Massachusetts has three priorities for Women’s and Maternal Health for 2020-2025.

1. Reduce rates of and eliminate inequities in maternal morbidity and mortality.
2. Prevent the use of substances, including alcohol, tobacco, marijuana and opioids, among youth and pregnant women.
3. Strengthen the capacity of the health system to promote mental health and emotional well-being.

 

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

 

Since 1997, MDPH has convened the Maternal Mortality and Morbidity Review Committee (MMMRC) to review maternal deaths, study the incidence of pregnancy complications, and make recommendations to improve maternal outcomes and eliminate preventable maternal death. Understanding the causes of these deaths provides insight into the factors that contribute to maternal morbidity and mortality. The performance measure for this priority tracks efforts to improve the timeliness of the review process and the efficiency with which review findings can be translated into strategies to address inequities in maternal health outcomes.

 

Objective 1 (SPM 1). By 2025, the MMMRC will increase the percent pregnancy-associated deaths that are reviewed within two years of occurrence from 0% to 25%.

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

Current statute allows MDPH to request birth and death records, but does not authorize the MMMRC to access other medical sources of data. Specifically, critical records that are not consistently available are autopsy reports from the Office of the Medical Examiners, prenatal care records, and other medical reports such as outpatient, emergency department and Emergency Medical System records, including reports from first responders or emergency medical technicians. MDPH plans to update the current MA legislation to provide legal authority to access additional relevant data sources and to expand Committee membership to include community members impacted by maternal mortality and morbidity. MMMR staff are comparing regulations in other states to assess how to strengthen the MA statute. With the national and state focus on maternal mortality, several community stakeholders, including March of Dimes, have been advocating for additional state legislation that would support and strengthen statutes pertaining to maternal mortality reviews. A stronger statute would enhance access to additional data sources, including outpatient records, autopsy records, and other pertinent medical records.

 

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

As discussed in the FY19 report, MDPH is working with CDC to establish an MOU so that CDC can host the MA MMRIA and provide IT support. Once this is in place and MMRIA data have been collected, MDPH epidemiologists will analyze the data to provide information to the public, clinicians and policy makers. Descriptive reports will include information on burden, causes, and distribution by age, race, ethnicity, and geographic area. These data also will be used to produce briefs that identify trends or highlight a particular issue, such as racial inequities or deaths related to hypertension. The data will be analyzed using a racial equity frame, to better contextualize the data in the setting of the broader historical and current policy and system factors that affect the health of communities. This will help the MMMRC to more effectively identify solutions to address root causes of the inequities.

 

Alliance for Innovation on Maternal Health 

PNQIN actively engaged birth hospitals across MA in implementing maternal safety bundles developed through the Alliance for Innovation on Maternal Health (AIM). AIM’s goal is to reduce maternal mortality and severe maternal morbidity and reduce racial disparities by working through state teams, to align state and hospital-level quality improvement (QI) efforts. Improving quality of obstetric care may improve both overall outcomes and reduce racial and ethnic disparities. PNQIN will implement relevant AIM bundles: Opioid, Obstetric Hemorrhage, Severe Hypertension in Pregnancy, and Reduction of Peripartum Racial/Ethnic Disparities. PNQIN will facilitate this collaborative QI project and serve as a liaison between the AIM national office and participating hospitals, providing guidance, education, and technical assistance to hospitals to support implementation of bundles using the QI process and submission of data to AIM. Implementation strategies are based on the Institute for Healthcare Improvement model for improvement and the AIM program implementation toolkit and have previously been used by PNQIN to implement the Obstetric Care for Women with Opioid Use Disorder AIM bundle in 22 hospitals.

 

Levels of Maternal Care

In January 2019, PNQIN convened a Task Force with members of diverse backgrounds, disciplines and geographic areas. The aims of the Task Force are to: 1) to administer, analyze, and interpret the CDC Levels of Care Assessment Tool (LOCATe) for self-assessment of maternal level of care at all MA obstetric units; 2) to explore the implementation of on-site assessments of hospitals for designation of level of care and linkage of LOCATe results with process and outcome indicators; and 3) to operationalize the levels of care designations and ensure equity and access to the appropriate level of care centers. The Task Force has three working groups to carry out these objectives: the LoCATe Working Group, the Site Visit Working Group, and the Implementation and Access Working Group. The LoCATe Working Group had planned to implement the LoCATe survey in late March 2020. However, because of shifting priorities related to the COVID-19 pandemic, this timeline has been delayed.

