NPM #1 Well Women Care – Improve pre-conception, prenatal and postpartum health care services for women of childbearing age.

 

The health and wellbeing of the mother before, during, and after pregnancy is important not only for the woman but also for the newborn. Women who maintain a healthy lifestyle during the preconception period are less likely to experience adverse pregnancy and obstetric outcomes and are also more likely to experience better postpartum health and across the life span. According to data from the 2019 Behavioral Risk Factor Surveillance System (BRFSS), 72.6% of Missouri women between 18-44 years reported having a preventive health care visit within the past year. This was slightly lower, but quite similar to the national percentage of72.8%. A slightly lower percentage of non-Hispanic, White women (72.0.3%) in Missouri had a routine well woman checkup than their counterparts at the national level (72.4%). The prevalence of getting a routine well woman checkup among non-Hispanic, Black women in Missouri (79.2 %) was also slightly lower  than for non-Hispanic, Black women at the national level (81.2.1%).

 

According to data from the 2018 BRFSS, a higher percentage of insured women (79.1%) compared to uninsured women (40.5%), in Missouri received a preventive visit.. A lower percentage of those with less than a high school education (55.6%)* received a preventive visit in the past year than college graduates (74.3%) in Missouri. However, the percentage of Missouri women who had a college degree that received a preventive visit in the last year was lower than at the national level (75.3%). In Missouri, those earning <$25,000 (69.7%) had a preventive visit than those earning >$75,000 (80.1%). There was no substantive difference across marital status in Missouri.

 

BRFSS data for 2020 indicate 71.3% of infants were born to mothers who received prenatal care in the first trimester, which is slightly higher but essentially the same as the percentage for 2019 (71.2%).Additionally, the 2019 data show 71.2% of infants were born to Missouri mothers who received prenatal care in the first trimester, compared to the 71.4% in 2018. Non-Hispanic Whites in Missouri were more likely to receive prenatal care in the first trimester (75.9%) than Non-Hispanic Blacks (55.7%) and Hispanics (57.5%). The U.S. prenatal care in the first trimester rate slightly increased from 77.3 in 2017 to 77.5 in 2018.

 

According to MO 2018 PRAMS, 87.5% of Missouri women received a postpartum checkup in 2018 compared to 88.9% in 2014. Women without health insurance (69.7%) had the lowest percentage of receiving a postpartum checkup than their counterparts who were privately insured (94.5%). Non-Hispanic Black women (78.7%) had lower rates of receiving a postpartum checkup compared to non-Hispanic White women (88.9%) and women with less than a high school education (72.4%) had lower rates than women with a high school education or higher (89.5%).

 

While, Missouri is not a Medicaid expansion state, legislation passed on August 4, 2020 will begin Medicaid Expansion on July 1, 2021. Missouri’s Medicaid system (known as MO HealthNet) has two programs covering pregnant women, unborn children, and newborns: MO HealthNet for Pregnant Women (MPW) and Show-Me Healthy Babies (SMHB). MPW provides healthcare coverage including 60-day postpartum coverage for pregnant women whose family income does not exceed 196% of the Federal Poverty Level (FPL). Once eligible, the coverage continues through the postpartum period despite subsequent increases in income. Coverage begins the first day of the month of application. SMHB program provides healthcare coverage for unborn children and their mother whose family income does not exceed 300% of the FPL. Once eligible, coverage continues despite subsequent increases in income. The application must be submitted prior to the delivery date. Coverage begins the date of application. Children born to a woman eligible for and receiving either MPW, SMHB, or other non-premium MO HealthNet health care coverage on the date of the infant's birth continue to be eligible for MO HealthNet coverage throughout the first year of life as long as the child maintains Missouri residence. The Extended Women’s Health Services program covers family planning-related services, pregnancy testing, sexually transmitted disease testing and treatment including pap tests and pelvic exams, and follow-up services. Participants are covered by MO HealthNet for uninsured women and must be between 18-55 years and have a Modified Adjusted Gross Income that does not exceed 201% of the FPL. The Title V MCH Program partners with Local Public Health Agencies (LPHAs) and the Home Visiting Program to assist pregnant women with enrollment in the programs listed above.

 

The MCH Services Program contracted with LPHAs to build MCH systems to promote improved preconception, prenatal, and postpartum health care services for women of childbearing age. The MCH Services Program supported LPHA efforts to: increase the number of women receiving adequate prenatal care; prevent preterm birth; reduce the incidence of preventable birth defects; increase knowledge related to and utilization of folic acid for women of childbearing age; prevent teen pregnancy; and improve access to care.

 

Ten LPHAs selected improvement of pre-conception, prenatal, and postpartum health care services as their MCH Services contract work plan priority health issue for the FFY 2019-21. The LPHAs implemented strategies including:

• t health promotion and education efforts to improve birth outcomes;
• ensuring quality of care for all women and infants;
• improving maternal risk screening for all pregnant women;
• enhancing service integration for women;
• improving access to care for women before, during, and after pregnancy;
• incorporating preconception and  interconception health messages into social media campaigns;
• supporting folic acid campaigns;
• reducing use of and exposure to harmful substances such as alcohol, tobacco, and environmental teratogens;
• using data to understand and inform efforts to improve birth outcomes;
• supporting Medicaid outreach and facilitate enrollment for pregnant women;
• engaging and collaborating with a diverse group of community partners to expand maternal health services;
• eliminating health disparities and promoting health equity to improve birth outcomes; and
• providing well woman exams, pregnancy testing and counseling, prenatal case management, and routine health office visits for women of childbearing age.

