Foa_Content_of_CDC-RFA-DP-24-0053 (6).pdf

Centers for Disease Control and Prevention

NATIONAL CENTER FOR CHRONIC DISEASE PREVENTION AND HEALTH

PROMOTION

Enhancing Reviews and Surveillance to Eliminate Maternal Mortality

CDC-RFA-DP-24-0053

05/20/2024

Table of Contents A. Funding Opportunity Description

B. Award Information

C. Eligibility Information

D. Application and Submission Information

E. Review and Selection Process

F. Award Administration Information

G. Agency Contacts

H. Other Information

I. Glossary

Part I. Overview Applicants must go to the synopsis page of this announcement at www.grants.gov and click on the "Subscribe" button link to ensure they receive notifications of any changes to CDC-RFA-DP- 24-0053. Applicants also must provide an e-mail address to www.grants.gov to receive notifications of changes.

A. Federal Agency Name:

Centers for Disease Control and Prevention (CDC) / Agency for Toxic Substances and Disease Registry (ATSDR)

B. Notice of Funding Opportunity (NOFO) Title:

Enhancing Reviews and Surveillance to Eliminate Maternal Mortality

C. Announcement Type: New - Type 1:

This announcement is only for non-research activities supported by CDC. If research is proposed, the application will not be considered. For purposes of this NOFO, research is defined as set forth in 45 CFR 75.2 and, for further clarity, as set forth in 42 CFR 52.2 (see eCFR :: 45 CFR 75.2 -- Definitions and https://www.gpo.gov/fdsys/pkg/CFR-2007-title42-vol1/pdf/CFR- 2007-title42-vol1-sec52-2.pdf. In addition, for purposes of research involving human subjects and available exceptions for public health activities, please see 45 CFR 46.102(l) (https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-A/part-46/subpart-A/section- 46.102#p-46.102(l)).

D. Agency Notice of Funding Opportunity Number:

CDC-RFA-DP-24-0053

E. Assistance Listings Number:

93.946

F. Dates:

1. Due Date for Letter of Intent (LOI):

2. Due Date for Applications:

05/20/2024 11:59 p.m. U.S. Eastern Standard Time, at www.grants.gov.

3. Due Date for Informational Conference Call:

Please email NOFODP24-0053@cdc.gov with any questions.

Below, please find call-in directions for the informational conference call.

Mar 26, 2024 3:00 PM Eastern Time (US and Canada)

Join ZoomGov Meeting https://cdc.zoomgov.com/j/1605707346?pwd=bDlkbVdqeHN1cWRlU1FBT1Z5Umhndz09

Meeting ID: 160 570 7346 Passcode: i3?+p0H@

Dial by your location

• +1 669 254 5252 US (San Jose)

• +1 646 828 7666 US (New York)

• +1 646 964 1167 US (US Spanish Line)

• +1 415 449 4000 US (US Spanish Line)

• +1 551 285 1373 US (New Jersey)

• +1 669 216 1590 US (San Jose)

Meeting ID: 160 570 7346 Passcode: 15802250

Find your local number: https://cdc.zoomgov.com/u/abuvoyDQRw

G. Executive Summary:

1. Summary Paragraph This NOFO aims to support the capacity for developing and implementing data-informed strategies to prevent pregnancy-related deaths and reduce disparities among disproportionately impacted populations by improving data availability and quality to better identify and characterize pregnancy-related deaths and related health inequities. This NOFO supports agencies/organizations that coordinate/manage Maternal Mortality Review Committees (MMRCs) to identify and characterize pregnancy-related deaths for prevention. Recipients will identify pregnancy-associated deaths; conduct vital records quality assurance; abstract clinical/non-clinical data into a standard data system (Maternal Mortality Review Information Application, ‘MMRIA’); conduct informant interviews to inform individual case review; conduct multidisciplinary case reviews by diverse committees; and enter committee decisions into MMRIA. Quality assurance processes, in partnership with CDC, will be used for improving data quality, completeness, and timeliness. Recipients will analyze data and share findings to inform prevention strategies that reduce pregnancy-related deaths, with a focus on reducing inequities.

a. Funding Instrument Type:

CA (Cooperative Agreement)

b. Approximate Number of Awards

c. Total Period of Performance Funding:

$133,725,000

d. Average One Year Award Amount:

$451,611

e. Total Period of Performance Length:

5 year(s)

f. Estimated Award Date:

September 30, 2024

g. Cost Sharing and / or Matching Requirements:

No

Part II. Full Text

A. Funding Opportunity Description

1. Background

a. Overview The death of a woman during pregnancy, at delivery, or in the year after the end of pregnancy is a tragedy for her family and for society. For over a decade, the United States has not observed improvement in the burden of deaths each year because of pregnancy or delivery complications, a chain of events initiated by pregnancy, or the aggravation of an unrelated condition by the physiologic effects of pregnancy. Further, considerable racial and ethnic disparities exist. Non- Hispanic Native Hawaiian and other Pacific Islander, Black, and American Indian/Alaska Native people have pregnancy-related mortality ratios 2 to 4 times higher than non-Hispanic White people. Additionally, rural populations have higher risk of pregnancy-related deaths than urban populations, with racial and ethnic disparities persisting within rural and urban communities.