 

Two hospitals have notified MDPH about their intent to close this year, which will impact close to 700 women who give birth in these facilities. Falmouth Hospital provided MDPH with 90 day notice on 4/30/20 of its intent to close its pediatric and maternity unit. Holyoke Medical Center also provided MDPH with a 120 day notice on 5/29/20 of its intent to close its maternity service, and that it will file a 90 day closure notice, at which time MDPH will schedule a hearing.

 

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

 

Objective 1 (NPM 14). By 2025, reduce the percentage of women who report smoking during pregnancy from the baseline of 4.3% in 2018 (PRAMS) to 3.5%.

Title V plays an important role in preventing substance use during pregnancy, a critical period of development in the lifecourse. Smoking during pregnancy increases the risk of complications, such as preterm birth, and increases an infant’s risk for low birth weight and congenital heart defects. NPM 14 tracks progress on reducing tobacco use during pregnancy to mitigate the high mortality, morbidity, and economic costs attributed to tobacco use.  

 

The ESM for this NPM is the percentage of women using the statewide smoking quit-line who are pregnant, with a goal of increasing from 1.2% in 2019 to 6.2% by 2025. 1-800-QUIT-NOW provides free and confidential services in English and Spanish, and translation for other languages, by a trained quit coach to stop smoking. Quit coaches connect callers with quit-smoking resources through the caller’s community programs, and callers may be able to receive free nicotine replacement therapy. According to the Surgeon General’s report, “More than two-thirds of smokers say they want to quit, and every day thousands try to quit. But because the nicotine in cigarettes is highly addictive, it takes most smokers multiple attempts to quit for good…the evidence is sufficient to infer that proactive quit-line counseling, when provided alone or in combina­tion with cessation medications, increases smoking cessation…and the evidence is sufficient to infer that tobacco quit-­lines are an effective population-based approach to motivate quit attempts and increase smoking cessation.”[1]

 

PRAMS

Key strategies to address this priority over the next five years are to add specific questions to the PRAMS survey related to cigarette smoking/e-cigarette use/vaping during pregnancy to include all trimesters and to use PRAMS data to report on nicotine use during pregnancy and validate reporting of cigarette smoking on the birth certificate.

 

Since CDC has postponed the Phase 9 survey revision to 2023, MA PRAMS will work on adding questions through a PRAMS supplement including cigarettes/e-cigarettes (vaping) in the first and second trimesters of pregnancy (the current Phase 8 survey asks about smoking during the three months before pregnancy and the third trimester of pregnancy). MA PRAMS will begin this work in FY21 to implement the supplement in FY22. Data from 2022 will be examined in FY24.

 

PNQIN

PRAMS data will be shared with PNQIN at 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 has heard from several hospitals that they are now more systematically screening for use of these substances, with referrals as necessary. For tobacco and marijuana, responsibility mostly remains with the OB providers to provide counseling and offer adjuncts like nicotine patches or gum in the case of tobacco, and counseling about potential effects of marijuana on the developing fetus. Some hospitals have specific signage in their bathrooms in outpatient spaces about marijuana use in pregnancy and lactation.

 

For example, at Massachusetts General Hospital (MGH), they refer patients to their HOPE clinic (Harnessing support for Opioid and substance use disorders in Pregnancy and Early childhood). The HOPE clinic provides coordinated care for pregnant and parenting women with substance use disorder and their families. The goal of the HOPE clinic is to maximize patients’ ability to successfully navigate pregnancy, early parenting and substance use recovery. The Brigham and Women’s Hospital uses a standardized substance use screen across three clinics. In response to positive screens for marijuana, tobacco, alcohol, prescription opioid misuse, or other substances, nurses and/or physicians provide counseling using the 5As (Ask, Advise, Assess, Assist, and Arrange), schedule a social worker consult, refer to the MA Child Psychiatry Access Program for Moms (MCPAP for Moms), and/or share cessation flyers. MCPAP for Moms builds the capacity of providers serving pregnant and postpartum women to effectively prevent, identify, and manage mental health and substance use concerns by offering real-time consultation and care coordination and linkages with community-based resources.