 

Implementation of these strategies resulted in:

• increased utilization of community based approaches with local coalition partners to reduce known risk factors for adverse birth outcomes;
• increased number of individuals and variety of fields represented who received education on the prevention and reduction of adverse birth outcomes;
• increased number of clients utilizing the LPHA programs who received education, screening, and referral and demonstrated an increased knowledge on the benefits of timely and adequate prenatal care and the risks of preterm delivery;

• 106 LPHAs reported providing pregnancy testing, education, and referral to OB/GYN care;
•  102 LPHAs reported providing education on the importance of prenatal care, including early entry into care, adequate number of prenatal visits, etc.;
•  64 LPHAs reported either referring to or providing direct prenatal case management;
•  107 LPHAs reported screening clients for insurance or MO HealthNet coverage;
•  103 LPHAs reported screening clients for having a primary care provider;
•  107 LPHAs reported providing referral to OB/GYN care;
•  75 LPHAs reported assisting pregnant women with enrollment in eligible MO HealthNet programs;
•  83 LPHAs reported providing education on the importance of postpartum follow up within the  four to six weeks after delivery, and 58 reported providing postpartum follow up within four to six weeks after delivery; and
•  87 LPHAs reported providing education on the importance of preconception and interconception care, and 53 reported providing preventive well-woman visits.

 

Specific LPHA achievements included the following:

• The Atchison County Health Department has created a Folic Acid campaign. In lieu of COVID-19, the health department used social media platforms and telephone screening. In 2020, 44 women of childbearing age received women’s health education at the health department as part of their health visit. 31 women participating in the WIC program received folic acid education as part of their exit counseling.
• The Christian County Health Department provided workshops on prenatal exercise and healthy eating to five prenatal women with their HOPE 365 (Health Outreach Prevention Education) program.
• The Daviess County Health Department has partnered with two local grocery stores to provide healthy recipes for consumers. The healthy recipe cards were also provided to a large local business and placed in their cafeteria for staff.
• The Hickory County Health Department created a quarterly calendar distributed to women of childbearing age and includes daily exercises and activities as well as healthy meal ideas and recipes. 75 calendars were distributed in 2020. The health department also implemented a Worksite Wellness plan for the local bank. 23 women of childbearing age participated.
• The Phelps/Maries Health Department has been conducting classes using the INJOY curriculum. In lieu of COVID-19, these classes were made available online. The health department continues to use social media platforms to educate the community and MCH population. A virtual Breastfeeding Walk was held to support women of childbearing age and breastfeeding mothers.
• The Nodaway County Health Department in partnership with the HERE (Health Exercise, Relationship and Empowerment) Committee has been instrumental in encouraging the community, including women of childbearing age to participate in The Punch Card Lifestyle Challenge to help create an understanding of healthy weight. The health department had 11 participants, all women of childbearing age, and they reported learning about a healthy BMI.

 

In FFY 20, the Section for Women’s Health (SWH) distributed 5,116 copies of the “Women: Take Charge of your Health” informational booklet. This booklet is available in hard copy or electronic format from the women’s health website. This resource is provided to the general public, LPHAs, and others upon request. The booklet provides information on topics such as preventative health, preconception health, obesity prevention, breastfeeding, and disease prevention. The Show Me Healthy Women (SMHW) program dispensed the booklet to their nurses who shared them at health care events and with other SMHW providers. SMHW offers free breast and cervical cancer screenings to women who meet age, income and insurance guidelines. The SMHW providers found the booklet helpful as it includes great visuals to help women identify which screening tests they should consider. In addition, the SWH shared current issues and timely information related to women’s health through weekly updates to the statewide Women’s Health Network listserv, which comprises organizations and individuals interested in women’s health topics. The SWH updated the format of the weekly updates to make it easier for recipients to find relevant information. Listserv recipients shared in an annual survey that the information they receive is useful (92% of survey respondents).

 

In FFY 20, the SWH distributed 463 My Health Tracking cards. These pocket-sized cards are useful for tracking health indicators and allow users to record important health information including blood pressure, weight and cholesterol, current medical providers and medications.

 

The SWH supports the Missouri Women’s Health Council, which was re-established in October 2017. Through quarterly meetings, the Council provides input and feedback on how best to improve outcomes as the Department of Health and Senior Services (DHSS) develops and implements strategies to improve women’s health in Missouri. Members spent FFY 20 supporting women’s health priorities, informing policy that extends Medicaid coverage for women in treatment for substance use disorders for up to one year postpartum, providing information and advice that supported Missouri in applying to become an Alliance for Innovation in Maternal Health state; and providing information and advice to support DHSS and the Department of Social Services in taking the beginning steps to developing a perinatal quality collaborative to support health care providers from across the state to drive improvement in obstetrical and newborn care. In October 2018, the Missouri Women’s Health Council co-sponsored the 16th Annual Missouri Health Policy Summit focusing on women’s health policy throughout the lifespan. The Council’s vice chair provided the keynote address on maternal mortality and morbidity, and additional council members participated in a panel discussion on mental health, violence against women, the unique needs of women with substance use disorders, and cardiovascular and cerebrovascular health in women. The SWH provided monetary sponsorship for the event.

 

The Newborn Health program produces and distributes the Pregnancy and Beyond booklet to provide important prenatal and newborn health information. The booklet states how early and regular prenatal care starting within the first trimester and continuing until delivery is the most important step to assuring the best birth outcomes. However, the book is not a complete health record and it does not replace a health care provider’s guidance and records. It was developed to track and record moms’ and babies’ preventive health exams and can be used to:

• Keep a record of mom’s health during the pregnancy.
• Answer questions about her pregnancy and new baby.
• Remind her of questions to ask her health care provider.
• Keep a record of her baby’s health, growth, and development.

