Well Woman Program

 

NPM 1: Percent of women, ages 18 through 44, with a preventive medical visit in the past year

 

ESM 1.1: Increase the proportion of women age 15-55 who report receiving a preventive medical visit in the past 12 months

 

The ADPH Well Woman program creates the opportunity for women ages 15-55 to receive preventative health screenings and management of chronic diseases. The program is an evidence-based program that utilizes the New Leaf intervention modules which were developed at the University of North Carolina at Chapel Hill. The goal of the program is to provide preconception and interconception care to women of child-bearing age as a foundation for wellness, identification of chronic diseases and planning to adopt a healthier lifestyle. The program started in 2017 as a pilot program in Wilcox, Butler and Dallas counties. The successes of the program in those three counties lead to an expansion. In October 2018, ADPH received funds from the governor's imitative to decrease infant mortality. With the funding of the governor’s initiative and MCH funds, the program expanded to the 3 new counties- Macon, Montgomery and Russell. The program is currently in 6 counties (Butler, Dallas, Macon, Montgomery, Russell and Wilcox). For fiscal year 2020, we were fortunate to expand to Marengo county. Due to COVID and staffing issues, the program hasn’t started in Marengo county yet. In fiscal year 2021, we have plans to implement the program in Henry and Barbour counties and discussions are underway to implement a traveling Well Woman team in West Central district covering Greene, Hale and Perry counties. Well Woman sites are illustrated on the Alabama map below.

Our mission is to provide a healthy living, prevention & early detection of diseases program, and to increase the quality of life for women ages 15-55. We encourage self-referrals, referrals from community partners, local physicians, and other programs within Alabama Department of Public Health like the Family Planning and STD clinics. Our ideal participant is the uninsured and/or underinsured but we will not deny services to any qualifying participant. The program enhances access to preventative screenings for cardiovascular disease, wellness checks, and vision and oral screenings. We offer services to address issues like obesity, hypertension, high cholesterol and diabetes. Also, we focus on counseling before and after pregnancies to improve birth outcomes in the state of Alabama.

 

Program staff consists of a variety of professional staff members. An administrative assistant enrolls the participant by ensuring the consent form is signed and by entering  the referral source, if noted. A clinic aide performs the biometric testing which includes weight, height, waist measurements, two B/P readings and lab results for the lipid panel and glucose levels. A registered nurse initiates the initial visit by completing the health and physical assessment and initial counseling to discuss prescreening lab results. The Nurse Practitioner completes the risk reduction counseling which consists of reviewing initial lab results and educating the client on ways to adopt a healthier lifestyle. The social worker is the driver of the program responsible for the case management of participants; coordinating health coaching sessions with participants either face to face or by phone and spearheading monthly support group meetings on a variety of topics; and reinforcing education provided by the registered nutritionist and Nurse Practitioner. Also, the program offers monthly nutritional education to participants by a registered nutritionist.

 

Clinic visits were postponed in the second quarter of fiscal year 2020 and resumed in the fourth quarter on August 27, 2020. The program enrolled 371 participants in fiscal year 2020. Though new clients could not be enrolled, existing clients continued to receive services via telehealth phone visits and virtual means. Telehealth/telemedicine was incorporated into protocols, which allowed continuation of services, such as health and nutrition coaching sessions, risk assessment and counseling, as well as other educational opportunities. New protocols for safety measures were put into place to ensure the well-being and protection of staff and clients. These new safety measures included provision of personal protective equipment to both staff and clients, social distancing and screenings for COVID related symptoms. Nurse practitioners conducted risk assessments by reviewing the participant’s history and physical and lab results. Treatment was initiated, if needed, and the participant was counseled on any identified conditions (such as hypertension). Web cameras were purchased for social workers and the nutritionist to host and participate in virtual opportunities. Participants benefitted from the web cameras also, with nutritional classes held twice weekly with a registered nutritionist. As physical activity is an important component of ensuring health, partnerships with local communities allowed multiple daily exercise classes to be offered via Facebook and other virtual platforms. The program hosted a virtual, three-day course for its second annual training for social workers. The training focused on motivational interviewing.

 

Near the final quarter of the fiscal year, the Well Woman Program was selected to host two student interns for summer 2020 through the National Maternal Child Health Workforce Development Center. The internship ran from June 8 through July 31. The interns worked with the program virtually and in-person to increase client awareness/understanding about the program and to identify and develop ways to collect and analyze data on program participants, including blood pressure readings, weight, current health issues, and reproductive and medical history. The interns also helped to develop an electronic version of the quarterly newsletters sent to staff for program updates, which allowed for easy dissemination. Through manual data collection remains a challenge, program staff work closely with the epidemiology division for assistance, with increased usage of data available in the ADPH electronic health record system. In subsequent years, improved data collection and analyses will likely have a long-term positive effect for quality improvement of the program and patient care.

 

Program Success Story:

One participant, from Russell county, joined the Well Woman program in February 2019. She desired to lose weight and become healthier. She was determined to reach her goals from the start and continued her journey throughout the pandemic by participating in daily virtual exercise classes. She has lost over 20 pounds and is committed to her goals.