There is a wide range in the pregnancy-related mortality ratio between states: the state with the highest pregnancy-related mortality ratio is four times higher than that of the lowest. Findings from Maternal Mortality Review Committees (MMRCs) indicate that more than 80% of pregnancy-related deaths are preventable. The most frequent underlying causes of death vary by race and ethnicity. Cardiac and coronary conditions were the leading underlying cause of pregnancy-related deaths among non-Hispanic Black people, mental health conditions were the leading underlying cause among Hispanic, non-Hispanic White, and American Indian and Alaska Native people, and hemorrhage was the leading underlying cause among non-Hispanic

Asian people. Information from MMRC reviews can be used to identify and prioritize interventions that prevent deaths and reduce health disparities.

This Notice of Funding Opportunity (NOFO) will support MMRCs to systematically and comprehensively review deaths to develop recommended strategies for preventing future deaths.

Review committees access multiple sources of clinical and non-clinical information that provide a deeper understanding of the circumstances surrounding a death as they develop recommendations for action to prevent similar deaths in the future. CDC will support jurisdictional MMRCs across the US to operationalize a national approach to collecting and sharing data on pregnancy-related deaths. With these data, MMRCs will be able to facilitate an understanding of the drivers of maternal mortality and complications of pregnancy and associated disparities; identify interventions at patient/family, provider, facility, system, and community levels for preventing future deaths; and support the implementation of policies, programs, and initiatives at the right time and in the right places for families and communities who need them most.

b. Statutory Authorities Public Health Service Act, as amended, 301(a) and Section 317K, 42 U.S.C. 241(a); 42 U.S.C.

247b-12

c. Healthy People 2030 Pregnancy and Child Birth

d. Other National Public Health Priorities and Strategies This NOFO aligns with the White House Blueprint for Addressing the Maternal Health Crisis and the HHS Action Plan to Improve Maternal Health in America: Healthy Women, Healthy Pregnancies, Healthy Futures, 2020. It also aligns with the National Quality Strategy and the National Quality Forum’s 2021 Maternal Morbidity and Mortality Recommendations Final Report.

e. Relevant Work This NOFO builds on previous work of CDC-RFA-DP23-0066, CDC-RFA-DP22-2211, CDC- RFA-DP19-1908, and the Building U.S. Capacity to Review and Prevent Maternal Deaths Initiative. Other current CDC activities that will support this activity include the National Vital Statistics System (NVSS), Pregnancy Mortality Surveillance System (PMSS), the Pregnancy Risk Assessment Monitoring System (PRAMS), Perinatal Quality Collaboratives (PQCs), the Maternal and Child Health Epidemiology Program (MCHEP), CDC LOCATe, and the National Violent Death Reporting System (NVDRS).

2. CDC Project Description

a. Approach

Bold indicates period of performance outcome.

CDC-RFA-DP-24-0053 Logic Model: Enhancing Reviews and Surveillance to Eliminate Maternal Mortality

Bold indicates period of performance outcome

Strategies and Activities

Short-term Outcomes Intermediate Outcomes

Long-term Outcomes

Actions that improve availability, quality, and timeliness of MMRC data.

Actions that improve multidisciplinary, population-level review of potentially pregnancy-related deaths and documentation of recommendations for prevention.

Actions that improve dissemination, access to, and employment of quality Maternal Mortality Review Information Application (MMRIA) data to drive opportunities for prevention.

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.

Reduced maternal complications of pregnancy during pregnancy and in the year after the end of pregnancy.

Eliminated disparities in complications of pregnancy during pregnancy and in the year after the end of pregnancy.

Improved population health maternal health outcomes.

Eliminated preventable pregnancy-related deaths.

i. Purpose This NOFO will support increases in the overall timeliness, comprehensiveness, and availability of information on strategies for prevention of pregnancy-related deaths and reduction of disparities in pregnancy-related mortality nationally. This NOFO will support agencies/organizations that coordinate/manage MMRCs to identify, characterize, and disseminate information on pregnancy-related deaths and opportunities for prevention.

ii. Outcomes The following outcomes are expected to be achieved by the end of the period of performance:

Short Term o Increased timeliness, accuracy, and standardization of information available about pregnancy-related deaths, including MMRC identified opportunities for prevention.

o Increased engagement and cooperation between MMRCs, partners, and communities to communicate information from data on pregnancy-related deaths.

o Increased availability of MMRC recommendations among communities, clinicians, public health practitioners, and decision makers.

Intermediate Term o Increased adoption of clinical and non-clinical policies and programs that reflect the highest standards of care.

o Increased implementation of recommendations that reach or consider the needs of populations disproportionately affected by pregnancy-related mortality.

iii. Strategies and Activities Actions outlined below represent activities implemented by a comprehensive maternal mortality review committee (MMRC) program and are the required strategies and activities of this award.

