Domain: Women/Maternal Health

Planning for October 2024-September 2025

Objective

By 2025, Minnesota (MN) aims to increase the percentage of women receiving a preventative medical visit in the past year by 10% from 75% in 2020 to 83.4% in 2025.

National Performance Measure

(NPM WWV) Percent of women, ages 18 through 44, with a preventive medical visit in the past year.

An annual well-woman visit provides a critical opportunity to receive recommended clinical preventive services, including screening, counseling, and immunizations, which can lead to appropriate identification, treatment, and prevention of disease to optimize the health of women before, between, and beyond potential pregnancies.[1]

Evidence-Informed Strategy Measure

(ESM WWV.2) Number of hospitals that are actively participating in MN Perinatal Quality MN’s goal for FY2025 is that 83.4% of all women receive a well-woman visit.

 Collaborative (MNPQC) initiative focused on the Alliance for Maternal Innovation (AIM) bundle on substance use disorders.

Members of the MNPQC recognize the importance of the issues addressed by the AIM, which is a national data-driven maternal safety and quality improvement initiative. AIM’s work aligns well with the MNPQC core initiatives, and formal involvement in the AIM Program aligns MN’s efforts with other states’ activities. The issues are relevant to discussions on quality improvement in MN as supported by the MN Maternal Mortality Review Committee (MMRC) and MNPQC Steering Committee.  The MNPQC steering committee had identified the initiative focused on opioid use disorder as a priority within the MNPQC strategic plan with intentions to model the AIM opioid / substance use disorder bundle.

The MNPQC led the state’s official enrollment in AIM in the Spring of 2022. The proposed AIM bundle for this opportunity was on Care for Pregnant and Postpartum People with Substance Use Disorder led by the MNPQC substance use disorder workgroup, Mother/Infant Opioid and Substance use Treatment and Recovery Effort (MOSTaRE).

MN’s goal for FY2025 is for 25 hospitals to be actively participating in MNPQC initiative focused on the AIM bundle on substance use disorders.

Community-Identified Priority Need: Care During Pregnancy and Delivery

MN’s five-year 2020 comprehensive needs assessment identified a significant area of need in increasing accessible, quality health care during pregnancy, making care during pregnancy and delivery the women’s health priority area for the state.

For more information on the impact and importance of care during pregnancy and delivery, see the Women/Maternal Health 2023 Report.

Strategies and Activities

Strategy A: Expand Family-Focused, Community-Based Policy and Funding

Addressing care during pregnancy and delivery from a population health lens focuses on expanding the immediate family’s role in care during pregnancy and the birthing process. This involves the evolution of funding and policies in MN to be responsive to the communities they serve. MN continues to develop new strategies and refine current ones to reflect the needs identified by communities. Statewide initiatives will focus on addressing foundational changes to delivery structure for maternal health and developing/expanding the workforce to reflect all our communities.  

State Level Activities

1. Champion Health Equity in the Child and Family Health (CFH) Division’s Policies, Practices, and Programming – Title V Supported

In the spring of 2022, the CFH Division contracted with a local research and evaluation firm to strategically continue to move health equity forward within the Division, with a final strategic plan completed and submitted to CFH leadership in September 2022, and implementation beginning October 2022. Out of the learning from this strategic plan and process, a division wide Health Equity Operations Workgroup was formed to identify opportunities to advance health equity using the strategic plan and staff engagement. The work of the Health Equity Operations Workgroup will continue to move forward in FFY2025, including continued management and implementation of identified tasks and deadlines among CFH Division staff.

The goal of this workgroup is to embed and elevate equity in all areas of work throughout the division, including the continuation of several communities of practice and strengthening an internal recognition process to highlight great equity work. A new funding opportunity will be launched for the division to support innovative ideas to further health equity. An explanation of health equity has also been added to the new employee orientation and employee manual. All staff will also have continued involvement in further health equity initiatives through their identified roles (via a system support mapping activity from 2023).

