The WHB develops and promotes programs and services that protect the health and well-being of reproductive age women and men, along with infants and families.  The WHB’s goal is to improve the overall health of women and men, reduce infant sickness and death, and strengthen families and communities.  The WHB also offers guidance, consultation and training for entities that provide health services for individuals of reproductive age. Increasing the percentage of women with a past year preventive medical visit (NPM#1) is a critical piece of the work of the WHB.  Per data from the 2017 BRFSS, 73.4% of women ages 18 to 44 surveyed had received such a service, which is a slight increase from the 2015 BRFSS rate of 70.1% and is higher than the national rate (65.6%).  Of the women who responded to the survey, those with higher income, higher educational attainment, and higher rates of health insurance coverage were more likely than other women to receive a preventive medical visit. Hispanic women (77.2%) were more likely to have had a visit than Non-Hispanic Black women (74.3%) or non-Hispanic White women (71.8%).  The Affordable Care Act (ACA) has ensured that the majority of health plans offer women coverage for well-woman visits without cost-sharing, but many women and/or their providers are not aware of this coverage.  The ESM for NPM#1 is the following: Percentage of women enrolled in Medicaid who deliver and receive a primary care visit within 12 months of delivery.  This measure is also a draft core indicator for Point 1 of the NC Perinatal Health Strategic Plan (PHSP): Provide interconception care to women with prior adverse pregnancy outcomes. With Medicaid paying for 55% of deliveries in 2016, an increase in this ESM will definitely affect NPM#1. For women giving birth in 2014, 21.6% of women continuously enrolled in Medicaid for twelve months after delivery received a primary care visit within twelve months of delivery; however, this percentage dropped to 17.2% for women giving birth in 2016 (the most recent data available).  Data for 2016 indicate that non-Hispanic White women were less likely to receive a primary care visit within 12 months (15.1%) than Black non-Hispanic women (19.1%), American Indian non-Hispanic women (18.5%), and Hispanic women (19.4%).

To increase the percent of women with a past year preventive medical visit, local health departments (LHDs) provide family planning core services that include contraceptive services, pregnancy testing and counseling, achieving pregnancy services, basic infertility services, sexually transmitted disease services, preconception health services, and related preventive health services.  LHD maternity clinics also provide maternal health services inclusive of clinical care, referral for Medicaid and WIC services, provision of tobacco cessation counseling, screening for intimate partner violence, depression screening, and provision or referral for nutrition consultation.  In addition, maternal care skilled nurse home visits are provided for women with high risk pregnancies.  Home visits for newborn/postpartum and newborn assessment and follow-up care home visits are also provided by nurses.  LHDs are also able to provide childbirth education services.  All LHDs that provide maternal health services in the state are Pregnancy Medical Homes (PMHs).

DPH continued its partnership with NC Medicaid and CCNC in implementing the statewide PMH program aimed at improving the quality of maternity care, improving maternal and infant outcomes, and reducing health care costs.  Approximately 90% of all obstetrical care providers (public and private) in NC are PMHs who provide prenatal care services to the state’s Medicaid population.  The PMH program is an outcome-driven initiative monitored for specific performance indicators, such as the rate of low birth weight and the primary cesarean delivery rate.  Participating providers receive financial incentives from Medicaid for risk screening and postpartum visit completion, ongoing collaboration with and support of a Pregnancy Care Manager, local CCNC network support, data and analytics, and clinical guidance materials and resources.  In turn, practices agree to work toward quality improvement goals, such as eliminating elective deliveries before 39 weeks, using 17P to prevent recurrent preterm birth, reducing primary C-section rates, and improving the postpartum visit rate.  The postpartum visit must include a depression screen, reproductive life planning counseling, and completed referral for ongoing primary care.  PMH Care Pathways have been developed to assist providers and care managers to follow standardized protocols of best practice.  The Postpartum Care and the Transition to Well Woman Care pathway provides a thorough overview of appropriate timing of postpartum care, components of the comprehensive postpartum visit, and specific guidance for women with various complications.  Other PMH pathways include: Hypertensive Disorders of Pregnancy, Management of Obesity in Pregnancy, Perinatal Tobacco Use, Progesterone Treatment and Cervical Length Screening, Reproductive Life Planning and the Use of Postpartum long acting reversible contraceptive (LARC) method, Substance Use in Pregnancy, Multifetal Pregnancy, and additional pathways specific to care managers on tobacco cessation and patient education.