Applicants should describe in their application how they will support planning activities (if appropriate), scale up and/or ongoing implementation of all the activities outlined to comprehensively review and document pregnancy-related deaths. Applicants should identify and address barriers and challenges to implementation of these activities.

Actions that improve availability, quality, and timeliness of MMRC data.

• Fully operationalize the MMRIA system to support core MMRC functions, including entry and/or import of vital records for all pregnancy-associated deaths identified; entry of all relevant case information into the relevant MMRIA case abstraction forms for the cases prepared for committee review); and entry of committee determinations into the MMRIA committee decision form for all cases reviewed by the

MMRC.

• Comprehensively identify pregnancy-associated deaths, defined as identifying deaths of residents of a specific jurisdiction, regardless of location of death, that occur during pregnancy or within a year of the end of pregnancy on a routine basis. Deaths should be identified no later than one year following the date of death through, at a minimum, use of death records and death records linked to vital records data (i.e., birth records and fetal death records) for the year preceding the date of death, as well as additional case identification methods that, at a minimum, are consistent with CDC best practices and the Reference Guide for Pregnancy-Associated Death Identification. Fully operationalization of the Maternal Mortality Review Information Application (MMRIA) within the jurisdiction requires entry and/or import of vital event records on all pregnancy-associated deaths identified.

• Implement approaches for improving quality of death records and for timely death record quality assurance for deaths requiring confirmation of pregnancy status (e.g., deaths for which the pregnancy checkbox is the only evidence of pregnancy). Quality assurance processes include partnering with jurisdiction vital records offices to establish processes and procedures for confirming pregnancy status within 3 months of identification of the death, documenting confirmation status for the MMRC and vital records, and initiating jurisdiction allowable correction processes when applicable.

Activities may include edits to electronic death registration systems relevant for improving pregnancy checkbox quality or to support quality improvement approaches, such as training events and materials for death certifiers. A Reference Guide for Certification of Deaths Associated with Pregnancy on Death Certificates may be utilized as a tool for planning training or quality improvement approaches.

• Apply a consistent process and standardized criteria for selecting deaths that will be fully abstracted for committee review based on the jurisdiction’s resources and ensuring timely review of all pregnancy-related deaths.

• Implement informant interview approaches, as allowed by their jurisdictional specific authorities and protections, consistent with CDC developed tools and resources, such as the Informant Interview Guide for Maternal Mortality Review Committees, as a key strategy for incorporating family and community perspectives in committee review. This includes: establishing or maintaining the protections for informant interview approaches as part of public health surveillance activities; hiring or supporting personnel who are trained in qualitative interviewing and/or bereavement counseling (e.g., licensed clinical social worker); establishing standard processes and procedures to scale informant interviews so that interview participants can be identified and an interview can be extended for every death sent for committee review within the program; conducting informant interviews; and preparing the information from informant interviews for committee review as part of routine abstraction (including MMRIA data entry) and case narrative development.

• Abstract and enter information from medical records, social service records, informant interviews, and other relevant sources about all deaths potentially related to pregnancy into MMRIA within 18 months of death in preparation for committee review for cases selected for multidisciplinary review within 24 months of death. Full operationalization of the MMRIA system requires entry of all relevant case information into the 14 MMRIA case abstraction forms for the cases prepared for committee review.

• Document committee decisions on the MMRIA Committee Decisions Form in MMRIA, consistent with tools and resources provided by CDC within 30 days of completing the review of a death. Full operationalization of the MMRIA system requires entry of committee determinations into the MMRIA committee decision form for cases reviewed by the MMRC.

• Perform data quality assurance checks on all relevant MMRIA forms, based on review of CDC-generated MMRIA Data Quality Reports and additional recipient defined quality assurance procedures within 90 days of completing the review of a death. Quality assurance completed on a case in MMRIA is defined as having completed your program-specific quality assurance activities as outlined per any internal protocols, and as described in the recipient Evaluation and Performance Measurement Plan submitted within 6 months of award. At a minimum, data quality assurance should include a check of completeness on a sample of deaths by a person who did not enter the data. Data quality assurance checks may include checking that the death record state of residence, committee review date for deaths that went to committee review, and case narratives are included for each case that went to review. Additional data checks may include ensuring out of scope or false positive deaths are appropriately marked on the Home Record, date of birth and date of death are correct, checking for completeness in the abstractor assigned timing of death, ensuring all pregnancy-related deaths have a PMSS-MM cause of death code, all recommendations have a description of the issue and contributing factor class assigned.

Actions that improve multidisciplinary, population-level review of pregnancy-related deaths and documentation of recommendations for prevention.

• Maintain a multidisciplinary review committee, inclusive of clinical (e.g., Obstetrics and Gynecology, Perinatal Nursing, Critical Care, Psychiatry) and non-clinical disciplines and organizations (e.g., Public Health, Healthy Start Agencies, Community Leadership), as identified in the MMRC Facilitation Guide.

