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Implementing Levels of Maternal Care Improves Access to Risk-Appropriate Care Lexa Giragosian Levels of maternal care support risk-appropriate care for pregnant and birthing populations. Risk-appropriate care (RAC) is a strategy to ensure that pregnant women and infants with high risk of complications receive care at facilities with personnel who offer services at the required level of specialized care. States can use the process of perinatal regionalization to create coordinated care systems based on levels of maternal care to support RAC access. Implementing and strengthening maternal RAC systems can improve health outcomes for pregnant and birthing populations and reduce the incidence of severe maternal morbidity and mortality. Wanda Barfield - Brief - Implementing Levels of Maternal Care Improves Access to RAC website yes

Partner Spotlight: Q&A with Kate Menard on Levels of Maternal Care State Implementation Advancing Levels of Maternal Care: Q&A with Kate Menard Lexa Giragosian Learn how health agencies should approach levels of maternal care implementation, with key insights from Kate Menard, a key leader and expert on the topic. As the maternal health crisis continues nationwide and states face hospital closures and workforce challenges, health agencies are increasingly implementing levels of maternal care (LoMC) to improve access to maternal health services. LoMC provides a standardized way to classify health care facilities based on their ability to manage maternal risk conditions and complications during birth. LoMC implementation helps to ensure that perinatal patients receive the appropriate care for their specific health needs, supporting optimal health outcomes. When states or territories adopt LoMC, it can strengthen access to risk-appropriate care and build more coordinated systems of perinatal regionalization. LoMC implementation is a critical lever in systems level improvement and supports efforts to reduce severe maternal morbidity and mortality. ASTHO spoke with Kate Menard, a key leader in advancing LoMC implementation nationally, to learn more about how health agencies should approach LoMC implementation in their jurisdictions. She co-led the development of the original LoMC guidelines by the American College of Obstetrics and Gynecology/Society for Maternal Fetal Medicine, collaborated with CDC on its Levels of Care Assessment Tool (LOCATeSM), and partnered with the American College of Obstetrics and Gynecology on pilot testing onsite LoMC verification. For jurisdictions beginning implementation of LoMC, what are the critical first actions to take? Establishing a shared understanding of why LoMC matters, and how it supports access to RAC, is vital for sustained commitment. Begin by engaging diverse stakeholders, such as public health leadership (including rural health, maternal child health, minority health, and regulatory agencies), clinical leadership, payers, health administrators, patient advisors, and emergency medical services. I would also recommend conducting a thorough assessment of the existing regionalization system in your jurisdiction, identifying strengths and opportunities. This assessment can help tailor the LoMC implementation process to specific regional needs and contexts. Using CDC LOCATeSM can enable some aspects of this preliminary assessment. Which stakeholders should be involved from the beginning, and how can health agencies effectively engage them? Relevant partners may include clinicians (obstetricians, pediatricians, anesthesiologists, etc.), hospital associations, health system administrators, payers, community representatives, emergency medical services, and legislative authorities. Health agencies are in a unique position to convene stakeholders and bolster early and effective engagement. They can organize stakeholder convenings that bring all parties together and facilitate collaborative discussions, foster relationships, and ensure that diverse perspectives are considered in the planning process. Are there any lessons learned from your experiences that would be beneficial to those in the process of LoMC implementation? I would recommend leading with the ‘why’ as you begin this process. Clearly articulating your jurisdiction’s most urgent maternal health challenges and how LoMC can help address them will create alignment from the beginning. For example, if closure of obstetric services in rural hospitals is a major concern, focus on the design of a regionalized system that supports rural hospitals through education, training, and seamless systems for escalation of care when needed (antenatal consultation/referral or maternal transport). Jurisdictions can use Maternal Mortality Review Committee findings and hospital-based severe maternal morbidities reviews to identify key needs. Building trust is equally critical and strong relationships among stakeholders helps overcome resistance to change. Using data and evidence-based practices will enhance credibility and encourage partner buy-in. What are the key considerations and best practices needed to effectively implement LoMC? Firstly, define specific objectives for the implementation process through collaboration with stakeholders, ensuring they are measurable and achievable within the timelines set. Leverage stakeholder engagement to collaboratively determine how your jurisdiction will implement LoMC (e.g., legislation, regulation, governing body, adoption of the American College of Obstetrics and Gynecology/Society for Maternal Fetal Medicine guidelines as is or with state specific adaptations, designation method, onsite verification). Through this process, maintain open lines of communication among all stakeholders to foster transparency and collaboration. Once your jurisdiction is prepared for implementation, agency leaders should ensure adequate training for health care providers and administrators to understand the LoMC system and their role within it. Don’t forget to embrace quality improvement and utilize data and feedback from the implementation process to make informed adjustments and improvements, confirming that care delivery continuously aligns with best practices. How can jurisdictions use their LoMC data to demonstrate its value and return on investment to hospital leaders and decision-makers? Defining LoMC is the first step. Building shared language to advance collaboration, risk appropriate care, and improved maternal outcomes is how the investment is realized. Jurisdictions should track and report on key performance indicators, such as reductions in maternal morbidity and mortality rates, improved access to care, and increased adherence to best practices in maternal health. To make the business case, highlight cost benefits that effective LoMC implementation creates, such as fewer unplanned ICU admission, shorter hospital stays or readmissions, and avoidance of medical legal claims. Emphasize that effectively utilizing a LoMC system may actually improve retention of providers and staff in rural hospitals. Patient feedback may additionally demonstrate improved experiences for mothers and newborns, reinforcing the need for continuous investment in LoMC. article yes