Oral Health Office

 

NPM 13.1 - Percent of women who had a preventive dental visit during pregnancy

 

ESM 13.1-lncrease the proportion of at-risk pregnant women who report receiving a preventive dental visit during pregnancy by piloting the First Steps Program.

 

The Oral Health Office (OHO) continues to partner with ADPH internal programs, such as WlC, Perinatal Health, Women's Health and external programs, such as Gift of Life (GOL), Head Start, and Pay lt Forward, that serve or connect with pregnant women to increase oral health awareness and to promote routine dental visits, even during pregnancy. These partners receive oral health kits containing pamphlets, toothbrushes, toothpaste, floss, hand sanitizer  and lip balm SPF rated to prevent oral cancers. Partners may submit requests to OHO for oral health kits throughout the year.

 

Promotion of preventive dental visits for expectant mothers was achieved by design and creation of EuroFit Wall Stands. One hundred of these displays were obtained and distributed to CHDs in each of the six public health districts, UABSOD, ADPH family planning clinics, and some FQHCs.

 

 

A 30 second Spectrum cable television and streaming advertisement began showing in September 2020 and ran through the month of October, National Dental Hygiene Month. The ad promoted preventive dental visits for expectant mothers and children ages 1-17, in addition to the newly FDA approved (age appropriate) HPV vaccine, for expectant mothers and children ages 9-17 years. The following summarizes the public reach of the Spectrum advertisement.

 

Television Overview

1,006 Airings

31 Networks

12 Zones

 

Streaming TV Overview

95,067 Impressions

93,727 Completions

98.59% Completion Rate

 

Ongoing activities in Alabama to improve oral health:

 

The only ADPH operated dental clinic that remains is located within the Tuscaloosa County.

The Tuscaloosa County Health Department (TCHD) provides preventive and restorative care for children, young adults, and pregnant women under the age of 21 who are covered by Medicaid, ALLKids, or Alabama Blue Cross Blue Shield. OHO utilized Title V  funds to equip the Tuscaloosa County Health Department’s dental clinic with new digital radiography equipment. Free oral hygiene supplies, educational material, and other assistance were provided to TCHD as requested. In 2020 there were a total of 1,672 patient visits to TCHD dental clinic. Of that total, 1,299 were preventive dental visits and 10 were pregnant women.

 

ADPH's Northern Public Health District continued to partner with OHO to provide healthy habits "gifts" to children in immunization clinics and also at appropriate health fair venues. OHO provided the district with 3,500 additional oral health kits. ln addition to providing a toothbrush, toothpaste, and dental floss in a "gift bag", county staff are using it as an opportunity to provide outreach, especially for WlC services, but also for other health department services such as family planning, additional immunization, breast and cervical cancer program, etc. Northern Public Health District home health staff are also assisting in outreach by providing the "gifts" and information in homes where there are family members that may also need these services.

 

Sarrell Dental, which managed several dental clinics within CHDs, has moved those clinics to free standing buildings. While no longer connected to ADPH, these clinics continue to provide dental homes for a significant number of Medicaid children and their families. Family Health Dental operates clinics in Mobile CHD which provide dental services via community health center-managed dental programs, which included dental services for uninsured or underinsured adults.

 

Community Water Fluoridation

 

OHO awards Fluoridation Grants totaling $100,000 (maximum $25,000 per site) by way of RFPs for purpose of replacing or updating fluoridation equipment to offer uninterrupted Community Water Fluoridation, as well as initiation of fluoridation. OHO provided grants totaling $57,396 to water plants for purchase of new or additional fluoridation equipment. These public water systems serve a total population of 123,998.

 

Annual CDC Fluoridation Quality Awards are presented (one year in arrears) to water plants that consistently maintain the optimal 0.7 ppm fluoride level on a monthly basis. The FY2019 FY fluoridation awards went to 109 wells and plants per CDC standards and guidelines—a 21% increase over the previous year. The FY2020 FY fluoridation awards will be presented to 121 wells and plants per CDC standards and  guidelines—a 10% increase over 2019.

 

The OHO fluoridation toolkit pamphlet was updated to indicate observance of the 75th year of Community Water Fluoridation in the U.S. The toolkit and pamphlet continue to  be available through the ADPH website and was the pamphlet distributed to all public water systems and included in the OHO oral health toolkits after the redesign. The pamphlet was also distributed at health fairs.

 

OHO hosted its first ever Oral Health and Community Water Fluoridation Conference, a goal of the director of the OHO since 2017. Using a virtual platform, OHO partnered with the City of Troy (Alabama) and the Alabama Department of Emergency (ADEM) Management to host the conference and provide four free CE hours to 187 water plant operators. In addition to the operators, state dental directors and college instructors were among the diverse group of attendees. Speakers for the conference were from the CDC (National Fluoridation Engineer), National Fluoridation Society (President), City of Troy (Utilities Engineer), and Hand Aqua Products (sales representative). The Oral Health Office partnered once again with the City of Troy for an in-person conference in Troy, Alabama. This conference provided seven free ADEM approved CE hours to 85 water plant operators and environmentalists. Approximately 721,699 residents will be positively impacted from the educational information provided by the conference.

