Well Woman Program
NPM 1 - Percent of women, ages 18 through 44, with a preventive medical visit in the past year
ESM 1.1 - Proportion of women age 15-55, who report receiving a preventive medical visit in the past 12 months by increasing total enrollment in the Well Woman Program by 2 points annually.
The goal of the ADPH Well Woman Program is to provide preconception and/or interconception health care to women as a foundation for wellness and to reduce cardiovascular disease (CVD) risk factors through education on healthy living and prevention and/or early detection of disease. This work also serves to assist in increasing the longevity and quality of life for women age 15 to 55 in Alabama. The program enhances access to preventative screenings for CVD, wellness checks, and vision and oral screenings. Free services to address issues such as obesity, hypertension, high cholesterol, and diabetes are also offered. After being enrolled in Well Woman, women are given the opportunity to participate in behavioral change programs addressing chronic diseases, food choices and portion control, physical activity, and smoking cessation. All program components are related to the delivery of screening, diagnosis, treatment of hypertension, and delivery of support to participants receiving Well Woman services.
The program began as a pilot program in FY 2017 with three counties and has been fortunate to expand to several counties in Alabama due to federal Title V grant funding and funds from the Office of the Governor. In FY 2022, the Well Woman Program expanded from six to twelve counties in Alabama. The increased number of program counties offering services allows for growth and the provision of more information for the continuation of care regarding preconception and interconception care, as well as promoting healthy lifestyle behaviors to women in the public health districts.
In October 2021, at the beginning of FY 2022, the program began a trial clinical travel team approach as a pilot in ADPH’s West Central District (Hale, Greene, and Perry Counties) to broaden services to a population of women in a medically underserved region of Alabama known as the “Black Belt”. Generally, the program’s clinical staff model consists of a nurse practitioner, social worker, registered nurse, clinic aide, and administrative support assistant II. However, the pilot program in Greene, Hale, and Perry Counties consisted of a clinical team that traveled to each county to conduct Well Woman Program visits on their respective clinic days. The goal for the composition of the clinical travel team was a nurse practitioner, social worker, and clinic aide. Staffing continued to be an obstacle throughout the year and these counties were unable to continue to provide Well Woman services after September 30, 2022. However, Marengo and Wilcox Counties resumed Well Woman services at the end of FY 2022. Future expansion is a goal of the program to continue to give women in each public health district the opportunity to receive preventative screenings and education in lifestyle modifications for health and wellness. There have been discussions with various ADPH districts, but there have not been any confirmed start dates for any of the potential counties. The map below illustrates the Well Woman counties available in FY 2022.
The Well Woman Program utilizes the New Leaf curriculum, which is a nationally recognized scientific-based intervention tool that emphasizes practical strategies for making changes in dietary intake and physical behaviors. There is also a licensed nutritionist that works with Well Woman participants as a part of the program to educate and provide resources, so participants can make informed choices about their eating habits. As physical activity is an important component of ensuring the health, partnerships with local community businesses and programs allow participants to engage in physical activity either virtually or in person. The program accepts referrals from a variety of sources including, but not limited to self-referrals, referrals from community partners, local physicians, and other programs within ADPH such as FP. Referrals are also received from ALL Babies care coordinators and health and wellness messaging through 211KNOW.
As a beta test campaign, 211KNOW was piloted in the Well Woman Program near the final quarter of FY 2021 and was a great success. As a result, the text messaging continued into FY 2022. The Office of Women’s Health and Well Woman Program partnered with the Alabama Women’s Commission and Explore Media to compile researched nutritional and physical activity information provided through weekly text messages to program participants to promote health and well-being. Participants received these educational messages at the same time twice weekly which allowed them to have access to recipes, self-improvement, physical activity tips, and other tools to empower women in their journey to adopt a healthier lifestyle. The geographical areas targeted within Alabama in 2022 were Sumter, Hale, Choctaw, Marengo, Greene, Perry, Dallas, Wilcox, Bibb, Chilton, Coosa, Tallapoosa, Clay, Randolph, Autauga, Lowndes, Elmore, Montgomery, Macon, Lee, Chambers, Russell, Bullock, Pike, Barbour, Butler, and Crenshaw Counties. The campaign sent a total of 38 messages to the targeted audience and there was a total of 1,896 links accessed from 2,137 subscribers in the same targeted geographical area throughout the year.
