best to refer, follow, and assist the patient through quitting.

 

The percentage of women smoking during pregnancy has been gradually decreasing over time. By assisting providers with techniques for encouraging patients to be smoke-free, the number of women offered counseling and assistance should increase, resulting in a continuation of this downward trend in smoking during pregnancy. The five educational modules have the ability to be paused, giving flexibility to accommodate hectic clinic schedules. Each module has an evaluation at the end, and staff who complete the evaluation are eligible for free continuing education credits. The modules will continue to be promoted for use by providers and staff on an ongoing basis through professional newsletters and regular meetings including the Northern New England Perinatal Quality Improvement Network (NNEPQIN), the Governor’s Task Force on Perinatal Substance Exposure, Primary Care meetings, and through collaboration with the WIC program.

 

Collaborations

 

In addition to working closely with the TPCP program, the Perinatal Nurse Coordinator is an active member of NNEPQIN, the Governor’s Task Force on Perinatal Substance Exposure, and is the coordinator of the NH Maternal Mortality Review Committee (MMRC). Collaboration with each organization will enhance ongoing work on disseminating educational opportunities for healthcare staff working with the perinatal population. Through these committees, MCH will continue to contribute to efforts to reduce smoking and other substance use among pregnant women by continued involvement in related projects and emerging issues on perinatal health. The Perinatal Nurse Coordinator will continue to collaborate with TPCP through the coming year in order to increase providers’ and the public’s knowledge of QuitNow-NH and the evidence based methods to assist women to quit prior to or during pregnancy. This Evidenced Based Strategy Measure will be discontinued at the end of this coming year and replace with the following new measure.

 

ESM#14.1 (new measure for 2020-2025) The percentage of postpartum women whose infant was monitored for the effects of in utero substance exposure who had a documented Plan of Safe/Supported Care (POSC).

 

Objectives:

• By July 1 2021, increase the percentage of postpartum women whose infant was monitored for the effects of in utero substance exposure who had a documented POSC from a baseline of 49% in SFY20 to 60% in SFY21.
• By July 1 2022, increase to 70%.
• By July 1 2023, increase to 80%.
• By July 1 2024, increase to 90%.
• By July 1 2025, increase to 95%.

 

Strategies:  

• The MCH Perinatal Nurse Coordinator will collaborate with the NH Maternal Infant Early Childhood Home Visiting (MIECHV) Program as it initiates learning opportunities about the NH POSC for home visiting providers, including the advantage the POSC can offer families in understanding the available and appropriate services to meet their needs.
• The Maternal Mortality Review (MMR) Coordinator will monitor the number of maternal deaths in NH related to or caused by substance misuse in which the mother and provider had developed a POSC.
• Through the Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM) Grant the NH MMR Coordinator and the MCH Epidemiologist will work with NNEPQIN to initiate the Alliance for Innovation for Maternal Health (AIM) bundles into NH hospitals. 
• The Perinatal Nurse Coordinator is a member of the Governor’s Task Force for Perinatal Substance Exposure, which is a multidisciplinary group that developed the NH POSC template and will continue to be involved in POSC work in collaboration with the task force.

 

Substance use has been on the rise nationally for many years and while the opioid epidemic has been of particular concern, other substances also continue to affect the health and well-being of women, their infants, and their families. In 2018 over 5% of pregnant women used illicit drugs, approximately 12% used tobacco, and 10% used alcohol during pregnancy.[2] The number of infants diagnosed with neonatal abstinence syndrome (NAS) in NH increased from 52 in 2005 to 269 in 2015. By 2015, at least 2.4 % of live births in NH had a diagnosis of NAS while 7.8% of those born to NH women at Dartmouth Hitchcock Medical Center were diagnosed with NAS.[3]  As described by the CDC Levels of Care Assessment Tool (LOCATe) webpage, pregnant women at high risk for complications should receive care at birth facilities that are best prepared to meet specific health care needs. Dartmouth Hitchcock cares for mothers with high risk pregnancies and has a high level Intensive Care Neonatal (ICN) unit in the State.[4]

 

As the tobacco focused ESM for the number of calls received by the NH Quitline will be phased out in 2020, this new ESM on substance use disorders, including tobacco, and specifically the POSC will address a significant and many faceted issue facing NH women and their families. The POSC model provides consistency in the resources offered to mothers with substance use disorders (SUD) by providers and healthcare workers statewide. The NH POSC template offers the guidance to address this issue consistently and on an individual level for each woman challenged by substance use and her family. A completed POSC signifies that there has been collaboration between the patient with SUD and a provider or other designated healthcare worker. This provider or other healthcare worker allotted the time to discuss the POSC and the resources that it offers. This time spent also allows a better understanding of that woman’s view of herself, including her perceived strengths and weaknesses, and her vision for her future.