Hypertension disorders in pregnancy are the leading cause of maternal death, but state and territorial health agencies can address hypertension in pregnancy and reduce maternal morbidity and mortality.

This ASTHOBrief addresses the financial challenges facing pregnant people in rural areas.

Learn how education and health agencies can work together to address adolescent health through school-based programs.

Enhancing Consumer Awareness Improves Access to Risk-Appropriate Care Lexa Giragosian Enhancing consumer awareness can improve health outcomes for pregnant and birthing populations. Risk-appropriate care (RAC) is a strategy to ensure that pregnant women and infants with high risk of complications receive care at facilities with personnel and services that can provide the required level of specialized care. States can utilize the process of perinatal regionalization to create coordinated care systems based on levels of maternal care (LoMC) to support RAC access. Implementing and strengthening maternal RAC systems as well as enhancing consumer awareness can improve health outcomes for pregnant and birthing populations and reduce the incidence of severe maternal morbidity and mortality. Maternal Mortality in the United States The U.S. maternal mortality rate nearly doubled between 2018 and 2021, with the starkest increases occurring among American Indian/Alaska Native and Black populations. Among other high-income nations, the United States has one of the highest maternal mortality rates and is continually increasing. According to the Maternal Mortality Review Committee's most recent data, over 80% of pregnancy-related deaths are preventable, and barriers such as low consumer awareness can inhibit the prevention of pregnancy-related deaths. The Importance of Consumer Awareness Consumer awareness refers to patient’s knowledge, attitudes, and awareness about their health. There is a gap in understanding among pregnant and non-pregnant women of the major health risks associated with pregnancy or what can pose a risk during pregnancy. There are also challenges surrounding consumer awareness of what levels of maternal care are, and which level is right for everyone. More specifically, there is a common misconception that higher levels are always the safest level to receive care. A lack of consumer awareness is associated with poor health outcomes and can create gaps in access to RAC. Providers have an important role in improving consumer awareness by educating their patients about their pregnancy risk factors and levels of maternal care, while also having adequate awareness about levels of maternal care themselves. Provider awareness about levels of maternal care can promote RAC accessibility since providers are often the main point of contact for pregnant women and are responsible for ensuring the patient receives care at the appropriate level. State Success Strategies Support and work with communities to build capacity for addressing consumer awareness. Promote community organizations’ ability to improve pregnant women’s understanding and usage of health information (literacy, language instruction, social support, etc.) to enhance consumer awareness and corresponding health outcomes. Specifically, supporting women of color-led community organizations will foster equitable consumer awareness. Implement and support policies that make doulas and community health workers more accessible within communities. Develop and disburse public health campaigns about maternal health. Utilize effective health communication techniques rooted in health equity. CDC’s Hear Her Campaign is an effective public health campaign that increases awareness of pregnancy complications and warning signs, empowers pregnant people to raise their concerns to their provider, encourages support systems to listen to pregnant people’s concerns, and provides the tools needed to foster communication between providers and patients. Ensure that health education materials are accessible and consider the social factors affecting the priority population. Inclusive and preferred language in educational materials should be applied and understandable, actionable, and culturally sensitive. Form partnerships with providers, hospitals, foundations, and professional associations to take a collaborative approach toward improving consumer awareness. Create resources with these relevant partners to inform patients about how to choose a provider and a hospital based on the level of care their pregnancy risks indicate. The National Accreta Foundation has a myriad of resources to help patients navigate the care process and ensure their access to RAC. Utilize partnerships with key stakeholders to disseminate materials in prenatal care settings such as provider offices or hospitals that outline RAC and the care coordination system in place at that location. Ensure that transferred/referred patients are receiving materials about the reason for their transfer/referral and about the new level of care they are entering. website yes

