[Federal Register Volume 87, Number 97 (Thursday, May 19, 2022)]
[Notices]
[Pages 30501-30506]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2022-10783]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Resources and Services Administration


Criteria for Determining Maternity Care Health Professional 
Target Areas

AGENCY: Health Resources and Services Administration (HRSA), Department 
of Health and Human Services (HHS).

ACTION: Final response.

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SUMMARY: Section 332 of the Public Health Service Act (PHSA) directs 
the Department of Health and Human Services (HHS), through the Health 
Resources and Services Administration (HRSA), to identify Maternity 
Care Target Areas (MCTA), or geographic areas within health 
professional shortage areas that have a shortage of maternity care 
health professionals, for the purpose of providing maternity health 
care assistance to such health professional shortage areas. On 
September 21, 2021, the Health Resources and Services Administration 
(HRSA) published a Federal Register notice soliciting feedback on 
proposed criteria to be used to identify Maternity Care Target Areas 
(MCTAs). HRSA requested feedback on six proposed criteria for inclusion 
in a composite scale to identify MCTAs with the greatest shortage of 
maternity care health professionals: (1) Ratio of females ages 15-44 -
to-full time equivalent maternity care health professional ratio; (2) 
percentage of females 15-44 with income at or below 200 percent of the 
federal poverty level (FPL); (3) travel time and distance to the 
nearest provider location with access to comprehensive maternity care 
services; (4) fertility rate; (5) the Social Vulnerability Index; and 
(6) four Maternal Health Indicators (pre-pregnancy obesity, pre-
pregnancy diabetes, pre-pregnancy hypertension, and prenatal care 
initiation in the first trimester). This notice summarizes and responds 
to the comments received during the 60-day comment period and presents 
the final criteria which will be used to identify and score MCTAs.

ADDRESSES: Additional information about MCTAs is available at https://bhw.hrsa.gov/workforce-shortage-areas/shortage-designation.

FOR FURTHER INFORMATION CONTACT: Dr. Janelle McCutchen, Chief, Shortage 
Designation Branch, Division of Policy and Shortage Designation, Bureau 
of Health Workforce, HRSA, 5600 Fishers Lane, Rockville, Maryland 
20857, [email protected], or 301.443.9156.

SUPPLEMENTARY INFORMATION: Section 332 of the Public Health Service Act 
(PHSA), 42 U.S.C. 254e, provides that the Secretary designate Health 
Professional Shortage Areas (HPSAs) based on criteria established by 
regulation. HPSAs are defined in section 332 to include (1) urban and 
rural geographic areas which the Secretary determines have shortages of 
health professionals, (2) population groups with such shortages, and 
(3) public or private medical facilities or other public facilities 
with such shortages. The required regulations setting forth the 
criteria for designating HPSAs are codified at 42 CFR part 5.
    Section 332(k)(1) provides that the Secretary, acting through the 
Administrator of HRSA, identify shortages of maternity care services 
``within health professional shortage areas.'' Section 332(k)(1) 
further requires HRSA to identify MCTAs and distribute maternity care 
health professionals within HPSAs using the MCTAs so identified. HRSA 
must also collect and publish data in the Federal Register comparing 
the availability and need of maternity care health services in HPSAs 
and must seek input from relevant provider organizations and other 
stakeholders.
    In a September 21, 2021, Federal Register notice (86 FR 53324), 
HRSA requested feedback on six proposed criteria to identify MCTAs: (1) 
Ratio of females ages 15-44 -to-full time equivalent maternity care 
health professional ratio; (2) percentage of females 15-44 with income 
at or below 200 percent of the federal poverty level (FPL); (3) travel 
time and distance to the nearest provider location with access to 
comprehensive maternity care services; (4) fertility rate; (5) the 
Social Vulnerability Index; and (6) four Maternal Health Indicators 
(pre-pregnancy obesity, pre-pregnancy diabetes, pre-pregnancy 
hypertension, and prenatal care initiation in the first trimester).
    HRSA carefully evaluated and analyzed the comments received and 
used them to guide the development of the final MCTA criteria.