Evaluation of the growth and sustainability of the program have been met with innovative strategies. Telehealth is incorporated into the program protocol as an option for nurse practitioners’ follow-up in completing the Risk Reduction Counseling session. The Risk Reduction Counseling session includes a review of medical history, healthy lifestyle assessment (to include preconception/interconception and healthy life planning), lab and clinical results from the enrollment screening; review and/or conduct (if not done) CVD 10-year risk calculation and discuss; review of baseline/risk reduction data information in the EHR; determination of target blood pressure reading for participants with hypertension; review of participant’s priority areas and determine readiness for change; discuss diet, physical activity and determine ability to participate in physical activity. With the addition of Well Woman staff, plans were made to offer nutrition classes, support groups, and physical activity resources available virtually as well. Program implementation of virtual means created flexibility and the opportunity to reach program participants in a capacity that has the potential to impact their lifestyle and behaviors regarding the goals made to improve health.
While there were various staffing challenges throughout FY 2022, there were also successes. The Well Woman Program added staff and made changes to include a division director, social work supervisor, epidemiologist supervisor, and statistician in the ADPH Central Office; social worker coverage for counties in the Southwestern and Southeastern Public Health Districts; and a second nutritionist. The addition of staff was important in continuing to provide the best care and education to program participants, creating a continuity in services throughout each of the program counties, and continuing evaluation and organization of program components to ensure that the program was able to continue to address the needs of participants and the community.
The Well Woman Program has been included as one of several strategies of the SAIMRP and has identified key strategies and barriers in programmatic efforts. Strategies of the program to meet the needs of participants and achieve established performance measure targets are to decrease the percentage of women enrolled with a blood pressure reading greater than the target range annually and increase the percentage of women enrolled in the program from a referral by a community partner. The barriers are poor follow-up from participants, poor treatment regimen adherence, and unfavorable beliefs about hypertension risk due to being asymptomatic. There are various components of the program that are key in providing the opportunity for healthy lifestyle education and change in order to address these strategies and barriers such as preconception/interconception health planning; CVD risk factor screenings; risk reduction counseling to help women understand their risks and discuss the participant’s readiness to change; and health coaching and support to help women discover healthy lifestyle behaviors to prevent, minimize, or delay the onset of chronic disease.
In FY 2022, the Well Woman Program enrolled a total of 554 participants. Of these 554 participants, 14 percent enrolled with a BMI >25 (overweight); 76 percent enrolled with a BMI >30 (obese); and a total of 50 percent showed a decrease in BMI from enrollment to their second appointment. The program recognizes hypertension as a systolic reading greater than or equal to 130 and a diastolic reading greater than or equal to 80. On the initial Well Woman visit, 59 percent of participants had a blood pressure reading greater than 130/80. On the second visit, 55 percent of participants had a reading of 130/80 or greater which shows a slight decrease. The average age of participants enrolled in 2022 was 37.5 years of age with 90 percent of participants enrolled identifying as Black, 2 percent of participants enrolled identifying as Hispanic, and 8 percent identifying as White.
Program Success Story:
A 54-year-old woman was referred to the Well Woman Program by a friend and enrolled in March 2022. When she enrolled, she weighed 277 pounds with a BMI of 45. She stated that she barely had an appetite and was mostly eating processed snacks, i.e. crackers and chips when hungry. She admitted that her self-esteem was very low because of her weight gain, which she stated started after getting hurt at work. She could not work out or go to the gym as she had previously done prior to her injury. This led to her unhealthy eating habits and becoming more sedentary in her lifestyle.
Since enrolling in the Well Woman Program, she now goes to the gym a minimum of 3 days a week. She enjoys the sauna and strength training machines. She states that being back in the gym has motivated her to leave the house and work on a plan to become healthy again. Although she still snacks on processed foods, she now understands the importance of eating “real” food. She was eating no fruits or vegetables, and very little meat when she enrolled in the program. She is now consuming vegetables and fish after being educated on the importance of a well-balanced diet.
This participant has lost 10 pounds since enrolling in the program, has gained more self-esteem, and is now making better choices concerning her diet to become an overall healthier person.