• Maintain a diverse review committee, inclusive of representatives from communities disproportionately impacted by pregnancy-related mortality and implement strategies that increase capacity of all committee members to meaningfully engage community perspectives. Activities should be tailored based on the needs/circumstances of the MMRC program and can include strategies that address challenges outlined in the Black Mamas Matter Alliance report on MMRCs Sharing Power with Communities. Activities should aim to increase capacity of all committee members to meaningfully engage community perspectives (e.g., Improve recruitment, orientation, training, and support for community members who are joining and serving on MMRCs; Provide trauma-informed training and mental wellness support for all committee members; Partner with health equity experts to train MMRC committee members to raise awareness of medical and systemic biases and meaningful community engagement).

Actions that improve dissemination, access to, and employment of quality MMRIA data to drive opportunities for prevention.

• Establish an analytic plan for pregnancy-related MMRIA data to provide at least annually information on burden, e.g., pregnancy-related mortality ratio, counts, causes, and distribution of deaths with stratification by disproportionally impacted populations (e.g., by age, race/ethnicity, rurality, community indicators), contributing factors, and/or opportunities for prevention. Analytic plans should incorporate activities that prioritize recommendations for action based on analyses of quantitative and qualitative MMRIA data, other process tools, and iterative engagement with committee members, and other clinical, public health, and community representatives within the committee’s jurisdiction. Disaggregation by populations disproportionately affected by pregnancy-related mortality is important to drive action that has the potential to reduce health disparities. Producing at least one analysis per period of performance, but per budget period where feasible (i.e., population size allows), on leading causes of pregnancy-related death stratified by populations disproportionally affected within recipient jurisdiction† (e.g., race-ethnicity, rurality) is a required strategy of this award. In order to meet the requirement, analyses should be included in a data product available to partners to inform action.

• Establish a dissemination plan for information on pregnancy-related analyses inclusive of strategies that prioritize use of MMRC information for public health action.

Plans should specify intended partners and audiences, and consider equitable approaches for informing data analysis, reporting and dissemination.

• Implement dissemination strategies for data products and related information from pregnancy-related analyses (e.g., reports, publications, presentations, briefs), when available, at least once per year to internal and external audiences for informing practice, program, and policy changes, with priority for community dissemination activities.

• Develop and sustain bidirectional partnerships with communities that increase the utilization of MMRC data and increase the transparency of MMRC process and data. Activities should be tailored based on the needs/circumstances of the MMRC program and jurisdictional context, and may include strategies that address challenges outlined in the Black Mamas Matter Alliance report on MMRCs Sharing Power with Communities. Activities may include strategies that increase capacity of MMRC programs to meaningfully engage community perspectives (e.g., listen to community members who have the expertise and solutions to address pregnancy-related mortality;

collaborate with local community members to ensure that MMRC recommendations are appropriate and responsive to the needs of communities). Activities may also support community partnerships that increase the transparency of MMRC processes, data analysis and dissemination, and prevention recommendations (e.g., host listening sessions, or data walks, with community members in communities disproportionately affected† by pregnancy-related mortality; engage with local communities to jointly assess and collaborate on analysis and interpretation of data, report development, and implementation of recommendations). New partnerships may be required and plans for partnership engagement should be described in the application narrative, where appropriate. Where partnerships exist, Letters of Support from partners may be included as a supplemental attachment in the application.

• Leverage partnerships to support action on MMRC information and inform practice, program, and policy changes in alignment with tools and resources provided in the State Strategies for Preventing Pregnancy-Related Deaths.

†Populations disproportionately affected by maternal mortality are designated and/or defined by your jurisdiction and should be data informed. Examples may include race (e.g., AI/AN, African American/Black,), payor source (e.g., Medicaid), geographic residence (e.g., rural, urban), or any other population characteristic that is relevant in your jurisdiction’s context.

1. Collaborations

a. With other CDC projects and CDC-funded organizations:

Required collaborations for all applicants:

• Evidence of an ability to share collected data with CDC. The ability to share the data collected and reported in a format that allows for analysis by CDC is indicated by the Preventing Maternal Deaths Act of 2018, 42 U.S.C. 247b-12 (317K of the Public Health Service Act). The following forms, signed by an authorized signatory in the agency/organization, are required for all applicants:

o MMRIA MOU

▪ Applicants must submit a MOU, signed by an authorized signatory in the agency/organization, utilizing the template available at:

https://www.cdc.gov/reproductivehealth/maternal-mortality/erase-mm/nofo/CDC-DP24-0053.html.

▪ This file should be uploaded as a PDF named “MMRIA_MOU” to www.grants.gov.

o MMRIA Data Sharing Agreement (DSA)

▪ Applicants must submit a DSA, signed by an authorized signatory in the agency/organization, utilizing the template available at https://www.cdc.gov/reproductivehealth/maternal-mortality/erase-mm/nofo/CDC-DP24-0053.html.