 

This ESM, reporting on the percentage of postpartum women whose infant was monitored for the effects of in utero substance exposure who had a documented POSC, will provide an estimate of the number of women with SUD who were provided the opportunity to learn about and be linked with the local resources and supports available to them in the area in which they live. Ideally this POSC is provided in the obstetric setting and follows the mother to the hospital of delivery and finally to the pediatric provider. This process allows the patient and all providers to understand the resources that the patient has chosen as the most beneficial to her family.

 

New Hampshire Plan of Safe Care – Background

 

The Federal Comprehensive Addiction and Recovery Act of 2016 (CARA) amended the Child Abuse Prevention and Treatment Act (CAPTA) to require the development of a Plan of Safe Care (POSC) for all infants affected by prenatal drug or fetal alcohol exposure. New Hampshire law (132:10-e, on Plans of Safe Care, and 132:10-f on Mandatory reporting), in compliance with federal law, requires that “when an infant is born identified as being affected by substance abuse or withdrawal symptoms resulting from prenatal drug exposure or a fetal alcohol spectrum disorder, the health care provider shall develop a plan of safe care, in cooperation with the infant's parents or guardians and the department of health and human services, division of public health services, as appropriate, to ensure the safety and well-being of the infant, to address the health and substance use treatment needs of the infant and affected family members or caregivers, and to ensure that appropriate referrals are made and services are delivered to the infant and affected family members or caregivers.”

 

With the goal of creating a model POSC for use in NH, which meets the requirements of the federal and state laws, a stakeholder group convened to develop a framework and an effective POSC document. The Perinatal Substance Exposure Task Force of the NH Governor’s Commission on Alcohol and other Drugs led this group, which included partners from a variety of healthcare organizations and community resource providers across the State who were already actively involved in addressing substance use disorders in pregnant and parenting women. Partners include the NH Division of Public Health Services, NNEPQIN, NH DCYF, NH Bureau of Drug and Alcohol Services, and the UNH Institute for Health Policy and Practice among many others.

 

Ideally created during pregnancy, the POSC is a living document for use through the pregnancy and after the birth of the infant. The intention of the POSC is to establish ongoing collaboration between the mother, her health care provider, and any other appropriate support professionals. The hospital or birth center provides a complete POSC copy to the mother upon discharge. The POSC is also included in the infant discharge paperwork sent to the primary care provider of the infant. The POSC is a tool to coordinate existing supports and referrals to new services, to support the safety and well-being of the infant and family. Mothers with SUD who stay connected to services and resources increase the opportunity for success in treatment. Every mother should be encouraged by her provider to share her POSC with any organization that is providing support, as for example, home visiting or Women, Infant and Children’s (WIC) services. In NH, providers are encouraged to develop a POSC for all mothers and infants, regardless of substance use status, as a best practice to ensure the safety of all infants and to facilitate supportive follow-up with all mothers.

 

The perinatal period is an opportune time to address issues related to substance use for women. Due to frequent contact with patients during pregnancy, providers have multiple opportunities over many months to build a trusting relationship with a woman and assess the potential for prenatal exposure to substances, a woman’s readiness to address substance use, and to begin planning for the safety of the infant after birth. Pregnancy can be an ideal time for behavior changes based upon concern for the health of the baby, especially with appropriate and consistent support. This is the time to help a woman challenged by substance use to find her strengths, encourage her to use them with the support of her provider, and connect her with available resources.

 

Key elements in creating and maintaining a POSC with a woman are trust, consistency, and connections with appropriate supportive resources. This effort requires not only the input from a variety of organizations across the State but educating all of those professionals and other support individuals involved in the care of the mother and infant about the laws, process, and resources for creating an effective POSC. The Governor’s Perinatal Exposure Task Force took on this challenge and brought together the necessary stakeholders to develop the plan that provided NH with the best process for the providers and women of the State.

