Overview

The Women’s Health program at the Department of Health (DOH) works to support women’s and maternal health in a variety of ways. Some of our most important work is to promote, influence, adopt, and revise policies and processes that can have positive impacts on women and families.

We offer educational materials and resources on a wide range of topics, including healthy eating, physical activity, vitamins and nutrients, oral health, genetic illness, mental health and depression, safe relationships, family planning, pregnancy, sexually transmitted illnesses, and substance abuse. Materials are available in a variety of languages.

National Performance Measure 1 – Well-Woman Visit

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

According to the Behavioral Risk Factor Surveillance System (BRFSS), the percent of women with a past year preventive medical visit was 69.7 percent in 2018, exceeding our objective. This is an increase from the previous year; the rate had remained steady between 2009 and 2017.

Women’s health staff continued to monitor issues related to the mandated preventive services for women and worked with the Office of Insurance Commissioner and Health Care Authority (HCA), the state’s Medicaid administrative agency, when appropriate to try to ensure access to these benefits.

Culturally and Linguistically Appropriate Services (CLAS) standards have been implemented in managed care contracts. The Women’s Health Nurse Consultant and the Perinatal, Women’s and Adolescent Health Program Manager were both involved in the Office of Family and Community Health Improvement group to develop a CLAS implementation plan specific to our programs.

Since 2016, HCA has been working to integrate physical and behavioral health services. The state will fully integrate the financing and delivery of physical health services, mental health services and chemical dependency services in the Medicaid program through managed health care by 2020. As the state moves toward a regional Medicaid purchasing approach, it creates a pathway for regions to "opt-in" and fully integrate physical and behavioral health care purchasing. This initiative, called Healthier Washington, as described in the Overview of the State, is a multi-agency effort supported by federal funding to build healthier communities through a collaborative regional approach, integrate how we meet physical and behavioral health needs so that the health system focuses on the whole person, and improve how we pay for services by rewarding quality over quantity.

In an effort to address the needs of women and infants impacted by the opioid epidemic, our women’s health staff have partnered with the Division of Behavioral Health and Recovery (DBHR) at the HCA, the Washington State Hospital Association (WSHA) and the March of Dimes (MOD) to improve the quality of care and access to care by forming a workgroup of the state opioid taskforce. The purpose of this workgroup is to integrate mental and physical (maternal) health care services through existing agencies and programs. We aim to decrease stigma while improving standards of care and easing access to care. Additionally, we aim to decrease addiction to opiates and increase recovery for women and their families.

This past year, the Women’s Health Nurse Consultant partnered with local maternal care providers at the MOD and HCA to support local efforts by partnering with Swedish Addiction Services in Seattle to provide maternal addiction training to perinatal and addiction service providers.

WithinReach is a Maternal and Child Health Block Grant contracted provider. This private, not-for-profit organization serves as a single point of entry to the many resources a family needs to be healthy. They connect Washington families to health and food resources, promote awareness and education about specific health issues, provide insurance information and make connections in person, online, and over the phone. They provide eligibility screening and referrals to Medicaid, the Women, Infants and Children Nutrition Program (WIC), and other services. They offer referrals and health education information about pregnancy, prenatal care, maternity support, childbirth, immunizations, and family planning.

WithinReach’s ParentHelp123.org resource website had 21,894 page views with 17,431 total unique page views in calendar year 2019.

WithinReach's Family Health Hotline (FHHL) is Washington State's maternal and child health hotline. During federal fiscal year (FFY) 2019, the FHHL received and responded to 14,063 calls. Questions relating to food and nutrition resources generated the greatest number of in-bound calls, and resulted in 8,224 food assistance referrals and 6,057 referrals to WIC. 162 referrals were made to immunization clinics. Numerous additional referrals were made for pregnancy-related services, including 26 referrals for breastfeeding support.

WithinReach provides health information in a variety of languages for people who are not proficient in English. During FFY 2019, the total number of FHHL Spanish phone calls was 669. FHHL averaged 218 non-English calls per quarter. Nearly all of the call center staff are bilingual, and nearly 99 percent of Spanish-language calls are completed without a third-person interpreter.

