State Systems Development Initiative (SSDI)   

Describe progress in completing SSDI work plan that aligns with SSDI goals. 

The goals of the MA SSDI program, which is housed in DMCHRA, are to: 

1.   Strengthen Massachusetts’ capacity to collect, analyze, and use reliable data for the Title V MCH Block Grant to assure data-informed programming 

2.   Strengthen Massachusetts’ ability to access and link key MCH datasets to inform MCH Block Grant programming and policy development, and assure and strengthen information exchange and data interoperability 

3.   Enhance the development, integration, and tracking of health equity and social determinants of health (SDoH) metrics to inform MA Title V programming 

4.   Develop and enhance Massachusetts’ capacity to collect timely MCH data, and support data analysis, reporting, and visualization to inform rapid state program and policy action related to emergencies and emerging issues/threats, such as COVID-19 

To support goal 1, strengthen Massachusetts’ capacity to collect, analyze, and use reliable data for the Title V MCH Block Grant to assure data-informed programming, SSDI uses PRAMS data to monitor several Title V priorities including ‘Foster healthy nutrition and physical activity through equitable system and policy improvements,’ which is tied to NPM4, percent of infants who are ever breastfed, and percent of infants who are breastfed exclusively. SSDI analyzes PRAMS data by race/ethnicity, insurance, WIC, maternity leave, disability, and postpartum depression. SSDI uses WIC programmatic data to monitor WIC participants receiving services from breastfeeding peer counselors who exclusively breastfed for at least three months (ESM 4.1).  

Strengthening the capacity of the health system to promote mental health and emotional well-being is another Title V priority. PRAMS data are used to track postpartum social support and emotional wellness across five related measures and collect information on the baby’s father’s financial and emotional support to the birthing parent. Parents with more financial and emotional support have lower prevalence of postpartum depressive symptoms and less stress. With the upcoming tenth anniversary of the Massachusetts Child Psychiatry Access Program (MCPAP) For Moms, SSDI staff are developing a PRAMS fact sheet on maternal mental health. Since 2022, MA PRAMS has included the Social Determinants of Health Supplement, allowing for deeper analyses on social supports. SSDI tracks these measures by race/ethnicity, education, insurance, and disability status. PRAMS Phase 9 also includes additional questions on social supports and sexual orientation/gender identity as well as doula utilization, which will be used to support Bureau initiatives on doula access.  

Central to the Title V substance use prevention priority action plan for 2020-2025 is inclusion of survey questions on the PRAMS Phase 9 to improve the measurement of tobacco, marijuana, and alcohol use during pregnancy. PRAMS Phase 9 was launched with January 2024 births and includes a Marijuana Supplement. Questions include if the participant was using marijuana during pregnancy and if yes, the reasons why. Questions on additional substances are included on the Phase 9 survey.  

In September 2023, SSDI staff launched a Fatherhood/Second Parent Survey as a pilot program to better understand pregnancy and birth experiences and behaviors among new fathers and second parents to support the MA Title V priority ‘Engage families, fathers and youth with diverse life experiences through shared power and leadership to improve maternal, child, and family health services.’ Data collection via web-based portal and mailed surveys will continue for six months and data collection via a phone vendor will continue for four months. Preliminary analysis is planned for early summer 2025.  

To support goal 2, strengthen MA’s ability to access and link key MCH datasets to inform MCH Block Grant programming and policy development, and assure and strengthen information exchange and data interoperability, SSDI staff analyze data from the Public Health Data Warehouse to identify risk factors contributing to severe maternal morbidity (SMM), by characteristics such as race/ethnicity, insurance, disability status, substance use disorder, incarceration, veteran status, and severe mental illness. The SSDI team collaborated on a data brief: An Assessment of Severe Maternal Morbidity in Massachusetts: 2011-2020, which showed an increase in SMM from 52.3/10,000 deliveries in 2011 to 100.4/10,000 in 2020, with rates for Black non-Hispanics (191.0/10,000 in 2020) nearly 2.5 times higher than the rate for White non-Hispanics (78.2/10,000 in 2020). People with obesity, pre-pregnancy diabetes, and pre-pregnancy hypertension had significantly higher rates of SMM compared to those without these conditions. The brief was posted on mass.gov and shared widely through the Maternal Health Task Force, PNQIN, and the media in July 2023. SSDI staff also analyzed SMM among Medicaid participants and a second data brief is in development. Information on maternal morbidity and mortality are also available on our new State Health Improvement Plan website at SHIP - Maternal Morbidity and Mortality | Mass.gov. 

