Women’s Health Program Objectives

 

The Arkansas Department of Health’s (ADH) Women’s Health program continues to:

 

1) Provide direct health care, referral services, pre- and inter-conception counseling, and preventive screenings for women of reproductive age in all 75 counties;

2) Provide education and referrals for smoking cessation to women of childbearing age;

3) Work with the University of Arkansas for Medical Sciences High Risk Pregnancy Program to increase screening of and consultation for high-risk women in ADH’s maternity clinics;

4) Work with the University of Arkansas  for Medical Sciences High Risk Pregnancy Program to provide after-hours consultation services to ADH maternity patients;

4) Develop campaigns to increase uptake of influenza and Tdap shots in pregnant women; and

5) Work to reduce smoking in pregnant women, including screening during the last three months of pregnancy.

 

According to the U.S. Census Bureau, approximately 520,000 Arkansas women ages 18-44 reside in the state. However, data from the 2018 Behavioral Risk Factor Surveillance Survey (BRFSS) show one out of four women (74.8%) in this age group did not have a preventive medical visit in the past year. Lower rates of uptake for preventive visits were reported in women with less than a high school education (59.2%), women with no health insurance (50.9%), and women of Hispanic ethnicity (66.4%).

 

The ADH has at least one local health unit in each of the state’s 75 counties. The health units serve the state’s vulnerable and hard-to-reach populations, especially those in rural areas where access to medical care is limited. The ADH’s Women’s Health program supports the provision of direct health care and referral services to address the perinatal, reproductive health, well woman, and other preventive service needs for women across the state.

 

The ADH currently offers maternity services in 57 local health units covering 53 counties. Maternity services include:

 

• Case management;
• Prenatal assessments, including risk assessments, health history, physical assessments, laboratory tests, gestational age assessments, and fetal assessments;
• Management of abnormal prenatal findings;
• Prenatal counseling and education;
• Women, Infants and Children (WIC) program; and
• Vitamin/Mineral Supplements.

 

The implementation of the Patient Protection and Affordable Care Act negatively impacted the number of Arkansas women who access family planning and maternity services at LHUs. The Affordable Care Act gives women the opportunity to choose a private health care provider and also allows teens to stay covered on their parent’s insurance until age 26.

 

Current Activities Related to Well Woman Care

 

Objective 1

 

Increase the number of women, ages 18-44, receiving an annual preventive medical visit in an ADH local health unit.

 

Strategy 1.1: Review medical record data reports for rates of preventive health services for women ages 18-44 provided in local health units.

 

In 2019, a total of 33,105 women ages 18-44 received a preventive health visit at ADH’s local health units. This is a 16% decrease in the total number of preventive health visits compared to 2018 data.

 

Strategy 1.2:  Request Medicaid data reports on preventive health visits for women ages 18-44 provided by private providers.

 

It is difficult to get these data from Medicaid because ADH is not considered a primary care provider.

 

Strategy 1.3: Provide fact sheets on risk factors identified to women.

 

Family Planning and Well Woman patients at ADH local health units receive education and counseling on the recommended preventive screenings that optimize health. Information on height, weight, body mass index, and blood pressure is gathered at each of these visits. After interviewing the client, further education, testing, and/or referrals are provided based on identified needs. Educational topics include sexually transmitted infection screening, pap tests, mammogram referral, hemoglobin testing, sickle cell screening, total cholesterol or cholesterol screening referral, wet mount, pregnancy testing, and fecal occult blood testing. The client is also screened for immunization status, smoking, alcohol, illicit drug use or abuse, human trafficking, and intimate partner violence. The ADH provides written materials on a wide variety of topics at the local health units.

 

There are many statewide resources aimed at primary prevention and smoking cessation among women. Many anti-tobacco programs and curricula are based in schools, particularly in schools that participate in the Coordinated School Health program which is supported by the Centers for Disease Control and Prevention (CDC-RFA-DP18-1801). Schools that participate in School Wellness Advocacy Groups and Project Prevent Youth Coalition, funded by the Tobacco Prevention and Cessation Program funds, also use the anti-tobacco curricula. The Coordinated School Health program collaborates with schools and communities to deliver programs that include tobacco and vaping prevention education, comprehensive school-based tobacco and vaping policies, and promotion of nicotine cessation for staff and students.