Comments on the Proposed Criteria for Identifying Maternity Care Target 
Areas

    HRSA received 21 responses to the request for comments. Comments 
and responses are summarized below.

Health Care Capacity Factors

Summary of Comments

Population-to-Provider Ratio
    All commenters supported the inclusion of a population-to-provider 
ratio and agreed with HRSA's proposal of a population ratio of females 
ages 15-44 -to-full time equivalent maternity care health professional 
ratio. However, several commenters questioned the use of only 
Obstetrician/Gynecologists (OB/GYNs) and Certified Nurse Midwives 
(CNMs) in the provider ratio and recommended the inclusion of family 
medicine physicians, physician assistants, and nurse practitioners. 
Specifically, one commenter indicated

[[Page 30502]]

``that a comprehensive system of maternity healthcare services is 
comprised of multiple types of care and considerations should be made 
for the inclusion of family medicine physicians in rural areas that 
deliver maternity care services.''

Response

    HRSA appreciates the recommendation for the inclusion of additional 
provider types and recognizes the important contribution all of these 
professionals play in the delivery of obstetrics care. Currently, 
standardized nationwide data is not readily available outlining the 
number of hours that individual family medicine physicians, physician 
assistants, and nurse practitioners spend providing these services, and 
thus the agency would have no way of uniformly comparing the hours that 
these providers spend contributing maternity care services. HRSA 
recognizes the important role of these clinicians in the provision of 
maternity care and will continue to review the availability of these 
data points to determine if additional provider types may be 
incorporated into the MCTA scoring criteria in the future. We continue 
to welcome recommendations on nationally available data sets for the 
incorporation of these provider types into MCTAs. Until that data is 
readily available for inclusion, HRSA will proceed with the population-
to-provider ratio as proposed.
Travel Time and Distance (TTD) to Nearest Source of Care (NSC)
    HRSA proposed including a measure of travel time and distance (TTD) 
to the nearest source of care (NSC) with access to comprehensive 
maternity care services. All commenters supported the inclusion of TTD 
to NSC criteria but presented varied methodologies on how to implement 
and score the criteria. Some commenters were concerned with the TTD 
point scale outline in the proposed criteria and suggested that HRSA 
adjust and expand the scoring scale to provide points for facilities 
identified within the 30 minute/mile TTD. A separate commenter 
requested that, ``In terms of distance from comprehensive services, I 
would ask HRSA to clarify that as the distance from a site that has 
more than one or two on-staff OB/GYN.'' Another commenter indicated 
that TTD should be the largest weighted factor, as it relates to the 
geographic accessibility of services and is part of the assessment 
needed to fully address the MCTA statutory requirements

Response

    Section 332(k)(5) of the PHSA defines `full scope maternity care 
health services' as care provided during labor, birthing, prenatal 
care, and postpartum care, with no specification regarding the quantity 
of providers available at the facility. As to the comment regarding 
including points for distance less than 30 minute/mile, the United 
States currently lacks an established benchmark for timely access to a 
facility for obstetric care. However, the American College of 
Obstetricians and Gynecologist (ACOG) proposes a 30-mintue capability 
for decision-to-incision for emergency cesarean delivery.\1\ HRSA will 
therefore retain its proposed approach.
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    \1\ 1Roa, Lina et al., ``Travel Time to Access Obstetric and 
Neonatal Care in the United States.'' Obstetrics and Gynecology (New 
York. 1953) vol. 136, no. 3 (2020): 610-612.
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    In reference to the comment for the explicit definition of 
``distance from a site that has more than one or two on-staff OB/GYN,'' 
HRSA will apply the current Primary Care HPSA NSC policy, which 
identifies the NSC based on the presence of a provider trained and 
licensed to provide the necessary care regardless of the number of 
providers at the location. In response to the comment regarding 
geographic accessibility, HRSA recognizes the importance of this 
measure and will retain it as proposed and continue to monitor this 
issue in the future.

Health Care Need Factors

    HRSA proposed the use of four Maternal Health Indicators (pre-
pregnancy obesity, pre-pregnancy diabetes, pre-pregnancy hypertension, 
and prenatal care initiation in the first trimester).