Pregnancy Care Management (OBCM) services were also available to pregnant and postpartum women enrolled in Medicaid statewide and to a limited number of low income, pregnant women ineligible for Medicaid in some counties.  Pregnancy Care Managers are registered nurses or social workers.  Care managers work in direct partnership with public and private prenatal care providers statewide in a collaborative team approach to patient-centered care, including supporting effective and prompt use of Medicaid eligibility determination processes and facilitating early access to prenatal care.  The primary mechanism for identifying Medicaid-eligible women with priority risk factors is the completion of a pregnancy risk screening form by a PMH prenatal care provider.  However, many women are identified and engaged in OBCM via the LHDs before contacting a prenatal care provider.  This gives the care manager an opportunity to assist women in applying for Medicaid coverage and selecting a prenatal care provider earlier.  Using risk screening and care management data, CCNC has identified women for whom care management can be shown to make a difference in their risk of low birth weight.  CCNC used this data to create the Maternal-Infant “Impactability” Score (MIIS), based on risk factors found on the risk screening form and other data sources including pregnancy assessment documentation, risk screens and pregnancy assessments from prior pregnancies, claims data that identifies various health conditions, and birth certificate data from prior pregnancies.  A higher score indicates that the patient is more likely to benefit from OBCM services.  Scores range from 0-1,000, and scores ≥200 are considered priority.  Based on CCNC data collected over time in the Case Management Information System (CMIS), it has been determined that to be effective, most care management interventions with priority patients need to be face-to-face.  The previous system of “priority risk factors” identified too many women for Pregnancy Care Management and gave them all equal priority.  The current system identifies fewer women to receive care management, about 25% of the total pregnant Medicaid population; however, the reduced caseload does not equate to reduced work.  The priority population requires eight to ten face-to-face interventions throughout the course of the women’s pregnancy.  The non-Medicaid OBCM program served 1,271 women during FY18.

The primary focus of Healthy Beginnings, the state’s minority infant mortality reduction program, is to improve birth outcomes specifically among communities of color.  Through partnerships with LHDs, community-based organizations, and faith-based entities, Healthy Beginnings serves minority women and their families in the preconception, prenatal, and interconception periods.  During FY18, the ten Healthy Beginnings program sites provided services in the preconception, prenatal and interconception periods to 502 pregnant women and women up to two years postpartum in 11 counties.

The WHB also works to develop and enhance preconception efforts within NC using the NC Preconception Health Strategic Plan Supplement for 2014-2019 as a guide.  In partnership with the national Office of Minority Health Resource Center, the WHB implements the Preconception Peer Educator (PPE) program.  Initially the PPE program focused on Historically Black Colleges and Universities (HBCUs), but the program has now expanded to other colleges and universities including community colleges.  With a focus on preconception health, college students are trained on reproductive life planning, HIV/STIs, tobacco use, healthy weight, and other wellness areas.  The PPEs in turn share this information on their college campuses and in surrounding communities.  There are 18 two and four-year colleges on the NC PPE roster.

NC is one of four states participating in the Preconception Collaborative Improvement and Innovation Network on Infant Mortality (PCH CoIIN) led by the UNC Center for Maternal and Infant Health (CMIH).  The overall aim of the PCH CoIIN is to develop, implement, and disseminate a woman-centered, clinician-engaged, community-involved approach to the well woman visit to improve the preconception health status of women of reproductive age, particularly low-income women and women of color.  The work of the PCH CoIIN began in December 2017 and will run through September 2020.  The NC PCH CoIIN consists of staff members from the WHB and the NC Chapter of the March of Dimes working in partnership with staff members from the three NC Healthy Start programs (UNC-Pembroke, Robeson Healthcare Corporation, and Forsyth County Department of Public Health [a NC Baby Love Plus site at the time of the CoIIN initiation]) and Mountain Area Health Education Center.  The metrics chosen for the project to determine if the goal/aim is met is the following: By September 2020, four states, in collaboration with the core CoIIN team and clinic partners, will develop an adaptable model to effectively integrate preconception care (PCC) into the well woman visit by: 1) working with clinics to implement validated screening tool(s) and response strategies, 2) enhancing state-level capacity to support effective implementation, 3) disseminating the model statewide and nationally.  An integral part of the work of this CoIIN is to use human-centered design involving the end-users in the process of problem-solving and developing the approach to the well-woman visit.  During FY18, the three NC PCH CoIIN projects, using a human-centered design approach, developed a preconception health screening tool specific to the needs of their clinic and population served. The current projects include the assessment of an existing patient screening tool, along with a newly produced training video for health care providers, a dummy code embedded into the electronic medical record to prompt and record preconception health screening, and a prototype (for a tool to be developed) for women to bring to their well-woman visit.