 

Community and State Partnerships

 

OHO initiated a collaboration with Life on Wheels, a non-denominational faith-based organization offering free pregnancy tests and ultrasounds in the River Region and Birmingham areas. Through  this partnership, oral health kits and educational materials about oral health during and after pregnancy are provided to clients. Since the organization's inception in 2016, 3,926 free pregnancy tests and 3,531 ultrasounds have been provided.

 

The Pay lt Forward program, administered by HandsOn River Region, was awarded a $25,000 grant from OHO in 2020 to continue its program and support the salary of a coordinator. The program is a value-based program where uninsured / under-insured clients (mothers and fathers) can receive dental treatment by logging volunteer hours with any of more than 200 volunteer sites within the River Region. The program coordinator is responsible for recruiting new volunteer dentists, orientation of new patients who enroll in Pay lt Forward, scheduling appointments, overseeing ADPH grant funds, exploring new modes of transportation for clients, and identifying additional partners for new clients. The following organizations partner with HandsOn River Region to enroll clients:

• Gift of Life — Gift of Life serves expectant and parenting moms and dads and children who are at a greater risk for infant mortality by reducing barriers to success, related to economic, social and health disparities and to improved birth outcomes
• Hope lnspired Ministries -- Hope lnspired Ministries serves low-skilled, poorly educated, and chronically unemployed men and women by preparing them to obtain and maintain employment.
• Nehemiah Center -- The mission of Nehemiah Center is to equip and enable the children and adults they serve with lasting skills enabling them to abundantly sustain themselves physically, spiritually and emotionally.
• Communities of Transformation -- The mission of Communities of Transformation is to move families from surviving to thriving by developing personal leadership skills and building authentic relationships.
• Transformation Montgomery - Transformation Montgomery is a nonprofit organization that seeks to transform lives one person, one family, one neighborhood at a time through holistic life skills training, relational community renewal, and affordable housing.
• Aid to lnmate Mothers -- Aid to lnmate Mothers provides services to Alabama's incarcerated women with emphasis on enhancing personal growth and strengthening the bonds between inmate mothers and their children.
• Friendship Mission -- Demonstrating love in action, Friendship Mission, lnc. provides a faith-centered place of refuge for the River Region's homeless and poor that exemplifies compassion, promotes self-sufficiency and offers the tools to achieve this goal.
• HOLA – Hispanic Outreach Leadership and Action - HOLA is a local non-profit that serves the Hispanic community in the river region.

 

The COVID pandemic had great impact on the Pay it Forward program due to the closure of dental offices and hesitancy of its clients to complete community service and dental visits for fear of contracting the virus. Orientation of new clients was affected as well, although, in person and ZOOM orientations are now underway.

 

Even with the numerous obstacles of COVID, Pay it Forward managed the following accomplishments for 2020:

• Number of orientations scheduled - 7
• Approximate number of people oriented - 41
• Number of appointments made - 3
• Number of successful appointments - 3
• Approximate number of volunteer hours by participants - 90
• Number of participating dentists - 7
• Number of visits/calls made to potential dentists to recruit for program – 1

 

In spite of all the obstacles of the last several months, the program continues to serve the underserved who otherwise might never have the opportunity to receive dental care.

 

County Health Department MCH Projects

 

ADPH, JCDH and MCHD coordinators submitted MCH proposals in 2020 to address needs within the Women/Maternal Health Domain, with projects focused on access to oral health care, expansion of the Well Woman services, and suicide prevention. While COVID-19 caused numerous disruptions and delays during FY 2020, the coordinators had begun implementing some projects, and were able to establish partnerships, purchase equipment and take other steps that would propel other activities in FY21 once clinics and other agencies reopened.  

 

Highlights

• West Central Public Health District:  Two QPR suicide curriculum trainings were facilitated and suicide prevention resources and promotional items were provided to residents in Perry, Pickens and Tuscaloosa counties.

 

• JCDH:  Coordinator facilitated the From Day One Program, a comprehensive patient centered program with a mission to improve pregnancy and birth outcomes. From October 2019-September 2020, Community Health Workers (CHWs) and other community agencies hosted of four baby safety showers, providing health and safety education and resources to 38 maternity clients, along with 24 family members.  

 

• MCHD:  provided referral services and linkages to preventive care and immunization services for 71 participants in the Family Support/Home Visitation program for pregnant and parenting teens in Mobile County as well as participants in the Fatherhood Initiative.

 

• Northern District: Developed partnerships with local agencies, including Community Services Planning Council (CPSC), County Interagency Councils, Caring Connection of the Shoals, Alabama Society of Health Care Social Workers, Children’s Policy Councils, hosted dental health awareness days in all 12 northern district counties, providing education and incentives for pregnant women and children. The MCH coordinator presented QPR training to 96 individuals and provided suicide prevention  resources to community partners such as meals on wheels, North Central Alabama Regional Council of Governments (NARCOG), and North West Alabama Council of Local Governments (NACOLG).

 

Barriers

• West Central Public Health District:  COVID-19 caused numerous disruptions and delays during FY 2020, therefore, the coordinator was not able to fully implement this dental plan  or QPR and Response trainings as planned

 

• JCDH:  Due to COVID 19 restrictions and guidelines, the Baby Safety Shower format had to be reevaluated and changed to virtual presentations, with a touchless pickup system.  Lack of experience with virtual platforms for program managers, agency volunteers, and program participants. Language barriers caused delays in hosting the Baby Safety Showers which were previously inclusive of English and Spanish speaking clients.

