MCH Population Domain: Women/Maternal Health

National Performance Priority Area: Well-woman Care, with an Emphasis on Minority and Low-income Women– 2023 Annual Report Narrative (October 1, 2022 – September 30, 2023):

According to the Behavioral Risk Factor Surveillance System (BRFSS), overall, North Dakotan women ages 18-44 have rates of well-woman visits that are on par with national rates. In 2021, 69.4% of women ages 18-44 in North Dakota had a well-woman visit compared with the United States (US) rate of 69.7%. Rates of well-women visits are increasing in North Dakota; up from 66.8% in 2020.

While overall rates may be similar between the US and North Dakota, disparities have emerged across multiple demographic variables. For example, those with lower income had rates below the state average and only 40.7% of women with no insurance had a well-woman exam. Differences from the state average rate were also found when examining rates based on race or ethnicity. One positive trend based on BRFSS data is that American Indian women had higher rates of well-woman visits at 79.1%. For other minority groups, including Black and Hispanic women, BRFSS data for North Dakota was unavailable, but other state-specific data sets and qualitative data gathered from the 2020 MCH Five-Year Needs Assessment clearly demonstrated the need to focus work efforts on minority populations. For example, data from the 2017-2019 North Dakota Pregnancy Risk Assessment Monitoring System (PRAMS) showed that compared to 75.5% of white women, only 43.8% of American Indian women and 47.8% of women of other races had a ‘routine’ check-up.

To improve rates of well-woman care among low-income and minority women, the North Dakota Department of Health and Human Services (NDDHHS) Title V team used various evidence-based strategies to improve well-woman care for minority and low-income women. The team leveraged local community-based organizations (CBOs) to reach ethnic and racially diverse populations of women, improved postpartum health for women by collaboratively extending Medicaid services postpartum, and implemented projects around doula care, increasing postpartum depression screening, and enhanced access to family planning services to improve women’s health in the interbirth interval.

CBOs are often well-positioned to gain the trust of ethnic and racially diverse women; partnering with these organizations can improve the efficacy of health messages and programs. For several years, the Title V team has worked closely with multiple local organizations in North Dakota to improve well-woman care. In 2022-2023, the grantees working with the Title V team on well-woman care were given the opportunity to continue their grant-funded work with NDDHHS to enhance and expand their current projects. While the team planned to continue grants with six organizations, one organization (Spirit Lake Health Center) decided to work on a different area of Title V and one organization was unable to complete contract requirements due to changes in workloads at the organization. Therefore, four organizations serving different immigrant communities were awarded grants to continue their work in 2022-2023.

Organizations could tailor and target outreach to specific populations of women in North Dakota using culturally appropriate evidence-based strategies that would improve well-woman visits. Each grantee developed different campaigns and activities to reach women. Some activities included:

• a group tour of a local health center to improve trust and comfort with screening,
• health fairs with ethnic dance and interpreters,
• outreach and mobile clinics in Spanish,
• group education sessions that were held at the local CBO office with local health professionals attending as guest speakers to increase trust and comfort with local providers.

The team measured the number of individuals reached by these campaigns, particularly those who scheduled and completed well-woman exams. Six hundred sixty-five people participated in activities and events with the four grantees. Grantees documented seventy-seven screenings completed and many more who scheduled a screening during the grant period. Figure 1 is a report summarizing grantee activities and successes.

Figure 1: One-page report on grant activities of CBOs working on well-woman care.

In addition to this local, targeted approach to improve well-woman care among immigrant women, the team also utilized several state-level strategies. One such strategy was developing a state-wide task force to address maternal health. The Title V team planned to use the task force to develop and disseminate a combined preventative health flyer/brochure through five pilot sites in North Dakota. The team contracted with a state-wide organization to convene a state-wide task force addressing well-woman care and to leverage the task force to develop the preventative health brochure and identify five pilot sites for flyer dissemination.

The planned activities were to identify ten organizations to join the task force and begin work on the well-woman educational materials. Unfortunately, due to changes in leadership, the organization could not continue its work and its contract was terminated. Other maternal health partners, such as Women’s Way, have discussed the potential of developing a flyer for dissemination, but this would likely not occur until 2024.

The team did have several other opportunities to distribute preventative health messaging, including distributing safe sleep materials with boxes of diapers that went to women in two tribal communities in North Dakota. Messages were distributed with 670 boxes of diapers.

Another strategy of the Title V team was improving services and support for women before and during pregnancy and postpartum, with a special focus on North Dakota Medicaid extension postpartum.  

Since 2019, Title V staff have focused on extending North Dakota Medicaid one year postpartum as a key strategy to improve preventative women’s care. Nationally, a major focus of many women's health campaigns is extending postpartum access to Medicaid as there is widespread understanding that extending Medicaid coverage ultimately can lead to better preventative health care.

In 2020, the team convened a task force of stakeholders and planned to develop a strategic plan for how to pursue the extension of North Dakota Medicaid coverage postpartum. However, unexpectedly, the American Rescue Plan Act allowed North Dakota to pursue the option of extending Medicaid. North Dakota made the decision to extend Medicaid one year postpartum starting on January 1, 2023. This exciting advance in North Dakota allowed the Title V staff to be on the cutting edge of policy changes in North Dakota, as they helped to develop and deploy a strategy for implementing the extension of Medicaid. The team helped develop messaging in English and Spanish, including rack cards, business cards, posters, and banners. Materials were paid for via Title V funds. By September 30, 2023, the following materials were distributed: 1,165 materials to WIC offices, 2,605 to the 19 local human service zones, 998 materials to Family Planning clinics, 4,963 materials to human service centers, 1825 materials to human service zones, and 848 materials to local public health offices across North Dakota. 1,473 materials were distributed to 134 medical providers serving North Dakota Medicaid patients with a letter attached to inform them about the update from Medicaid.