In 2010, the state rolled out the 2003 Revised Birth Certificate.  This update included the capturing of the actual date prenatal care was initiated as compared to the prior certificate only asking for the month.  Because of this change, any data regarding prenatal care initiation prior to 2011 are not comparable. During 2011-2013, approximately 70% of infants were born to women who initiated care in the beginning of the first trimester of pregnancy.  In 2017, data reflected that this percentage was at 68.6%, leaving opportunities for growth.  Almost 76% of White, non-Hispanic women received prenatal care in the first trimester in 2017, while only 61% of Black, non-Hispanic women and 58% of Hispanic women did.  In an effort to increase these rates and support improvement, LHDs continues to offer or assure access to high quality, evidence-based Maternal Health Services to all women in the state.  In FY18, per reports from the old HIS and the new LHD-HSA, these services were provided to 34,914 unduplicated patients.  OBCM services were provided to approximately 1,271 uninsured women, ineligible for Medicaid, in FY18.  The state program team continued to explore potential mechanisms to facilitate earlier entry to prenatal care, with a particular focus on opportunities for improvements with Medicaid eligibility determination. LHDs are also required to provide Sudden Infant Death Syndrome (SIDS) Counseling to families who have experienced an infant loss.

North Carolina continues to conduct a formal review of maternal deaths.  The focus of the review is to identify deaths determined to be pregnancy-related as well as those that are pregnancy-associated.  The support of state legislation (§130A-33.52) and the cooperation of healthcare systems and professionals made the retrieval of protected health information possible to perform this mandated work.  The focus of the review aligns with that of the CDC’s recommendations to identify potential preventable and contributing factors on the patient/family, community, provider, facility, and system levels.  The overarching goal is to improve maternal health outcomes.  The Committee meets three times per year.  There are nine appointed members to the Maternal Mortality Review Committee (MMRC), with additional specialty consultants in attendance by invitation, along with select staff from DPH.  The Committee reviews both pregnancy-related and pregnancy-associated deaths.  The SCHS provides identified cases that meet established criteria for abstraction.  Of the 93 cases provided by the SCHS from 2015, twenty-seven were brought forward for closer examination to the committee during FY18.

Title V funding, along with Title X, TANF, state, and local funding, was allocated to all 84 LHDs for the delivery of family planning services in FY18.  According to the 2018 Family Planning Annual Report, 81,305 female patients were seen in these LHDs.  The number of female patients are much lower than reported in 2017. At the end of 2017, during the preliminary transition to the new LHD-HSA reporting system, many counties did not report data correctly through the retiring database. Self-report data was used to supplement the FPAR, and due to the combining of data sources many users were mistakenly duplicated and the total user number for 2017 was inflated. The 2018 number of female patients compared to the 2017 number will be much lower, but more aligned with data from 2016 and previous years.  Female patients were able to choose an appropriate method of birth control from among the range of options.  During CY18, it is estimated that 18% of female patients chose a LARC method.  These methods help women to create more optimal birth spacing between pregnancies, potentially resulting in healthier birth outcomes for their children.  In addition, the C&Y Branch used Title V funds to support adolescent reproductive health services as part of their increased emphasis on adolescent health.