Oral Health Office
NPM 13.1 - Percent of women who had a preventive dental visit during pregnancy
ESM 13.1.1 - Percentage of dental providers receiving information/education regarding the importance of preventive dental visits for expectant mothers
ESM 13.1.2 - Percentage of dental providers that received information/education regarding their perinatal patients about the FDA-approved HPV vaccine in order to reduce the risk of oropharyngeal, cervical, and other HPV-related cancers
Early in FY 2022, ADPH OHO had the privilege of hosting Timothy Ricks, D.M.D, F.I.C.D., during the November 2021 quarterly meeting of the Oral Health Coalition of Alabama (OHCA). Rear Admiral (RADM) Ricks was the Assistant Surgeon General at the time and his presentation to the very diverse OHCA membership spanned a broad range of topics which were then narrowed to pertinent Alabama-specific topics and concerns. This meeting was the first in-person OHCA meeting to be held since the beginning of the COVID-19 pandemic. Oral health disparities/inequalities, access to dental care, and the oral health workforce—all of which greatly impact our state—were addressed. Also of particular interest, and in perfect alignment with Alabama’s state oral health plan, multi-directional integration of oral health and overall health strategies were discussed.
After the meeting, campaigns and initiatives underway and proposed in Alabama were shared with RADM Ricks. One such topic was the nationally recognized #WATCHYOURMOUTH Oral Cancer Awareness Campaign, created through the collaborative efforts of OHO and USA Health Mitchell Cancer Institute. A subsequent and resulting article was featured in the US Public Health Service Chief Dental Officer Newsletter Issue #63. Dentists and hygienists in attendance at the meeting were granted between four and seven continuing education credits from the Alabama Board of Dental Examiners upon request from OHO. RADM Ricks visit to Alabama was also featured in the ADPH’s agency newsletter, Alabama’s Health.
In addition to the in-person presentation of RADM Ricks, the OHCA virtually welcomed Jane Grover, D.D.S., M.P.H, Director, Council on Advocacy and Prevention of the American Dental Association for her presentation titled Action for Dental Health: Practice-Based Community Strategies.
The partnership between OHO and HandsOn River Region and its Pay It Forward Program is in its fifth year. Through this partnership, OHO provides a grant in the amount of $25,000.00 annually to help low-income citizens who lack dental insurance receive needed dental treatment and give back to the community at the same time. HandsOn River Region provides staffing for Pay It Forward to orchestrate a value-based program allowing clients to log volunteer hours (choosing from over 200 nonprofit agencies in the River Region) in exchange for dental treatment. Initially, the target population was expectant mothers vetted through the Gift of Life Foundation. Since its inception, the program has expanded to include expectant fathers enrolled in the Gift of Life Foundation programs, as well as chronically unemployed individuals. The partnership was recognized as a best practice by the Association of State and Territorial Dental Directors (ASTDD) in 2020. The program has experienced its share of challenges due to the closing of dental offices during COVID-19, as well as a decrease in the number of participating dentists, citing the need to see their own patients that could not be seen during the pandemic.
Tuscaloosa County Health Department (TCHD) Dental Clinic
While great thought goes into the projects and campaigns of OHO, there are times that plans encounter obstacles that prevent the expenditure of funds on their intended target. Decreased travel expenses and decreased requests for Fluoridation Grant money resulted in funds that needed to be redirected. The Central Office of ADPH has only one dental clinic over which it has purview, TCHD Dental Clinic. Over the years, the clinic chairs fell into disrepair and, due to their age, parts were often not available. By redirecting the unused funds of the OHO fluoridation program, three new operatory chairs and exam lights were installed allowing for the continued safe and efficient treatment of patients. WIC participants at the TCHD clinic receive oral health education from the dental students that rotate through the dental clinic. Ten pregnant women were screened in 2022 at the dental clinic.
Calhoun Community College and Wallace State Community College
Realizing the desperate need for access to oral health care, the Northern District of ADPH embarked upon a partnership with two community colleges within their District. Calhoun Community College and Wallace State Community College both have dental hygiene programs. Wallace State’s program is well established with graduates spanning over 20 years, with Calhoun’s program experiencing its inaugural year in 2022. Both programs have agreed to accept ADPH MCH population patient referrals for preventive dental services, in-kind, for preventive dental visit supplies. Additionally, educational materials and discussions regarding the importance of preventive dental visits for children ages 1-17 years and expectant mothers are provided. Interprofessional collaboration is evidenced as well by education regarding the Human Papilloma Virus (HPV) and promotion of the HPV vaccine which targets not only cancers of the head and neck but five additional cancers throughout the rest of the body. Questionnaires are completed by patients at the end of their visits to gauge patients’ increased knowledge of the importance of good oral health as a result of the interaction with the student hygienists. The partnership benefits both patients’ well-being as well as providing the programs and students with a much-needed patient population. We anticipate and welcome the continued growth of the mutually beneficial partnership. The partnership was featured in ADPH’s agency newsletter, Alabama’s Health.
