The state priority need for the Maternal/Women’s Health Domain is to improve access to health care for women to improve preconception and interconception health, specifically women who face significant barriers to better health.

The national performance measure selected for this priority was NPM 1: Percent of women with a past year preventive medical visit. The Department has identified objectives and strategies to improve the health of Florida’s women.

Using a broader, more inclusive, and more realistic way to impact women's health and the health of the entire community, the Department has reassessed, updated, and realigned the strategies and objectives to address the state priority to improve access to health care for women and to improve preconception and interconception health, specifically women who face significant barriers to better health.

Pregnancy provides an opportunity to promote women’s overall health and establish a strong foundation for children’s health. A child’s health during the prenatal, infancy, and early childhood periods influences his or her health later in life. The Department, through the state’s Healthy Start program, provides care coordination services to pregnant women at risk for preterm or low birth weight infants. This is an optimal opportunity to ensure pregnant women receive prenatal care, including screening for conditions such as gestational diabetes, monitoring for potential complications, and education to encourage healthy behaviors such as smoking cessation and healthy eating.

Preconception health provides opportunities to promote the health of women before they become pregnant through improved access to health care, whether it be through an actual well-care visit or through services offered through the Department’s other programs such as diabetes prevention and breast or cervical cancer screening. With half of all U.S. pregnancies unplanned, preconception health and health care are important for all people of reproductive age. Primary care for women encompasses screening and assessment, health promotion and counseling, and brief interventions or referrals for additional services when warranted.

The Department will continue to purposefully breakdown internal silos and better integrate existing Department programs and services for women, and share those resources and educational opportunities through the Healthy Start program and other contracted providers of services for women and men of reproductive age.

The Department will continue to build and strengthen state and community partnerships to develop comprehensive systems of care for women and use data to inform program development and policy change. Partnerships between Florida’s Title V MCH program and other state and community agencies such as Florida’s Medicaid agency; providers; home visiting programs including the MIECHV program; local health departments; and community health centers are critical to developing and advancing comprehensive preconception health efforts at the state and local level as well as the overall system of care for women.

Strong state leadership and an ongoing structure such as the Department’s State Health Improvement Plan, the integrated county health departments, and the Florida Perinatal Quality Collaborative are core elements of sustained success and the ability to make improvements to policies, programs, and services for not only low-income women and their families but all women and families in Florida.

The Department will continue to use Title V funding to provide interconception care (ICC) through Florida’s Healthy Start Program. In addition, to reach women before their first pregnancy, the Department’s MCH Section will be partnering with the Adolescent and Reproductive Health Section to work on a statewide project promoting preconception health targeting the adolescent population.

Title V funding will continue to be provided through Schedule C and a Statement of Work to all 67 county health departments to provide well-woman preventative health visits; prenatal care; education for chronic disease management and prevention for pregnant women; preconception health counseling; reproductive health services; dental care services for pregnant women and children with an emphasis on children up to age six; and activities that promote access to care, health literacy, community engagement and/or establishment of policies that positively influence social and economic conditions to address the social determinants of health.

The Department will use Title V funding to focus on human trafficking. Populations who are the most vulnerable for becoming victims of human trafficking also have risk factors that increase their chance of a poor pregnancy outcome such as having experienced childhood abuse or neglect, being of a racial and ethnic minority, having a low income, having a history of substance abuse, etc. The Department will be working with LiveStories to create a web based visual communication tool that will present a story of human trafficking and provide current county level data.

The CDC Vital Statistics Online Data Portal (2018) suggests that Florida has the 11th highest stillbirth rate in the country. In 2019, the stillbirth rate in Florida was 6.8 per 1,000 deliveries (FLCHARTS).  Women who are black experience stillbirth at twice the rate of the general pregnant population. The Department is planning to use Title V funding to continue implementation of the Count the Kicks campaign. Count the Kicks is a stillbirth prevention campaign that teaches moms to count their babies’ movements daily during their third trimester of pregnancy and to call their obstetric provider if they notice a change in what is normal for their baby.

The Department’s MCH Section will continue to contract with the Florida Pregnancy Care Network to implement the Department’s Florida Pregnancy Support Services Program. The program is a network of nonprofit crisis pregnancy centers that provide support and assistance to women, men, and their families faced with difficult pregnancy decisions. Services include free pregnancy tests, peer counseling, and referrals; and most of the centers offer classes on pregnancy, childbirth, parenting, and personal finance management. Funding is provided through the General Appropriations Act. During the 2018 legislative session, HB 41 codified the program into law. The program also provides wellness services such as well woman exams and health screenings for non-pregnant women 18 and older and STI testing. The Department provides technical support to the program on evidence-based models and promotes the availability of the wellness services to the Florida Association of Healthy Start Coalitions and to the county health departments as a referral source.