Summary of Comments

Inclusion of Cigarette Smoking as Maternal Health Indicator
    Several commenters suggested inclusion of a tobacco usage 
indicator. Commenters noted that smoking in the 3 months leading up to 
pregnancy can increase the risk of preterm birth and of adverse 
maternal health outcomes, and recommended inclusion of tobacco use as 
an indicator. Additionally, commenters highlighted that a significant 
proportion of women who smoked cigarettes prior to pregnancy continue 
to smoke into the later stages of gestation.

Response

    HRSA agrees that the smoking of cigarettes is a significant risk 
factor for adverse maternal health outcomes and will add cigarette 
smoking as a Maternal Health Indicator. For this purpose, cigarette 
smoking will be defined as women who report smoking one or more 
cigarettes daily for the 3 months prior to pregnancy or during any of 
the trimesters of their pregnancy.
    One point will be added if the prevalence of cigarette smoking 
before or during pregnancy in the MCTA is greater than or equal to the 
median among all counties in the United States. If the prevalence of 
cigarette smoking before or during pregnancy in the MCTA is less than 
the median among all counties, zero points will be added.

------------------------------------------------------------------------
                    Cigarette smoking                         Points
------------------------------------------------------------------------
Prevalence of Cigarette Smoking Before or During                       1
 Pregnancy >=50th percentile............................
Prevalence of Cigarette Smoking Before or During                       0
 Pregnancy <50th percentile.............................
------------------------------------------------------------------------

    To accommodate the inclusion of this factor, one point will be 
removed from the total possible number of points awarded for the 
percent of the population living at or below the 200 percent Federal 
Poverty Level indicator. The rationale for this change is that 
household income relative to the federal poverty line is represented 
not only in this criterion but also in the Social Vulnerability Index 
criterion.
Lower Point Threshold for Maternal Health Indicators
    HRSA proposed that the threshold for receiving points for Maternal 
Health Indicators would be 75%. Two commenters noted that the threshold 
to receive a point for the Maternal Health Indicators was ``too 
restrictive.'' One commenter recommended that the threshold be 
decreased for each indicator from the top quartile (75th percentile) to 
the median (50th percentile).

[[Page 30503]]

Response

    HRSA conducted an impact analysis applying both percentiles to 
existing primary care HPSAs. The results of the analysis indicated that 
lowering the percentile threshold for Maternal Health Indicators to the 
median resulted in a slightly more standard distribution of the points 
across currently designated primary care HPSAs. The chart below 
provides a visual of the difference in the score distribution between 
the two thresholds. Based on this analysis, HRSA will adjust the 
threshold for the Maternal Health Indicators to reflect the 50th 
percentile recommendation of the commenters.
[GRAPHIC] [TIFF OMITTED] TN19MY22.014

Social Vulnerability Index
    Several commenters requested that HRSA provide points based on the 
individual factors of the Social Vulnerability Index (SVI) to allow for 
an increased impact of the social determinant factors within the SVI. 
Additionally, commenters proposed increasing the number of points 
allotted to the entire SVI.

Response

    HRSA recognizes the importance of the SVI in the prioritization and 
distribution of resources. The scientific research that correlates the 
SVI to a need for additional health care resources was conducted using 
the entire index and not the individual factors. In addition, 
accommodating all 15 of the individual factors of the SVI would dilute 
the impact of Maternal Health Indicators that are more closely 
associated with the need for maternal health care. Increasing the 
weight of the SVI in the MCTA scoring criteria would decrease the 
impact of other factors, such as initiation of prenatal care and pre-
pregnancy diabetes. HRSA will continue to apply the SVI as a whole to 
the MCTA scoring criteria and maintain the proposed point scale.
Inclusion of Behavioral Health Factor as Maternal Health Indicator
    Several commenters recommended the inclusion of a behavioral health 
factor as part of the Maternal Health Indicators. One commenter 
specifically recommended a composite point based on prevalence of 
perinatal mood, anxiety disorders, and substance use disorder. 
Commenters highlighted that a pre-pregnancy diagnosis of a mental 
health illness can be an indicator of an increased risk of mental 
health concerns during pregnancy, which also increases the potential 
for adverse perinatal/post-partum health outcomes.