2. Seek Community Input on Access to Midwife and Doula Services – Title V Supported

MN Doula Workforce Survey

MDH staff developed   a survey aimed at building a more comprehensive profile of doulas and birth workers in MN. MDH contracted with a consulting firm to help with distribution across the state. For the purposes of this survey, a doula or birth worker is defined as someone who provides continuous physical, emotional, and informational support to a birthing person before, during, and after childbirth to help them achieve the healthiest, most satisfying experience possible. The goal of this work is to develop a better understanding of doulas and birth workers in the state, identify barriers to becoming or practicing as a doula and gaps in service, and opportunities to improve access by building on strengths of the doula and birth worker workforce. In FFY 2024, MDH and the contractor will compile, analyze, and create a summary report of the final survey results.

Maternal Care Access Coordinator

To help improve health equity in pregnancy and postpartum outcomes, MDH hired a Maternal Care Access Coordinator to develop a strategic plan and to develop and implement policies, activities, and programs, with community input, aimed at expanding access to prenatal care, doula, and midwifery services by working with internal and external partners and stakeholders. In FFY2025, the Maternal Care Access Coordinator will finalize the review of frameworks created by community doulas involved with Ramsey County’s Birth Equity Community Council’s (BECC) policy committee that aims to improve the doula certification process and reimbursement, which was recently increased by Medical Assistance in MN. Community input and assessment will be developed and implemented to reflect the suggestions outlined by the community doulas and other partners for improving the process and expand organizations for required training for birth doulas. Additionally, the Maternal Care Access Coordinator will assess the access to midwife services for communities experiencing the highest rates of disparate pregnancy outcomes. This information will be used to inform cross-sector collaborations with internal and external stakeholders working to advance policies and systems changes to remove barriers to access for doula and midwife services such as trainings, certification, and reimbursement.

Strategy B: Integrate Health and Social Services to Optimize Cross-Sector Collaboration

Integrating services to provide wrap-around care, allows families to work with a care team that can comprehensively meet the needs of the expecting family, as well as identify gaps in care and promote preventative health.

State Level Activities

1. Strengthen and expand the MN Perinatal Quality Collaborative (MNPQC) – Title V Supported

The state PQC grant program will continue to implement continuous quality improvement tools and strategies to improve practices and meet goals.

1. Advance evidence-based and evidence-informed clinics and other health service practices and processes through quality care review, chart audits, and continuous quality improvement initiatives that enable equitable outcomes.
2. Review current data, trends, and research on best practices to inform and prioritize quality improvement initiatives.
3. Identify methods that incorporate antiracism into individual practice and organizational guidelines in the delivery of perinatal health services.
4. Support quality improvement initiatives to address substance use disorders in pregnant people and infants with neonatal abstinence syndrome or other effects of substance use.
5. Provide a forum to discuss state-specific system and policy issues to guide quality improvement efforts that improve population-level perinatal outcomes.
6. Reach providers and institutions in a multidisciplinary, collaborative, and coordinated effort across system organizations to reinforce a continuum of care model; and
7. Support health care facilities in monitoring interventions through rapid data collection and applying system changes to provide improved care in perinatal health.

AIM program via I-MOM – Title V Supported

Ongoing MNPQC leadership activities include:

• Develop and support data collection, resources, and reporting tools for each AIM bundle.
• Evaluate AIM Quality Improvement initiative with summary and analysis to inform a sustainability plan for each AIM Bundle Initiative.
• Plan, implement, and evaluate multiple QI initiatives through a collaborative learning model that use AIM bundles.

For future AIM Bundles, MNPQC will continue to host and facilitate monthly online AIM quality improvement activities (for example, trainings, webinar, case studies and/or related QI activities).