The Department will continue to use Title V funding for four regional part-time nurse abstractors, an epidemiology staff person for data analysis, and additional staff as needed to support the statewide volunteer PAMR team. Reduction of maternal death is a national and state priority. Florida’s Pregnancy-Associated Mortality Review is an ongoing system of surveillance that collects and analyzes information related to maternal deaths to promote system improvements through evidence-based actions aimed at preventing future untimely deaths. Florida’s PAMR team is a public-private partnership. Actions of the team include reports covering multiple years of review, which are beneficial for evaluating trends and proposing recommendations for change. In addition to monitoring annual data and trends, select topics are chosen for further analysis to obtain a more complete understanding of a particular issue or condition and promote the development of targeted actions that may prevent future deaths. The FPQC is one method that is used for moving recommendations to action through quality improvement projects.

A recurring recommendation from the PAMR team is to stress the importance of a woman receiving education on preconception health and the need to have a medical home to manage chronic disease processes and to maintain optimal weight. Florida’s PAMR data also notes that non-Hispanic black women are significantly more likely to die from pregnancy complications compared to non-Hispanic white and Hispanic women.

The PAMR team will continue to promote and develop timely messages and action items, to support initiatives related to preventing maternal deaths in Florida and develop briefs on PAMR findings to distribute to professional organizations through the PAMR team representatives, and post the messages on the Department website.

MCH Section staff will continue to serve on the core team for the Policy Academy on Pregnant Women with Opioid Use Disorders In-Depth Technical Assistance Project with the National Center for Substance Abuse and Child Welfare. Florida’s Department of Children and Families (DCF) serves as the lead agency as they are the recipient of the SAMHSA grant.

The Department’s MCH Section will continue to work with the FPQC on the Neonatal Abstinence Syndrome (NAS) Quality Improvement Initiative. The goal is to develop a standard of care for treating infants born with NAS.

The Department will continue their efforts related to the perinatal mental health grant from HRSA, The Development of a Sustainable Screening and Treatment Model to Improve Maternal Mental Health Outcomes in Florida. The purpose of the project is to develop a sustainable screening and treatment model to improve maternal mental outcomes in Florida. Over the five-year grant period the team members will work to achieve the following overarching goals:

• Build capacity in Florida to fully and competently deliver all aspects of screening, referral, engagement, and mental health consultation trainings to all major obstetrics practices and birth hospitals in the targeted region.
• Build and implement a screening and treatment model for maternal mental health in all major prenatal health care practices in the targeted region.
• Develop and implement training program for obstetrics providers on tool use, follow up, and the Massachusetts Child Psychiatry Access Program (MCPAP) model; develop and refine the psychiatric consultation model.
• Initiate and maintain provider participation and engagement in the program.
• Expand mental health and substance abuse referral networks in the regions.
• Increase statewide maternal mental health resources and capacity.
• Increase access to screening, referral, and treatment for women in rural and non-rural areas through telehealth resources.
• Train community mental health providers in evidence-based psychotherapy and management of perinatal mental health disorders.
• Develop and implement a State Data Dashboard System.

The MCH program will continue to collaborate with the Bureau of Tobacco Free Florida to look at Florida’s data more closely regarding the interaction between socioeconomic status and race on birth outcomes as they relate to smoking and preterm birth, particularly among black women. There are racial and ethnic differences in the age of onset of smoking with black women initiating smoking later than white women. Prevention interventions should continue beyond adolescence well into the adult years, especially for black women.

The Tobacco Free Florida program has spent more than 10 years bringing awareness to the dangers of tobacco, while also providing free resources that have helped tens of thousands of Floridians to quit. The program has made remarkable progress in helping reduce tobacco use across the state. However, when it comes to tobacco use and exposure to secondhand smoke, there are still many geographic and demographic inequalities across our state. Over 2.4 million adults in Florida, 14.5 percent of the adult population, still smoked cigarettes during 2018.