Response

    HRSA recognizes the important impact of behavioral health factors 
on maternal health outcomes. A Report from the 14-state Maternal 
Mortality Review Committee found that 11% of the 421 pregnancy related 
deaths with an identified underlying cause of death determination, were 
due to mental health conditions. The Review Committee also determined 
that 100% of the pregnancy-related mental health deaths with a 
preventability determination were preventable.\2\
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    \2\ Trost, Susanna L., et al. ``Preventing Pregnancy-Related 
Mental Health Deaths: Insights from 14 US Maternal Mortality Review 
Committees, 2008-17: Health Affairs Journal.'' Health Affairs, 1 
Oct. 2021, https://www.healthaffairs.org/doi/10.1377/hlthaff.2021.00615.
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    The Centers for Disease Control and Prevention (CDC) and Emory 
University conducted a cross-sectional multilevel analysis of all 
pregnancy-related deaths and all live births with available ZIP code or 
county data in the Pregnancy Mortality Surveillance System during 2011-
2016 for non-Hispanic Black, Hispanic (all races), and non-Hispanic 
White women aged 15-44 years. Among health care need and service 
indicators, the number of mental health care professionals per 100,000 
population had a strong inverse relationship with the pregnancy-related 
mortality ratio. Each standard unit increase in the number of mental 
health care professionals was associated with 5.55 (95% CI -8.11 to -
2.99) fewer deaths per 100,000 live births among Black women and 1.42 
(95% CI -2.08 to -0.76) fewer deaths per 100,000 live births among 
White women.\3\
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    \3\ Barrera, C., & Et.Al. (2022). County-Level Associations 
Between Pregnancy-Related Mortality Ratios and Contextual 
Sociospatial Indicators. Journal Of Obstet Gynecol, 00(00), 1-11.
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    HRSA agrees that access to behavioral health is a significant risk 
factor for adverse maternal health outcomes and will include a 
behavioral health access factor as a Maternal Health Indicator.
    One point will be awarded if a portion or all of MCTA service area 
is designated as a Mental Health HPSA meeting the following population-
to-provider median ratio thresholds based on its mental health provider 
type. Zero points will be awarded if a portion or all of the MCTA 
service area is not designated as a Mental Health HPSA or

[[Page 30504]]

the Mental Health designation does not meet the population to provider 
ratio threshold.

------------------------------------------------------------------------
                    Behavioral health                         Points
------------------------------------------------------------------------
Portion or all of MCTA service area is designated as a                 1
 Mental Health HPSA meeting the following population-to-
 provider ratio thresholds based on its mental health
 provider type..........................................
     Psychiatrist ONLY: Psychiatrist population-
     to-provider ratio >=45,000:1.
     Core Mental Health: Core mental health
     population-to-provider ratio >=18,000:1.
     Psychiatrist and Core Mental Health:
     Psychiatrist population-to-provider ratio
     >=35,000:1 and Core mental health population-to-
     provider ratio >=6,000:1.
     No Psychiatrists or Core Mental Health
     Providers: >=7,500: 0.
Portion or all of MCTA service area is designated as a                 0
 Mental Health HPSA and does not meet the population-to-
 provider ratio thresholds above, OR is not designated
 as a Mental Health HPSA................................
------------------------------------------------------------------------

    To accommodate the inclusion of this factor, one point will be 
removed from the total possible number of points awarded for the travel 
time and distance (TTD) to nearest source of care (NSC) criteria. The 
rationale for this change is to ensure that all Health Care Capacity 
Factors are equal in value.

Conclusion of Comment Response

    HRSA appreciates the comments and recommendations received and has 
used them to guide the development of the final Maternity Care Health 
Professional Target Area criteria. Comments were not received on the 
proposed Federal Poverty Level or Fertility Rate factors; they will be 
finalized as proposed. The final MCTA criteria are included below. If 
you have any questions, please contact Dr. Janelle McCutchen at 
[email protected].

