Data to Action Success Story: Maryland
Maryland: Integration of Intimate Partner Violence Screening into Women’s Health Services
More than one out of every three women in the United States reports having experienced intimate partner violence (IPV) at some time in her life. IPV is a significant public health problem with serious consequences for the victims, families, and communities. IPV is linked with health problems including chronic pain, depression, post-traumatic stress disorder, and an increased likelihood of substance abuse that could affect maternal and infant health [PDF – 362KB].pdf icon Specifically, IPV is associated with adverse pregnancy outcomes, such as low birth weight, preterm birth, and perinatal death, and adverse maternal health outcomes.1
In 2012, the United States Preventive Services Task Force (USPSTF) recommended routine assessment of intimate partner violence for all women of reproductive age. Screening for interpersonal and domestic violence is a covered preventive health service without cost sharing under the Affordable Care Act.
Program Activity Description
The Maryland PRAMS program published a short brief called Intimate Partner Violenc pdf icon[PDF – 207KB]external icon in March 2011 revealing that 7.2% of Maryland mothers reported being physically abused by a current or former partner either during or in the year prior to pregnancy. In addition, a review of pregnancy-associated homicides in Maryland was published in Obstetrics and Gynecology in June 2010. The review revealed that homicide was the leading cause of pregnancy-associated death in Maryland, and that two-thirds of these homicides were perpetrated by an intimate partner. Using both the Maryland PRAMS data and maternal mortality data about the adverse effects of IPV on maternal health and pregnancy outcomes, the Maryland PRAMS project director worked with the American College of Obstetricians and Gynecologists (ACOG) Committee on Health Care for Underserved Women to write and release Committee Opinion 518 “Intimate Partner Violenceexternal icon” in February 2012, which serves as a standard of care for obstetricians and gynecologists (ob/gyn).
Later that year, in September 2012, the Maternal and Child Health Bureau of the Maryland Department of Health and Mental Hygiene (DHMH) established a Maryland IPV Task Force. The Task Force was made up of clinicians from various medical specialties including obstetrics/gynecology, internal medicine, psychiatry, family medicine, pediatrics, and emergency medicine. To facilitate IPV assessment among clinicians, members of the Task Force developed a three-question screening. This tool, which focuses on physical harm and was adopted in 2013, is for use by health care providers following a period of public comment and feedback from Maryland-based primary care providers and local and national IPV experts. The screening tool includes resources for immediate referral by the health care provider.
In conjunction with the release of the screening tool, DHMH initiated a project with ACOG to educate medical students, ob/gyn residents, academic faculty and their office staff about IPV, and to promote use of the screening tool. From 2012–2013, 14 educational training sessions for providers were held around the state, reaching a wide range of public health professionals and health care providers. In October 2013, Johns Hopkins School of Medicine began a pilot project implementing training on IPV assessment and use of the screening tool for third-year medical residents. The pilot project will continue through September 2014, and may be adopted by other medical schools if found to be effective.
Also in 2013, Maryland was awarded the Project Connect: A Coordinated Public Health Initiative to Prevent and Respond to Violence against Women grant. The project will span 3 years starting in January 2013. Project Connect Maryland will focus on integrating intimate partner violence assessment into the Title X Family Planning Program. Preventive women’s health services will be integrated into pilot domestic violence program sites such as the House of Ruth Marylandexternal icon.
Program Activity Outcomes
Following adoption of the three-question screening tool for use by health care providers and the training promoting the use of the screening tool in 2012 and 2013, more than 500 pledges were collected from providers to integrate IPV screening and referrals into their work. The Maryland Maternal Mortality Review Committee and the local domestic violence fatality review teams will assess the effect of the training and tool use during mortality case reviews. DHMH will arrange to review the medical charts of homicides perpetrated by an intimate partner to determine whether IPV assessment was done during the clinical visit. The training project at Johns Hopkins University—started in 2013—will have an evaluation component to assess knowledge about health effect of IPV and to determine prevalence of IPV screening among physicians at Hopkins. Results will be reported after the project is completed in 2014.