 

PNQIN will work with hospitals that have strong screening and referral processes in place to engage additional hospitals, with the goal of increasing screening and referral to existing statewide support services such as the MDPH Tobacco Cessation Program.

 

MA MIECHV

In FY21, MA MIECHV will provide training on substance use, NAS, substance use screening, and trauma-informed practice, and all home visitors will routinely screen participants for substance use. Data on tobacco cessation referrals are 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 identified an opportunity for improvement with the performance measure and has worked to develop a toolkit to support home visitors with resources on tobacco cessation and strategies for having conversations with participants about tobacco use. MA MIECHV aims to disseminate the Tobacco Cessation Toolkit in FY21.

 

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

PRAMS

MA PRAMS will continue to use the current opioid supplement to collect marijuana use during pregnancy. The 2019 PRAMS data collection is ongoing and will be completed by July 31, 2020. Data from 2019 will be examined in FY21.

 

Since CDC has postponed the Phase 9 survey revision to 2023, MA PRAMS will work on adding questions through a PRAMS supplement 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). MA PRAMS will begin this work in FY21 to implement the supplement in FY22. Data from 2022 will be examined in FY24.

 

Center for Birth Defects Research and Prevention

In FY21, the Center for Birth Defects Research and Prevention will continue the Birth Defects Study To Evaluate Pregnancy exposureS (BD-STEPS), a population-based case-control study aimed at understanding the causes of birth defects and identifying potential risks for having a baby with a birth defect, including marijuana use. As part of the study women participate in an hour-long telephone interview on a wide range of topics, including but not limited to sociodemographics, medications used during pregnancy, illnesses in pregnancy, chronic medical conditions, treatments for infertility, physical activity, and occupational exposure. The interview includes questions on marijuana use during the first trimester of pregnancy. Women are specifically asked the route of marijuana use (e.g., smoke, vape, eat, consume drinks, dab, or other methods), the frequency of use, and the reason for use (e.g., relieve nausea/vomiting, relieve stress/anxiety, etc.). Women who participate in this study include 1) control mothers who had a liveborn infant with no birth defect and 2) case mothers who had an infant with one of the 23 eligible birth defects. Control women are randomly selected from the birth population and their responses reflect marijuana exposures in the MA birth population.

 

The Stillbirth Study was incorporated into BD-STEPS to leverage the existing study design to understand risk factors and interventions to reduce the occurrence of stillbirths. As part of this study, women whose pregnancies ended in a stillbirth and were not affected by a birth defect are recruited into the study and participate in the main interview, as well as a follow-up interview focused on risk factors for stillbirth. Women who participate in this study include 1) control women who had a liveborn infant with no birth defect and 2) case women who had a pregnancy that ended in a stillbirth (including stillbirths with and without a birth defect). Women in this study are asked the same questions on marijuana use as above. Given this is a population-based study, responses among the women represent those in the general population.

 

Fetal Alcohol Spectrum Disorders Task Force

Fetal Alcohol Spectrum Disorders (FASD) continues to be an invisible disability in MA. The main goal of the FASD Task Force, co-chaired by the Title V MCH Director, is to highlight this developmental disability and strategies to prevent FASD, support families with children diagnosed with FASD and support children, youth and young adults living with FASD. Over the next five years, the FASD Task Force will be reframed to have an explicit focus on prevention efforts in response to Title V needs assessment findings.

 

In FY21 the focus will be on developing educational materials for pregnant women who are at higher risk of drinking alcohol during pregnancy. The materials will be published and distributed through MDPH’s Bureau of Substance Addiction Services (BSAS). Additionally, the Task Force plans to develop tools, approaches and training for BSAS-licensed co-occurring substance use disorder treatment programs on how to work with clients who may have FASD. Task Force efforts will include as many stakeholders as possible, using remote technology as needed.

 

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

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

 

PRAMS

MDPH was awarded CDC funding for the PRAMS opioid supplement, opioid call-back survey at nine months post-delivery, and disability supplement. The disability and opioid supplements will continue in 2021 while the opioid call-back survey concluded in April 2020.