In Phase 7 of the Pregnancy Risk Assessment Monitoring System (PRAMS) survey, the question regarding pregnancy intendedness (Thinking back to just before you got pregnant with your new baby, how did you feel about becoming pregnant?) was modified to include a choice of “I wasn’t sure what I wanted” to go along with the responses that the person wanted to be pregnant later, sooner, then, or not then or at any time in the future.  With this change, data prior to 2012 are not comparable to data from more recent years.  Low participation has been a substantial problem for NC PRAMS from 2012 to 2017, with overall weighted response rates ranging from 51% to 57%.  In response to this question in 2012, 26.3% of respondents wanted to be pregnant later, 11.4% wanted to pregnant sooner, 41.3% wanted to be pregnant then, 8.5% did not want to be pregnant then or any time, and 12.6% were not sure what they wanted.  The 2017 PRAMS responses were similar, as 23.4% of respondents wanted to be pregnant later, 13.5% wanted to pregnant sooner, 42.7% wanted to be pregnant then, 7.1% did not want to be pregnant then or any time, and 13.4% were not sure what they wanted.

The state teen birth rate for females 15-17 years of age reached a low of 8.9 per 1,000 women in this age group in 2017.  That same year, the teen birth rate for girls age 15 to 19 in North Carolina decreased by 6% from the rate in 2015 to 20.6 per 1,000, leaving North Carolina with the 22nd highest teen birth rate in the nation, with the national rate being 18.8 per 1,000.  The Teen Pregnancy Prevention Initiatives (TPPI) support communities across North Carolina with programs that prevent teen pregnancy and support teen parents. The Adolescent Parenting Program (APP) helps teen parents prevent a repeat pregnancy, graduate from high school, keep themselves and their babies healthy, and build skills that will help them support themselves and their babies.  The Adolescent Pregnancy Prevention Program (APPP) prevents teen pregnancy by providing young people with essential education, supporting academic achievement, encouraging parent/teen communication, promoting responsible citizenship, and building self confidence among their participants.  The Personal Responsibility Education Program (PREP) is designed to educate teens on abstinence and contraception to prevent pregnancy and sexually transmitted infections (STIs).  PREP also addresses adulthood preparation subjects such as parent-child communication, healthy life skills, positive adolescent development, financial literacy, and educational/career preparation.  TPPI also received funding from the Office of Adolescent Health (OAH) in 2015 to work with three counties (two counties in FY18) around implementation of evidence-based teen pregnancy prevention programs to scale, called Project REACH (Redefining & Empowering Adolescents & Community Health).  The expected number of youth to be served in these counties is 1500 youth per year.  The program provides key educational interventions to improve NC adolescents’ knowledge, attitudes, and beliefs regarding sexual health, which will impact adolescent birth rates in these counties as well as increase the number of youth seeking services at local family planning clinics.

In FY18 through Title V, TPPI funded SHIFT NC (Sexual Health Initiatives for Teens) to provide information, education, resources, consultation and training to professionals and stakeholders working to reduce teen pregnancy in the state.  TPPI also provided SHIFT NC funding for their annual conference.  The conference was held in May 2018 with 227 people attending.  Through Title V, TPPI also funded the North Carolina School Health Training Center that is housed at East Carolina University.  The Training Center provided professional development and skill-building for program facilitators funded through other TPPI programs.  This included: a networking conference held combined for primary and secondary education programs; training on Data Visualization; working with the developer of Teen Speak, a curriculum for parents on talking to their teens, to provide a train the trainer event for North Carolina; and holding the Adolescent Parenting Program Conference which is a skill-building conference for facilitators and adolescent parents that includes recognition of recent high school graduation of adolescent parents.  The networking conference was held in August 2017 with 116 attendees. The Data Visualization Training was held in September 2017 with 28 attendees, and the Adolescent Parenting Program Conference was held in June 2018 with 113 attendees.

In addition to the teen pregnancy prevention work funded through Title V in FY18, TPPI funded 54 agencies to implement adolescent pregnancy prevention programs or adolescent parenting programs.  Through the 31 primary prevention programs funded in 29 counties, 9,123 youth completed an evidence-based or evidence-informed teen pregnancy prevention program.  TPPI funded 24 secondary prevention programs in 23 counties.  A total of 644 participants were served with monthly home visits using an evidence-based curriculum (either Parents as Teachers or Partners for a Healthy Baby) and offered a minimum of a quarterly peer to peer group instruction.  Of the 598 female participants, 1% had a repeat pregnancy and 49% reported using a LARC. Of the 644 total participants, 2.5% reported dropping out of school that year.