There are large populations of Floridians, including many children, for whom tobacco use and exposure to secondhand smoke is a daily fact of life. These groups are disproportionately impacted by the health burden of tobacco use, which is especially high among certain subpopulations, including racial and ethnic minorities, low-income individuals, the LGBT community, and those with mental health conditions.

For example, smoking among white, non-Hispanic adults in Florida has declined since 2012, but smoking among blacks and Hispanics in Florida has not changed significantly. Lower income cigarette smokers suffer more from diseases caused by smoking than smokers with higher incomes. Tobacco use is higher among Florida adults who are not heterosexual as compared to heterosexual adults. Adults reporting poor mental health have higher smoking rates than adults reporting good mental health.

It is not a coincidence that these disparities in tobacco use exist. The tobacco industry has a long history of heavily marketing its products to vulnerable populations. There is a higher density of tobacco retailers in communities with higher percentages of blacks, Hispanics, people living below the poverty line, or women older than 25 without a high school diploma.

Studies have found nearly double the number of tobacco retailers near where smokers with serious mental illnesses live, versus near where other members of the general population live. Tobacco companies advertise at pride festivals and other LGBT community events and contribute to local and national LGBT and HIV/AIDS organizations.

The Department will continue researching ways to provide postpartum cessation or relapse support in addition to the SCRIPT program. The evaluation of SCRIPT found that SCRIPT efficacy has only been examined through 90 days postpartum, potentially falling short of long-term support for mothers postpartum. By incorporating a postpartum support program, women in the interconception period are reached as well.

The Department continues to promote Tobacco Free Florida’s Quit Your Way. The Florida Quitline is available 24 hours a day, seven days a week, offering telephone counseling in English, Spanish, and other languages through a translation service. Pregnant tobacco users who are ready to quit receive expanded services including 10 counseling sessions, and with a medical release they may receive a two-week starter kit of nicotine replacement therapy. Self-help materials are also provided by mail.

Tobacco users may also access resources to help them quit through Florida’s Web Coach online service. Tobacco users can plan their quit date and even receive nicotine replacement therapy through the free online service. The telephone and online services also provide another feature to help tobacco users quit, Text2Quit. Text2Quit is a new digital service that texts positive messages to tobacco users before, during, and after they quit.

The MCH section will collaborate with the Bureau of Tobacco Free Florida to update the www.tobaccofreeflorida.com website with information relevant to pregnant women. This will include information on quit resources available during pregnancy and information on the effects of smoking during pregnancy and on the baby once born.

As a new component of Florida’s Healthy Babies Initiative, the MCH Section will continue to collaborate with the Bureau of Tobacco Free Florida to expand existing tobacco cessation activities and ensure these efforts will continue. The Bureau of Tobacco Free Florida is providing additional funding to county health departments that may be used for staffing, education materials, and training that support cessation objectives.

The Department will continue to collaborate with the Bureau of Tobacco Free Florida to educate residents on the negative effects of tobacco through a media campaign utilizing proven messages to encourage tobacco cessation. The Bureau of Tobacco Free Florida utilizes media housed in the CDC’s resource center, so the campaign’s $21 million budget is focused primarily on media placement. The Tobacco Free Florida brand has over a 90 percent brand recognition.

County health departments, Healthy Start Coalitions, and Department staff will continue to monitor prenatal smoking indicators and compliance with guidelines on counseling pregnant women and women of childbearing age on the dangers of tobacco use and second-hand smoke.

Family planning providers across the state will screen their clients for the extent of tobacco use and provide information on Florida’s Quit Your Way. The Department will continue to encourage all health care providers to counsel women of childbearing age and all pregnant women on the dangers of tobacco use as well as the dangers of secondhand smoke. The Department will also continue to monitor compliance with the chapter of the Healthy Start Standards and Guidelines that focuses on tobacco cessation.

The Department is committed to helping Florida residents in all corners of the state reach their fullest health potential by living tobacco free lives.

In addition to initiatives previously described, the Department will continue to support staff with Title V funding to provide oversight and monitoring of the following contracts (discussed more fully in the Annual Report section) to address maternal and women’s health priorities:

• Contracts with 11 Fetal Infant Mortality Review (FIMR) projects to provide for the implementation of FIMR services.
• Contract with the Family Health Line, a toll-free hotline to provide information and referrals on maternal and child health topics.
• Contract with the Ounce of Prevention Fund of Florida to identify, fund, and evaluate innovative prevention programs.
• Contract with the FPQC to engage perinatal stakeholders to improve maternal and infant health outcomes at the systems level.