Ongoing activities in Alabama to improve oral health:
Water Fluoridation
OHO provides funding opportunities for community water systems to apply for grants up to $25,000.00 each ($100,000 total) for the purpose of updating old fluoridation equipment, purchasing/upgrading fluoridation equipment, or initiating community water fluoridation. The OHO fluoridation coordinator sends RFPs statewide to all systems, both adjusting and non-adjusting. Preference is given to any system that wishes to initiate fluoridation. There were two grantees in FY 2022. The Waterworks Board of the City of Birmingham was awarded $25,000.00 and the Perdido Bay Water, Sewer and Fire Protection District Inc was awarded $11,943.00. While increasing numbers of systems are opting to reconsider their fluoridation efforts, 123 CDC Water Fluoridation Quality Awards were awarded in Alabama in 2022 (for 2021/one year in arrears), an 11 percent increase over last year (109). More information is available on Alabama’s community water fluoridation efforts at alabamapublichealth.gov.
Oral Health Education
To further the promotion of preventive dental visits for expectant mothers, OHO began adding oral health messages to the Well Woman Program’s 211KNOW campaign. The following is an example of a featured message: “Some bacteria that cause gum disease are common to pre-term and low-birth weight babies. Both of these conditions are associated with infant mortality. Preventive dental visits are important before, during, and after pregnancy to improve healthy birth outcomes.”
After being postponed for over 2 years due to COVID-19, Alabama’s first Remote Area Medical (RAM) event occurred on April 23 & 24, 2022 in Gadsden, Alabama. RAM was initially founded in 1985 by pilots and physicians with the goal of bringing medical care to isolated areas of the globe but immediately began getting requests from rural parts of the United States. In Alabama, about 10 percent of residents have no medical coverage at all. Many of those with health insurance don’t have supplemental policies for vision and dental. The event offered patients opportunities to receive treatment from two of the three disciplines: medical, optometry, and dental. Sixty dental chairs were in use, clinically staffed primarily by close OHO partners from the UAB School of Dentistry. Numerous ADPH volunteers from various areas of the state assisted in a variety of roles. The RAM event was featured in ADPH’s agency newsletter, Alabama’s Health, and on al.com, which is self-declared as Alabama’s largest news site.
The OHO director was invited by ASTDD to be on a committee for the development of a publication for raising awareness about the importance of older adult oral health and increasing collaborative efforts to improve health and well-being. The publication, Older Adult Oral Health Resources for Collaboration, was completed and released in September 2022. It is a free resource available electronically on the ASTDD website. Hard copies are also available by request through OHO.
ADPH Public Health District Initiative
ADPH, JCDH, and MCHD coordinators submitted MCH FY 2022 project proposals to address needs within the Women/Maternal Health Domain. The following is a summary of those county projects.
East Central Public Health District
The Well Woman Program continued to be implemented in Montgomery, Macon, and Russell Counties to enhance access to healthcare for women ages 15 to 55, provide preconception and interconnection care counseling, provide risk assessment and behavior modification, to prevent and/or manage a chronic disease, and reduce maternal and infant morbidity and mortality. The district coordinator and clinic staff partnered with community programs, including The Gift of Life Foundation, Inc. (a Healthy Start Program grantee), the Wellness Coalition, and the Alabama Cooperative Extension System, in order to continue implementing the district’s Well Woman Program. The program has had some great success. The enrollees have seen a 2 percent decrease in BMI and one participant has lost over 100 pounds. The program and its partners were able to host their first annual Well Woman and Safe Sleep Conference in Montgomery. Over 200 Alabamians were educated on healthy lifestyles and the MCH Program. The district MCH coordinator also partnered with Alabama State University and Auburn University to distribute healthy lifestyle information to over 700 students.
Southeastern Public Health District
According to the 2020 Maternal Mortality Review, Alabama had the third highest national rate of maternal mortality at 36.4 per 100,000 live births. According to the 2022 Robert Wood Johnson County Health Rankings, Barbour County’s overall health outcome rank declined from the previous rank of 45 in 2020, to 51 in 2021, to 56 in 2022. Henry County’s rank has declined from 13 in 2020, to 17 in 2021, to 20 in 2022. Barbour County saw an increase by 1 percent in low-birth-weight deliveries, now at 12 percent. Henry County experienced the same increase in the percentage of low-birth weight deliveries to 11 percent. In Barbour County, 17 percent of adults are uninsured. In Henry 16 percent of adults are uninsured. Barbour County has a ratio of 2,740:1 population to primary care physicians. Henry has a ratio of 3,440:1 population to primary care physicians. Diseases of the heart were the leading cause of death in Barbour County, causing 152 deaths under the age of 75. Diseases of the heart were the second leading cause of death in Henry County, resulting in 72 deaths under the age of 75. The district focused its efforts to address its morbidity and mortality issues by continuing to implement the Well Woman Program in an effort to increase preventive medical visits in two of its counties with elevated risks for maternal mortality.