 

• MCHD:  The Covid-19 pandemic caused significant changes in the functions of the agency and the delivery of MCH services. Family Support/Home Visitation and Fatherhood programs saw some declines due to the Covid 19 pandemic. Some participants were out of work and trying to navigate the closure of daycares and schools. In-person education classes were replaced with virtual education and follow-up, which introduced new barriers for participants such as a lack of adequate phones, computers, internet services and other technology. The number of participants for virtual activities experienced a drop compared to the in-person meetings.

 

Other ADPH Women/Maternal Health Programs

 

Family Planning

 

The APDH Family Planning Program provides confidential family planning and related comprehensive health care services throughout the state to women, men, and adolescents in need of reproductive health care. In CY 2020, the ADPH Family Planning Program and its sub-recipients, Jefferson County Department of Health and Mobile County Health Department, served 45,497 clients in 99,137 visits. Over 23,000 clients reported incomes of 100 percent or less of Federal Poverty Level, and more than half of the clients served during CY 2020 were uninsured. However, ADPH also provides family planning services to patients insured by Alabama Medicaid (Plan First and/or full Medicaid) or Blue Cross Blue Shield of Alabama.

 

ADPH Family Planning services include reproductive life planning, contraceptive counseling, breast and cervical cancer screenings and follow up, screening and treatment for sexually transmitted infections. Clients also receive referrals for health care services outside the scope of family planning, through partnerships with other ADPH programs, such as the Alabama Breast and Cervical Early Detection Program, and external entities, such as Alabama Department of Human Resources, contracted professional services providers, and Alabama Coordinated Healthcare. Clients have access to a broad range of contraceptive methods, including long-acting reversible contraceptives (LARC). During CY 2020, just over 31 percent of clients selected a LARC method, as compared to just over 34 percent during FY 2019.

 

During CY 2020, Family Planning Program clients and service provision were dramatically impacted by the onset of the COVID-19 pandemic. With Alabama Medicaid’s approval, ADPH implemented a virtual visit model, which allowed continued provision of essential family planning services. Beginning in March 2020, Alabama Medicaid extended approval for telehealth family planning visits on a month-to-month basis. Telehealth visits are especially beneficial to ADPH clients whose access to services may be limited by barriers, such as lack of transportation, inability to fit in-person visits into hourly work schedules, and lack of childcare.

 

In 2019, Family Planning physicians began providing colposcopy services, traveling to selected CHDs on a rotating schedule, in order to facilitate easier access for patients within surrounding multi-county geographic areas. The addition and expansion of this critical procedure greatly facilitates continuity of care for patients who require follow up of abnormal cervical cancer screening results. As with other clinical services, colposcopies were necessarily limited during 2020.

 

However, a continuation plan, including use of personal protective equipment for patients and providers, was implemented to ensure timely access to this critical diagnostic procedure for high-risk and/or emergent cases that could not be safely postponed. Plans are in development for ADPH nurse practitioners (NPs) to receive colposcopy training, beginning in the next fiscal year. Upon completion of training, the NPs will utilize mobile colposcopy equipment and existing telehealth capacity to transmit live colposcopy imaging, allowing physicians to diagnose and recommend treatment options remotely.

 

Special Supplemental Nutrition Program for Women, Infants, and Children

 

Alabama’s WIC Program implemented eWIC statewide during 2019. The transition to eWIC allows families to purchase their food benefits using an electronic benefits transfer (EBT) eWIC card in place of paper checks. One of the flexibilities of eWIC is that families may purchase foods as they need the food each month. eWIC improves the family shopping experience and reduces the stigma associated with assistance programs. The transition to eWIC also enabled Alabama’s WIC Program to quickly respond to the federally declared COVID-19 public health emergency. Several WIC waivers were implemented during 2020 to promote social distancing and keep Alabama’s WIC participants safe. Physical presence and remote benefits issuance waivers allow benefits to be loaded remotely without requiring a face to face appointment. During COVID-19, most WIC participants receive benefits automatically through auto issuance; certain participant groups require a monthly remote telephone visit to receive benefits.

 

To assist with communication during COVID-19, text messaging was launched providing appointment reminders and auto issuance notifications. Another ongoing outreach activity that has helped during COVID-19 is the Alabama WIC app. The free Alabama WIC app is available for participants to access on Apple and Android devices. The WIC app features a clinic locator, appointment and benefit expiration reminders, notification pushes to share pertinent information, a searchable WIC approved food list, a bar code scanner to determine if specific food items are WIC approved, nutritious recipes, education focused on nutrition and breastfeeding, and more. WIC participants are encouraged to download the app and explore what it offers.

 

The WIC program continues to offer electronic nutrition education as a partner with wichealth.org. This arrangement allows low risk participants to complete nutrition education lessons via a website. The nutrition education lessons directly interface with Alabama’s WIC Crossroads Management Information System, so that clinics can confirm completion of these lessons. WIC providers also conduct nutrition education visits via telephone to reduce the number of visits that the family must make to the clinic.

