WOMEN’S AND MATERNAL HEALTH DOMAIN

Nebraska Annual Report for the 2021-2022 Year

 

In this section, Nebraska MCH Title V reports on the accomplishments and activities in the Women’s/Maternal Health Domain for the period October 1, 2021 to September 30, 2022. This represents the second year of activity in the Title V needs assessment cycle.  The numerical sequence of headings used to organize the narrative below correspond to the narrative guidance for the Annual Report year as found on page 42 of the Title V Maternal and Child Health Services Block Grant to States Program: Guidance and Forms for the Title V Application/Annual Report, OMB Number 0915-0172, Expiration Date 1/31/2024.

 

From the 2020 Needs Assessment, the Nebraska Priorities selected in the Women’s and Maternal Health Domain for 2020-2021, with NPM, SPM, and ESM statements for the period are as follows:

 

• Cardiovascular Disease including Diabetes, Obesity, and Hypertension

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

ESM: Participation in the Women’s Community Health Initiative for Preventing Cardiovascular Disease

 

1. Context: The State of the Women’s and Maternal Population Domain

In the 2020 Needs Assessment, stakeholders developing the Issue Brief entitled “Cardiovascular Disease Including Diabetes, Obesity, and Hypertension,” focused on obesity and women, and the racial disparities seen in disease rates of obesity related co-morbidities such as diabetes and hypertension.  Racial disparities such as these can lead to elevated rates of death, earlier onset of illness, and greater severity of disease for minority populations.

 

For the 2020-2025 Needs Assessment, Title V worked with the Nebraska Association of Local Health Directors to bring forward a summary of current priorities identified through the Community Health Needs Assessment and Community Health Improvement Plans that local public health departments regularly undertake in their respective jurisdictions. This summary allowed stakeholders to consider degree of alignment with local and regional priorities when determining the final selection of priorities for the upcoming five-year period. Six local public health departments identify obesity as a priority issue in their regions.  Eight local health departments identify heart disease prevention as a priority, while four name diabetes prevention.  Three health departments have a priority statement related to healthy lifestyles and wellbeing.

 

Title V in Nebraska draws on a collaborative infrastructure for activities in maternal and women’s health for women of childbearing age.  Within DHHS, Title V is the connecting link between the Reproductive Health Program, the Women’s Health Initiative, STD prevention program, the Maternal Child Adolescent School Health Program, the Office of Rural Health, the Nebraska Maternal Infant Early Childhood Home Visiting program (N-MIECHV) and the Office of Health Disparities and Health Equity.  Additionally, Title V works to leverage the expertise of external partners, such as the Nebraska Perinatal Quality Improvement Collaborative, the Women’s Fund of Omaha, local public health departments, and health systems growing their community health footprint in the state. 

 

By the close of the 2021-2022 Title V year, some developments stand out as notably impactful on the state’s population of women of childbearing age, primarily the COVID-19 pandemic and Medicaid Expansion in Nebraska.

 

Ongoing Impact of COVID-19 on Women of Childbearing Age in Nebraska

In 2021-2022 COVID-19 continued to impact Nebraskans. Real-time observations indicate that women of childbearing age have been affected by the pandemic in numerous ways.  More women than men dropped out of the work force to care for children when schools and childcare providers closed.  Women dominate many service sector jobs, and as a result were more at risk of job loss and economic hardship during the pandemic.  Women of childbearing age have been subjected to rumors and misinformation about the effects of COVID-19 vaccine on fertility and fetal development. Due to rolling closures of clinic services for non-essential care, access to STD and contraceptive services diminished during the COVID-19 pandemic. 

 

In addition, the pandemic has taken a toll on mental well-being of women, with data showing higher rates of depression and anxiety among women, compared with pre-pandemic levels. Particularly for women already vulnerable due to socioeconomic stress, alarmingly high rates of new or worsening mental health problems have been seen. This has been complicated further by raising awareness of structural racism in systems such as law enforcement, health care, housing, and other sectors. This has further compounded the stress women may feel about pregnancy, childbirth, and parenting.

 

The COVID-19 pandemic notably altered access to care for all Nebraskans, prompting many people to defer or delay non-essential care.  This affected women of childbearing age seeking prenatal care, contraception, routine screenings, and other aspects of non-urgent health care.

 

Medicaid Expansion in Nebraska

Medicaid Expansion was passed by a ballot initiative in Nebraska in 2018.  Enrollment opened in August 2020, and benefits became effective October 2020.  According to the Nebraska Medicaid Annual Report for State Fiscal Year 2022, since October 2020 over 75,000 Nebraskans have enrolled in Medicaid Expansion. This represents a significant opportunity for some of the most vulnerable Nebraskans to access health insurance.  The significance of Medicaid expansion for women of childbearing age cannot be overstated, as it creates the opportunity for eligible women, to receive preconception and interconception health care.  Typically, Nebraska’s Medicaid coverage for pregnancy ends at 30 days postpartum, removing opportunities for continuous health care coverage following and between births.