Additional Work Supporting Women’s/Maternal Health

Policy and Process Improvement

We have an evidence-based strategy measure (ESM) to count the number of policies and practices influenced and promoted by staff that positively impact the rate and quality of well-women medical visits for women of child-bearing age in Washington. We exceeded our 2019 goal of one policy/procedure with eight policies/procedures, described briefly below:

• The Department of Health has partnered with WSHA to join the Alliance for Innovation on Maternal Health (AIM), which is a national organization run in partnership with the American College of Obstetricians and Gynecologists (ACOG) to improve maternal outcomes through the implementation of hospital-wide quality improvement protocols. Title V staff have participated in coordinating monthly trainings and bi-annual in-person trainings and most participating birthing hospitals have access to the data system. The state is working on hemorrhage and equity/disparities and will transition to maternal mental health and substance use in November 2020. Additionally, they participated in site visits in rural areas to support local quality improvement efforts (1).

• As part of quality improvement resulting from maternal mortality review recommendations, perinatal staff led regular meetings of the state’s autopsy workgroup. The workgroup developed recommendations for maternal death reporting and autopsy. As a result perinatal staff worked to amend the maternal mortality law to require birthing hospitals and licensed birth facilities to report the deaths of people that occur during pregnancy or within 42 days of the end of the pregnancy to the local county coroner or medical examiner’s office. Upon reporting, county offices are required to conduct a death investigation and autopsy is strongly recommended using the Guidelines for Maternal Death Autopsy as developed by the workgroup. The law went into effect July 28, 2019. Perinatal staff will monitor reporting and autopsy as part of the maternal mortality review work (2).

• Interagency collaboration is occurring between state agencies, WSHA, MOD, and key stakeholders to intervene for the maternal needs of women and their babies who have been impacted by the opioid epidemic. The Department of Health is leading the state opioid response team and Title V staff leads the workgroup that addresses the maternal child impact. This workgroup has several areas of work including increasing low-barrier access to contraception, improving perinatal care, addressing clinician bias, conducting community-level need analysis, linking pregnant and postpartum women to clinical and community resources, expanding access to medication-assisted treatment, expanding wraparound services, working with birthing hospitals to develop rooming-in policies for mothers and babies with withdrawal and to transition to using the eat/sleep/console tool, working with the Department of Children, Youth, and Families (DCYF) to increase consistency in child removal practices, and determining breastfeeding guidelines. (3)

• DOH is also leading two other interagency initiatives working to address the maternal/child/family impact of the opioid epidemic:

In November 2018 an Association of State and Territorial Health Officials (ASTHO) interagency team led by Title V staff launched two initiatives: (1) to clarify and write policy around the federal 2016 Child Abuse Prevention and Treatment Act (CAPTA) regulations to notify Child Protective Services of all drug-affected infants, and (2) to address the needs of women who have not received substance use treatment and prenatal care during pregnancy and want to move into recovery and parent their child. This is to be accomplished by creating billing structures for birthing hospitals to treat the mother and baby together (start on medication-assisted treatment and monitor baby for withdrawal), and then transition mother and baby to residential treatment for pregnant and postpartum women. This assures the safety of the infant and supports the maternal recovery and parenting transition of the mother (4).

1. To address the first initiative, DOH has partnered with DCYF to look at the state’s child welfare policy that directs the reporting and notification of infants born affected by substances. They are currently re-writing policy for the notification and reporting process and will be developing policy around the federal requirements for plans of safe care.

2. To address the second initiative, in the 2019 legislative session the HCA was required to write a report and fiscal analysis with recommendations for the care and treatment of neonatal abstinence syndrome and maternal stabilization. Additionally, DBHR was allocated funding to increase the number of residential treatment facilities that allow mothers to bring their children with them.

In March 2019 an Association of Maternal and Child Health Programs (AMCHP)/ASTHO interagency team led by Title V staff was launched to address the housing needs of families impacted by the opioid epidemic through policy changes. This was a cohort of the national Predictive Risk Intelligence SysteM (PRISM) project. During the 2019 fiscal biennium, Washington allocated $35 million for housing services that prioritize people with behavioral health needs and DBHR is increasing their contracts for recovery residents (housing) for people in recovery from substance use (5).