 

During 2020, Alabama’s WIC program focused nutrition education efforts on improving the oral health of WIC participants as part of the FY 2021-2022 Nutrition Education Plan. The WIC Nutrition Education Plan supports these efforts with nutritious recipes incorporating WIC approved foods, tips for increasing dairy intake, education on high calcium and high phosphorus foods, and dental hygiene reminders. Families are provided incentive items in the form of a clear zipper pouch containing a toothpaste squeezer and a tooth brush sand timer to educate and encourage WIC participants about the oral health benefits of WIC foods. Alabama’s WIC program will continue to monitor food benefit redemption data to determine if the education provided increases redemption of calcium and phosphorus rich WIC approved foods.

 

WIC continues to increase public awareness of the importance of breastfeeding. In 2019, the WIC Programs in Dallas and Walker counties were recipients of the Loving Support Award of Excellence for exemplary breastfeeding promotion and support activities. The WIC Breastfeeding Coordinator provided breastfeeding information for ADPH's Alabama's Health newsletter. The Breastfeeding Coordinator and other members of the Alabama Breastfeeding Committee (ABC) participated in CDC's State Breastfeeding Coalition teleconference calls. The WIC Breastfeeding Coordinator continued training WIC staff and offering breastfeeding education to staff from Alabama hospitals. She served on the board of the Alabama Lactation Consultant Association, which continued to meet virtually during COVID-19. Also, the coordinator served on the board of ABC, which continued to meet. Nurses, doctors, lactation consultants, and various other health professionals are members of ABC, which focuses on encouraging, supporting, and protecting breastfeeding in Alabama. The WIC State Breastfeeding Coordinator participated as a member of the Central Alabama Breastfeeding Task Force.

 

The Alabama Breastfeeding Resource Guide was updated for ADPH's website. Materials were distributed to county health departments to promote Breastfeeding Awareness Month in August. As of September 2020, there were a total of 70 breastfeeding peer counseling sites. Although COVID-19 has slowed some activities, efforts to expand Alabama’s WIC Breastfeeding Peer Counseling Program continue. During 2020, virtual training was offered for the Breastfeeding Peer Counseling Program. To monitor its effectiveness, a WIC Alabama Breastfeeding Enrollment Report is available for public health district Nutrition Directors. The report provides breastfeeding initiation and duration rates for each clinic and district.

 

Pregnancy Risk Assessment Monitoring System

 

The PRAMS Project began collecting data in 1992 and was designed to help state health departments establish and maintain a surveillance system of selected maternal behaviors and experiences. The Centers for Disease Control (CDC) collaborated with Alabama, other states, and the District of Columbia to implement this system. The Alabama PRAMS Project was transferred to the FHS from the Center for Health Statistics (CHS) on May 1, 2016. The CHS continues to provide the required data to the BFHS to carry out the PRAMS grant activities.

 

Through the relocation of the PRAMS Project to the BFHS, staff now have direct access to Alabama PRAMS data. Alabama PRAMS is positioned to collaborate with other partners and key stakeholders for maternal and child health in the state. Alabama PRAMS works with the Alabama MCH Title V Program, which fosters relationships with programs both internal and external to the BFHS and with many statewide and community groups and governmental and private organizations to address various issues. As such, Alabama PRAMS works to collaborate with WIC, Medicaid Maternity Care Providers, birthing facilities, health care providers (obstetricians/gynecologists, pediatricians, nurses, etc.), Healthy Child Care staff, the Alabama Chapter of March of Dimes (MOD), other BFHS and ADPH program staff, and other key stakeholders, as deemed appropriate. These collaborations provide opportunities to promote the awareness of and benefits of participating in the survey, if selected.

 

The Alabama PRAMS Project seeks to help improve the health of mothers and babies in Alabama. To perform these tasks, the PRAMS questionnaire asks mothers questions about their behaviors and experiences around the time of their pregnancy to determine why some babies are born healthy and some are not. Each year, approximately 1,450 Alabama mothers are randomly selected from the state birth certificate registry to receive the questionnaire, via mail or phone, for completion. In 2019, 798 Alabama mothers participated in PRAMS.

 

In the future, there will be an option to answer the PRAMS survey via a web application, which the Alabama PRAMS Project will seek to implement once available. With improved rewards and increased brand recognition, Alabama PRAMS improved recent response rates, which have exceeded the CDC response rate threshold. Maternal behavior and pregnancy outcomes have been strongly associated, thus, the impetus for seeking to improve efforts to understand contributing factors to infant mortality and low birth weight. Topics of PRAMS questions include, but are not limited to, the following: breastfeeding, contraception, infant sleep environment, prenatal care, and maternal mental health.

 

Since Healthy People 2020 goals and objectives include numerous maternal and child health indicators, Alabama PRAMS data will be used to measure the status of the maternal and child health related indicators, as applicable. Alabama PRAMS data will also be used by Alabama’s Title V MCH program to monitor progress related to the National Performance Measures selected for programmatic focus during the current funding cycle.

 

The Alabama PRAMS Project is currently participating in the supplemental opioid research that began in May 2019 and will continue until further notice. The main goal of the Alabama PRAMS Opioid Supplement is to use the existing PRAMS methodology to assess maternal behaviors and experiences related to opioid use among women before, during, and after pregnancy in the United States.