 

2. Summary of Programmatic Efforts and Use of Evidence-based or Evidence-informed Approaches to Address Priority Needs

 

Priority: Cardiovascular Disease including Diabetes, Obesity, and Hypertension

2020-2021 Objectives and Strategies

 

Objective WM1a: By 2025, increase access to preventive health care and address health disparities in order to reduce rates of obesity, diagnosed diabetes, and diagnosed hypertension in women ages 18-44 years

 

Strategy WM 1a(1): Title V will conduct outreach and education on Heritage Health Adult (Nebraska’s Medicaid Expansion) to promote enrollment and benefits, particularly for disparate and disadvantaged women of childbearing age and other parents/caregivers.

 

Strategy WM 1a(2): The DHHS Women's Health Initiatives Program will develop, implement, and evaluate a project collaboration with a community cultural organization to enhance local navigation and health services.

 

Strategy WM 1a(3): The DHHS Women's Health Initiatives Program will collaborate with partners to identify needs for updates and/or translations for existing educational materials for women on cardiovascular disease, and review use of social media, in order to assure cultural relevance and inclusion of disparate audiences.

 

Summary of Programmatic Efforts

Planned strategies related to this objective included promoting Medicaid Expansion by conducting outreach and education about the benefits of health insurance and how to apply, with a focus on disparate and disadvantaged women of childbearing age.  The Women and Men’s Health Programs provide all enrollees of the Every Woman Matters program with information about Medicaid and how to enroll in it. All materials are available in English and Spanish.

 

Regarding Medicaid Expansion, during the 2021-2022 period, education and outreach activities were provided by the Women’s Health Initiative (WHI) program, the Women’s and Men’s Health Programs, and the Maternal & Child Health Program.  Promotional materials in several languages were routed to school nurses statewide for passing along to parents of students.  The Title V Community Health Worker continuing education project delivered, and recorded for on-demand reply, a live online session on Medicaid delivered by CHW and Medicaid co-presenters. The Medicaid expansion presentation for Community Health Workers had over 50 attendees and 80 registrants.  

 

The WHI program and the Women’s and Men’s Health Program developed the Making Sustainable Health Impacts in Underserved Neighborhoods (MSHIUN) project to enhance local navigation and health services. One community-based organization implemented the program in the summer of 2022. They paired speaker education and walking time to increase participant’s awareness about healthy behaviors and ways to make lifestyle changes. The framework for the project included goals, partners, a logic model, and an evaluation process.  The community-based project served seven women of reproductive age but the community-based organization WHI programs had many lessons learned about ways to improve the project in future iterations.

 

For the translation project, the Women’s Health Initiative met with the DHHS Chronic Disease Prevention and Control Program and the Office of Women’s and Men’s Health Program to review materials.  Since programs have moved away from printing materials and instead post links from nationally recognized agencies and programs on web pages, links were checked and fixed where needed to assure access to educational materials. This strategy is complete.

 

Use of Evidence-based or Evidence-informed Approaches in this Priority

In May 2020, HRSA released MCH Evidence Resources for Nebraska, which included an ESM Development Guide, and an Agency-specific ESM brief.  In this document, readers are pointed to strategies which have proven effective in addressing NPM 1: Percent of women ages 18-44 years with a preventive medical visit in the past year.  Evidence-linked and promising practices are described. 

 

The Centers for Disease Control and Prevention, Division of Nutrition and Physical Activity and Obesity are a source for reliable evidence-based intervention strategies in this priority area. CDC is also noted as being a source for programs that are culturally appropriate in REACH (Radical and Ethnic Approaches to Community Health https://www.cdc.gov/nccdphp/dnpao/state-local-programs/reach/index.htm). During the childbearing years, breastfeeding as a prevention behavior improves health and nutrition outcomes for both mother and child.

 

The Nebraska ESM: participation in the Women’s Community Health Initiative for Preventing Cardiovascular Disease, measures a quantity of individual participants in a pilot project.

 

3. Assessment of Alignment of NPMs, ESMs, SPMs, and SOMs with Priority Needs

 

Priority: Cardiovascular Disease including Diabetes, Obesity, and Hypertension

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

ESM: Participation in the Women’s Community Health Initiative for Preventing Cardiovascular Disease

 

Alignment: Prevention of cardiovascular disease and co-morbidities such as diabetes, obesity, and hypertension, is not accomplished through the delivery of health services alone, in fact by some estimates access to health care may account for only 20% of overall population health.  The NPM does not encompass the social, cultural, environmental, and economic aspects of prevention and well-being that are fundamental to reducing the toll of cardiovascular disease in the United States.   The ESM statement measures a quantity unrelated to impact or significance of the project when implemented.

 

4. Progress in Achieving Established Performance Measure Targets along with Other Programmatic Impact

 

Since 2015, Nebraska Title V has been writing and utilizing Results-base Accountability (RBA) measures to make annual impacts and achievements more discernable to front line staff and stakeholders.  In addition, use of RBA has specifically highlighted inclusion and equity-focused efforts that have been transforming Title V work.