During FY 2022, Barbour County enrolled 72 participants in the Well Woman Program. Henry County enrolled 61 participants, with a total of 133 enrollees. Due to FY 2022 being the first year of implementing the program, decreases in risk factors such as blood pressure were unmeasurable. There was a total of five participants regularly attending the Eufaula Recreation Center gym membership. There were five main community partners to support the Well Woman program, including Wallace Community College, The Eufaula Pregnancy Resource Center, the Chamber of Commerce, the UAB Cancer Center, and the Cooperative Extension Office.
The Southeastern Public Health District also made strides to address infant mortality rates during FY 2022. In 2020, the District had a rate of 7.6 for all 10 counties. It is noted that every county within the district experienced at least 1 infant death during 2020, with a total loss of 37 precious infants. According to the ADPH Center for Health Statics, Henry County had an alarming rate of 12.4 per 1,000 live births, the highest in the district. Houston County was second at a staggering 11.2 per 1,000 live births. Barbour County followed at 10.8 per 1,000 live births. All counties in the district, not including Butler and Coffee, were listed as higher than the national average.
During FY 2022 the district collaborated with the regional perinatal coordinator to evaluate the creation of the Safe Bama Baby Safe Sleep Survey. The premise is to implement this survey in the three district counties with the highest infant mortality rates. Safe Sleep Ambassadors will identify pregnant WIC recipients, meet with the identified expecting parents, and provide a tote bag with safe sleep-related items, such as: pacifier, brochures, and onsies that remind the parent to place the baby on their back for sleep. A consent form was developed and approved through the Internal Review Board (IRB). The form is presented to the expecting parent for permission to conduct the Safe Bama Baby Safe Sleep Survey. If the expecting parent provides consent, the survey is completed during the third trimester of pregnancy. The survey will help to provide individualized education and identify the lack of a safe sleep space for the expected infant. If a safe sleep space is needed, the Safe Sleep Ambassador will assist with a referral for a Cribs for Kids® pack ‘n play from FHS. The incentive item for completing the survey will include a Snoozzzette zip-able blanket from Cribs for Kids®. The zip-able blanket reinforces safe sleep practices.
Mobile County Health Department (MCHD)
MCHD has a primary care division, Family Health (FH), with clinics located throughout Mobile County. These FH clinics are designated as FQHCs and Primary Medical Homes. FH serves uninsured, underinsured, Medicaid recipients, and those with other forms of health insurance. MCHD has patient care coordinators to help navigate community members to various services provided at the agency.
As stated previously, Alabama has the third highest maternal mortality rate in the United States at 36.4 per 100,000 live births. The state’s maternal mortality rates among Black mothers remain disparaging with poverty, a lack of education, and the lack of access to quality maternal care being among the key factors.
The MCHD MCH program helps to encourage and promote healthy women during pregnancy, childbirth, and postpartum. The program provides education, resources, access, and referrals to recommended prenatal and well-childcare appointments; infant and maternal mortality prevention education services; behavioral health services to address postpartum depression and other concerns; newborn screenings; child immunizations; and maternal, infant, and child nutrition through WIC services.
The goal of the MCHD MCH Program is to increase awareness of factors that adversely affect the health of mothers and babies, increase and promote education and resources available to mothers living in Mobile County, and provide services to decrease the rates of infant and maternal mortality in the county and state.
The MCH Family Support/Home Visitation Programs support social group activities with young pregnant and parenting youth & teens aged 10-19. The programs promote oral health and dental screenings, educate on the importance of breastfeeding, provide education on safe sleep practices, promote car seat safety, provide education and referrals to doula services, and encourage positive parenting in collaboration with the Fatherhood Initiative Program. The Family Support/Home Visitation Program serviced over 100 families and children in FY 2022.
The month of March was specifically devoted to strategic planning and emphasizing women’s wellness. The MCH program staff participated in March’s group connect activity with Family Support/Home Visitation to promote the importance of taking care of yourself. There was a presentation advocating for yearly reproductive health screenings, frequent sexually transmitted disease testing, violence prevention, and tobacco usage prevention.