SSDI staff also linked PRAMS data to the Pregnancy to Early Life Longitudinal (PELL) data system and are participating in a multi-state analysis of SMM and maternal characteristics including substance use, health problems, stressors, insurance, physical abuse, and types of health care used. SSDI staff have linked WIC and PELL data to better understand SMM at delivery among WIC participants and to hospital-based healthcare utilization for both birthing people and infants.  

To support goal 3, enhance the development, integration, and tracking of health equity and SDoH metrics to inform MA Title V programming, BFHN staff are collaborating with the Department of Family Medical Leave (DFML) to monitor implementation of the Massachusetts Paid FML (PFML) legislation, implemented on January 1, 2021. SSDI will compare trends for maternity leave from PRAMS to DFML data and will link DFML data to PRAMS and PELL to better understand characteristics of those who do and do not take FML. In 2022, one year after the start of PFML benefits, PRAMS data showed that 16.1% of employed birthing people took unpaid leave only, 64.1% took paid leave only, 6.9% took both paid and unpaid leave, and 3.3% took no leave, compared to 33.2%, 47.5%, 13.1%, and 6.3% in 2020, prior to PFML benefits. SSDI shared findings through its PRAMS Advisory Committee meeting on May 28, 2024. Advisory Committee members include representatives from other DPH programs and bureaus, clinicians, researchers, and community organizations. SSDI continues to monitor trends in postpartum leave-taking patterns and will work with DFML to promote equitable utilization of PFML through data linkage and analysis.  

SSDI helped create a Title V Maternal and Child Health dashboard, with objectives and metrics for NPMs, SPMs, and ESMs for Massachusetts Title V priorities. Data are displayed by Title V priority with details on the associated performance measures, MCH domains, and 5-year objectives, and include values from 2019 through the current year, with projected values through 2025. The new Dashboard allows programs, policymakers, and researchers to track population-level improvements in a wide range of MCH activities across Title V MCH priorities.  

SSDI works broadly to support goal 4, develop and enhance MA’s capacity to collect timely MCH data, and support data analysis, reporting, and visualization to inform rapid state program and policy action related to emergencies and emerging issues/threats, such as COVID-19. 

MA PRAMS data have been used to track unintended pregnancies since 2012. With the 2022 ruling of the Supreme Court overturning Roe v. Wade, it is likely that the prevalence of unintended pregnancy will increase. MA SSDI continues to use PRAMS data to monitor pregnancy intention and contraception use by race/ethnicity, disability, insurance, and WIC participation. In 2022, 15.4% of respondents reported their pregnancy was unintended, with another 12.9% feeling unsure of how they felt about the pregnancy, findings that have remained consistent since 2019. SSDI plans to create a fact sheet on pregnancy intention and postpartum contraception using PRAMS data to share with clinicians and community partners.  

SSDI has worked collaboratively on a statewide NAS Dashboard of key metrics to monitor aspects of care across three key time periods: prenatal, neonatal, and infancy for families affected by perinatal substance use. The SSDI program used PELL data to update the Dashboard to cover years 2010-2020. The data can be sorted by insurance type, race/ethnicity, mother’s age and education, gestational age, birth weight, method of delivery and region. Data for 2021 births will be added late Summer 2024, as data are available. SSDI is partnering with DSRPPH to include active NAS surveillance data on the dashboard to improve timeliness, case identification, and utility of the data. The Dashboard has been used by PNQIN to track population-level improvements while using hospital-based data to monitor key performance measures including reduction in use of pharmacologic therapy for NAS, increase in use of skin-to-skin care, reduction in average hospital length of stay, reduction in care in a special care nursery or neonatal intensive care, and increase in use of Plans of Safe Care by hospital discharge.    