Final Approach for Determining Maternity Care Health Professional 
Target Areas

    An MCTA score will be generated for each primary care HPSA using 
the HPSA's service area. The following six scoring criteria will be 
included in a composite scale that will be used to identify MCTAs with 
the greatest shortage of maternity care health professionals: (1) Ratio 
of females ages 15-44 -to-full time equivalent maternity care health 
professional ratio; (2) percentage of females 15-44 with income at or 
below 200 percent of the FPL; (3) travel time and distance to the 
nearest provider trained and licensed to provide the necessary care; 
(4) fertility rate; (5) the SVI; and (6) Maternal Health Index which 
contains the following six indicators: Pre-pregnancy obesity, pre-
pregnancy diabetes, pre-pregnancy hypertension, prenatal care 
initiation in the first trimester, cigarette smoking, and the 
behavioral health factor. Each of these six criteria will be assigned a 
relative weight based on the significance of that criterion relative to 
all the others.
    The weighted scores will be summed to develop a composite MCTA 
score ranging from zero to 25, with 25 indicating the greatest need for 
maternity care health professionals in the MCTA. Accordingly, the 
higher the composite score, the higher the degree of need for maternity 
care health services.

Score for Population-to-Full-Time-Equivalent Maternity Care Health 
Professional Ratio

    Population-to-provider ratio will measure the number of women of 
childbearing age in the service area compared to the number of 
maternity care health professionals in the service area. Women of 
childbearing age will be defined as women between the ages of 15-44 
years old and maternity care health professionals will be defined as 
OB/GYNs and CNMs. A population-to-provider ratio of 1500:1 will be used 
as a minimum requirement for a population to be considered reasonably 
served by OB/GYNs and CNMs.
    Population-to-provider Ratio point values will be distributed as 
follows:

------------------------------------------------------------------------
              Population-to-provider ratio                    Points
------------------------------------------------------------------------
Ratio >=6,000:1, or No CNMs or OB-GYNs and Population                  5
 (Pop) >=500............................................
6,000:1 > Ratio >=5,000:1, or No CNMs or OB-GYNs and Pop               4
 >=400..................................................
5,000:1 > Ratio >=3,000:1, or No CNMs or OB-GYNs and Pop               3
 >=300..................................................
3,000:1 > Ratio >=2,000:1, or No CNMs or OB-GYNs and Pop               2
 >=200..................................................
2,000:1 > Ratio >=1,500:1, or No CNMs or OB-GYNs and Pop               1
 >=100..................................................
Ratio <1,500:1, or No CNMs or OB-GYNs and Pop <100......               0
------------------------------------------------------------------------

Score for Percentage of Population With Income at or Below 200 Percent 
of the Federal Poverty Level

    The percentage of people living in the service area at or below 200 
percent of the FPL will be used to score MCTAs, based on poverty data 
from the U.S. Census Bureau.
    Population with income at or below 200 percent of the FPL point 
values will be distributed as follows:

------------------------------------------------------------------------
    Population with income at or below 200% FPL ratio         Points
------------------------------------------------------------------------
Percentage of population with income at or below 200%                  5
 FPL >=50%..............................................
50% > Percentage of population with income at or below                 4
 200% FPL >=45%.........................................
45% > Percentage of population with income at or below                 3
 200% FPL >=40%.........................................
40% > Percentage of population with income at or below                 2
 200% FPL >=35%.........................................
35% > Percentage of population with income at or below                 1
 200% FPL >=30%.........................................
Percentage of population with income at or below 200%                  0
 FPL <30%...............................................
------------------------------------------------------------------------


[[Page 30505]]

Score for Travel Distance/Time to Nearest Source of Accessible Care 
Outside of the MCTA

    The Nearest Source of Care is defined as the nearest provider 
trained and licensed to provide the necessary care, as determined by 
the ESRI StreetMap Premium road network. Travel Time and Distance is 
defined as the average time to travel by road miles or the actual 
distance in road miles to the nearest source of care.
    Travel Time and Distance to the Nearest Source of Care point values 
will be distributed as follows:

------------------------------------------------------------------------
                Travel time and distance                      Points
------------------------------------------------------------------------
Time >=90 min or Distance >=90 miles....................               5
90 min > Time >=75 min or 90 miles > Distance >=75 miles               4
75 min > Time >=60 min or 75 miles > Distance >=60 miles               3
60 min > Time >=45 min or 60 miles > Distance >=45 miles               2
45 min > Time >=30 min or 45 miles > Distance >=30 miles               1
Time < 30 min and Distance <30 miles....................               0
------------------------------------------------------------------------

Score for Fertility Rate

    Fertility rate has been included to reflect the increased need for 
maternity care services among populations that experience a higher rate 
of births. Women of childbearing age will be derived from the American 
Community Survey and births will be derived from the National Vital 
Statistics System.
    Fertility Rate point values will be distributed as follows:

------------------------------------------------------------------------
                     Fertility rate                           Points
------------------------------------------------------------------------
Fertility Rate >=90th Percentile........................               2
90th Percentile > Fertility Rate >=50th Percentile......               1
Fertility Rate <50th Percentile.........................               0
------------------------------------------------------------------------

Score for Social Vulnerability

    Social vulnerability is defined as the resilience of communities 
when confronted by external hazards such as disasters or disease 
outbreaks per the Agency for Toxic Substances and Disease Registry's 
Geospatial Research, Analysis and Services Program within the Centers 
for Disease Control and Prevention. A score for overall social 
vulnerability will be incorporated into the MCTA composite score using 
the Centers for Disease Control and Prevention's SVI.
    Social Vulnerability point values will be distributed as follows:

------------------------------------------------------------------------
               Social vulnerability index                     Points
------------------------------------------------------------------------
Social Vulnerability >=75th Percentile..................               2
75th Percentile > Social Vulnerability >=50th Percentile               1
Social Vulnerability <50th Percentile...................               0
------------------------------------------------------------------------

Score for Maternal Health Indicators

    Maternal Health Indicators are defined as factors associated with 
poor maternal health outcomes using data from the National Vital 
Statistics System and the Shortage Designation Management System. 
Scores will consider pre-pregnancy obesity, diabetes, hypertension, 
cigarette smoking, and whether prenatal care began in the first 
trimester as well as access to behavioral health services. Only women 
of childbearing age will be considered for these indicators. HRSA will 
use the National Vital Statistics System Natality file as the data 
source to determine the sub-score for pre-pregnancy obesity, diabetes, 
hypertension, cigarette smoking, and whether prenatal care began in the 
first trimester. The Shortage Designation Management System Mental 
Health Professional Shortage Area file will be the data source to 
determine the sub-score for the behavioral health access factor.
    Maternal Health Indicator criteria point values will be distributed 
as follows:

 Pre-Pregnancy Obesity

    Pre-pregnancy obesity is defined as having a Body Mass Index of 30 
or higher. One point will be awarded if the prevalence of pre-pregnancy 
obesity in the area is greater than or equal to the 50th percentile 
among all counties in the United States. If the prevalence of pre-
pregnancy obesity in the area is less than the 50th percentile among 
all counties, zero points will be awarded.

------------------------------------------------------------------------
                  Pre-pregnancy obesity                       Points
------------------------------------------------------------------------
Prevalence of pre-pregnancy obesity >=50th percentile...               1
Prevalence of pre-pregnancy obesity <50th percentile....               0
------------------------------------------------------------------------

 Pre-Pregnancy Diabetes

    One point will be awarded if the prevalence of pre-pregnancy 
diabetes in the area is greater than or equal to the 50th percentile 
among all counties in the United States. If the prevalence of pre-
pregnancy diabetes in the area is less than the 50th percentile among 
all counties, zero points will be awarded.

[[Page 30506]]



------------------------------------------------------------------------
                 Pre-pregnancy diabetes                       Points
------------------------------------------------------------------------
Prevalence of pre-pregnancy diabetes >=50th percentile..               1
Prevalence of pre-pregnancy diabetes <50th percentile...               0
------------------------------------------------------------------------

 Pre-Pregnancy Hypertension

    One point will be awarded if the prevalence of pre-pregnancy 
hypertension among women in the area is greater than or equal to the 
50th percentile among all counties in the nation. If the prevalence of 
pre-pregnancy hypertension among women in the area is less than the 
50th percentile among all counties, zero points will be awarded.