 

 

This featured diagram above was developed through this group in order to clarify for providers when a POSC is required. The diagram also shows how the development of the plan relates to the necessity for reporting to DCYF. The diagram explains to providers at the hospital level who should be aware of the POSC for a mother in order to provide follow up. The form will move through a number of steps beginning with the identification of a pregnancy in which the infant may be affected by substance use. This a living document that is ideally begun with the prenatal provider and will then become a part of the mother’s prenatal record that arrives to the hospital in anticipation of delivery. Prior to the passing of CARA and the subsequent development of the POSC model for NH, there had not been a reliable and consistent statewide system for identifying those infants at risk due to prenatal substance exposure. Initially some neonatal abstinence syndrome (NAS) data could be captured in the hospital discharge data, however different hospitals coded the diagnoses differently so there was no consistency or reliability in this data. The birth certificate data questions around POSC related to this new measure will help to understand the number of women who have developed a plan and therefore has had a a discussion about resources in their area with a provider.

 

MCH Activities

 

In July 2018, a second phase of prenatal opioid exposure data collection and monitoring for NAS began through the Situational Surveillance Module created by the Division of Vital Records Administration (NH DVRA). Situational surveillance allows for the temporary addition of questions to the birth certificate form used by all birth hospitals in the State. The data below is for the period from January 1, 2019 through December 31, 2019.

 

Situational Surveillance Notification Questions, January 1-December 31, 2019
Exposure Aim: Determine the number of infants exposed to opioids in utero.	Concern Aim: Determine the number of infants considered to be at risk for withdrawal by the medical team.
Was there documented opioid exposure at any time during the pregnancy?   3.6% (400/11,236)	Was the infant monitored for signs of opioid withdrawal or neonatal abstinence syndrome (NAS)? 3.2% (359/11236)

 

As the NH POSC model was evolving, a birth data quality workgroup that included stakeholders from birth hospitals, the Perinatal Substance Exposure Task Force, the NAS Collaborative, and colleagues at NH DVRA and NH DCYF along with the NH MCH Epidemiologist worked to revise the questions used in the situational surveillance. The situational surveillance questions were deactivated in April 2020 to make room for COVID‑19 questions. The revised questions are now permanently located in a (new) third page of the NH Facility Worksheet for Live Birth.

 

Revised Questions Perinatal Substance Exposure Questions Added to the birth certificate April 29, 2020
Prenatal Substance Exposure 82A.Was the infant monitored for effects of in utero substance exposure?    Yes     No If YES, Type of substance(s): (check all that apply) opioids stimulants (amphetamines, methamphetamines,    other) cocaine cannabis benzodiazepines barbiturates alcohol nicotine bath salts Kratom Other (Specify)	To determine clinical concern relating to in utero substance exposure. Stakeholders with expertise in SUD recommended the list of substances. The choice of “other” was added in case of new and emerging substances of concern.
82B.Was the infant identified as being affected by substance misuse or withdrawal symptoms resulting from prenatal drug exposure, or a Fetal Alcohol Spectrum Disorder?    Yes     No	Uses language directly from the CAPTA legislation (with a change of “abuse” to “misuse”) in order to meet the federal reporting requirement.
83. Was a Plan of Safe/Supportive Care (POSC) created?    Yes     No	Relates directly to the metric required in the new Evidence-based Strategy Measure (ESM).

 

 

Provisional data from Item 83 show that in the six (6) week period from end of April through mid-June 2020 nearly half of women who gave birth to an infant who was then monitored for the effects of in utero substance exposure did in fact have a documented POSC.

 

The NH MCH section has significant resources and the capacity to play a key role in promoting and monitoring the use of the POSC across the State. The Perinatal Nurse Coordinator is an active member of several groups involved in planning and implementing the POSC including the Governor’s Task Force for Perinatal Substance Exposure Taskforce, NNEPQIN, and the NH Maternal Mortality Review Committee (MMRC). The NH Maternal Infant Early Childhood Home Visiting (MIECHV) Program reports that some home visiting agencies have added the POSC discussion to the work that they do with pregnant and postpartum women. If a POSC has not been developed the home visitors use the template and create one with the mother. If the home visitor determines that the mother is interested in particular services, the home visitors will work with the family to connect them to those resources. This would be similar to the way that a prenatal provider that completes the form with the mother would refer the mother to the requested services.