 

While there are rich programmatic and administrative data available in MA, there are not yet population-based survey data on opioid use and misuse before, during, and shortly after pregnancy. Therefore, the addition of a set of opioid supplemental questions to the PRAMS survey will allow MA to assess maternal behaviors and experiences related to the use of prescription pain relievers and other opioids and to understand their effect on the health of the mother and infant. It will provide a more complete picture of opioid exposure in the perinatal period, particularly among women who have not been diagnosed and treated for substance use disorder. The findings from the opioid supplement will be used to inform the Interagency Task Force on Newborns with NAS and Substance Exposed Newborns, whose charge is to assess existing services and programs in the Commonwealth for mothers and newborns with NAS, identify service gaps, and formulate a cross-system action plan for collecting data, developing outcome goals, and addressing service and support gaps in the Commonwealth. 

 

MDPH received the 2019 PRAMS opioid mini-dataset (containing five months of data) in January 2020. Since preliminary analyses showed that there were a small number of women reporting opioid use during pregnancy, MDPH will wait to receive the full year of 2019 PRAMS data to conduct additional analysis. This will allow for a better estimate of the annual prevalence of opioid use disorder among pregnant women. Starting in May 2020, BSAS is providing additional funding to support the ongoing opioid supplement data collection.

 

Birth Defects Monitoring Program

In FY21, the Birth Defects Monitoring Program (BDMP) will pilot the inclusion of NAS as a reportable condition to the program, thus creating a population-based active surveillance system for NAS. By leveraging an established active surveillance system, the BDMP will be able to provide accurate, reliable and timely estimates and trends of the incidence of NAS. These data will be used to inform optimal care, improve associated health outcomes, identify disparities, help develop targeted plans for mothers and infants, assess the immediate and potential long-term needs of infants with NAS and their mothers, and ensure proper allocation of resources.

 

Essentials for Childhood

With supplemental funding from the CDC to develop strategies to reduce child abuse and neglect for families affected by Opioid Use Disorder (OUD), Essentials for Childhood (EfC) staff designed the Essentials for Community Connection (ECC) strategy. EfC coordinated with communities implementing FIRST Steps Together, a home visiting program for pregnant and parenting families with OUD using peer recovery coaches to provide parenting support. The goal of ECC is to create partnerships in communities between families in recovery and service providers to develop a community perinatal opioid action plan for families with OUD. This includes a three part process: 1) engaging with families with OUD and in recovery in a Network Mapping exercise that examines the community continuum of care from the family perspective;

2) engaging with community leaders and providers to complete a systems mapping exercise to define the community response to opioid and substance use; and 3) convening a community Perinatal Opioid Coalition to develop an action plan that includes multiple perspectives and could serve as a community Plan of Safe Care. 

 

In FY20, EfC completed the Network Mapping with communities, but cancelled the meeting with providers and the workshop to create the community plan because of the COVID-19 pandemic. In FY21, the ECC strategy will be completed, documented, and included in the EfC Community Toolkit (described relative to the mental health and emotional well-being priority) as a model for other communities. 

 

Moms Do Care 

In FY21, MDPH plans to use the next round of State Opioid Response Funding to continue to fund the six original Moms Do Care (MDC) sites and to expand the eligibility to include women with stimulant use disorders. MDPH will continue to assist the seven MDC sites to sustain the peer-led care integration and system change initiatives while also exploring fiscal sustainability after the grant funding has ended. As such, MDPH will continue to work with MassHealth to develop a reimbursement plan for this regional model of integrated wrap-around support for this population.

 

The Journey Recovery Project

In FY21, there will be content expansion of this interactive, web-based resource for pregnant and parenting women who are in recovery or who have questions or concerns about substance use. The new content will focus on the developmental stages of a young child and tips for parents on how to balance parenting and recovery at each developmental stage. A new facilitator’s guide to using the Journey Project in group settings will be printed and disseminated.