Throughout the year, the MCHD MCH coordinator attended women’s health luncheons, summits, and workgroups, focused on varied topics, such as the impact of stigma on those with substance use disorder, environmental justice workgroup, health care quality, and parent engagement. The MCHD MCH coordinator also participated in weekly outreach initiatives at the MCHD/FH WIC clinic sites to share information, resources, and incentives with mothers who presented for their WIC appointments. In addition, the MCHD MCH coordinator developed community partnerships and participated in many other outreach events throughout the county.
Northern Public Health District
Oral Health was the chosen area of focus for the Northern Public Health District in order to address deficiencies in the lack of access and availability of dental care within the district. The goal was to recruit and establish resource options for access to dental care for the target population, children ages 0-17, and expectant mothers. The district MCH coordinator and the OHO established a partnership with Calhoun Community College and Wallace State Community College. Per the MOU between the colleges and the district, the colleges agreed to provide preventive health hygiene dental services and education to ADPH MCH clients, to provide data regarding number of clients served, and to provide ADPH outreach documents for distribution to potential clients requesting and needing preventive dental health services. The district was responsible for identifying patients in need of preventive dental health services, promoting the availability of free preventive dental services, and purchasing oral care supplies and materials to provide preventive dental services for the ADPH clients served. Additionally, the OHO coordinated with the colleges allowing dental hygiene students to provide teaching opportunities as feasible, within the scope of ADPH and the Alabama Dental Practice Act practice opportunities.
- A dental care screening tool was developed to allow the CHD WIC staff to identify patients needing assistance with dental treatment and other related resources.
- Oral health information cards were produced in English and Spanish and disseminated to promote the oral health partnership.
- Dental incentive items were ordered for dissemination at health fairs and different community organizations as needed.
- Forty-four WIC clients were referred and two individuals received a dental exam.
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A total of 94 patients were served by dental hygiene students, 6 of them being pregnant women.
- Thirty-two patients received dental cleanings and exams at Wallace State and 62 patients at Calhoun, exceeding the initial goal of 50 expectant mothers and children receiving dental cleanings and exams.
- Each patient completed a patient satisfaction survey.
More than 700 oral health information cards about the oral health partnership and 500 incentive items were provided to the 12 CHDs, community organizations, public schools, provider offices, and community health and resource fair events within the district. This distribution exceeded the initial goal of providing 500 pieces of educational information.
Additionally, the district MCH coordinator attended health and community resource fairs and events, participated in various community organization meetings throughout the twelve-county district, and visited obstetrics and gynecology offices across the district sharing information about oral health and resources available through ADPH.
Southwestern Public Health District
ADPH’s 2019 Marengo County profile indicates 12.7 percent of females are aged 15-44. According to the 2019 State Health Assessment, nutrition and physical activity ranked as one the top health concerns in the district. In 2019, Marengo County reported that 27 female deaths were due to heart disease and 2 deaths because of diabetes.
Due to the poor health outcomes for women in Marengo County, the Southwestern Public Health District decided to implement the evidence-based Well Woman Program. The district’s goal was to improve the overall health of women in Alabama and to reduce morbidity and mortality rates by providing a comprehensive foundation for wellness, health promotion, disease identification, and management while promoting healthy lifestyles through health counseling/coaching, education, and coordination with community support services.
Due to staffing shortages, the Well Woman Program was not implemented in Marengo County until September 2022. Due to the late start, during FY 2022, only one Well Woman participant was enrolled. The district hopes to see these numbers improve by continuing to promote the Well Woman Program in Marengo County.
Other ADPH Women/Maternal Health Programs
Office of Women's Health (OWH)
OWH was created in 2002 through the Alabama Legislature Act 2002-141 to be an advocate for women's health issues through the formation of the OWH's Health Steering Committee. The steering committee consists of physicians, nurses, pharmacists, dieticians, and business leaders appointed by their professional organizations. The OWH is located in FHS and is directed by the perinatal division director. The OWH steering committee meets quarterly to receive updates on activities at ADPH and address current issues related to women's health, which may include topics such as maternal mortality, mental health, barriers to care, and health equity.