 

The Governor’s Task Force for Perinatal Substance Exposure

 

The Perinatal Nurse Coordinator is an active member of this group. The NH Center for Excellence has been working with the Task Force to coordinate efforts around the opioid epidemic. As mentioned previously, one aspect of this work is the development of a model for the POSC. This has been a well-organized collaborative effort with significant input from stakeholders including NH DHHS, OB-GYN providers, pediatricians, hospital staff, mental health providers, legal professionals, NH DCYF, and experts in the field of substance use disorders, among others. A conference in January 2019 titled Optimizing Care for Mothers & Babies Affected by Prenatal Substance Exposure: Summit to Address Plans of Safe Care in New Hampshire served as a kickoff for the use of the NH POSC template. The conference covered education about CARA/CAPTA, examples of the use of the POSC template, legal understanding of the POSC and discussion of ongoing support through a webpage hosted by the NH Center for Excellence, dedicated to the POSC information for NH. The webpage includes links to organizations and resources for providers and families as well as access to the template, a living document.

 

In February 2020, the NH Perinatal Nurse Coordinator gave a presentation at the Dartmouth Pediatric Conference highlighting the connection between case findings of the MMRC and the need for recommendations for developing a POSC in order to connect mothers to needed services. The title of the conference was Contemporary Issues in Office Pediatrics. The primary cause of maternal deaths in NH from 2016‑2019 is substance use related. With this in mind, the development of a POSC for pregnant women and the potential to make improvements around maternal mortality and morbidity in NH was the theme of the presentation. The work of the MMRC is anticipated to evolve and provide new opportunities to integrate findings of the MMRC with POSC efforts. The Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM) Grant awarded to the NH MMR Program that began in September 2019 will provide connections to POSC work and decreasing maternal morbidity and mortality. If a POSC can be developed with all mothers experiencing SUD, community resources will be offered and if utilized, could make a positive difference for the future for that mother and family.

 

The MMRC Connection

 

Beginning with the maternal death cases that occurred in 2018, as the work around the POSC was actively moving forward, the MMRC Coordinator began to request infant records as part of the review of all maternal deaths that were associated with substance use. The intent of the request is to assess the infant’s chart for a POSC. The infant charts of those mothers who have developed a POSC with their provider should contain a copy of the plan. The desire to include the POSC in the pediatric record is to ensure that all professionals caring for the mother-child dyad are aware of the resources that the mother has named as relevant to her and requested by her. In the case of maternal death of a mother who did have a POSC some relevant questions are:

 

• Can it be determined whether the mother obtained the services that she saw as beneficial to her family?
• If this mother never pursued beneficial resources, is there a known reason why she was not able to do so?
• Could a recommendation be made that would lead to a positive outcome for other women?

 

The baseline for the ESM regarding a documented Plan of Safe/Supported Care is 49%. This baseline was established from a small data set from new questions added to the NH birth certificate data beginning in 2020. Going forward, the MMRC Coordinator will be requesting the pediatric record for the infant of any woman who died within one year of her pregnancy who had a substance use disorder. If the infant is found to have a POSC, the MMRC will be in a position to assess this POSC and develop appropriate recommendations through what is learned from the words of that mother.

 

Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM) grant

 

A new grant from the CDC, entitled Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM), began in September of 2019 for a five (5) year period concluding in 2024. The NH MMR Program work plan includes several strategies to improve educational opportunities for women and providers. This will be through collaborative work with NH’s perinatal quality collaborative, NNEPQIN. A large part of the activities for year one (1) of the grant included the work to establish a contract with NNEPQIN, under the auspices of Dartmouth Hitchcock Medical Center.

 

NNEPQIN has been an important contributor to the NH MMRC process since its inception per RSA 132:29-31 in 2012. The ERASE MM grant and subsequently the contract has allowed the ongoing collaborative relationship to become even stronger. This grant has provided the ability to acquire an additional abstractor to work on maternal death cases. The abstractor will be working closely with NNEPQIN and the MMR Coordinator to collect records, abstract information and collaborate on preparation of the cases for presentation to the MMRC. The presence of the abstractor will allow more time for the MMR Coordinator to address the deliverables of the grant, the preparation of cases to be brought to the review committee and ultimately to address the drivers of maternal mortality and morbidity in NH.