 

Office of Women’s Health

 

The Office of Women's Health (OWH) was created by Alabama Legislature Act 2002-141 to be an advocate for women's health issues. The purpose of the office as described in the legislation is as follows:

• To educate the public and be an advocate for women's health by establishing appropriate forums to educate the public regarding women's health, with an emphasis on preventive health and healthy lifestyles.
• To assist the state health officer in identifying, coordinating, and establishing priorities for programs, services, and resources the state should provide for women's health issues and concerns.
• To serve as a clearinghouse and resource for information regarding women's health data, services, and programs that address women's health issues.
• To provide an annual report on the status of women's health and activities of the office to the Governor and the Legislature.

 

The law provides for an advisory committee for the office. The Steering Committee consists of the following:

• Three physicians appointed by the Medical Association of the State of Alabama
• Three nurses appointed by the Alabama State Nurses Association
• Three pharmacists appointed by the Alabama Pharmacy Association
• Three employers appointed by the Business Council of Alabama
• One consumer appointed by the Governor, one appointed by the Lieutenant Governor, and one appointed by the Speaker of the House
• Three members appointed by the Alabama Hospital Association
• Three registered dietitians appointed by the Alabama Dietetic Association

 

Women on Wellness

The Women on Wellness (WOW) Speakers Bureau was developed by the OWH Steering Committee to promote the health of women throughout the state by facilitating and coordinating evidence-based information and education about women's health. The WOW Speakers Bureau features great public communicators who are experts in women's health and focus on specific issues affecting women's health through the lifespan. WOW speakers are physicians, nurses, dietitians, pharmacists, social workers, community health advocates, and other healthcare providers who are qualified expert speakers available for any audience interested in learning more about specific women's health issues.

 

Women's Health Update

The OWH Twelfth Annual Women's Health Update was cancelled in 2020 due to COVID and scheduled to resume virtually in FY21.

 

Opioid Misuse in Women and Neonatal Abstinence Syndrome

 

The OMW/NAS Taskforce continued to meet quarterly in March, July, September, and December. The goal of the taskforce, formed through an ADPH Office of Women's Health partnership with the AAP, Alabama Chapter, is to target the misuse of opioids in Alabama among women and address the trend of infants born addicted to drugs (NAS/ NOWS), by introducing preventative strategies and proposing standardized screening protocols to address early identification in women and in babies exhibiting NAS after delivery. In 2018, the three core subcommittee teams - legal, protocol, and education - were expanded to include the treatment, resources & recovery committee. The target population continues to be girls/women (including incarcerated women) and NAS/NOWS infants.

 

Committee members participated in a panel discussion with the Executive Director of the Alabama Office of Prosecution Services/Alabama District Attorneys Association in 2019, at the AAP, Alabama Chapter meeting, to discuss the Alabama child endangerment law and criminalization of mothers who use illegal substances during pregnancy. Mothers continue to be charged with chemical endangerment of the child. Discussions are ongoing for the development of a position statement that would include decriminalization for women in treatment programs. The taskforce hopes to develop the basis for a communication piece for the State of Alabama that stresses, if the mother gets treatment during pregnancy, she will not be charged. The document would carry logos of the Attorney General, the AAP, Alabama Chapter, and ADPH. Draft language for the position statement flyer was submitted for literacy level review by staff at UAB.

 

The taskforce is working to address universal testing of all mothers in labor and delivery units and reduce variation in treatment of opioid exposure. Data is needed for comparison of outcomes and translation into better care. A comparison of three years of data from Huntsville/Madison hospitals (which test all mothers), to UAB and St. Vincent's data (which do not test all mothers), is being explored. Challenges include the fact that providers keep circling back to fear of prosecution if the baby tests positive for opioids.

 

Maternal Mortality Review Program

 

ADPH established the MMRP in March 16, 2018. The purpose of MMRP is to understand how a wide array of social, economic, health, educational, environmental, and safety issues relate to maternal death. The goal is to do an in-depth look into the circumstances of each case of maternal death to understand how to prevent them. An additional goal is to promote change among individuals, communities, and health care systems in order to improve the well-being of women of childbearing age, infants, and families. The maternal mortality review process begins with the ADPH nurse abstractor gathering information about a maternal death and synthesizing the information into a case summary. The de-identified case summary is presented to the Maternal Mortality Review Committee (MMRC). MMRC is a multidisciplinary team which reviews cases of maternal death that occur during pregnancy or within one year of pregnancy and makes recommendations that will lead to a more effective and efficient statewide maternal care system.

 

The Alabama MMRC convened for the first time on December 7, 2018 for a mock case review. ADPH and a team from CDC provided information on the importance of conducting maternal death reviews and oriented members about the role they each play on the committee. The MMRP has consulted and collaborated with the Division of Reproductive Health National Center for Chronic Disease Prevention and Health Promotion Centers for Disease Control and Prevention in the implementation and operations of the Alabama MMRP. On Friday, February 8, 2019, the Alabama MMRC conducted its first case review meeting with more than 45 professionals from across the state in attendance. During the year, the MMRC met quarterly and reviewed all of the 36 maternal deaths selected for review out of 56 maternal deaths that occurred in 2016. Support for the MMRC was provided by the American College of Obstetricians and Gynecologists.