 

Plans of Safe Care

In FY21, training and technical assistance will be provided to support MA residents and providers to develop and utilize Plans of Safe Care for substance affected families. The Journey Recovery Project Birth Planning Kit for pregnant women affected by substance use will be completed and be available to Massachusetts residents through the Health Promotion Clearinghouse. This resource provides a walk-through guide of the perinatal process, with worksheets, organizational tools, and resources to help with the Plan of Safe Care process.

 

Intra-agency Pregnant and Parenting Women Opioid Workgroup

A number of workgroups were established in FY20 by the MDPH Commissioner which reflected the priority populations affected by opioid misuse. This included a workgroup on pregnant and parenting women, led by BFHN staff. Deliverables from FY20 helped to guide the continuation and expansion of FIRST Steps Together and Moms Do Care, reflected above. In FY21, the workgroup will continue to meet in order to identify gaps in services and data collection, coordinate efforts across bureaus, and provide guidance for future initiatives for the MCH population.

 

Safe Sleep and Substance Use

The Safe Sleep Task Force will update the MDPH Safe Sleep fact sheet, and is planning a Safe Sleep training for home visitors, including how to do remote safe sleep audits. All educational efforts will continue to incorporate messaging about risks of tobacco exposure and sedating parental medication. 

 

PNQIN

In FY21, Title V will continue to support PNQIN QI initiatives and statewide summits, which convene almost all birth hospitals in the state to share best practices for the care of substance exposed newborns (SEN) and their families. PNQIN has been working for the past four years on addressing perinatal opioid use by targeting outcomes during three key time periods: 1) during pregnancy, focusing on increasing the percent of mothers with opioid use disorder who are in medication assisted treatment during pregnancy; 2) at delivery, focusing on improving breastfeeding rates among mothers of infants with NAS; and 3) during the first year of life, focusing on increasing the enrollment of infants with NAS in EI services.

 

Additional goals for PNQIN include the following:

• Improving provider training measured by (1) the number of providers with waivers to prescribe or dispense buprenorphine to pregnant and postpartum women; (2) the number of providers trained on stigma, bias, and trauma informed care, and on MAT treatment for pregnant and postpartum women with OUD;
• Improving protocol implementation by (1) increasing the number of hospitals with standardized protocols for care of pregnant and postpartum women with OUD and newborns with NAS; and (2) increasing the number of hospitals with referral plans connecting community supports with healthy systems to improve the follow-up of infants with NAS after discharge; and
• Improving screening and linkage to care by increasing the percent of infants at risk for NAS who receive non-pharmacologic care and the percent of infants at risk for NAS who are referred to EI and Early Head Start by hospital discharge.

 

As described previously, MDPH and PNQIN are working with hospital QI teams to implement the Opioid AIM bundle. They will create customized key driver diagrams to address what is most pertinent and attainable for their institutions, and conduct Plan, Do, Study, Act cycles to reach optimal results. Currently, 93% (n=43) of hospitals are participating in at least one of the three goals of PNQIN’s QI initiative (43 perinatal and 3 pediatric hospitals).

 

In FY21 PNQIN will also focus on breastfeeding among substance-exposed newborns, which can reduce need for pharmacologic treatment in infants at risk for NAS, and also appears to improve mother-infant bonding and reduces maternal stress and addiction behaviors. Please refer to the Infant Health domain for additional information.

 

FIRST Steps Together

In FY19, BFHN secured two years of funding through the State Opioid Response Grant for seven home visiting programs for opioid affected families with children aged less than five years. Programs are staffed by parents in recovery, with additional mental health and dyadic clinical support. Besides providing direct services, the initiative will continue to create mechanisms to implement Plans of Safe Care, expand and refine the perinatal and parenting peer recovery workforce, expand perinatal collaboratives, increase referrals to EI and develop and disseminate best practices. In FY21, two additional years of funding will begin. One or two new sites will be added, likely in partnership with MIECHV’s Parents as Teachers program. An implementation study will be completed in FY21, as will an implementation toolkit. Peer staff, in recovery themselves and highly reflective of the client population, are on the planning committee for the implementation study and the toolkit. A program evaluation is also planned. Programs will continue to learn how to modify services which are now being provided remotely due to COVID-19. In FY21, eligibility will expand from solely opioid use to opioid and stimulant use, and will include fathers. In FY21, a racial equity initiative will begin with staff education and review of accessible data by race to ascertain and address service gaps.  