Family Planning (FP)
ADPH FP 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 2022, FP and its sub-recipients, JCDH and MCHD, served 46,827 clients. Over 29,000 clients reported incomes of 100 percent or less than the FPL, and more than 21,000 of the clients served during CY 2022 were uninsured. However, ADPH also provides FP services to patients insured by Medicaid (Plan First and/or full Medicaid) or Blue Cross Blue Shield of Alabama. ADPH FP services include reproductive life planning; contraceptive counseling; breast and cervical cancer screenings, and follow-up; and screening and treatment for sexually transmitted infections. Clients also receive referrals for health care services outside the scope of FP through partnerships with other ADPH programs. Those partner programs include the Alabama Breast and Cervical Early Detection Program, and external entities, such as DHR, contracted professional services providers, and ACHN. Clients have access to a broad range of contraceptive methods, including long-acting reversible contraceptives (LARC). During CY 2022, just over 31 percent of clients selected a LARC method. During CY 2022, FP clients and service provision were dramatically impacted by the onset of the COVID-19 pandemic. With Medicaid’s approval, ADPH implemented a virtual visit model, which allowed the continued provision of essential FP services. Beginning in March 2021, Medicaid extended approval for telehealth FP 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. FP Program NPs completed over 2,400 telehealth visits during CY 2022.
In 2019, FP 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 facilitate continuity of care for patients who require follow-up of abnormal cervical cancer screening results. As a result, 592 colposcopies were completed during the reporting period and as a result, 142 pre-invasive or invasive cervical cancers were detected.
Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)
WIC provides federal grants managed by the United States Department of Agriculture (USDA), Food and Nutrition Service (FNS) to states for supplemental foods, health care referrals, and nutrition education for low-income pregnant, breastfeeding and non-breastfeeding postpartum women, and to infants and children up to age 5 who are found to be at nutritional risk. Each state receives an annual food and Nutrition Services Administration (NSA) allocation. In addition to the food and NSA allocation, each state is entitled to an annual Breastfeeding Peer Counseling (BFPC) grant award to further support breastfeeding among WIC participants. Alabama’s WIC program is managed by FHS. There is no state match requirement to receive WIC funding and no state or other federal program funds are provided to support Alabama’s WIC Program. The fiscal year for WIC begins October 1, and runs through the following September 30.
During FY 2022, Alabama’s WIC program responded to the Abbott formula recall and the resulting nationwide formula shortage. In February 2022, Abbott (one of the largest formula manufacturers in the nation) recalled several powdered formula products and temporarily closed the affected formula manufacturing facility. This resulted in a widespread and long-lasting infant formula shortage that the nation has still not fully recovered from over a year later. Although Alabama’s WIC contract formula manufacturer is Mead Johnson, the effects of the nationwide formula shortage required Alabama to implement alternative noncontract formula options to effectively feed the more than 25,000 infants served by Alabama’s WIC program. Alabama WIC implemented numerous formula waivers made available at the federal level to respond to this nationwide emergency. As flexibilities and timelines continue to change, Alabama’s WIC program shifts to make necessary changes to care for the infants served by WIC, which represent approximately half of the infants born in Alabama. Communication has been key to ensuring accurate messaging and understanding of evolving needs and available resources. Alabama WIC has utilized multiple communication platforms including news releases, social media, text messaging, website updates, the WIC app, and verbal messaging from WIC staff to participants. Currently, FNS is unwinding infant formula flexibilities with a tiered return to normal formula offerings. Noncontract formula alternatives ended on February 28, 2023. Additional sizes and products of contract brand formulas are set to expire on April 30, 2023, and waivers related to specialty formulas for medically fragile infants are set to expire on June 30, 2023. FNS remains in close communication with WIC state agencies, infant formula manufacturers, and large retail corporations to assess the need for additional flexibilities beyond the current unwinding schedule.
One opportunity realized with the nationwide infant formula shortage is the potential for more new mothers to be open to breastfeeding. Breastfeeding promotion and support are available for moms and babies enrolled in WIC. Breastfeeding support includes information on techniques to improve supply, infant latch, and other components of successful lactation. Moms desiring to breastfeed can receive breast pumps and be paired with a breastfeeding peer counselor to provide additional support. Breastfeeding peer counselors are funded through the BFPC grant while breast pumps are purchased with WIC food funds. During FY 2023, Alabama WIC launched Pacify, a mobile app providing 24/7 video calls with International Board Certified Lactation Consultants (IBCLCs). Alabama’s WIC program is excited to provide real-time access to IBCLCs whenever WIC breastfeeding moms need it and hopes this innovation will enhance and improve the breastfeeding experience resulting in an increase in initial breastfeeding rates as well as the duration of time WIC infants are breastfed. Alabama’s WIC program is open to data-driven innovations, methodologies, and new technologies to further support breastfeeding promotion and support efforts.