1Sarkar NN. The impact of intimate partner violence on women’s reproductive health and pregnancy outcome.external icon J Obstet Gynaecol. 2008 Apr;28(3):266-71.
Maryland PRAMS Influences Provider Counseling to Pregnant Women on Oral Health
In 2001, the US Surgeon General recommended improving oral health during pregnancy as a strategy for improving maternal and infant health. More recently in 2010, provisions of the Patient Protection and Affordable Care Act (ACA) called for a public health education campaign regarding the oral health of pregnant women, as well as including oral health surveillance among pregnant women, using PRAMS for data collection. Pregnancy presents an important opportunity to address oral health because dental care during pregnancy could help delay or prevent mother-to-child transmission of the infectious agent associated with dental caries, or cavities. The cavity-causing bacteria can be passed from caregivers, especially mothers, to children. Providing oral health services to pregnant women not only improves women’s oral health, but also presents an important opportunity for pregnant women to receive education on how to prevent dental cavities for their children. According to the Maryland Pregnancy Risk Assessment Monitoring System (PRAMS) survey, few women with live-born infants obtain oral health care during their pregnancy. Maryland data show that from 2004-2008, 28% of postpartum mothers reported that it had been 1-5 years since their last teeth cleaning; 8% reported that it had been 5 or more years, and 8% reported that they had never had their teeth cleaned.
Program Activity Description
Using 2004-2008 data from the Maryland PRAMS, a short report called a Focus Brief was published in December 2009. The brief report indicated that 62% of women did not get their teeth cleaned during pregnancy. The brief was presented and discussed at the annual Maryland PRAMS Steering Committee Meeting in 2010. The Maryland Department of Health and Mental Hygiene (DHMH) Oral Health Director attended this meeting, and collaborated with the Maryland PRAMS project to disseminate the information from the focus brief. Starting in 2010, the Maryland Dental Action Coalition (MDAC) agreed to broaden their goals to include increasing receipt of oral health care among women around the time of pregnancy. In addition, the PRAMS oral health data were also published in the 2010 Maryland Title V Needs Assessment and the 2010 Burden of Oral Diseases in Maryland Report. The findings were also made nationally available through publication of two articles in the Maternal and Child Health Journal; the first, entitled “Dental Cleaning Before and During Pregnancy Among Maryland Mothers,” was published in January 2013, and the second, “Disparities in unmet dental need and dental care received by pregnant women in Maryland,” was published in April 2014.
The collaboration between the Maryland PRAMS Project and the Maryland oral health director moved forward with a specific activity to increase oral health visits during pregnancy in Maryland. They developed a 2-page quick reference guide called Oral Health Care during Pregnancy: At-a-Glance Reference Guide in 2011, which was updated in 2013. The guide features tips for dentists about caring for obstetric patients and also included results from the 2009-2011 PRAMS data about the prevalence of dental cleaning during pregnancy in Maryland. This guide was disseminated to Maryland dentists to share with their pregnant clients and was posted on the DHMH website.
Following the release of the guide, a media campaign was launched in fall 2012. Obstetricians and oral health care providers were featured on WBAL (NBC) TV and in the Baltimore Sun newspaper and promoted oral health care during pregnancy. The campaign targeted the general public to promote oral health during pregnancy.