▪ This file should be uploaded as a PDF named “MMRIA_DSA” to www.grants.gov.

Optional collaborations – as applicable

Applicants are also expected to develop and maintain collaborative relationships with other CDC-funded projects, when available within their states, to achieve the outcomes shown in the logic model.

These optional collaborations are not required but can greatly increase the quality and effectiveness of MMRCs. When relevant, applicants are encouraged to document how these collaborations will assist their implementation of activities, as well as file a copy of Memoranda of Understanding (MOUs), Memoranda of Agreement (MOAs), Data Use Agreements (DUAs), or letters of support with their application, as appropriate, name the file “MOUs_MOAs”, and upload it as a PDF file at www.grants.gov. This may include, but is not limited to:

• CDC-funded Perinatal Quality Collaboratives (PQCs) or other recognized PQC network, as available in the applicant’s state/jurisdiction, to translate clinical recommendations into implementation to prevent maternal mortality at the health system level.

• Other CDC-funded surveillance programs to identify strategies for improving data quality and information available for the MMRC, such as their state Violent Death Reporting System and the CDC Pregnancy Mortality Surveillance System.

• CDC state assignees to facilitate working with state and local agencies. These assignees provide epidemiologic research and scientific expertise and information for maternal and child health program and policy development.

• Organizations that are implementing the CDC Levels of Care Assessment Tool (LOCATe) to operationalize a coordinated regional system of risk-appropriate care to ensure that pregnant women at high risk of complications receive care at a birth facility that is best prepared to meet their health needs.

• Applicants are encouraged to collaborate with Pregnancy Risk Assessment Monitoring System (PRAMS) recipients in their jurisdictions to understand more state-specific, population-based data on maternal attitudes and experiences before, during, and shortly after pregnancy. This can be an important linkage to measure gaps and opportunities to address MMRC prevention recommendations.

• CDC-funded community health worker programs, such as the Community Health Workers for COVID Response and Resilient Communities (CCR).

• CDC-funded Racial and Ethnic Approaches to Community Health (REACH) recipients in their jurisdictions to understand more specific, population-based initiatives to reduce racial and ethnic health disparities.

b. With organizations not funded by CDC:

Applicants are expected to have established jurisdictional authorities and protections in place which provides them with the fundamental ability to coordinate key components of a MMRC. In addition, applicants are expected to maintain collaborative relationships with the following organizations to accomplish the activities and outcomes outlined in this funding opportunity.

Required collaborations must be supported by an applicant’s description of how the collaborating organization will assist the applicant in implementing activities, addressing barriers and challenges, and achieving outcomes; and must also include verification of this collaboration through memoranda (MOAs or MOUs, DUAs, and/or Letters of Support) from each collaborating organization. Memoranda should describe a commitment to the outlined tasks.

When applicable, applicants should discuss agreements for data access and sharing. Similarly, each optional collaboration identified by the applicant must include a description of how the collaborating organization will assist the applicant in implementing activities and achieving outcomes; and must also include verification of this collaboration through memoranda (MOAs or MOUs, DUAs, and/or letters of support) from each collaborating organization, outlining a commitment to the defined tasks.

Required collaborations for all applicants:

• Authorities and Protections. Applicants must submit evidence of authority that provides the MMRC access to clinical and non-clinical records; and confidentiality protection of data collected, proceedings, and activities. Evidence can be documented by submitting copies or through reference to specific authorities, including but not necessarily limited to state statutes, rules, legislation, or a letter from the applicant’s legal authority documenting these authorities and protections.

o These files should be uploaded as a PDF with the application and named "Auth_Protect_MOU" to www.grants.gov.

• State/Jurisdictional Vital Records Offices. Death, birth, and fetal death certificates that include identifiers (e.g., names, locations, dates) are crucial to the identification of pregnancy-associated deaths. This memorandum of support from the vital records office should outline the level of access to vital records the applicant has or will have at the time of award (i.e., live-time electronic access; monthly data sets, etc.) and current relevant vital statistics data quality assurance and improvement initiatives.

o Participation in the National Association of Public Health Statistics and Information Systems - State and Territorial Exchange of Vital Events (STEVE) system maternal mortality project can be acknowledged in the memorandum.

o These files should be uploaded as a PDF with the application and named “Vitals_MOU” to www.grants.gov.

• Medicaid Offices. Electronic Medicaid data that include identifiers (e.g., names, NPI, locations, dates) can increase the identification of pregnancy-associated deaths beyond vital records. This memorandum of support should outline acknowledgement by the State/Jurisdictional Medicaid Office that the MMRC has the authority to access medical records for the purposes of the MMRC; the level of access to identified Medicaid data the applicant has/will have at the time of award (i.e. live-time electronic access; monthly data sets, etc.) for the purposes of increasing the identification of pregnancy-associated deaths and locations of relevant medical records; and the participation level of the State

Medicaid Office in MMRC processes (e.g., Medicaid Medical Director is an active member of the MMRC).

o These files should be uploaded as a PDF with the application and named “Medicaid_MOU” to www.grants.gov.