 

A Maternal Mortality Recommendations Implementation Workgroup (MMRIW) was established. The workgroup consists of key participants of the MMR Program and NNEPQIN leaders. The group began meeting via Webex™ in June of 2020. The NH MMR Program is in the process of starting a number of initiatives with NNEPQIN in compliance with the ERASE MM grant. The focus of the grant work is to initiate action upon the drivers of maternal death in NH. Each of the projects that NNEPQIN is managing, through the contract, touches upon an aspect of the past and present recommendations that the MMRC has developed through review of maternal death cases.

 

One of these projects includes an application for NH to become a state participating in the Alliance for Innovation on Maternal Health program. AIM is a national alliance to promote consistent and safe maternity care to reduce maternal morbidity. The evidence- based AIM bundles for maternal safety include clinical aspects of maternal care as well as mental health and social aspects of pregnancy. In NH over the past three years, the clear driver of maternal death is substance use disorders (SUD), often with documented mental health concerns in the past. The intent is to address the postpartum period for women with SUD in order to decrease maternal morbidity and mortality in this population. The close involvement in NH of NNEPQIN with MCH staff is integral in developing action plans around recommendations developed from the MMRC meetings. Because of the high percentage of maternal death due to overdose, the MMRIW made the preliminary decision to put focus on three main AIM bundles that will begin to address the recommendations that the MMRC meetings have developed. These are:

 

 Maternal Mental Health: Depression and Anxiety

 Obstetric Care for Women with Opioid Use Disorder (+AIM)

 Postpartum Care Basics for Maternal Safety 

 

Another project with NNEPQIN is the initiation of the AWHONN Post Birth Warning Signs education program in our NH hospitals. The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) has developed this postpartum program to encourage mothers to know the signs of postpartum complications and to be reassured that it is important to act on the signs and to seek medical care. The ERASE MM grant made it possible for the MMR Program to purchase the toolkits necessary to train nurses to provide education regarding signs and symptoms of problems in the postpartum period. The MMR Program plans to use the material developed by AWHONN to educate women and families about paying attention to symptoms, even in women with no health issues prior to or through the pregnancy.

 

NH currently has seventeen birth hospitals and all are members of NNEPQIN. Each hospital will have a designated administrator of the AWHONN education material and NNEPQIN has named a colleague to oversee the initiation of the program in hospitals. The designee will work with the MMR Coordinator to answer questions about the program and troubleshoot issues. This program provides knowledge to all postpartum women regardless of medical or mental health history. The program is appropriate to mothers of any socioeconomic status, race or ethnicity. Understanding what is normal and what is concerning in the postpartum period and how to appropriately explain the issue increases the health and wellbeing of our postpartum mothers. There will simultaneously be efforts toward public awareness through social media postings..

 

Social Media

 

The use of social media provides a readily available tool to share information with the public. The MMR Coordinator will utilize social media as per the work plan for the ERASE MM grant. The social media sources that are available to NH DPHS programs at this time are Facebook, Twitter and Instagram. Over the next year, the MMR Coordinator’s focus on social media will be to educate the public on postpartum warning signs. Women who are aware of issues that can arise in the weeks and months after pregnancy will seek care in a timely manner when warning signs appear. Additionally, by using social media there is a greater opportunity to share the information widely. Social media consumers who find a post important to themselves are likely to “share” it with friends and family. The MMR Coordinator will revise and update the MCH perinatal webpage to include information on resources and supports available in NH.

 

Data visualization

 

Additional Tableau server dashboards will be constructed to expose the data fields from birth and fetal death data needed for MMRIA data entry. The potential to construct Tableau dashboards using standardized MMRIA data extracts will be explored. This work will include collaboration with colleagues both in NH and across the country.

 

 

[1] https://www.hhs.gov/opa/performance-measures/long-acting-reversible-contraceptive-methods/index.html

[2] https://www.samhsa.gov/data/sites/default/files/reports/rpt23250/5_Women_2020_01_14_508.pdf

[3] Smith, Kristin, “As Opioid Use Climbs, Neonatal Abstinence Syndrome Rises in New Hampshire”, The Carsey School of Public Policy, University of New Hampshire, 2017.

[4] “CDC Levels of Care Assessment Tool (CDC LOCATe).” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 29 May 2019, www.cdc.gov/reproductivehealth/maternalinfanthealth/cdc-locate/index.html.