Nationally, WIC is focusing on outreach, innovation, modernization, and new technologies to remove barriers and increase participation. Alabama's WIC program utilizes a portion of NSA funds on outreach activities, such as recruitment and retention efforts aimed at increasing WIC participation. Alabama’s WIC program utilizes electronic benefit transfer (EBT), known as eWIC in Alabama. Issuing food benefits through eWIC significantly improves the shopping experience and allows WIC participants to redeem benefits at different stores based on their current needs. WIC families can purchase some or all of their WIC benefits during a single shopping trip. For authorized vendors offering self-checkout, WIC shoppers can also utilize self-checkout with eWIC. Another innovative outreach method utilized in Alabama is the WIC mobile app. The Alabama WIC app is a one-stop shop for several resources including eligibility requirements, a map to find the nearest WIC clinic, the WIC-approved foods brochure, a bar code scanner that can be used while shopping to determine if a food is included in the WIC approved product list, a custom-built appointment reminder, healthy recipes, breastfeeding resources, a convenient link to online nutrition education classes, and social media posts to stay up-to-date with any current WIC news. Alabama’s WIC program also partners with WICHealth to provide online nutrition education to WIC participants that easily accessible with age-appropriate feeding topics to support healthy nutrition at all stages from pregnancy through birth, infancy, toddler years, and early childhood. In addition to new technologies, WIC continues to utilize partnerships with other organizations to reach potentially eligible families. For example, WIC partners with Head Start programs to provide outreach and additional sites for WIC enrollment. As many families served by Head Start may be eligible to receive WIC, this is an ideal partnership for both programs. Another alternate site for WIC enrollment includes select birthing hospitals in Alabama. Future outreach plans include partnerships under the new WIC Community Innovation and Outreach (CIAO) grants, which are open to community-based and other non-WIC partners serving WIC’s eligible population. The first round of CIAO grants will be awarded in the summer of 2023.
During FY 2022, Alabama’s WIC program continued to enroll new participants and certify existing clients remotely through federally approved WIC waivers implemented during COVID-19. WIC appointments were conducted over the telephone or other remote means, with in-person appointments remaining available on a case-by-case basis for those with special needs. Moving into FY 2023, Alabama's WIC program began to safely reopen WIC clinics to the public while continuing remote appointments for those unable to attend in person. During FY 2022, the monthly average of participants receiving WIC benefits was 108,661. With the return to in-person services, the WIC caseload is beginning to grow and exceeded 110,000 by the spring of 2023. To support WIC participation, Alabama's WIC Program implemented text message notifications to let families know that benefits were added to their eWIC cards. Beginning in June 2021, WIC participants began receiving a temporary increase in cash value benefits (CVB) for fresh fruits and vegetables. Monthly CVBs initially increased from $9 per child and $11 per woman, to a flat rate of $35 per participant. Tiered CVBs were implemented during FY 2022 with children receiving $24, pregnant and postpartum women receiving $43, and breastfeeding women receiving $47. These amounts increase to $25 per child, $44 for pregnant and postpartum women, and $49 for breastfeeding women in FY 2023. Due to the significant increase in CVBs, Alabama’s WIC program expanded produce options to include both fresh and frozen fruits and vegetables, adding thousands of frozen fruits and vegetables to the WIC-approved product list in FY 2023. During FY 2024, Alabama’s WIC program hopes to implement opt-in text messaging to notify participants of newly added and expiring WIC benefits. This endeavor will help with benefit redemption as WIC benefits must be redeemed within 30 days of issuance prior to expiration. More information is available on the ADPH website at www.alabamapublichealth.gov/wic.
Maternal Mortality Review Program
The Maternal Mortality Review Committee (MMRC) is comprised of a diverse group of individuals from all over the state. There are a total of 58 members with a variety of disciplines/specialties that include: obstetricians/gynecologists, maternal-fetal medicine, pathologists, psychiatrists, substance use disorder specialists, cardiologists, emergency physicians, registered nurses (RN)/nurse practitioners, social workers, family physicians, certified nurse midwife, PharmD, anesthesiology, public health, a diversity officer, private insurance and Medicaid, hematology/oncology, community health worker, March of Dimes, ALPQC, the DHR, Gift of Life Foundation. Inc., coroner, Women’s Foundation of Alabama, and My Care Alabama. The MMRC has reviewed COVID-19-related deaths as they occurred in order to increase knowledge of the impact of the virus on pregnant and postpartum women and develop recommendations for medical providers.
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