 

The first section of the booklet focuses on the mom and the second section on the baby and the final section is for the toddler and preschool age child. The “Mom’s Section” includes a list of steps to improve the chances of having a healthy baby/reducing the risk of birth defects. It focuses on the importance of knowing family health history, discusses prenatal care, and shares things to know throughout the stages of pregnancy. In FFY20 21,893 booklets were distributed to hospitals, doctor’s offices, LPHA’s, birthing centers, and other partners.

 

The Newborn Health Program also distributed over 19,000 pieces of literature aimed at improving pre-conception health and prenatal and postpartum health care in FFY19. These pieces of literature included 9 Things to Do Before Getting Pregnant (English and Spanish), Planning for a Baby, and Healthy Moms, Healthy Babies. This also included Postpartum Depression in English and in Spanish. These literature items are handed out at a variety of conferences and baby expos. The program also receives orders for literature from hospitals, LPHA’s, and doctor’s offices.

 

TEL-LINK is the DHSS’ confidential, toll-free telephone line for maternal and child health care. The purpose of TEL-LINK is to provide information and referrals to Missouri residents concerning a wide range of health services. Callers requesting referrals are transferred to the appropriate agency. The TEL-LINK Program provided information and referrals on services such as WIC, MO HealthNet, prenatal clinics, community health centers, mental health services, home visiting programs, and smoking cessation for preconception, prenatal, and postpartum care. During FFY20, TEL-LINK connected 3,267 callers directly to maternal and child health services, which lead to 912 referrals for preconception, prenatal, and postpartum care services such as WIC, MO HealthNet, prenatal clinics, Title X clinics, community health centers, mental health services, home visiting programs, and smoking cessation. In FFY20, the TEL-LINK Program ran a 12-month search engine campaign that directed participants to TEL-LINK. With this campaign, our calls have doubled and the ads have received over 150,000 views.

 

The Bureau of Genetics and Healthy Childhood (GHC) funded home visiting services offered in 26 counties and served 966 families through the Missouri Building Blocks (BB), Healthy Families Missouri Home Visiting (HFMoHV) and the Maternal, Infant and Early Childhood Home Visiting (MIECHV) programs. These programs implement the following evidence-based models:

• Nurse Family Partnership;

• Healthy Families America;

• Parents as Teachers; and

• Early Head Start Home Based Option.

 

The GHC Home Visiting program specifically tracks the number of women enrolled: during pregnancy, within 30 days postpartum through 8 weeks as well as those who receive postpartum follow up. In FY20, 71.6% (111/155) of women received a postpartum follow-up visit.

 

During monthly subrecipient monitoring conference calls, the Home Visiting Program regularly surveilles the local implementing agencies for barriers that interfere with home visiting participants accessing needed services. In FY20, the COVID-19 pandemic posed a significant challenge for women to access ongoing prenatal care given the statewide stay-home order in effect from April 6, 2020 through May 3, 2020; and in some places in Missouri, local stay-home orders in effect longer due to high COVID-19 transmission. Though these stay-at-home orders did allow for essential services such as medical appointments to continue, DHSS supported agencies reported women were missing appointments either due to provider cancellations, or due to pre-existing transportation challenges through Medicaid non-emergency medical transportation (NEMT) that were exacerbated by the COVID-19 pandemic. Additionally during FY19, in the southeastern region of Missouri, the closure of a local hospital and adjourning clinics resulted in home visiting clients traveling greater distances to see a physician. These ongoing and new barriers contributed to increased challenges for accessing adequate well woman care in the most at-risk population of women in Missouri. To help address this challenge, the following resources were sent to all GHC contracted home visiting staff through the Missouri Home Visiting Gateway Weekly Update:

• 4/10/20 - Links for each Medicaid managed care plan’s guidance on transportation
  • Home State Health We’ll help you get there
  • Missouri Care Enhanced Transportation Benefits
  • United Healthcare Non-Emergency Transportation (NEMT) Member Benefit Handbook, pg. 32 and 63
• 8/21/20 – Link to the Centers for Disease Control and Prevention Hear Her Campaign. Intended to raise awareness of potentially life-threatening warning signs during and in the year after pregnancy
• 12/20/19 – Link to article regarding Extending Medicaid after Childbirth Could Reduce Maternal Deaths

 

NPM #2 Low Risk Cesarean Deliveries – Improve maternal / newborn health by reducing cesarean deliveries among low-risk first births.

 

Childbirth by its very nature carries potential risks for women and their babies, regardless of the route of delivery. Although cesarean sections (C-sections) are medically required in some instances, these births pose a greater risk of maternal and neonatal morbidity and mortality than vaginal births. According to the American College of Obstetrics and Gynecologists (ACOG), potential risks of cesarean delivery for moms and babies include a longer hospital stay, an increased risk of respiratory problems for the infant and greater complications in subsequent pregnancies including uterine rupture, placental implantation problems, and the need for a hysterectomy. According to the Vital Statistics data, the low risk C-section delivery rate for Missouri decreased from 24.1% in 2019 to 23.2% in 2020. According to the 2019 Vital statistics data, there were 5,448 (24.0%) C-sections among Missouri women with low-risk first births compared to 25.6% nationwide (NVSS Provisional 2019 data). Low risk C-sections were highest among Non-Hispanic Black women (25.3%), followed by Hispanic women (23.6%) and Non-Hispanic white women (23.5%). The US 2019 provisional data also showed highest C-section rates among non-Hispanic Black women (30.0%) followed by Hispanic women (24.8%) and Non-Hispanic whites (24.7%). Low-risk cesarean delivery is defined as a cesarean delivery among nulliparous (first birth), term (37 or more completed weeks based on the obstetric estimate), singleton (one fetus), and cephalic (head first) births.