In FY24, MA PRAMS received CSTE funding to add supplemental COVID-19 questions to the survey. These data help MDPH to understand women’s experiences and needs during pregnancy and postpartum related to COVID-19, particularly around how information on vaccination is best received, and provide state-level data to examine racial/ethnic inequities among pregnant women around receiving vaccination and pandemic messaging. 

Address contributions of SSDI in building and supporting accessible, timely, and linked data systems 

Pregnancy to Early Life Longitudinal System (PELL) Data System 

SSDI helps support the MA PELL data system, which tracks MCH outcomes over time. The core PELL linkage consists of birth certificates and fetal death reports, provided by vital statistics, and linked annually to their corresponding birth and delivery inpatient hospital discharge records. PELL also incorporates non-delivery inpatient hospital discharges (HD), emergency department (ED), observational stay (OS) and some program participation and surveillance data. Data from Early Intervention (EI), birth defects, WIC, newborn hearing screening, and home visiting are among those that have been linked. SSDI completed the PELL linkage of births from 2018-2021 and case mix data and will link 2022 births by fall 2024. PELL linkage of birth certificate data to delivery hospital discharge records has a 99% linkage rate for instate resident births. One of the challenges of PELL is the lack of timely casemix data (HS, ED and OS) for annual linkages with the birth certificates. The Center for Health Information and Analysis (CHIA) provides casemix data annually for the two prior fiscal years.  

In FY23, DMCHRA received grant funding through ASTHO to conduct a linkage of PRAMS and PELL as part of a learning community effort. DMCHRA achieved 100% linkage between PRAMS and PELL and shared lessons learned with the learning collaborative. DMCHRA is now participating in a multi-state analysis to examine SMM rates using PRAMS-PELL linked data. Data have been shared and analyses are underway.  

PELL & WIC Linkage 

SSDI also supports the linkage of PELL data to WIC participation data for 2017-2021 births and will link 2022 births in early fall 2024, after PELL data are updated. Approximately 93% of infant WIC participants link with the birth certificate. SSDI continues to analyze linked data to evaluate the impact of WIC participation on infant/childhood and maternal Emergency Department visits, observational stays, and in-patient hospital utilization. Further analyses of PELL-WIC data include examining SMM at delivery among WIC participants by type of SMM event. 

Describe key SSDI products or resources developed to support Title V 

As discussed above for goals 3 and 4, SSDI helped create a Title V Maternal and Child Measures Dashboard and expanded upon the existing NAS Dashboard, to increase access to timely data for both programmatic and public use. 

To support the Title V priority of improving timeliness of maternal mortality data, and with the help of SSDI staff, a CSTE Applied Epidemiology Fellow created a process map of steps involved in the reporting data on maternal deaths into the Maternal Mortality Review Information Application (MMRIA) and clarifying the roles of each DPH staff contributor. This work allowed for identification of “pain points” and redundancies that were then addressed to improve efficiency. Timely review of maternal mortality cases will facilitate understanding of the upstream causes of maternal mortality and SMM and associated inequities. SSDI staff also were instrumental in the drafting of the 2020-2021 Report on Maternal Mortality in Massachusetts, the first maternal mortality report for Massachusetts since 2014. In FY25, SSDI staff will co-draft another maternal mortality report, which will include data from 2022 and include data on SMM. 

SSDI is updating the annual PRAMS Report to include data from the recently released 2022 births. This report will be available online during Fall 2024. Fact sheets, providing a deeper dive into specific PRAMS topics including maternal mental health, vaccination status and education, experiences of racism, social, emotional, and financial supports, and family medical leave are planned for FY25. These will be available on mass.gov and disseminated through clinical and community partners. 

SSDI staff worked with oral health champions and the DPH Office of Oral Health to update the MA Perinatal Oral Health Practice Guidelines for Pregnancy and Early Childhood, originally released in 2016. The percent of women who had a dental visit during pregnancy has steadily increased: 56.2%, 57.8% and 58.8% in 2017, 2018 and 2019, respectively. However, most likely due to the COVID-19 pandemic, this percent decreased to 51.1% in 2020 but began to rebound in 2021 at 52.7% and increased to 58.2% in 2022. The updated guidelines, which will include the latest available knowledge including interpretation associated with the risk of dental amalgam, are planned for release in late summer 2024.