• Home visiting: One of the Maternal Mortality Review Panel’s (MMRP) recommendations was to ensure funding and access to postpartum care through the first year after the end of pregnancy, specifically during the first seven to ten days after the end of the pregnancy. One panel-suggested implementation of this recommendation is through the promotion of universal home visiting that would include a nurse home visit within the first 2-3 days after the end of pregnancy/discharge that is focused on the medical, psychosocial and emotional needs of both the mother and infant. During the 2018-2019 legislative session, the Governor’s Office introduced a bill in the state for a universal home visiting model. The adopted bill resulted in a pilot study with several organizations. (6)

• Led by perinatal contractors, the obesity workgroup met regularly with guidance from the Title V-supported Perinatal Nurse Consultant. The obesity workgroup is developing guidelines/protocols for the care of pregnant women with a high body mass index (BMI). (7)

• Maternal mortality review: This year, staff completed the second Maternal Mortality Review Report, which was released in October 2019 and covered deaths from 2014-2016. This report also included data and findings related to deaths from suicide and behavioral health conditions. Staff has been disseminating the findings from that report through presentations and communications materials available to providers, hospitals, and other partners and interested groups. (8)

Maternal Mortality Review

In March 2016, the legislature passed Engrossed Second Substitute Senate Bill 6534 (codified at RCW 70.54.450) creating the Maternal Mortality Review Panel (MMRP) to conduct multidisciplinary review of all maternal deaths in Washington. The law set out to identify factors associated with the deaths and make recommendations for system changes to improve women’s health care services in the state. The law requires a report outlining the findings of the review and recommendations to be submitted to the health care committees of the Washington State House of Representatives and Senate every two years. The inaugural review was completed in spring 2017 and reflected the review of maternal deaths from 2014 and 2015. The subsequent Maternal Mortality Review Report was released in August 2017.

The MMRP reviews each maternal death (death of a woman during pregnancy or within the first 365 days after pregnancy from any cause), and distinguishes which deaths were pregnancy-related (the death occurred during the woman’s pregnancy or within 365 days after the end of her pregnancy from a cause that was complicated by pregnancy, a chain of events initiated by pregnancy, or the aggravation of an unrelated condition by the physiological effects of pregnancy) and which deaths are preventable.

Feedback from members of the MMRP and key partners led to an expansion of the scope of work of the review to include suicide and substance-use related deaths. After recruiting additional behavioral health specialists, including people from addiction medicine and psychiatry, the panel and perinatal staff successfully reviewed maternal deaths from suicide and accidental overdose from 2014-2015 and have integrated those types of deaths into all subsequent reviews. The findings from these reviews, in addition to the review of maternal deaths from 2016, were analyzed and published in October 2019.

Funding for basic infrastructure and staffing for the maternal mortality review and report is still largely provided for by state funds and MCHBG. In 2019, the Department was awarded $375,000 annually for five years as part of the CDC’s Preventing Maternal Deaths Grant, Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM). These funds will be used to enhance the review process to identify deaths more timely and to increase activities around implementing the MMRP’s recommendations as outlined in reports.

Messaging

Women’s health staff continued to use the DOH website and social media to disseminate messages about issues impacting women’s health, including the importance of folic acid, safe relationships, substance use awareness, and around special events, including Women’s History Month, Black Maternal Health Week and National Women’s Health Week.

We continue to partner with HCA (Medicaid), WSHA, and MOD to encourage increase in the number of providers offering group prenatal care, especially to women struggling with substance use disorder and mental health issues. The March of Dimes has received funding to offer four pilot sites that integrate substance use needs with group prenatal care and they should be ready to offer services in fall 2020.

We work with partners, including the Department of Corrections (DOC) and medical providers, on ensuring availability and accessibility of all women to long-acting reversible contraception (LARC). Women’s health staff are collaborating with the DOH Family Planning program to support DOC in offering Nexplanon and intrauterine device (IUD) access for female inmates. We are also working with Title X partners to assist with training. The Women’s Health and Perinatal Nurse Practitioner has connected with Upstream (a non-profit) to assist providers, billers, schedulers, medical assistants, and nurses in training for same-day LARC insertion. The objective is to integrate family planning into primary care and to increase access for all women who want a LARC. Another goal with DOC is to increase provider training for IUD insertions. Upstream continues to offer trainings and has contracted with a health system in Tacoma to begin training for early postpartum LARC insertion.

COVID-19

The Women and Perinatal Nurse Practitioner has convened a perinatal COVID-19 workgroup that includes representation from DOH, WSHA, HCA, birthing hospitals, and many different types of inpatient and outpatient perinatal providers. We are meeting regularly to discuss the maternal/infant impacts and needs of the COVID-19 pandemic and developing written information/guidance for pregnant and parenting people and case tracking measures for COVID-19 in pregnancy.