 

There is great variation in the rate of cesarean delivery across Missouri hospitals ranging from 14% to 33%. Studies have suggested that other potentially modifiable factors such as patient preferences and practice variation among hospitals, systems, and health care providers likely contribute to the variation in cesarean delivery rates. Reducing primary cesarean deliveries among low-risk first births is critical to reducing both maternal and neonatal morbidity and mortality.

 

Conducting pregnancy-associated mortality reviews (PAMR) aims to: clarify gaps in care, identify systemic service delivery issues, and make recommendations to facilitate improvements in the overall system of care. A full-time nurse abstractor position abstracts all pregnancy-associated mortalities. Missouri was one of the states awarded the Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM) grant by the Centers for Disease Control and Prevention (CDC). The ERASE MM initiative is a 5-year grant that will support the PAMR program by increasing capacity to conduct timely reviews, facilitate an understanding of the causes of maternal mortality, and inform prevention efforts for families and communities. Missouri continued to use the CDC’s MMRIA, which was installed locally in 2018, for abstraction of maternal mortality information. The PAMR program published its first report on maternal mortality in the state in June 2020. The report was based on maternal deaths from 2018 and included Key Recommendations for stakeholders. Due to COVID-19, the report was shared electronically with a wide range of stakeholders across the state and was also uploaded on the PAMR website at https://health.mo.gov/data/pamr/.

 

DHSS committed to reducing maternal mortality as identified in the Department’s strategic plan. The Office of Performance Management (previously the strategic initiatives team) continued to work with programs and develop the department dashboard. The dashboard included four department themes: reduce opioid misuse, improve the health and safety of Missourians most in need, enhance access to care, and foster a sustainable, high-performing department. Improving the health and safety of Missourians most in need included initiatives to address chronic disease and maternal mortality. The PAMR program continues to access the MO HealthNet (Medicaid) database that assists in requesting records necessary for a comprehensive maternal mortality review. Awareness of the MO HealthNet database was initiated from collaboration with the WISEWOMAN program and continues to play a large role in accessing information that was not available to the PAMR program previously.

 

Collaborative efforts continued between DHSS, MHA, MOD, MO Chapter of the American College of Obstetricians and Gynecologists (MO ACOG) and the MO Chapter of the American Academy of Pediatrics to form a Perinatal Quality Collaborative (PQC). The group leading this effort, the Maternal and Child Learning and Action Network (MC LAN), met in February 2020 for an in-person meeting and two other times virtually throughout the remainder of the year. During the meetings, the MC LAN shared a recap on current initiatives, activities, and discussed next collaborative projects including seeking faculty volunteers for the Alliance for Innovation on Maternal Health (AIM) Severe Hypertension in Pregnancy Collaborative. The role of the faculty was to present during collaborative webinars and ensure all collaborative materials were evidence-based. There were 39 participating entities in the Severe Hypertension in Pregnancy Collaborative. An in-person kick-off meeting was held in October 2019 followed by four virtual meetings to didactically share information, offer shared learning and networking and provide collaborative updates. The MC LAN continues to meet on a quarterly basis but has not yet been successful in securing funds for a fully functioning PQC. Three members of the MC LAN, including the PAMR coordinator, attended the AIM-National Network of Perinatal Quality Collaborative’s Annual Virtual Meeting in July 2020 to collaborate and learn from other PQCs.

 

Of the 114 statewide Local Public Health Agencies (LPHAs):

• 36 LPHAs reported providing education on the risks associated with C- section delivery, and 47 reported providing education on the risks associated with delivery prior to 39 weeks gestation;
• 106 LPHAs reported providing pregnancy testing, education, and referral to OB/GYN care, with interconception care education being provided with all negative pregnancy tests;
• 67 LPHAs reported either providing direct prenatal case management or referral to prenatal case management;
• 86 LPHAs reported providing education on preconception and/or interconception care, including birth spacing; and

 

99 LPHAs reported providing education on the importance of prenatal care including early entry into care, adequate number of prenatal visits, etc. The Pregnancy and Beyond booklet specifically discusses why scheduling an early birth can be a problem for both mom and baby. The booklet goes on to explain that babies born between 34 to 36 weeks are considered “late preterm.” They can seem healthy at first but can later develop breathing problems, feeding difficulties, and other difficulties.

 

One goal of BB, HFMoHV and MIECHV home visiting programs is to increase healthy pregnancies and positive birth outcomes through home-based services. Data from FY19 indicated that 90% of infants (131/145) were born at term among mothers who enrolled in home visiting before 37 weeks gestation.

 

Through ongoing monthly subrecipient monitoring conference calls with all GHC contracted home visiting agencies, the Home Visiting program continually reviews and provides resources on pre-conception, prenatal, and postpartum needs to help home visitors support women in having healthy full term pregnancy outcomes. Resources were shared with all home visiting agencies via the Missouri Home Visiting Gateway Weekly Update during FY20 and included the following:

• 10/30/20 – Webinar link - Reducing Preterm Birth: States Share Interventions, Policy

Efforts & Emerging Issues

• 8/21/20 – Link to the Centers for Disease Control and Prevention Hear Her Campaign. Intended to raise awareness of potentially life-threatening warning signs during and in the year after pregnancy

 

NPM #14 Smoking – Prevent and reduce smoking among women of childbearing age, pregnant women.