Required collaborations for applicants under specific circumstances

• State Medical Examiner/Coroner Offices. In the case where the State Medical Examiner/Coroner Office is not the applicant, this memorandum should detail the relationship between the applicant and the State or jurisdictional Medical Examiner/Coroner offices. This memorandum of support, at a minimum, should outline the level of access to autopsy, next of kin interview, and death scene investigation reports the applicant has or will have and the participation level of medical examiners, coroners, and forensic pathologists in MMRC processes.

o Applicants should include MOUs, MOAs, DUAs, and letters of support, as appropriate. These files should be uploaded as a PDF with the application and named “ME_C_MOU” to www.grants.gov.

• Public Health Agencies. In the case where the State/Jurisdictional Public Health Agency is not the applicant, this memorandum should detail the relationship between the applicant and the Public Health Agency. This memorandum of support, at a minimum, should outline the roles and responsibilities of the Public Health Agency, including:

Level of access to specific public health data (beyond Vital Records); Analyses of MMRC data; Administrative support to the specific MMRC processes (e.g., abstraction, meeting logistics, coordination of processes); and Reporting and disseminating MMRC findings and recommendations. In addition, because state Title V Maternal and Child Health Programs are the most common unit within a state public health agency for MMRCs to be engaged with, a letter of support for the applicant from the State Title V Maternal and Child Health Director should also be included (or integrated) describing:

o How the MMRC relates to the state’s Title V priorities;

o Any budgetary and/or in-kind support provided to the MMRC by the state MCH

Program; and o The participation level of State Title V staff in MMRC processes (e.g., Maternal and Child Health Epidemiology staff are active members of the MMRC).

o Applicants should include MOUs, MOAs, DUAs, and letters of support, as appropriate. These files should be uploaded as a PDF with the application and named “SPHA_MOU” to www.grants.gov.

Optional collaborations – as applicable

The partnerships listed below can be critical collaborators for ensuring the success of applicants in implementing clinical and non-clinical recommendations for prevention. When relevant, it is strongly encouraged that the applicant includes a letter of support that, at a minimum, outlines the roles and responsibilities of the partner related to specific MMRC processes or community engagement strategies. Example partnerships include:

• State/Jurisdictional Hospital Associations

• Clinician Membership Organizations (e.g., Association of Women’s Health Obstetric and

Neonatal Nurses (AWHONN), State Obstetrical and Gynecological Societies and/or

American College of Obstetricians and Gynecologists (ACOG) Sections, American Academy of Family Physicians (AAFP), American Psychological Association (APA), American College of Nurse midwives (ACNM) Sections or Chapters)

• Title V Maternal and Child Health Services Block Grant Programs

• State Maternal Health Innovation Program

• Healthy Start Programs

• Community Based Organizations

• Patient Advocacy Organizations

• Tribes and/or Tribal Serving Organizations

Applicants must file the MOU or MOA, as appropriate, name the file “Opt_Partners_MOUs_MOAs”, adding a number to the end to differentiate these files from each other (for example, Opt_Partners_MOU1, Opt_Partners_MOU2) and upload it as a PDF file at www.grants.gov.

2. Population(s) of Focus The population of focus for this funding opportunity is all pregnant and postpartum people in each jurisdiction. This group will benefit directly from a reduction in pregnancy-related deaths and complications of pregnancy. Applicants are required to include a description of how subpopulations are disproportionately affected by pregnancy-related deaths and complications of pregnancies (i.e., based on geography, race, ethnicity, socioeconomic status, insurance type, preferred language, or other relevant factors) and strategies the applicant will implement to address these disparities. Applicants should describe any disproportionately impacted populations using CDC Preferred Terms for Select Population Groups & Communities.

This NOFO, including funding and eligibility, is not limited based on, and does not discriminate on the basis of race, color, national origin, disability, age, sex (including gender identity, sexual orientation, and pregnancy) or other constitutionally protected statuses.

a. Health Disparities The goal of health equity is for everyone to have a fair and just opportunity to attain their highest level of health. Achieving this requires focused and ongoing societal efforts to address historical and contemporary injustices; overcome economic, social, and other obstacles to health and healthcare; and eliminate preventable health disparities.

Broadly defined, social determinants of health are non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces (e.g., racism, climate) and systems include economic policies and systems, development agendas, social norms, social policies, and political systems. See content below and in other sections (e.g., Approach, Collaborations, Populations of Focus) for information on how this specific NOFO affects social determinants of health.

A health disparity is a preventable difference in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by populations that have been socially, economically, geographically, and environmentally disadvantaged. Health disparities are inextricably linked to a complex blend of social determinants that influence which populations are most disproportionately affected by these diseases and conditions.

Pregnancy-related mortality ratios vary widely by race-ethnicity and geography, emphasizing the need to document, understand, and reduce these disparities and address the social determinants that are driving these inequities.