------------------------------------------------------------------------
               Pre-pregnancy hypertension                     Points
------------------------------------------------------------------------
Prevalence of pre-pregnancy hypertension >=50th                        1
 percentile.............................................
Prevalence of pre-pregnancy hypertension <50th                         0
 percentile.............................................
------------------------------------------------------------------------

 Cigarette Smoking

    One point will be awarded if the prevalence of cigarette smoking 
before or during pregnancy among women in the area is greater than or 
equal to the 50th percentile among all counties in the nation. Before 
pregnancy will be defined as smoking one or more cigarettes daily for 
the 3 months prior to pregnancy. During pregnancy will be defined as 
smoking one or more cigarettes during any trimester of pregnancy. If 
the prevalence of cigarette smoking before or during pregnancy among 
women in the area is less than the 50th percentile among all counties, 
zero points will be awarded.

------------------------------------------------------------------------
                    Cigarette smoking                         Points
------------------------------------------------------------------------
Prevalence of Cigarette Smoking Before or During                       1
 Pregnancy >=50th percentile............................
Prevalence of Cigarette Smoking Before or During                       0
 Pregnancy <50th percentile.............................
------------------------------------------------------------------------

 Prenatal Care Initiation in the 1st Trimester

    One point will be awarded if the prevalence of women who did not 
initiate prenatal care in the first trimester of their pregnancy is 
greater than or equal to the 50th percentile among all counties in the 
nation. Zero points will be awarded if the prevalence of women who did 
not initiate prenatal care in the first trimester of their pregnancy is 
less than the 50th percentile among all counties.

------------------------------------------------------------------------
            Prenatal care in first trimester                  Points
------------------------------------------------------------------------
Prevalence of No Prenatal Care in First Trimester >=50th               1
 percentile.............................................
Prevalence of No Prenatal Care in First Trimester <50th                0
 percentile.............................................
------------------------------------------------------------------------

 Behavioral Health Factor

    One point will be awarded if a portion or all of MCTA service area 
is designated as a Mental Health HPSA meeting the following population-
to-provider median ratio thresholds based on its mental health provider 
type. Zero points will be awarded if a portion or all of the MCTA 
service area is not designated as a Mental Health HPSA or if the Mental 
Health designation does not meet the population to provider ratio 
threshold.

------------------------------------------------------------------------
                Behavioral health factor                      Points
------------------------------------------------------------------------
Portion or all of MCTA service area is designated as a                 1
 Mental Health HPSA meeting the following population-to-
 provider ratio thresholds based on its mental health
 provider type..........................................
     Psychiatrist ONLY: Psychiatrist population-
     to-provider ratio >=45,000:1.
    Core Mental Health: Core mental health population-to-
     provider ratio >=18,000:1.
     Psychiatrist and Core Mental Health:
     Psychiatrist population-to-provider ratio
     >=35,000:1 and Core mental health population-to-
     provider ratio >=6,000:1.
     No Psychiatrists or Core Mental Health
     Providers: >=7,500: 0
Portion or all of MCTA service area is designated as a                 0
 Mental Health HPSA and does not meet the population-to-
 provider ratio thresholds above, OR is not designated
 as a Mental Health HPSA................................
------------------------------------------------------------------------

Paperwork Reduction Act

    The criteria used to identify MCTAs under section 332(k) of the 
PHSA, as described in this announcement, will not involve data 
collection activities that fall under the purview of the Paperwork 
Reduction Act of 1995. If the methods for determining MCTAs fall under 
the purview of the Paperwork Reduction Act, HRSA will seek the Office 
of Management and Budget clearance for proposed data collection 
activities.

Carole Johnson,
Administrator.
[FR Doc. 2022-10783 Filed 5-18-22; 8:45 am]
BILLING CODE 4165-15-P