 

From 2020 Vital Statistics data, 11.9% of Missouri women smoked during pregnancy, which is more than double the national average of 6.5%. The prevalence of smoking during pregnancy was higher among women with less than a high school education (26.0%) compared to women with a high school diploma (19.7%), some college (12.7%), or college graduates (1.3%).  Medicaid insured women (22.3%), were also more likely to smoke than those privately insured (4.4%), those who had other public insurance (7.6%) and those that were uninsured (8.2%). A greater percentage of women that were unmarried (20.9%) smoked than those that were married (5.5%) in Missouri, nearly double the percent of unmarried women who smoked nationally (13.2%). In Missouri, non-Hispanic American Indian/Alaskan Natives had the highest proportion of women who smoked (24.7%). This is higher than the rate for non-Hispanic white women (13.4%), non-Hispanic Black women (9.0%) and Hispanics (4.7%), as well as the national rate for non-Hispanic American Indian/Alaskan Natives (15.5%). Missouri women smoked during pregnancy at a greater proportion than their national counterparts across all age groups. The greatest proportion in Missouri was for age 20-24 year olds (14.8%) compared with 9.2% nationally. The percentage of women who smoked during pregnancy in Missouri was higher than the national level for every category. However, the percentage of women smoking during pregnancy has decreased from 18.4% in 2006 to 11.9% in 2020 Missouri Vital Statistics data.

 

In 2018, 728 Missouri women 18-44 years called the Missouri Quitline. Percentages varied by sociodemographic characteristics and pregnancy status. Among women 18-44 years, callers were predominantly White (70.3%), followed by African American (27.5%). Hispanic callers were 3.1%. Among these women, 3.8% were pregnant, 2.4%were planning to become pregnant, and 1% were breastfeeding.

 

Smoking during pregnancy continues to be a significant public health concern for Missouri’s MCH populations. Pregnancy is a teachable moment and smoking cessation education efforts need to be sustained. Promoting and providing cessation resources have a positive impact on the MCH population and increase the number of quit attempts by pregnant women who smoke. Missouri’s comprehensive tobacco control initiatives included the strategies outlined below. Strategies often addressed both tobacco cessation and the dangers of secondhand smoke.

 

The MCH Services Program supported Local Public Health Agency (LPHA) efforts to: promote tobacco avoidance and cessation among adults and youth, and identify and eliminate tobacco-related disparities among population groups. Of the 114 LPHAs, 107 reported performing maternal assessment of tobacco use and providing cessation education as indicated, 50 reported providing tobacco cessation programs, 106 reported referring clients to the Missouri Tobacco Quitline, 30 reported providing worksite tobacco programs, 44 reported participating in anti-electronic cigarette initiatives, and 13 reported implementing the evidence-based BABY & ME – Tobacco Free Program™ to improve birth outcomes by helping women quit smoking prenatally.

 

Specific LPHA achievements included:

• Cole, Audrain and Franklin County Health Departments screen prenatal WIC participants for smoking status and those who smoke are referred to participate in the maternal smoking cessation program using SCRIPT as a tool.
• The St. Genevieve County Health Department reviews birth records and makes contact with mothers who are reported as smoking to provide education and smoking cessation referrals and resources.
• The Harrison County Health Department is working with Parks and Recreation Department to implement a Tobacco Free Parks policy. The health department in collaboration with the Health and Wellness Coalition (HAWC) of Bethany provides a Freedom from Smoking class made available to anyone with a need.

 

Following the AAP guidelines, the Safe Cribs for Missouri program provides cribs and two educational sessions to qualified women who have no other means to provide a safe sleep environment for their child. In FFY20, 337 pregnant and postpartum women received one-on-one educational sessions through this program. One component of the educational sessions focused on tobacco use, both the dangers of smoking while pregnant and the dangers of secondhand smoke for babies.

 

Multiple resources were available to pregnant women and women of childbearing age including Pregnancy and Beyond, and TEL-LINK. The Pregnancy and Beyond booklet was available to agencies that provide services to pregnant women, such as medical providers and LPHAs. They then shared this with the women they serve. The booklet covers a variety of topics, including a section on the dangers of smoking while pregnant and the health effects of secondhand smoke on babies. TEL-LINK is the Missouri Department of Health and Senior Services’ (DHSS) confidential, toll-free telephone line for maternal and child health care. The purpose of TEL-LINK is to provide information and referrals to Missouri residents concerning a wide range of health services. Callers requesting referrals are transferred to the appropriate agency. In FFY20, TEL-LINK connected 17 callers directly to smoking cessation services including the Missouri Tobacco Quitline.

 

Home Visiting

The Bureau of Genetics and Healthy Childhood (GHC) evidence-based home visiting programs promote smoking cessation for all primary caregivers who answer yes to smoking status at enrollment and at subsequent six month time points during follow-up. Data from FY20 indicated that 88% (30/34) of primary caregivers enrolled in GHC funded home visiting who reported using tobacco or cigarettes at enrollment were referred to tobacco cessation counseling or services within three months of enrollment.

 

The following resources were shared with all GHC supported home visiting agencies during FY20 via the Missouri Home Visiting Gateway Weekly Update:

• 1/31/20 – Link for article on vaping-related lung injury, electronic cigarette resource. Visit the Missouri Department of Health and Senior Services Tobacco Prevention and Control Program web pages site for more information and resources.
• 1/3/20 – Link – E-Learning Course on Alcohol and Drug Exposed Pregnancies (including tobacco)

 

SPM #5 Mental Health – Percent of women with a recent live birth who reported frequent postpartum depressive symptoms.