This NOFO will support MMRCs to identify and characterize pregnancy-related deaths for identifying prevention opportunities. Informant interviews have emerged as a critical information source for MMRCs to better understand the perspectives of family members, and, by extension, community perspectives related to the issues presented in each case. Review committees are multidisciplinary, inclusive of both clinical and non-clinical membership, to better understand the circumstances surrounding a maternal death and translate committee findings into recommendations. Applicants are encouraged to establish and maintain relationships with critical collaborators that can address the social determinants of health affecting maternal mortality, such as access to care and barriers to transportation. The Maternal Mortality Review Information Application (MMRIA) includes the capability for geocoding, that can be used to leverage community level information about potential structural contributors to disparities in maternal mortality. Dissemination of MMRC data and information on recommendations for prevention within communities is an important aspect of building bidirectional partnerships with communities that increase the utilization of MMRC data to address disproportionate burdens of maternal mortality.

iv. Funding Strategy Recipient funding formula is based on average costs associated with comprehensive MMRC functions (i.e., case identification, vital records data quality assurance, case record abstraction, informant interviews, case narrative development, committee coordination, meeting logistics, MMRIA data analyses, dissemination activities, and travel for up to 4 staff to an annual required reverse site visit), adjusted for the 3-year average of state-level numbers of pregnancy-associated deaths, as indicated by 2019-2021 CDC WONDER mortality data. A reference sheet on using CDC WONDER to identify ICD-10 based estimates of 'pregnancy-associated' deaths, and eligible, state-specific breakdowns are provided for potential applicants at:

https://www.cdc.gov/reproductivehealth/maternal-mortality/erase-mm/nofo/CDC-DP24- 0053.html. In order to ensure maximum U.S. coverage, no more than one application per state, US territory or freely associated state, or District of Columbia will be funded.

The following amounts are subject to the availability of funds. CDC will not fund any application over the funding amount for the jurisdiction indicated in the table below.

Number of deaths per year Funding amount

Less than or equal to 4 $295,000

5-11 $370,000

12-25 $495,000

26-39 $570,000

40-55 $595,000

56-85 $620,000

Equal to or greater than 86 $860,000

Depending on applicants, awards can potentially range from $295,000 to $860,000.

b. Evaluation and Performance Measurement

i. CDC Evaluation and Performance Measurement Strategy

CDC Performance Management Strategy CDC will use a core set of priority performance measures to monitor the implementation of strategies and activities and assess achievement of the outcomes expected throughout the period of performance. Priority performance measures are integrated below as mapped to the Short Term or Intermediate Outcome they assess.

Short Term Outcomes Increased timeliness, accuracy, and standardization of information available about pregnancy-related deaths, including documented opportunities for prevention.

• Outcome measure 1: Proportion of pregnancy-associated deaths identified within 12 months of death.

• Outcome measure 2: Proportion of death records with a pregnancy checkbox error that are corrected in the final data provided to CDC’s Division of Vital Statistics

• Outcome measure 3: Proportion of deaths identified for committee review, fully abstracted, and ready for review within 18 months of death.

• Outcome measure 4: Proportion of deaths identified for committee review, reviewed within 24 months of death.

• Outcome measure 5: Proportion of cases reviewed by the committee that include information from an informant interview.

• Outcome measure 6: Proportion of recommendations from pregnancy-related deaths that include What/ Who/When statements.

Increased engagement and cooperation between MMRCs, partners, and communities to communicate information from data on pregnancy-related deaths.

• Process measure: Committee composition (i.e., multidisciplinary, representativeness)

• Outcome measure 7: Number of engagements with organizations/agencies /community groups that serve or represent populations disproportionately affected†

Increased availability of recommendations of the MMRCs among communities, clinicians, public health practitioners, and decisionmakers.

• Outcome measure 8: Number of MMRIA data products.

• Outcome measure 9: Number of dissemination activities of MMRIA data products.

Intermediate Term Outcomes

Increased adoption of clinical and non-clinical policies and programs that reflect the highest standards of care.

• Outcome measure 10: Number of data driven recommendations being implemented from MMRIA data.

o Number of data driven clinical recommendations.

o Number of data driven non-clinical recommendations.

Increased implementation of recommendations that reach or consider the needs of populations disproportionately affected by pregnancy-related mortality.

• Outcome measure 11: Proportion of data driven recommendations being implemented from MMRIA data that reach or consider the needs of populations disproportionately affected†.

†Populations disproportionately affected by pregnancy-related mortality are designated and/or defined by your jurisdiction and should be data informed. Examples may include race (e.g., American Indian/Alaska Native, African American/Black), payor source (e.g., Medicaid), geographic residence (e.g., rural, urban), or any other population characteristic that is relevant in your jurisdiction’s context.

CDC Program Evaluation Strategy CDC may conduct other program evaluation activities throughout the period of performance.

Activities will be informed by recipient and partner feedback and will assess how increased support for a national approach to the review of pregnancy-related deaths by MMRCs across the US has contributed to changes in public health capacity, awareness of MMRCs, and policies, programs, or services that have the potential for improving maternal health outcomes.

