Ohio was recently notified that it will receive two new federal grants to address maternal mortality and severe maternal morbidity in the state. These grants come from two separate agencies within the U.S. Department of Health and Human Services. The Centers for Disease Control and Prevention (CDC) awarded funding outlined in the Preventing Maternal Deaths Act to support data collection and investigation of maternal deaths. The Health Resources and Services Administration (HRSA), through its Maternal and Child Health Bureau, established the State Maternal Health Innovation Program and awarded grants to nine states to address disparities in maternal health and improve outcomes.
CDC - Preventing Maternal Deaths: Supporting Maternal Mortality Review Committees
The Preventing Maternal Deaths Act, or H.R. 1318 of the 115th Congress, is a bipartisan bill passed in late 2018 designed to help states improve how they track and investigate deaths and morbidity of new mothers. (For a primer on this topic, check out this piece.)
Maternal death rates in the United States have steadily risen over the past three decades.
Maternal death rates in the United States have steadily risen over the past three decades and have more than doubled from 10.3 per 100,000 live births in 1991[1] to 23.8 in 2014.[2] This is especially alarming when you consider that the death rate itself only captures the most severe maternal health outcomes in the United States. In 2014, nearly 55,000 women suffered from severe maternal morbidity, also called “near misses,” when a woman suffers life-threatening complications related to pregnancy or delivery. This is nearly triple the number of near misses from 1993.
Since data and variability across states seem to be the biggest hurdles to tackle the country’s rising maternal mortality rate, it was important to the bill’s sponsors that data collection be a priority.
For example, states don’t always distinguish between cause and often count all pregnancy-associated and pregnancy-related deaths together. If a woman has a stroke during delivery that is counted as a maternal death in some but not all states. If state X reports more maternal deaths than state Y because of inconsistent definitions, it could impact funding and policy recommendations. This could also result in poorly planned and targeted resources and intervention.
Among other things, the legislation supports the Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM) program, which is housed at the CDC, by establishing a state-based grant opportunity to create and support existing maternal mortality review committees (MMRCs).
For the more than 40 states that already have a formal maternal mortality review committee in place, the grants can be used to enhance their current efforts to review all pregnancy-associated deaths, analyzing factors contributing to the deaths and translating the lessons into policy change.
The first round of awardees, announced in late August, include 24 awards ranging from $150,000 to $600,000 supporting 25 states. Recipient funding is based on the average cost of MMRC functions, adjusted for the three-year average (2014-2016) of state-level numbers of pregnancy associated deaths. The grants were accompanied with guidelines which must be met every year to continue receiving the funds.
Ohio was awarded $2,250,000 over five years to help support its MMRC, which despite being in place since 2010 as the Pregnancy-Associated Mortality Review (PAMR) board, hasn’t produced public data since 2014.
To be eligible for the first round of awards, applicants had to meet several preliminary requirements. Applicants had to have existing MMRCs that have met for at least 12 months and be currently reviewing deaths. Additionally, applicants were to submit evidence that their state’s MMRC is in statute with authorities and protections. Ohio’s PAMR board up until this budget cycle, operated under the supervision of ODH but lacked specification on membership, meetings per year, privacy protections and obligation to collect and report data. During the last budget, passed in late July, Ohio’s PAMR board was codified into state law formalizing the operating practices.
Award recipients are required to identify pregnancy-associated deaths within one-year of death, conduct multidisciplinary reviews, submit a detailed Evaluation and Performance Measurement plan, abide by data requirements including using the Maternal Mortality Review Information Application for data and comply with continuous reporting requirements in order to apply for annual continuation of funding.
Recipients are also encouraged to improve racial demographic data tracking to highlight and address racial disparities.
Recipients are also encouraged to improve racial demographic data tracking to highlight and address racial disparities. When you break down race by Black, white and “other races” for example, you inevitably erase discrepancies between different oppressed minority populations. It’s important that these specific disparities be elevated in reports to raise awareness of disproportionately impacted women and target solutions that are population specific.