 

Early Intervention

As fewer opioid exposed newborns in the state require pharmacological treatment for withdrawal symptoms (due in large part to QI efforts described previously), EI programs are reporting a decrease in referrals for infants with NAS.  In FY21, the EI system will implement two new child and family factors in determining eligibility to ensure children that are born substance exposed do not fall through the cracks: 1) SEN diagnosis; and 2) another child in the family with diagnosis of SEN or NAS.

 

WIC

WIC will screen women for substance use both in the perinatal and postpartum periods during the certification process and will refer families to community-based resources as needed. WIC nutrition education materials and resources will be reviewed to ensure that participants receive accurate information about substance use via WIC nutrition services. New WIC staff will complete a mandatory substance use training module as part of their new staff training.

 

MA MIECHV

In FY21 MA MIECHV will support collaboration between home visiting and Department of Children and Families (DCF) offices at the state and local level to support services for families affected by substance use who are DCF-involved. Given racial inequities in the child welfare system in the United States, policies that facilitate access to home visiting through transitions in custody arrangements would promote more equitable access to the benefits of home visiting. During custody disruptions, home visiting has the potential to support participants in their identities as parents, understanding their children’s ongoing development, and allowing for continuity of voluntary services through different stages of involvement with DCF, and home visitors have emphasized the importance of maintaining connections with families through transitions in custody arrangements. MA MIECHV programs identify strategies to enhance continuity of services for families who are working to regain custody of their children, including through support and education for parents working toward reunification, and support for families in which grandparents may have custody. In FY21, MA MIECHV will engage the Parents as Teachers (PAT) national model developers to pilot a PAT policy change to better support families involved with DCF.

 

MA MIECHV will also continue an innovative strategy of piloting an overlay of a Peer Recovery Coach into the PAT program. Through training in the PAT model and Recovery Coach, and through their lived experiences, home visitor/recovery coach positions have the skillset required to engage families affected by substance use, credibility and understanding of recovery, a deeper understanding of challenges experienced by families throughout the stages of recovery, and the ability to support families in their change efforts. The pilot was initiated in Berkshire County where the PAT program hired a home visitor with lived experience. The home visitor attended the Training in Recovery Coaching and Ethical Considerations training required for Recovery Coach Certification and participates in peer learning with other programs with Recovery Coaches to support both professional development and systems building. Supervisors attended the Recovery Coach Supervisor training to understand the unique needs of employees. The home visitor/recovery coach has access to specialized training provided through FIRST Steps Together, as well as to the peer learning collaborative, thus leveraging and integrating the State Opioid Response and MA MIECHV resources. The home visitor/recovery coach also provides training and support to other home visitors and staff within the agency to reduce stigma associated with substance use, treatment and recovery, and to promote an inclusive agency culture. MA MIECHV will apply lessons learned from the pilot to better understand how to implement and sustain the overlay of a recovery coaching and evidence-based home visiting to offer this unique service in more communities in FY21.

 

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

 

Emotional wellness affects the development of individuals during key times in their lives. It is a cumulative outcome of heredity, experiences, support, education, and environment. This priority therefore applies to the maternal, child, adolescent, and CYSHN domains and is discussed in each domain. The national performance measure relates to developmental screening in children. Another key measure for tracking progress on this priority as it relates to women’s/maternal health is the percent of women who have social support following the birth of their baby. Activities to address this measure are described below.

 

Objective 1. Increase to 92% from baseline (89.5%, PRAMS 2018) the percent of women who have moderate or high social support following the birth of their baby.

MA PRAMS will continue to collect data on maternal pre-pregnancy, perinatal and postpartum depression and screening by health care providers. MDPH added a social/emotional connectedness question to the MA PRAMS Phase 8 Questionnaire in FY16, and data collection is ongoing until 2022. In 2016, 87% of women reported that they have moderate or high social support, which increased modestly to 89.5% in 2018. Data for 2019 will be examined in FY21. Using 2016-2019 data, MDPH will examine the characteristics of women with a lower score of social/emotional connectedness, and the association of frequent postpartum depressive symptoms with this social connectedness question to identify vulnerable populations and guide efforts to promote mental health and emotional well-being.