Program Activity Outcomes
The efforts of Maryland PRAMS and the DHMH Oral Health Department to increase awareness of the issue of oral health during pregnancy throughout Maryland have been far-reaching. Approximately 4,500 dental providers and 750 obstetric providers in Maryland, and nearly 1.87 million people of the general public were reached through the TV and radio media campaign. Further, the impact has extended nationally. In 2011, the Maryland PRAMS project director, a member of the national American College of Obstetricians and Gynecologist (ACOG) Committee on Health Care for Underserved Women, recommended drafting a Committee Opinion about oral health during pregnancy. Both multi-state and Maryland-specific PRAMS data were referenced in ACOG Committee Opinion 569, “Oral Health Care During Pregnancy and through the Lifespan,” published in August 2013. ACOG Committee Opinions are distributed to obstetricians across the country and become a standard of care for clinical practice. Future efforts in Maryland will include working with the Medicaid Administration in Maryland to expand dental care coverage during pregnancy and postpartum, and to maximize patient use of dental coverage benefits during pregnancy.
Reducing Sleep-Related Infant Deaths in Maryland
Sudden Unexpected Infant Death (SUID) is an important cause of infant death among babies aged 1 to 12 months in the United States. SUID occurs suddenly and unexpectedly, and the cause is not immediately obvious before investigation. Sudden infant death syndrome (SIDS), a type of SUID, accounts for approximately 50% of these deaths. Other causes of SUID frequently reported are unknown cause and accidental suffocation in bed pdf icon[PDF – 337KB]external icon.
In Maryland, the Baltimore City Child Fatality Review identified 89 unexpected infant deaths that occurred during sleep in 2002-2006. An unsafe sleeping environment (not sleeping on back; co-sleeping; or having extra blankets, toys, or pillows in the bed) was found in 91% of the deaths. Maryland Pregnancy Risk Assessment Monitoring System (PRAMS) data from 2001-2009 were analyzed to determine the prevalence of back sleeping in Baltimore City. Among all jurisdictions in Maryland, Baltimore City had the lowest prevalence (56%) of mothers placing their infants to sleep on their backs (range 56%-78%, state average, 67%), a practice known to reduce the risk of SIDS.
Program Activity Description
In 2010, Baltimore City launched a parent education campaign to teach new mothers about safe sleep for infants as part of the B’More for Healthy Babies campaign to decrease infant mortality. The need to continue and strengthen this campaign was sparked by the PRAMS data. The Baltimore City Health Department increased its educational efforts in 2011 and developed videos and trainings about safe sleep, including messages about co-sleeping and smoke exposure. In partnership with the Baltimore City Health Department, Health Care Access gave out cribs to families who could not afford them. In 2012, the most recent part of Baltimore City’s Safe Sleep campaign was an education effort aimed specifically at fathers in hopes that they will help reinforce safe sleep practices in their families and communities. A new video about safe sleep addressing fathers was released to the general public in 2013.
In addition to the campaign in Baltimore City, Maryland Governor O’Malley’s administration supported the safe sleep educational activities in the state and recognized the campaign’s potential role in improving infant mortality. In May 2011, the Maryland Secretary of Health, Dr. Sharfstein, invited a panel of medical professionals to advise the Maryland Department of Health and Mental Hygiene about the use of crib bumper pads. Public comments on crib bumper pad safety were also obtained and included responses from the Maryland Chapter of the American Academy of Pediatrics, Maryland Medical Society, Office of the Chief Medical Examiner, and other national infant sleep experts.
Program Activity Outcomes
After gathering comments and expert opinions for 18 months for the Secretary’s initiative, there was a clear consensus that crib bumpers offer no meaningful benefit and pose potentially serious risks to infants, including suffocation and death. This opinion was consistent with that of the American Academy of Pediatrics. In June 2013, Maryland became the first state to ban the sale of crib bumpers.
Since the Baltimore City Health Department began safe sleep messaging in 2010, preliminary data collected during 2009-2012 suggest that sleep-related infant deaths may have decreased annually. Because of the success of the Baltimore City campaign, the Maryland Department of Health and Mental Hygiene started distributing many of Baltimore City’s materials statewide to delivery hospitals, home visiting programs, local health departments, and WIC sites. The PRAMS survey will continue to collect information about infant sleep position that can be used to assess changes in these practices throughout the state.