Figures 2 & 3: Sample of the front side of business cards and front of rack cards, developed in part by the Title V team and paid for through Title V funds. Partners, such as WIC, provided these cards to women when they attended their office visits.

With extended North Dakota Medicaid postpartum, Medicaid-covered women have additional benefits to improve postpartum health. A complementary strategy is to improve the benefits available during this period, such as improving availability and access to doulas. The team planned to develop a pilot doula project in a tribal community, in collaboration with at least four obstetric providers in 2022-2023. Activities included working with the Tribal Health Liaisons to reach Tribal partners, providing resources/research on doulas to be used for educating the community, and helping to ensure the doula program was integrated into other programs for women. During initial conversations with community leaders, the team focused on the postpartum period as the best starting point to improve doula access. With the extension of North Dakota Medicaid postpartum, a focus on postpartum doula care made sense.

The team went to the Spirit Lake Tribe, along with the Tribal Health Liaison serving the area, to discuss the possible pilot project with partners working in maternal and child health. The team quickly identified that women were not aware of doula services and offering different culturally appropriate services that were already familiar to women would be best. Therefore, the Title V staff supported the development of the Tunwin program, a program designed for postpartum women and families to provide support in parenting. The team reached out to a program serving immigrants to determine if a pilot doula project may be possible by partnering with this organization. The New American Consortium already held a Title V grant to improve well-woman care, so adding funds to conduct doula training was a good fit. The New American Consortium held introductory meetings to discuss what doulas are and how to become a doula. They eventually identified 11 immigrant women who were interested in training to become doulas, and a trainer was identified. Unfortunately, the New American Consortium was not able to complete the work by the end of September 2023, and will be conducting the training in 2024.

In the 2022-2023 year, Title V staff planned to expand work around postpartum depression screening at well-child visits via two activities. Initially, the team called nurse managers in pediatric offices around the state to gather information about postpartum depression screening. The intent was to glean information on how screenings were recorded in the EHR and any barriers that were occurring in the process. Unfortunately, the team was unable to reach nurse managers and after dedicating many hours to this task, they decided to end this approach. 

A second approach the team planned was to develop an incentivized webinar/training on why postpartum screening is important at well-child visits. During the 2022-2023 year, the team developed an extensive presentation on this topic and offered continuing education for participants. Three opportunities to participate in the training occurred in the 2022-2023 period and all were led or co-led by a well-known pediatrician and former President of the local chapter of the American Association of Pediatrics. All presentations offered Continuing Medical Education (CME) and one offered Continuing Education Units (CEUs). The following trainings occurred in the 2022-2023 period:

1. NDDHHS Community Engagement Lunch and Learn, virtual presentation, open to the public.
2. The 86th Annual Meeting of the North Dakota Society of Obstetrics and Gynecology, September 9, in person meeting of primarily physicians.
3. The 2023 Pediatrics and Primary Care Behavioral Health Conference on September 21, virtual presentation, open to the public.

Figure 4: flyer from Lunch and Learn educational webinar hosted by HHS.

The final strategy of the Title V team was to identify components of the IMPLICIT model that could be appropriate in North Dakota to improve interconception care for women. The IMPLICIT (Infants Using Continuous Quality-Improvement Techniques) Interconception Care Model is a cutting-edge model that embeds care for moms who might become pregnant again into well-child visits. It is a preventive care model that incorporates assessments and referrals. An important component of IMPLICIT is identifying a woman’s pregnancy intention and helping her align her health behaviors accordingly, such as offering family planning services.  

To this end, Title V staff focused on expanding family planning services to women with the highest need in the state, focusing on the southwestern part of the state. Since the closure of a Title X family planning service site in 2019, the southwest corner of North Dakota has been without services. The prior service site served 500 unduplicated clients annually. Family Planning provides confidential preventive health services for women and men of reproductive age.

Title V Maternal Child Health Block grant provided funding in the amount of $15,000 to Upper Missouri District Health Unit (UMDHU), an existing family planning subrecipient to travel to Dickinson, North Dakota 1-2 days per month. Clinic hours will be 9 am – 3 pm, with walk-in clinic appointments available. UMDHU estimates they will serve 60 women per year.

The initial challenge was finding available space to accommodate the needs of a clinic. Women Empowering Women, a current MCH grantee, connected UMDHU to St. Joe’s Plaza. This facility was a previous hospital that was renovated to accommodate a variety of services and businesses. These include substance use disorder treatment services, daycares, boutiques, restaurants, barber shops, and martial arts, making it a diverse location to meet the needs of the community.

During the months of July through October, a space within this facility was updated to meet the needs for clinic space. The first day of clinic occurred on November 15, 2023. Ongoing marketing efforts through community engagement, radio ads, Facebook, and flyers have been developed with the MCH funds to promote well-woman preventive care.

UMDHU’s clinician and nurse collaborated with local public health, Dickinson State University, Primary Care providers, Obstetrics & Gynecology, and Human Service Zones to increase awareness of the services now available.