 

Currently, the MMRP staff is abstracting 2018 maternal deaths. The MMRC is meeting quarterly to review the 2018 case summaries and make recommendations. An abbreviated report of the MMRC findings is being prepared and scheduled to be published by the end of 2021. The MMRP was provided state funds through the general budget to hire additional staff and provide funding to perform maternal death autopsies. Two additional nurse abstractors and an administrative support assistant were added to the staff in October 2020. Contracts have been secured with the UAB to perform the autopsies and the Steele City Mortuary Transport to transport the decedents to and from UAB. A student intern is working with the MMRP to research and develop a process to incorporate interviews from the next of kin. The interviews will assist the MMRP in gaining a better understanding of the factors that contribute to maternal deaths.

 

State of Alabama Infant Mortality Reduction Plan

 

In December 2017, Governor Kay Ivey convened the Children's Cabinet to address the issue of infant mortality in Alabama. A subcommittee was created to develop an action plan. This subcommittee was comprised of leaders and staff from DECE, DHR, DMH, ADPH, Medicaid, and OMA. Title V funded program managers and MCH Epi staff developed and implemented strategies and data support for governor's initiative. Following is an overview of the initiative’s maternal health strategies.

 

Home Visiting

The Alabama Department of Early Childhood Education (DECE) contracted with two programs to provide home visiting services in the three original target areas, Macon, Montgomery, and Russel counties, using the Parents as Teachers (PAT) and Nurse Family Partnership (NFP) models of service delivery. The programs began the year fully staffed and trained. However, throughout the year staff turnover caused new staff to go through the processes of becoming both model and DECE trained, which usually takes at least a few months. During and after the training period, staff members continued to work to gain public awareness in the communities and recruit families to participate. Despite the challenge of staff turnover, the goal to serve 100 families across the target counties was achieved, with 145 active families in FY2020.

 

State funding was blended with federal (Health Resources & Services Administration Maternal, Infant, and Early Childhood Home Visiting) funding which allowed more families to be served. Additionally, matched funding from the Alabama Medicaid Agency, funds from the Department of Human Resources, and increased research and training allowed DECE to expand home visiting to all counties in the state. One of the models provided phones and service plans to families who were without these means. These provisions allowed home visitors to continue to maintain contact with families and refer them to resources for necessities, such as housing and food. Some of the screenings and assessments were completed virtually and allowed the continuation of data collection. Collectively, 190 screenings were provided, which assessed child development, parent-child interaction, and intimate partner violence. Additionally, five women were referred for tobacco cessation services.

 

There were many challenges to overcome during this year. The narrow eligibility requirements for NFP of first-time mothers prior to 28 weeks gestation, made it difficult to find enrollees. When eligible mothers were identified, it was challenging to get them to reschedule after the initial visit. This challenge is typical in communities where there is limited awareness about a new program. It is hoped that with increased enrollment, more mothers will find out about the program through word of mouth, which is often the best form of advertisement. Similarly, receipt of referrals from usual sources decreased with business closures and staff transitioned to working from home. Program staff continued to reach out to establish new referral sources.

 

Reliable referral sources for the program were more difficult to locate, due to the location of one of the pilot counties and the impact of the COVID-19 pandemic. The program using PAT only serves Russell County, which is large, both urban and rural, and with a transient military community. It also borders Georgia, where some families choose to receive medical and other services. Many families choose physicians and delivering hospitals in Georgia (who accept Alabama insurances), and the programs have to rely on them for referrals. Regarding the effects of the COVID-19 pandemic, it was difficult to identify new referral sources due to limited travel and the inability to go into offices and meet with staff in person. Many agencies and programs transitioned to providing services remotely, making referrals an afterthought in dealing with the demands of virtual service delivery. However, both programs serving Russell County reported progress, new partnerships, and referral sources over the past year.

 

The novel coronavirus (COVID-19) pandemic presented the most significant challenge this year. However, both models of home visiting were quick to provide guidance on how to continue visiting families virtually. The transition was almost seamless, and the programs were able to retain most of the families. This transition resulted in positive movement on team goals. Figures 3a – 3c depict select performance measures and outcome indicators, with targets where applicable, for the second year. At least 50 percent of primary caregivers in Montgomery and Russell counties reported safe sleep practices. More than half of the mothers who delivered during the time period initiated breastfeeding in all three counties. The percentage of infants born preterm varied by county.

 

Screening, Brief Intervention, Referral to Treatment (SBIRT) Tool

The SBIRT tool can be a useful instrument in identifying, reducing, and preventing substance use, domestic violence, and depression. Research has been completed on best practices in providing services among pre- pregnancy, prenatal, and post-partum women. Additionally, training strategies and outreach models have been explored to determine the optimal ways to effectively provide screenings. In this way, a training program and support for providers may increase the number of screenings that take place.