 

Depression after having a baby can range from “baby blues” to postpartum depression (PPD). Baby blues usually last a few days or weeks, but PPD symptoms are more severe and last longer. PPD can interfere with daily life and caring for the baby. Based on Missouri PRAMS 2019 data, 14.6% of Missouri women with a recent live birth reported having postpartum depression (PPD); this was an increase from the 2014 rate of 12.6%. In Missouri, prevalence was highest among women with less than a high school education (20.5%) compared to college graduates (7.4%) and among unmarried women (21.2%) compared to married women (8.5%). Women who received Medicaid in Missouri (17.1%) were also more likely to report having PPD than their counterparts with private insurance (11.1%), and experienced this slightly less frequently than their national counterparts on Medicaid (17.4%). Missouri mothers less than 20 years old (23.5%) were more frequently reporting PPD symptoms than those 30-34 years old (10.6%) and 35 or older (11.9%). WIC participants in Missouri (22.1%) more frequently experienced PPD symptoms than those not participating in WIC (7.8%) and their national counterparts (17.2%).  PPD is associated with not breastfeeding, earlier weening and may affect maternal-infant relationships as well as infant behaviors. Furthermore, untreated PPD could lead to chronic mental health illness and harmful consequences for both the mother and the child. Strategies were implemented to better educate women to identify signs and seek treatment if needed.

 

Several resources are available on mental health care and “baby blues.” These materials discuss possible symptoms, helpful tips, and how to seek help. One resource is the free “Women: Take Charge of Your Health” informational booklet. Mental health is addressed as a serious health problem outlining symptoms related to eating disorders, anxiety, traumatic events, suicide, and PPD. The resource reinforces the need to seek medical help and to discuss every symptom in detail with a medical provider. This resource is also available on the Department website at www.health.mo.gov/womenshealth. Another resource, the Pregnancy and Beyond booklets, is distributed to hospitals, doctor’s offices, Local Public Health Agencies (LPHAs), birthing centers, and other partners. New OB patients are given a booklet to be used as a reference for a wide range of information including PPD. Distribution of additional materials related to PPD occurs through conferences, baby expos and other outlets. In FFY20, 16,470 pieces of literature in English and Spanish were distributed. The Newborn Health Program distributed literature related to PPD at 2 exhibits

 

All primary caregivers prenatally enrolled in the Bureau of Genetics and Healthy Childhood (GHC) Home Visiting Programs are required to be screened for depression within three months of delivery. Primary caregivers not enrolled prenatally are required to be screened within three months of enrollment. Home visitors utilize the Patient Health Questionnaire 9 (PHQ-9) depression screening tool at these prescribed time points, as well as anytime home visitors recognize potential symptoms of depression. Individuals who screen positive are referred to appropriate services. Data from FY20 indicated that 93% of primary caregivers (208/223) enrolled in home visiting were screened for depression within three months of enrollment (for those not enrolled prenatally) or within three months of delivery (for those enrolled prenatally).

 

During FY20, the GHC Home Visiting Program, through an inter-agency collaboration with the Children’s Trust Fund (CTF), brought Northwestern University’s evidence-based Mothers and Babies (MB) maternal intervention training to Missouri. The MB intervention is designed to help home visitors address PPD and general stressors of high needs families; and is considered a model enhancement for all of the evidence-based home visiting models implemented in Missouri through Title V MCH and MIECHV funding: Healthy Families America, Nurse Family Partnership, Parents as Teachers, and Early Head Start Home Based Option. Model concurrence for the MB intervention training was obtained from the Parents as Teachers National Center and the National Healthy Families America Office. The National Office of Head Start and the National Office for the Nurse Family Partnership declined siting maternal depression interventions already existing within those models. After many revisions (necessitated by the challenges of the COVID-19 pandemic) to the training dates and method of training, the training was delivered virtually in July 2020 to the local agency staff implementing the Parents as Teachers and Healthy Families America models. 

 

The GHC Home Visiting Program has streaming rights to the PPD documentary “Dark Side of the Full Moon” and provides access to all GHC contracted home visiting agencies. This streaming package includes discussion materials and depicts the importance of assisting women in screening for and treatment of PPD symptoms. Access to the streaming channel is indefinite with continued use and sharing of this powerful documentary was encouraged in FY20 to all GHC contracted home visiting agencies.

 

Additional resources were shared with GHC supported home visitors through the Missouri Home Visiting Gateway Weekly Update and included:

• 4/3/20 - Link - COVID-19 Emotional Health Resource
• 5/22/20 – Link - COVID-19, Coping in a Crisis
• 5/22/20 – Link - Mental Health and COVID-19 Information and Resources
• 12/20/19 – Link - Brochures for Women, Partners, Families: Depression and Anxiety During and After Pregnancy
• 1/10/20 – Link - How Health Care Systems Can Isolate Women

 

WIC agencies screen for and assign the nutrition risk factor 361 Depression, which is defined as clinical depression and includes PPD, for women participants. The risk factor is assigned when a prenatal, breastfeeding, or non-breastfeeding woman indicates she has clinical or PPD as diagnosed, documented, or reported by a physician, clinical psychologist, or someone working under a physician’s orders. The diagnosis may also be self-reported by the applicant/participant/caregiver. In FY20, risk factor 361 was assigned to 682 prenatal women, 296 breastfeeding women, and 635 non-breastfeeding women. Assigning this risk factor decreased from 1,691 women in FY19 to 1,613 women in FY20. Several WIC agencies also utilized the PHQ-9 depression screening tool to assist in identifying PPD.