 

Perinatal Mental Health Data Analysis Plan 

During FY20, MDPH was awarded a budget earmark that instructs the Department to expend funds to produce a report, in consultation with other state agencies and hospital systems, to define a set of measures to track the annual perinatal mental health outcomes for all deliveries in the Commonwealth and to outline a process for the collection and reporting of said measures. Specifically, it requires that:

• Measures shall include, but not be limited to, the rate of screening for postpartum depression, the identification of perinatal mental health diagnoses, and the incidence of postpartum psychosis.
• The report shall include, but not be limited, to the cost, timing, and feasibility of the data analysis plan.
• MDPH shall report to the clerks of the House of Representatives and Senate, House and Senate Committees on Ways and Means, the Joint Committee on Mental Health, Substance Use and Recovery, and the Ellen Story Commission on Postpartum Depression no later than March 1, 2021.

 

MDPH has hired a consultant to support this work, which is ongoing. 

 

Perinatal Mental Health Training and Technical Assistance 

MDPH will continue to provide training and technical assistance on perinatal mental health (including maternal mental health and co-morbidities such as substance use and interpersonal violence) to state agencies (such as DCF), providers (including home visiting programs), and health plans. The training and technical assistance will contribute to increasing awareness and reducing stigma, and will support continued implementation of the Postpartum Depression regulations.  

 

MA MIECHV

Home visitors will continue to screen women for depression prenatally and postpartum, and provide education, brief intervention and counseling services to women identified with depression. Data on completed depression screens will be collected and analyzed 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. In addition, data will be collected and analyzed to report on an outcome performance measure assessing the percent of primary caregivers referred to services for a positive screen for depression who receive one or more service contacts. Staff will support families in accessing mental health services as needed, and both programs will continue to offer social connectedness support groups.

 

Welcome Family

The Welcome Family Learning Collaborative is a forum for the five local implementing agencies to plan and implement quality improvement projects and share best practices and lessons learned across programs. The Learning Collaborative has two in-person meetings per year, each of which is followed by a six-month action period during which the five programs carry out Plan, Do, Study, Act cycles. In the past, improvement projects have focused on topics such as increasing referrals to the program, reducing racial and ethnic inequities in home visit completion, and increasing domestic violence screening rates.

 

In FY21, the first six-month Learning Collaborative cycle will focus on depression screening, response to concerns identified, and/or referrals to community-based services. The specific focus will vary by program, depending on the area their data show as needing the most improvement. The Learning Collaborative meeting will be held virtually over two days in July 2020. The first day will include training in perinatal mental health by the BFHN Director of Maternal Health Initiatives. The second day will include breakout sessions by 1) Welcome Family role (e.g. nurse or coordinator/supervisor) to reflect on what was learned during the training and brainstorm improvement ideas based on role, and then 2) by program, to develop aim statements and tests of change that will be carried out over the action period.

 

This Learning Collaborative topic was chosen in collaboration between MDPH and local program staff due in large part to the growing mental health concerns and social isolation resulting from COVID-19. Welcome Family aims to leverage its experience with structured quality improvement projects to address this important need among families with newborns.

 

EIPP

Home visitors will continue to screen women for depression prenatally and postpartum, and provide education, brief intervention and counseling services to women identified with depression. Staff will support families in accessing mental health services as needed, and will continue to offer social connectedness support groups.

 

FOR Families

FOR Families works to improve the emotional well-being of infants, children and their families by providing in-home support to caregivers. Visitation schedules are mutually agreed upon and vary from weekly in person visits to once every six weeks depending on needs of the family. In between visits there are phone calls and texts to offer brief check-ins on the families’ situation.

 

In FY21, the program aims to continue its success in engaging families who are at high risk for stress, depression and substance use. Visiting this population in the home helps promote a strong foundation for family resilience and emotional wellness. Home visitors will monitor clients for symptoms of depression and provide education, supportive counseling and referrals to mental health services. Staff have been successful in building community relationships with their local mental health resources and services to ensure a smooth referral process for families.

 

[1]  https://www.hhs.gov/sites/default/files/2020-cessation-sgr-full-report.pdf