HRSA - State Maternal Health Innovation Program
HRSA has expanded its programming in the maternal health space with the establishment of the State Maternal Health Innovation Program (State MHI). The State MHI program fits squarely into the work that HRSA currently supports on maternal health. Announced in spring 2019, awards for the State MHI program totaled $18,650,000 for nine awardees. Ohio will receive $2,134,389 for the project year beginning September 30, 2019. The overall project period is five years, $2.1 million each year, but funding for all subsequent years of the project is subject to Congressional approval.
Ohio will receive $2,134,389 for the project year beginning September 30, 2019
The State MHI program is intended to further states’ ability to collaborate with maternal health experts and advance existing efforts to improve maternal health, in Ohio that includes coordination with the PAMR board. The grant application specified that this work should aim to address disparities in maternal mortality and severe maternal morbidity. Ultimately this work should result in strategies to prevent and reduce maternal deaths and morbidity. The goals of the State MHI grant are phased throughout the five years, with deliverables included throughout.
The first year’s goal is to establish a state-focused Maternal Health Task Force that will create and implement a strategic plan.
There are a series of requirements of all State MHI grantees. The first year’s goal is to establish a state-focused Maternal Health Task Force that will create and implement a strategic plan. This task force should be comprised of multidisciplinary stakeholders to ensure a thorough strategy is developed. This plan will be tied to Ohio’s most recent Maternal and Child Health Services (Title V) Needs Assessment. The strategic plan must be developed by September 29, 2020. Also by this date, Ohio will produce a report with baseline data on maternal deaths and “make policy and programmatic recommendations aimed at reducing preventable maternal deaths.”
By the end of the first grant year, all award recipients, including Ohio, are expected to document all of the following:
- “Increases within the state from baseline on September 30, 2019 for the following:
- The percentage of women covered by health insurance.
- The percentage of women who receive an annual well-woman visit.
- The percentage of pregnant women who receive prenatal care.
- The percentage of pregnant women who receive prenatal care in the first trimester.
- The percentage of pregnant women who receive a postpartum visit.
- The percentage of women screened for perinatal depression.
- Decreases within the state from baseline on September 30, 2019 for the following:
- The rate of pregnancy-related deaths.
- The racial, ethnic, and/or geographic disparities in pregnancy-related mortality rates”[3]
All of these measures must be subsequently reported on annually throughout the duration of the five-year grant period.
An overall goal of the State MHI program is to “promote and execute innovation in maternal health service delivery.”[4] Innovation can fall into any number of categories that address the specific needs of Ohio and can include “improving access to maternal care services, identifying and addressing workforce needs, and/or supporting postpartum and interconception care services, among others.”[5] By the end of September 2021, grantees must update the strategic plan to reflect what the data shows related to maternal health and incorporate additional recommendations that more specifically address the gaps identified for Ohio.
These grant dollars will go a long way to move Ohio forward in its work to reduce and prevent maternal deaths and severe maternal morbidity.
Conclusion
These grant dollars will go a long way to move Ohio forward in its work to reduce and prevent maternal deaths and severe maternal morbidity. Tying these dollars to specific goals with time frames builds upon the structure added to Ohio’s PAMR in the state budget. Strengthening the process by which Ohio tracks maternal health outcomes will better enable all involved stakeholders to identify gaps and needs and develop strategies to improve outcomes for women across the state.
[1] https://www.ncbi.nlm.nih.gov/pubmed/12576252
[2] https://www.ncbi.nlm.nih.gov/pubmed/27500333
[3] Notice of Funding Opportunity, Maternal and Child Health Bureau, Division of Healthy Start and Perinatal Services, State Maternal Health Innovation Program. https://www.hrsa.gov/grants/fundingopportunities/default.aspx?id=4a36c363-b829-4608-af5e-9bc1fa884f41