Results Based Accountability (RBA) measures Cardiovascular Disease including Diabetes, Obesity, and Hypertension
	Proposed for 2021-2022	Achieved 2021-2022
How much did we do?	How many Title V programs promoted Medicaid Expansion?   How many Community Health Workers participated in Medicaid Expansion professional education?   How many women were served through the Community Health Initiative for Preventing CVD?	3: Every Woman Matters; Maternal & Child Health Program; Women’s Health Initiatives   53   7, there were more than 7 participants, but 7 were women of reproductive age
How well did we do it?	In how many ways did CHW contribute to development of approaches to promote Medicaid Expansion?   Were the women participating in the Community Health Initiative for Preventing CVD members of the target population?	CHWs helped design the training and hosted the training about Medicaid Expansion   Some were, yes.
Is anyone better off?	What trends are occurring in Medicaid Expansion enrollment?   Was positive change seen in health measures of participants of the Community Health Initiative for Preventing CVD?	Medicaid Expansion is being utilized by Nebraskans     There is too little quantifiable data to determine there was positive change.

 

Discussion – Other Programmatic Impacts

Title V’s involvement in Community Health Worker workforce development continues with strong engagement and purpose.  Promoting Medicaid Expansion, or Heritage Health Adult, is a common theme in population domains involving adults or adults-as-caregivers.  Community Health Worker workforce development is discussed in more detail in the Cross-cutting/Systems-building Domain.

 

By July 2022, nearly 75,000 new enrollees were part of Heritage Health Adult.

 

5. Challenges and Emerging Issues

 

Mobilizing Community Partners for Subawards.

As with many lean state agencies, a primary methodology for work and impact is through funding subrecipient entities in the community with capacity and reach to undertake public health action.  Such a methodology only works if local entities perceive the application and procurement processes offered by the state as accessible, fair, and rewarding.  During the initial period of project development by the Women’s Health Initiative, a Request for Applications received no responses.  Various anecdotal reasons for this include: lack of awareness of opportunity; perception that the application is too burdensome for size of award; and/or local agencies are understaffed and lacking capacity for new project development.  The challenge of locating community partners willing to enter into procurement processes and state requirements is compounded when program developers wish particularly to partner with local organizations led by and embedded in hard-to-reach communities and groups. 

 

Maternal Mental Health

As noted above in discussion about impacts of COVID-19 on women of childbearing age, the strain on mental health is evident to many providers and systems of care in Nebraska.  The pandemic has taken a toll on the mental well-being of women, with early data showing higher rates of depression and anxiety among women, compared with pre-pandemic levels. Particularly for women already vulnerable due to socioeconomic stress, alarmingly high rates of new or worsening mental health problems have been seen. This has been complicated further by raising awareness of structural racism in systems such as law enforcement, health care, housing, and other sectors. This has further compounded the stress women may feel about pregnancy, childbirth, and parenting.  From a life course perspective, the significance of this on infants and children as well as mothers, cannot be overstated. 

 

Maternal Mortality Review

In the period 2020-2022, Nebraska Title V, specifically the Office of MCH Epidemiology, included the Maternal Mortality Review Committee in the Women’s and Maternal Health population domain. Initially, the MMRC discussion was included in the Women’s and Maternal domain out of the expectation that the MMRC would over time be able to develop data-to-action opportunities to improve women’s health entering and following childbirth. Later, for the 2022-2023 application, the Title V team determined the better placement for relevant discussion is in the Perinatal/Infant Domain.

 

The review of all maternal deaths in Nebraska began in 2014 after being added to the Child Death Review Team’s scope in 2013. The review of deaths that occurred in 2014-2016 was conducted by the Nebraska Medical Association, through a contract agreement with DHHS. In 2018, the Child and Maternal Death Review Team (CMDRT) utilized new guidance and best practice tools from CDC to reorganize how maternal death reviews were conducted in NE.  This resulted in the formation of a sub-committee within the CMDRT: the Nebraska Maternal Mortality Review Committee (MMRC). The MMRC became operational in 2019 and has been undertaking a review of five years of maternal deaths (sufficient sample size to release data in a report) in order to comprehensively understand maternal mortality in Nebraska. In 2021-2022, the MMRC had a committee representative of the diversity of the state of Nebraska and completed reviews of maternal deaths in Nebraska. 

 

6. Overall Effectiveness of Strategies and Approaches: Addressing Needs and Promoting CQI

 

Title V’s participation in promoting Heritage Health Adult has resulted in more families with parents and caregivers, as well as women of childbearing age, receiving information about opportunities and eligibility for health insurance.  In Nebraska, prior to the onset of the COVID-19 pandemic, an estimated 80,000 adult individuals would be newly eligible for health insurance coverage because of the ballot initiative in 2018.

 

Alignment between Title V workforce development activities for CHW, and Title V population health priorities has become a reliable way to amplify and reinforce virtually all the Title V population health priorities, especially as relate to more effectively addressing disparities.

 

A quality improvement approach to improve the extent to which Title V can effectively engage with diverse subrecipients to achieve objectives is needed.  The poor response to an initial RFP release was disappointing and attempts to attract additional community-based organizations have been met with limited interest. These roadblocks to project-implementation point to the need to better understand what changes are necessary to effectively work with non-traditional community partners.