Data Use Program data from ERASE MM recipients and related activities, will be used to monitor progress of programmatic activities and assess achievement on core strategies of this opportunity.

MMRIA data will be used by CDC and the recipients for monitoring progress and improving public health outcomes by:

• CDC will describe pregnancy-related deaths by analyzing aggregated MMRIA data and identify common opportunities for prevention on a routine basis.

• Recipients will describe pregnancy-related deaths, including among populations disproportionately affected, by analyzing their aggregated MMRIA data and identifying common opportunities for prevention at least annually.

Data Management Plan Applicants are not required to submit a Data Management Plan as CDC manages the data system, Maternal Mortality Review Information Application (MMRIA). CDC developed and received approval for a system-wide Data Management Plan.

ii. Applicant Evaluation and Performance Measurement Plan

Applicants must provide an evaluation and performance measurement plan that demonstrates how the recipient will fulfill the requirements described in the CDC Evaluation and Performance Measurement and Project Description sections of this NOFO. At a minimum, the plan must describe:

• How applicant will collect the performance measures, respond to the evaluation questions, and use evaluation findings for continuous program quality improvement, including, as applicable to the award, how findings will contribute to reducing or eliminating health disparities and inequities.

• How key program partners will participate in the evaluation and performance measurement planning processes.

• Available data sources, feasibility of collecting appropriate evaluation and performance data, and other relevant data information (e.g., performance measures proposed by the applicant).

• How evaluation findings will be disseminated to communities and populations of interest in a manner that is suitable to their needs.

• Plans for updating the Data Management Plan (DMP) as new pertinent information becomes available. If applicable, throughout the lifecycle of the project. Updates to DMP should be provided in annual progress reports. The DMP should provide a description of the data that will be produced using these NOFO funds; access to data;

data standards ensuring released data have documentation describing methods of collection, what the data represent, and data limitations; and archival and long-term data preservation plans. For more information about CDC’s policy on the DMP, see https://www.cdc.gov/grants/additional-requirements/ar-25.html.

Where the applicant chooses to, or is expected to, take on specific evaluation studies, the applicant should be directed to:

• Describe the type of evaluations (i.e., process, outcome, or both).

• Describe key evaluation questions to be addressed by these evaluations.

• Describe other information (e.g., measures, data sources).

Recipients will be required to submit a more detailed Evaluation and Performance Measurement plan, including a DMP, if applicable, within the first 6 months of award, as described in the Reporting Section of this NOFO.

c. Organizational Capacity of Recipients to Implement the Approach The applicant’s organizational capacity statement must clearly describe the applicant has the necessary skills and relevant experience to successfully implement the strategies and activities outlined in the Logic Model and manage a federal award. Applicant should describe required skills including program planning, MMRIA data analysis and use, performance monitoring, financial reporting, budget management and administration, and personnel management.

Applicant must describe their ability to manage the required procurement efforts, including the ability to write and award contracts in accordance with grants regulations, if applicable.

Applicant must have a financial management system that will allow for funds management and segregation of funds by program, and meet the requirements as stated in the Uniform

Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards. The financial system should permit the preparation of reports required by general and program-specific terms and conditions; and the tracing of funds to a level of expenditure adequate to establish that such funds have been used according to the federal statutes, regulations, and terms and conditions of the federal award.

Applicants must:

• Describe experience and organizational capacity to address health inequities, including ability to identify drivers of health inequities (e.g., structural determinants of health) and the ability to engage review committee members with non-clinical expertise and/or community members.

• Include clear, specific, and referenced descriptions of the applicant's ability to reach a significant, if not all, of a state’s population, access to clinical and non-clinical records relevant for case abstraction and preparation for MMRC review. Applicants must identify data sources they have successfully accessed in the past and identify strategies to access new required data sources with solutions to address barriers to access.

• Describe a staffing plan and project management structure that will be sufficient to achieve the project outcomes, and which clearly defines staff and partner roles. The applicant will provide a staffing plan that identifies individuals capable of and/or having experience with abstraction, epidemiologic analysis of public health data, conducting interviews with community members around sensitive issues and program coordination.

• Describe history of collaborations to address inequities in pregnancy-related deaths and increase MMRC data utilization among communities.

d. Work Plan Applicants will be required to provide a detailed work plan for the first year of the period of performance. The work plan assists the Project Officer in monitoring recipient activities and reflects activities supported by the annual budget award. The work plan should display how the strategies, activities, timelines, and staffing/collaborations work together. The work plan should align with evaluation plan and must at a minimum include:

• Strategies and activities: Activities and timelines to support achievement of NOFO outcome. These activities should be in alignment with the NOFO logic model and should have appropriate performance measures for accomplishing tasks. Each element of the plan must contain the following elements: overall period of performance outcome and outcome measure, strategies and activities, and process measures.

• Responsible Position/Party: Staff, contracts and administrative roles and functions to support implementation of the award.

• Process Measures, Completion Date(s): Administration and assessment…