The MCH Services contract supported LPHAs providing screening and referral for PPD. Of the 114 LPHAs, 77 reported providing screening and referral for PPD, 78 reported having community partners who provide screening and referral for PPD, 88 reported providing postpartum follow-up within 4-6 weeks after delivery, and 83 reported having community partners providing postpartum follow-up with 4-6 weeks after delivery. Several LPHAs collaborated with behavioral health partners and/or the University of Missouri Extension Services to participate in and/or provide Mental Health First Aid education. Callaway County Health Department partnered with Central Missouri Community Action (CMCA) to form a Maternal Mental Health Coalition, which has brought trainings and awareness on postpartum mental health to area health care providers and community members including the showing of the documentary "The Dark Side of the Full Moon" to highlight the tragedy of PPD. Seven agencies in Callaway County are willing to treat women with PPD and many groups including Parents as Teachers and some healthcare providers are routinely screening postpartum women with evidence-based screening tools such as the Edinburgh Postnatal Depression Scale (EPDS) and conducting subsequent referrals as needed. Nurses in the WIC program routinely screen and making referrals for PPD, and in FY20 they screened 14 postpartum women and referred 5 for additional services. Columbia-Boone and Callaway County health departments partnered to establish a work group to: enhance PPD screening, implement a referral list of providers/services, create an awareness campaign, and provide trainings for those providing support or services for women. Columbia-Boone MCH staff and 10 other women who had interest in becoming peer support completed the first training from the MOMS Line through SSM. They plan to complete the second part of the training. Looking ahead, more discussion will be had on what it would look like to starts a MOMS Line at the Columbia Boone County Department of Health. The health department also worked with the organization Postpartum Support International to provide an in-depth virtual training over four days to 142 providers in Columbia.

 

The CCHC Program provided 1.5 hours of specialized consultation and 29 hours of stress management for adults and children through continuing education to child care providers. These trainings discussed stressors, the effects of stress on the body and mind, the difference between acute and chronic stress, how stress affects children, stressors in children’s lives, stress management (including techniques and methods of relaxation), and modeling healthy stress management for children. As a result of this training, child care providers are better able to manage their stress, model healthy stress management, as well as guide children in managing their own stress.

 

SPM #6 Oral Health – Percent of women who had a preventive dental visit during pregnancy.

 

A preventive dental visit during pregnancy is recommended because changing hormone levels can result in increased plaque—leading to pregnancy gingivitis. This can lead to bleeding and sore gums. Left untreated, gingivitis can become periodontal disease, a serious form of gum disease. Morning sickness may lead to vomiting, which can also damage the teeth. A visit to the dentist during pregnancy can help monitor for pregnancy gingivitis, periodontal disease, or other oral health problems. During regular dental visits, the patient can have their teeth professionally cleaned and receive education on good oral health. For example, a dental hygienist may educate a patient about proper brushing and flossing techniques, and the importance of a healthy diet.

 

Based on PRAMS 2019 data, 45.2% of Missouri women had a preventive dental visit during pregnancy, which was slightly lower than the 2014 proportion of 47.0%. In Missouri, mothers 20-24 years old (27.0%) were less likely to have had a preventive dental visit than those 30-34 years old (52.7%) or those 35 years or older (65.0%). In addition, Medicaid enrollees (32.2%) were less likely to have a preventive dental visit than their counterparts with private insurance (50.8%) in Missouri. A greater percentage of college graduates (59.8%) had a preventive dental visit in Missouri than any other educational level (the highest percentage nationally was 62.7% for college graduates) while pregnant. Married Missouri mothers (49.0%) were more likely to have had a visit than unmarried mothers (32.8%). This trend follows the national estimates of 53.9% for married and 35.9% for unmarried mothers. Missouri WIC recipients less frequently (34.2%) had a preventive dental visit during pregnancy than those who were not WIC participants (47.9%).

 

The ODH has an ongoing initiative to educate mothers and children about the importance of oral health for their overall health and well-being. This includes the promotion of dental visits during pregnancy. This was accomplished via continued collaboration with the Missouri Primary Care Association (MPCA) to provide educational brochures to women about the importance of dental visits during pregnancy. The MPCA also assisted the ODH to educate dentists, dental hygienists, and dental assistants about dental care during pregnancy. This was done at quarterly meetings with Federally Qualified Health Center (FQHC) dental directors at the MPCA’s annual conference, and by assisting the ODH to distribute messages via its FQHC Listserv. This was often counter-intuitive for women, and even some medical and dental professionals, who assumed that dental cleanings during pregnancy were harmful to mother and/or child. The ODH provided education to women about the importance of oral health for the mother’s overall health, during pregnancy, and throughout her lifespan. This education took place through literature, including the “A Healthy Smile for Your Young Child” brochure from the National Maternal and Child Oral Health Resource Center distributed through WIC, and the “Healthy Smiles from the Start” booklet developed by the ODH and the Missouri Dental Association (MDA). 3,478 of the “Healthy Smiles from the Start” booklets were distributed last year to women via an ongoing successful collaboration with the Bureau of Genetics and Healthy Childhood Home Visiting programs. The education provided by home visitors to women enrolled in home visiting programs included information about the importance of addressing their oral health as well as education about activities to support good oral health for their children.