 

To increase the number of providers who use SBIRT, the team worked diligently throughout this year to construct an Alabama-specific, online training module. After extensive research into evidence-based literature was conducted, the content of the training was drafted. The process towards production remained ongoing, which involved working with a software development company to solidify plans to bring the project to fruition. The team also explored different opportunities to involve other partners whose clients may benefit from the screening tool. This exploration resulted in discussions and implementation of virtual SBIRT training with ADPH staff involved in the ALL Babies and Family Planning programs. Moreover, coordination was initiated with the Alabama Medicaid Agency on the ways in which Alabama Coordinated Health Network (ACHN) case managers may use the SBIRT model with pregnant women. In this way, more at-risk women may be identified and receive appropriate follow-up care. Grant funds will be used to help offset costs for ACHNs on incorporating the screening tool into their electronic health records system. To further increase awareness of the model and its relevance, the team plans to present at a conference in the next fiscal year for healthcare professionals, introducing them to the model and process in OB/GYN practices.

 

Preconception and Inter-Conception Care

The WW program provides preconception and inter-conception care to women of child- bearing ages (15-55 years), as a foundation for wellness, identification of chronic diseases, and the adoption of a healthier lifestyle. In the first year of the initiative, a referral process was developed and initiated for enrollment into the program. The project year started off strong for the Well Woman team, with a total of 120 participants enrolled in the pilot counties within the first quarter. However, the onset of the COVID-19 pandemic in the second quarter was particularly challenging for the Well Woman team, which serves clients who are at increased risk of severe outcomes. Groups at risk include those with underlying health conditions, such as obesity, hypertension, diabetes, high cholesterol, and heart disease. The goal to enroll 500 women across all six counties during FY2020 (which averages to approximately 83 enrollees per county) was not met, as a result of the pandemic. However, 371 participants were enrolled across all six counties, 221 of which were in the pilot counties. Among those enrolled, 59 (27 percent) women were hypertensive and underscored the need for chronic condition management and healthy lifestyle adjustment.

 

Clinic visits were postponed in the second quarter and resumed in the fourth quarter on August 27. Though new clients could not be enrolled, existing clients continued to receive services via telehealth phone visits and virtual means. Telehealth/telemedicine was incorporated into protocols, which allowed continuation of services, such as health and nutrition coaching sessions, risk assessment and counseling, as well as other educational opportunities. New protocols for safety measures were put into place, to ensure the well-being and protection of staff and clients. These new safety measures included provision of personal protective equipment to both staff and clients, social distancing, and screenings for COVID-related symptoms. Nurse practitioners conducted risk assessments reviewing the participant’s history and physical and lab results. Treatment was initiated, if needed, and the participant was counseled on any identified conditions (such as hypertension). Web cameras were purchased for social workers and the nutritionist to host and participate in virtual opportunities. Participants benefitted from the web cameras also, with virtual nutritional classes held twice weekly with a registered nutritionist. As physical activity is an important component of ensuring health, partnerships with local communities allowed multiple daily exercise classes to be offered via Facebook. The team hosted a virtual, 3-day course for its second annual training for social workers. This training focused on motivational interviewing.

 

Near the final quarter of the fiscal year, the Well Woman program was selected to host two student interns for summer 2020 through the National Maternal Child Health Workforce Development Center. The internship ran from June 8 through July 31. The interns worked with the program virtually and in-person to increase client awareness/understanding about the program and to identify and develop ways to collect and analyze data on program participants, including blood pressure readings, weight, current health issues, and reproductive and medical history. The interns also helped to develop an electronic version of the periodic newsletters sent to staff for program updates, which allowed for easy dissemination. Though manual data collection remains a challenge, program staff work closely with the epidemiology division for assistance, with increased usage of data available in the ADPH electronic health record system. In subsequent years, improved data collection and analyses will likely have a long-term positive effect for quality improvement of the program and patient care.

 

Perinatal Regionalization

Enhancing perinatal regionalization (PR) is a priority of the State of Alabama Infant Mortality Reduction Plan. For several years, the team has been working and continues to work to implement a fully coordinated system of perinatal regionalized care in Alabama. The foundation for such a system will be dependent upon relevant data that the workgroup began collecting in year 1. Furthermore, the workgroup, in collaboration with the Alabama Hospital Association and the State Health Planning and Development Agency (SHPDA), has worked to identify the level of neonatal care of delivering hospitals through self-declaration of the facilities. Baseline data for self- declared neonatal level of care was received from the SHPDA, and pertinent data was requested from the Center for Health Statistics. In March 2019, a conference call was convened with Dr. Wanda Barfield, OB/GYN and Rear Admiral with CDC, to discuss recommendations for engaging providers. In May 2019, Dr. Whit Hall, Neonatologist at the University of Arkansas, traveled to Alabama and met with staff and providers at the three delivering hospitals in Montgomery to discuss opportunities, options, challenges, and barriers. Review of the aforementioned data and support from CDC and experts will further advance the efforts underway to develop a perinatal regionalization system in the state.

 

During this fiscal year, epidemiologists and research analysts analyzed pertinent data to create an evidence base upon which to act. These analyses included information on birth characteristics and outcomes in the state. Unfortunately, loss of staff during the fiscal year, coupled with the reassignment of team members to COVID response efforts, hindered the anticipated progression of PR activities. Moving forward, efforts will continue in order to effectively communicate the findings of the analyses, such that stakeholders may begin implementation of the PR model. Once the PR model is adopted, trainings will be provided to hospital administrators and staff, as well as Emergency Medical Services workers. In this way, those involved in the care and transport of at-risk mothers will have all the resources needed to ensure transport to the appropriate level of care hospital, which consequently will improve maternal and child health.