2. Address Maternal Opioid Misuse

MOSTaRE Initiative – Title V Supported

This upcoming phase will overlap the active MNPQC SUD Quality Improvement initiative as the MNPQC uses the Institute for Health Improvement Model that recommends a project timeline of 9-18 months to reinforce ongoing team support for systems change. The MNPQC will determine if the SUD initiative will model a similar maintenance period led by their hypertension initiative in order to sustain support to the current teams. A maintenance schedule will be developed to inform team communications, AIM data plan, and potential topics to expand on quarterly action period calls. From the MNPQC SUD initiative, participating hospital teams demonstrated the need for smaller and more focused quality improvement initiatives. As a next step, MNPQC intends to lead two Community of Learnings (COL) that will offer interested hospital teams the opportunity to expand practices on nonpharmacologic methods (primarily eat, sleep, and console) for infants exposed to opioids in utero and develop and improve Plans of Safe Care for families affected by SUD.

Substance Use Task Force – Title V Connected

In 2023, the MN Legislature established a Task Force on Pregnancy Health and Substance Use Disorder. The Task Force’s goal is to recommend protocols for when physicians, advanced practice registered nurses, and physician assistants should administer a toxicology test and requirements for reporting for prenatal exposure to a controlled substance. The Task Force began the fall of 2023 and will end their work December 1, 2024, with the submission of a bipartisan report of recommended policy guidelines to the MN Legislature.

Comprehensive Drug Overdose Prevention – Title V Connected

Ongoing grant support will be provided to grantees implementing maternal mortality recommendations, as well as increasing access to medication-assisted treatment options, addressing stigma around substance use during pregnancy, collecting baseline data, and applying quality improvement methods to measure and report efforts to improve maternal health outcomes for individuals with a substance use disorder. During this time the CHYSN section will be in the initial strategic planning stage of a NAS surveillance system to be integrated within birth defects monitoring.

3. Address Hypertension During Pregnancy and Postpartum Period – Title V Connected

See Women’s Health Report for more details.

Future plans from the MNPQC recommend that teams continue to report data to understand where the interventions sustain, when impact may begin to falter, and to track how processes continue to improve. Additionally, MNPQC recommend teams to continue their engagement in quarterly action period calls and to report data. MNPQC will expand focus to design new initiatives to include prevention and the postpartum period.

4. Strengthen State Capacity to Improve Maternal Health Outcomes and Address Maternal Health Disparities – Title V Supported

In FFY2023, MDH was awarded a new HRSA grant from the State Maternal Innovation and Data Capacity Program. The purpose of the award is to support state capacity to improve maternal health and address maternal health disparities through quality services, a skilled workforce, enhanced data quality and capacity, and innovative programming that aims to reduce maternal mortality and severe maternal morbidity. MDH created the “Innovations for Maternal Health Outcomes in MN (I-MOM)” program. The purpose of the I-MOM program is focused on alignment and strengthening of the implementation of innovative, data-driven, community-informed and supported perinatal health programs to improve perinatal health outcomes for communities experiencing the highest rates of disparities in MN (Black, American Indian, other populations of color, new immigrants, refugees, and rural).

I-MOM activities include innovative programing, increased data capacity, implementation of AIM statewide quality improvement care initiatives, and support for building a skilled perinatal health workforce to reduce perinatal morbidity and mortality, and goals include:

• build a shared perinatal health vision.
• strengthen data infrastructure.
• improve the collection, reporting, and analysis of AIM data.

Strategy C: Strengthen and Expand Culturally Responsive, Trauma-Informed Care for Women of Childbearing Age

Our partners across healthcare systems and community organizations have relayed the need to transform health care training, locations of delivery services, and funding for meeting the culturally responsive and trauma-informed care needs of women of childbearing age. Increasing access to culturally responsive, trauma-informed care, will allow mothers to have autonomy and agency while seeking services, and will create opportunities to build a trusting relationship with their health provider.

State Level Activities

1. Expand and Improve the MN Maternal Mortality Review Project (MMRP) – Title V Supported

The goal of the MMMRP is to improve the health outcomes of pregnant people through maternal mortality and morbidity reviews. The MMMRP houses the Maternal Mortality Review Committee (MMRC), which reviews maternal death cases and develops recommendations to prevent future deaths.