Reducing the Impact of Eating Disorders on Adolescent Girls eating disorders, adolescent girls, youth mental health, school-based health systems, prevention strategies, bmi, social media usage, public health, health problems, united states, risk factors. higher risk. mental illnesses, mental disorders, physical activity, wide range, mental health conditions, people with eating disorders, intense fear of gaining weight, body mass index bmi, eating disorder include, social media platforms, distorted body image, long term, treatment options, high school, age 18, family members, astho, association of state and territorial health officials Lexa Giragosian Eating disorders are behavioral health conditions that affect physical and mental health through altered ideas about food, eating habits, weight, exercise, body image, and related factors. There are many different types of eating disorders, the most common including anorexia nervosa, bulimia nervosa, and binge-eating disorder. They are among the deadliest mental illnesses, second only to opioid misuse, and co-occur often with anxiety, depression, obsessive-compulsive disorder, substance use, and post-traumatic stress disorder. Their economic cost in the United States is $64.7 billion every year. Eating disorder risk factors include experiencing weight stigma, bullying, limited social networks, trauma, and dieting, which can impact people of all ages, races, genders, and sexual identities. That said, adolescents are largely affected by eating disorders and experienced a 107.4% increase in eating disorder diagnoses from 2018 to 2022, which was exacerbated by the COVID-19 pandemic. The majority of parents reported their adolescents’ social media usage increased during COVID-19’s peak. Adolescent’s exposure to weight-stigmatizing content on social media also increased during this time and is correlated with increased rates of body dissatisfaction. Social media usage can negatively influence body image and lead to body comparison, body dissatisfaction, and disordered eating—all contributors to eating disorder development. Reports indicate that adolescent girls use social media more than adolescent boys and are disproportionately affected by eating disorders, having a higher prevalence of eating disorders with increasing incidence compared to the general adolescent population. Further, according to a recent CDC study, pediatric emergency department visits among adolescent girls with eating disorders doubled during COVID-19. State Policy Actions Addressing youth mental health and social well-being is a top public health program and service priority area for several state and territorial health departments, as indicated by ASTHO’s 2023 Environmental Scan of Current and Emerging Public Health Priorities. Many states have recently proposed or enacted legislation that supports this focus, which may alleviate the impact of eating disorders on adolescent girls. Recent bill highlights include: New York SB-S5225: This active bill of the 2023-2024 session would add eating disorder assessments to the existing health certificate requirements for public school students. Louisiana HB 440: This legislation, passed during the 2022 session, requires schools to provide age-appropriate education about eating disorders as well as how to prevent them. Schools can incorporate this information into their current health education, physical education, or other related courses. Pennsylvania HB-148: The Pennsylvania House of Representatives passed this bill requiring schools to provide educational information to parents of children in 6th-12th grade about eating disorders as well as create a state task force to develop guidance and resources about eating disorders among adolescents. The bill is currently in the Pennsylvania Senate. California CA SCR14: A legislative resolution designated the week beginning on February 20, 2023, as Eating Disorders Awareness Week to improve awareness, visibility, and support. Colorado SB 23-14 and SB 23-17: These complementary bills created a program within the state health department dedicated to preventing eating disorders, limit the use of body mass index (BMI) in determining treatment criteria and appropriate care levels, and restrict the sale of diet pills to minors. Texas HB-18: The governor signed this bill in June 2023 which aims to regulate social media content available to minors. The new law requires social media platforms to develop and implement strategies to prevent the exposure of minors to negative material, including content that promotes, glorifies, or facilitates eating disorders. 