 

Title V MCH funds support ODH maintenance of an Oral Health webpage, which shares a variety of oral health information and resources and includes a link to the Centers for Disease Control and Prevention’s (CDC) Water Fluoridation Reporting System that displays Community Water Fluoridation (CWF) statistics for each Missouri county and water system. The ODH provided CDC with Missouri’s water fluoride levels quarterly in order to update the state data. The ODH also maintained the Missouri Oral Health Surveillance System. This included posting updated fact sheets compiling oral health statistics and related information on the ODH website. The ODH’s Five-Year State Oral Health Plan is also posted on the ODH website. During the FY19 year, there were 13,213 visits to the Oral Heath website.

 

Title V MCH funds also pay for printing educational resources that are disseminated via dental offices and community outreach events. From October 1, 2019 to September 30, 2020, ODH shipped out 186,115 toothbrushes, toothpaste, and floss to participants in Preventive Services Program (PSP) sponsored and other oral health events. In that same time period, ODH shipped out 283,884 pieces of literature to people participating in the afore-mentioned events.

 

Fluoride protects against tooth decay at any age, and water fluoridation is the least expensive method to reduce cavities. Increasing awareness of this benefit is a key factor in dental education. ODH provided education to the public, city officials, dental and medical professionals, and public health authorities about the safety and effectiveness of CWF for the prevention of dental caries. ODH contracted with the Missouri Coalition of Oral Health (MCOH) to provide education on and promote the importance of oral health including water fluoridation. MCOH coordinated and organized the Oral Health Caucus with legislators and other stakeholders to share the numerous existing projects bringing dental services and awareness of the importance of oral health to Missourians. MCOH attends (virtually during the pandemic) monthly meetings of the Kids Win Missouri Health Workgroup and annual meetings with the Oral Health Progress and Equity Network. MCOH also made connections with local oral health advocates who work with Community Health Workers and LPHAs in order to educate those stakeholders on the importance of oral health among their Communities. MCOH also reached out to social justice groups in the Kansas City area to start working together for improved oral health. MCOH’s annual policy conference “Show Me Access to Care” had sessions on community water fluoridation, dental sealants, an update from the Assistant Surgeon General and how to increase access to care.

On September 1, 2018, ODH became the recipient of two new grant awards from the Health Resources and Services Administration (HRSA) and CDC. These grants were used to begin developing: teledentistry training, teledentistry sites at nursing homes and schools, and a teledentistry program to promote and apply dental sealants. Grant efforts also included providing education about CWF, updating the State Oral Health Plan, and providing fluoride varnish at LPHA sites. These grants continue, and ODH is working diligently across Missouri to raise awareness on the importance of oral health through these grants.

State statute 640.136.1 was agreed upon by the Missouri legislature in 2016 and states that any public water system or public water supply district, which intends to make modifications to fluoridation of its water supply shall notify the Department of Natural Resources, the MO Department of Health and Senior Services, and its customers of its intentions at least 90 days prior to any vote on the matter. This gives community members and organizations such as the MDA and MCOH the opportunity to educate decision-makers and the public about the safety and importance of CWF. ODH regularly meets with MDA and MCOH to discuss CWF issues and plans of action. In Jefferson County, MO, the water board continues to debate the water fluoridation issue in the Festus area. Many oral health stakeholders (MDA, MCOH, local dentists, CWF experts, and volunteers) came together to educate the water board about the benefits of CWF. So far, the water board has decided to look into this issue further and not bring it to a public vote. Park Hills, MO in St. Francois County was the latest community to discuss the possibility of discontinuing water fluoridation in an effort to cut their budget. Many of the same stakeholders were involved in educating the Park Hills city council regarding the importance of community water fluoridation. ODH was also able to secure PHHS funding to purchase new equipment for Park Hills and was able to provide technical assistance from an engineer to advise Park Hills on moving their fluoride intake to another section of their water system in order to lessen the amount of fluoride they needed to add in order to achieve the optimal amount of fluoride in the water. Park Hills decided to keep water fluoridation, which was a major accomplishment for ODH. Of the Missouri community water systems continuing to provide fluoridated water, there were 19 that received CDC’s Water Fluoridation Quality Award for maintaining their fluoride at optimal levels in the water system.

Through screening, referral, and participation in the provision of preventive dental services, LPHAs worked to increase the number of women who had a preventive dental visit during pregnancy. Of 114 LPHAs, 95 reported screening clients for an identified dental care provider and providing dental referrals as indicated, and 91 reported having community partners who provided oral health screening and referral. A total of 35 LPHAs reported providing dental screenings and/or services. The MCH Services contract supported LPHAs providing oral health education and dental services to the MCH population within their communities. Dallas County Health Department has a Bright Smiles Program in which MCH contract funds were utilized to pay a part-time coordinator to conduct regular brushing and oral health education to students in kindergarten through 2nd grade at a local elementary school. Joplin City Health Department partnered with a local dental school, and dental students provided education on oral care once a week to WIC participants. Howard County Health Department WIC staff provided toothbrushes to participants and referrals as needed. Vernon County Health Department has a nurse on staff that helped provide fluoride treatment to uninsured women and children in the Miles for Smiles mobile dental unit. Clay County Health Department has registered dental hygienists who provided dental screenings, oral health education, and fluoride varnish applications for children enrolled in the WIC program. Multiple LPHAs collaborated with community partners to host mobile dental vans at health departments, schools, and other community sites

 

During FFY20, the toll-free MCH hotline, TEL-LINK, connected 117 callers directly to a dental clinic. .

 

* Interpret with caution due to sample size limitations.