The MMMRP activities for FFY2025 include the following:

• Analyze multi-year data and provide demographics, geographic burden, distribution of death, and cause of death, to inform change of practice or policies. 
• Review all pregnancy- associated maternal deaths within 18 months of date of death, and document findings and decisions in the Maternal Mortality Review Information Application (MMRIA) to assist with ongoing analysis.
• Expand community members and/or those with lived experience representation on the MMRC. 
• Disseminate committee findings, analysis, and recommendations to internal and external stakeholders annually. 
• Develop and disseminate a report on 5 years of maternal mortality reviews including recommendations to (internal and external) stakeholders
• Develop targeted reports on leading causes of death in MN for specific stakeholder groups including providers and policy makers
• Track the implementation of MMRC recommendations at multiple levels
• Collaborate with partners to strategically develop statewide actionable interventions to reduce contributing factors identified by the case reviews. 
• Promote recommendations from our community action team (perinatal subcommittee) to identify strategies and resources needed for the community to implement recommendations and mitigate barriers to improved pregnancy outcomes.
• Train, and cross-train, internal staff on data management and system processes to improve timely access to case information, abstraction, and data entry.
• Invest in community driven interventions to address maternal mortality and build upon communities working in culturally tailored approaches in maternal health.
• Improve case identification and completion of record collection in partnership with Department of Human Services, other divisions within MDH, the MN Hospital Association, State Medical Examiners, and Law Enforcement entities. 
• Develop feasible processes and systems to collect and analyze maternal morbidity data to identify leading causes of morbidity in the state. 
• Tailor quality improvement interventions, in conjunction with the MNPQC, to target and address maternal mortality and morbidity. 
• Implement an informant interview protocol through a contract with external partners – which reflects a recommendation from the CDC for MMRC partners to use informant interviews for comprehensive case reviews.  (Qualitative data gathered from the interviews are used to supplement medical records and other records abstracted for MMRC to review)
• Expand the Hear her campaign to additional populations, specifically Native American persons, their loved ones and care providers.

Additionally, maternal morbidity reviews are set to occur in FFY2025.

2. Address Violent Maternal Deaths through Surveillance and Evidence-Based Intervention – Title V Supported

MDH staff are partnering with MDH’s Injury and Violence Prevention Section (IVPS) on a maternal violent death project funded by the Office on Women’s Health (OWH). This five-year grant (2021-2026) is designed to reduce deaths among pregnant and postpartum women due to violence with specific interventions around suicide, homicide, and domestic violence. This project aims to 1) enhance surveillance of violent maternal deaths, and 2) expand the evidence-based Confidentiality, Universal Education and Empowerment, Support (CUES) intervention. The project team worked closely with the MMRC, MNPQC, and local violence-prevention organizations toward achieving these goals.

The project team will continue working closely with the MMRC, MNPQC, and other local organizations toward achieving these goals, and will engage in the following activities in FFY2025:

• Continue Violent Death Reviews using an updated review protocol.
• Implement an internal maternal violent death database and quality improvement of reporting forms.
• Continue partnership with the MNPQC and intervention partners to develop and disseminate resources on maternal violence in MN.
• Focus reporting for violent maternal deaths to be shared with MMRC members and partners.
• Develop a dissemination and information sharing plan for data connected to this grant.
• Reimburse MMRC members for participation in this the small sub-working group.
• Form meaningful connections with medical examiners, including relationship-building through visits to county medical examiners’ offices.
• Develop an implementation tracker of recommendations related to maternal violence prevention created during the MVDR workgroup members.
• Title V staff will continue working with a contractor to conduct informant interviews in FFY2025.  The informant interview protocol will be updated based on what was learned from the first round of informant interviews in FFY2023 and FFY2024. Please note, in FFY2025, the contract with an interviewer/team of interviewers will be funded by another source of funds. IVPS partners will continue to support Title V staff with the informant interviews.