The Medicaid Be Smart Family Planning (Be Smart) program is designed to reduce unintended pregnancies and improve the well-being of children and families in North Carolina.  Family planning/reproductive health services are provided to eligible men and women whose income is ≤195% of the federal poverty level.  The Be Smart program covers annual exams and physicals, laboratory procedures, FDA-approved contraceptive methods, STI testing and treatment, and family planning counseling.  One Be Smart program manager is housed in the WHB and works collaboratively with staff in Division of Health Benefits.

In conjunction with wanting to increase intended pregnancies, another objective of the WCHS is to promote healthy behaviors for women prior to pregnancy, including increasing the percent of women of childbearing age taking folic acid regularly.  Data for this measure are obtained through the BRFSS, and due to changes in the BRFSS methodology, data prior to 2011 are not comparable.  According to survey responses, the percent of women taking folic acid regularly has ranged from 33% to 43% since 2011, with 39% of women responding in 2016 that they took a multivitamin daily.  Due to BRFSS space and time limitations, since 2016, the folic acid questions are only asked every other year.  In partnership with the NC March of Dimes (MOD) Preconception Health Campaign, during FY18, the WHB provided folic acid education to 920 public and private health care providers via in-office trainings and webinars; 3,284 health care providers during presentations at professional health care conferences and meetings; and 80 health educators and/or health care providers during an educational forum.  MOD staff also trained 36 Community Ambassadors (lay health educators) about preconception health and folic acid who educated 237 peers; coordinated and conducted 15 community-based trainings and educated 289 consumers about preconception health and folic acid; conducted the Healthy Before Pregnancy curriculum in 24 high school classrooms and educated 457 students; and conducted the Healthy2: Now & Later curriculum in seven middle school classrooms and educated 100 students.  In addition, the WHB worked with MOD to host a focus group for middle and high school students to further refine school-based preconception health curricula and adapt preconception health messages for young audiences.  Twelve hundred women were educated via the Spanish language promotora program about folic acid and preconception health and 35,556 bottles of multivitamins were provided to low income women of reproductive age through the statewide multivitamin distribution program, which includes an online training program for health care professionals, continued to promote the folic acid message for women of childbearing age and encourage the new or continued behavior of daily folic acid consumption.  The EveryWoman NC website was maintained to address folic acid and preconception health education.  Also, EveryWoman NC Facebook and Twitter accounts posted press releases and electronic newsletters.  Spanish language media was provided to address the high rates of neural tube defects in the Hispanic population and included radio, television, newspaper, and web ads.

Improving appropriate weight gain during pregnancy and decreasing the amount of overweight and obesity among women of reproductive age remain important to the WHB as they work to improve the health of all women.  Birth certificate data for the 2012-2017 time period show that just under 30% of pregnant women gained within the Institute of Medicine Recommended Weight Gain Ranges.  In 2017, 53% of women giving birth were overweight or obese (BMI≥25) prior to pregnancy.  In partnership with the MOD Preconception Health Campaign, healthy weight education and training continued to be offered to health care providers and consumers in offices, communities, and online. The Healthy Before Pregnancy high school and Healthy: Now & Later middle school curricula, which include a healthy weight component, were provided in additional classrooms. After successful pilot testing, a bilingual (English and Spanish) gestational weight gain education card was printed (5,000) and added to the WHB requisition form so health care providers can order at no charge for distribution to their patients.  The providers in North Carolina's LHD maternity clinics continued to assess gestational weight gain for all pregnant women and provided guidance as necessary in FY18, and this is actually an action step in the Perinatal Health Strategic Plan 2016-2020.

As per state mandate, North Carolina LHD family planning clinics continued to record BMI and provide education for all patients and made referrals as needed for patients who were not at a healthy weight.  Healthy weight was promoted and integrated into Healthy Beginnings and the NC Baby Love Plus program activities as a required component.  Finally, the NC Preconception Health Strategic Plan Supplement for 2014 -2019 reiterates healthy weight as a priority area, and the plan has been promoted and distributed statewide.