1/4 bottom Recommendations to Address Eating Disorders Among Adolescent Girls Collaborate within Multidisciplinary Teams to Promote Eating Disorder Care Coordination Diagnosing and treating eating disorders is a complex process that requires various players, such as primary care and mental health providers, dietitians, state health agencies, schools, clinics, and payers. Establishing care coordination systems for eating disorders with these players can improve diagnosis rates and access to appropriate treatment by developing services and partnerships, including referral pathways, provider training, and universal screening. They can be modeled after evidence-based care coordination systems for substance use disorders, which are effective in accomplishing these very goals. Vermont’s eating disorder workgroup recently developed a report for their legislature in accordance with these recommendations to improve care coordination and increase access to eating disorder services for all populations, including adolescent girls. Implement Prevention Strategies in Schools Focusing on school-based health systems offers an opportunity to improve adolescent mental health. School-based policy strategies to improve adolescent girls’ mental health may include incorporating eating disorder content into health education curricula, building staff capacity to address mental health concerns, and improving screening and treatment access for mental health issues such as eating disorders. Creating a supportive, accepting school environment that does not stigmatize weight is also an important role of schools in eating disorder prevention. The American Academy of Pediatrics provides additional key recommendations for schools and their collaborators regarding their role in addressing eating disorders among students. Support Policy Action Limiting the Use of BMI as an Indicator for Eating Disorder Treatment A stereotypical eating disorder patient is characterized as being “thin” with a low BMI; however, there are higher rates of disordered eating behaviors among those whose BMI classifies them as “overweight” or “obese.” There is an overreliance on BMI as a diagnosable criterion for eating disorders and a prevalence of weight stigma and assumptions in clinical care, contributing to the underdiagnosis of eating disorders. Even with a diagnosis, insurers often use BMI as an indication of treatment need, length of stay, and level of care, which inhibits access to appropriate treatment. In June 2023, the American Medical Association issued a new policy that recognizes the issues of using BMI to measure health as a step towards limiting the use of BMI. Address Social Media Use in Programmatic and Policy Initiatives Social media usage rapidly increased in recent years, and the effects on child and adolescent development are an ongoing concern. Evidence indicates that there is an association between social media usage and adolescent development of eating disorders due to unrealistic body expectations and diet culture outlined in media. The Surgeon General and the American Psychological Association developed guidance on addressing social media usage for children and adolescents, and specified strategies to support healthy social media use that can be utilized in public health initiatives. Moving Forward Eating disorders among adolescent girls are an urgent public health concern. State and territorial health agencies can move forward with prevention efforts by fostering care coordination, collaborating towards policy and programmatic developments in schools, improving access to care, and addressing social media usage. For more information about legislative trends related to eating disorders among adolescents, refer to ASTHO’s resource “Supporting Mental Health: Addressing a New Public Health Crisis,” from the 2024 Legislative Prospectus Series. website yes

Rural hospital closures exacerbate poor socioeconomic conditions, job loss, cost of health services, transportation times and barriers, and inequitable access to quality care, all of which contribute to unfavorable maternal and infant health outcomes.

The COVID-19 pandemic has had a particularly negative impact on the mental health of adolescent girls. Fortunately, state legislators have been addressing school-based mental health through legislation enacted since the beginning of the pandemic.