3. Partner to Implement Requirement for Birthing Facilities to Provide Anti-Racism and Implicit Bias Training to Staff – Title V Connected

MDH staff will work to provide ongoing implementation support to birthing facilities required, through the Dignity in Pregnancy and Childbirth Act, to provide staff with anti-racism and implicit bias training annually beginning in January 2023. With our partners at the University of MN’s Center for Anti-Racist Research for Health Equity and Diversity Science, MDH looks forward to supporting health systems, birthing hospitals, and clinics to ensure that training is provided. The first two modules launched in December 2022 and April 2023.

4. Develop and Implement Data-informed Strategies to Prevent Pregnancy-Related Deaths and Reduce Disparities Among Disproportionately Impacted Populations – Title V Supported

In 2024, the MCH section within the Child and Family Health Division at MDH responded to a NOFO from the CDC National Center for Chronic Disease Prevention and Health Promotion for “Enhancing Review and Surveillance to Eliminate Maternal Mortality”. If awarded, this funding would support MN’s Maternal Mortality Review Committee (MMRC) within MDH to identify and characterize pregnancy-related deaths for prevention by identifying pregnancy-associated deaths; conducting vital records quality assurance; abstracting clinical/non-clinical data into a standard data system (Maternal Mortality Review Information Application, ‘MMRIA’); conducting informant interviews to inform individual case review; conducting multidisciplinary case reviews by diverse committees; and entering committee decisions into MMRIA.

MDH’s goal will meet criteria to accomplish short term and intermediate goals for this funding request beginning in FFY2025:

• Increased timeliness, accuracy, and standardization of information available about pregnancy-related deaths, including MMRC identified opportunities for prevention.
• Increased engagement and cooperation between MMRCs, partners, and communities to communicate information from data on pregnancy-related deaths.
• Increased availability of MMRC recommendations among communities, clinicians, public health practitioners, and decision makers.
• Increased adoption of clinical and non-clinical policies and programs that reflect the highest standards of care.
• Increased implementation of recommendations that reach or consider the needs of populations disproportionately affected by pregnancy-related mortality.

Additional Related Activities

This section details efforts that are related to the women/maternal health domain, but do not fall specifically within one of the strategies or they are ongoing. These activities ultimately help to improve the health and well-being of women and pregnant people in MN.

State Level Activities

1. Provide Holistic Health and Well-Being Support to Women, Pregnant People, and Their Families Through Family Home Visiting (FHV) – Title V Supported

FHV is an effective upstream intervention that serves as a key link to other interventions and community supports and is a notable contributor to improved maternal and infant health outcomes. FHV services in MN are supported by several funding streams including state, federal and local resources. Together, these funding streams will provide approximately $39 million annually to support home visiting programs across the state that serves upwards of 6,500 families.

In FFY2025, Title V Staff will support MDH’s FHV staff to:

• Implement activities that provide culturally and linguistically appropriate services to priority populations, including home visitors attending implicit bias training or other trainings that promote culturally responsive, trauma-informed care, and using funding to support the American Indian specific evidence-based FHV Curriculum – Family Spirit. 
• Implement promising practices and evidence-informed strategies to specifically reach culturally diverse underserved communities with limited access to family home visiting services.
• Connect families to needed community services.
• Promote the importance of well-women visits, prenatal and postpartum care, and strive to assure that the women served have health insurance and are connected to a primary care provider.
• Work closely with primary care providers to encourage cross-sector collaboration to provide a more holistic approach to caring for families during pregnancy and after the birth of their child.
• Support parents early in their role as a child’s first teacher and foster parenting skills that decrease the risk of child abuse.
• Help parents develop safe, stable, and nurturing environments that support healthy development.
• Provide screening, using validated tools, for: depression during the postpartum period; intimate partner violence, parent-child interactions, and developmental and social emotional concerns for children – and, subsequently, make appropriate referrals.
• Provide health information and encouragement to families including, but not limited to, family planning, breastfeeding and child nutrition, and child growth and development.

[1] Committee on Gynecologic Practice. ACOG Committee Opinion Number 755: Well-woman Visit. Obstet Gynecol. 2018 Oct 132(4):e181-e186. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/10/well-womanvisit