 

 

The ADH Tobacco Prevention and Cessation Program (TPCP) continues to support coalitions, colleges, community-based organizations, corporations, health care providers, hospitals, law enforcement agencies, local health units, media companies, non-profits, and other state agencies in efforts focused on tobacco prevention and cessation.

 

During the 2019 legislative session, Act 959 was created to increase coverage for medications approved by the U.S.  Food and Drug Administration for tobacco cessation in the Arkansas Medicaid program. The Medicaid program coverage includes nicotine replacement therapy patches, gum, lozenges, nasal spray, and inhalers. Medicaid coverage also includes the medications Bupropion and Varenicline. Prior authorization shall not be required for coverage of the medication. In addition to Act 959, Arkansas signed Act 580 into law, which now prohibits the sale of tobacco and vaping products to anyone under the age of 21.

 

Lastly, the ADH TPCP continues to support strong enforcement of laws regarding Arkansas tobacco manufacturers, wholesalers, and retailers. The ADH Hometown Health Improvement initiative encourages communities and coalitions to focus on tobacco prevention and cessation. The ADH electronic health record incorporates the meaningful use indicator in all programs (family planning; maternity; WIC; sexually transmitted infection; and BreastCare) to screen patients for tobacco use as well as to provide counseling, education, and referrals to the tobacco quit line. In addition, between November 2018 and December 2019, at least one local health unit nurse from each county attended a four-day training to become Tobacco Treatment Specialists. The specialists are able to provide tobacco cessation counseling sessions, diabetes management, hypertension resources, and prescriptions for nicotine replacement products.

 

Strategy 1.4: Provide referrals to community resources for identified risk factors or medical procedures unavailable at the local health unit.

 

In calendar year 2019, the Family Planning and Well Woman programs referred patients for a total of 7,251 health related services not provided by ADH, which was a 6% decrease from 2018. The services include laboratory tests, radiology, mammography, colposcopy, social services, dental, tobacco cessation, and referrals to other medical providers. The Family Planning program also made 4,507 referrals to the Special Supplemental Nutrition Program (SNAP) for the WIC program in 2019. This number represents a 7% increase from 2018. In November 2018, the ADH launched Be Well Arkansas to provide Arkansans with resources to improve their health and well-being.  In 2019, the program grew and 294 referrals were made to the ADH Be Well Arkansas program, compared to 79 in 2018. With Be Well Arkansas, TPCP staff are operating a call center to connect callers to tobacco and nicotine cessation services and wellness counseling for diabetes and blood pressure control. These wellness services are accessible by calling the 833-283-WELL phone number, or online at the Be Well Arkansas website (https://www.healthy.arkansas.gov/programs-services/topics/be-well-arkansas). In addition, the number 1-800-QUIT-NOW for tobacco cessation will route callers to the Be Well Call Center.

 

The maternity program referred patients for 5,088 services including laboratory tests, ultrasound, genetics counseling, telemedicine, high risk maternity provider, and nutrition counseling. This number represents a 9% decrease from 2018. The maternity program made 1,986 referrals for WIC program services, including prenatal education classes, a 23% decrease from 2018.

 

On June 30, 2017, grant funding for the ANGELS Program ended that had supported cervical cancer testing in colposcopy clinics in the University of Arkansas for Medical Sciences High Risk Pregnancy Program to ensure that all women continue to have access to colposcopy services, the ADH assists women with application to the BreastCare program, which provides coverage for colposcopy for eligible women, refers patients to community providers where available, and refers to University of Arkansas for Medical Sciences.

 

In July 2017, the ADH established a workgroup to determine the unmet need for colposcopy services. The agency implemented a colposcopy pilot clinic in the local health unit in Hempstead County (Southwest Region) in May 2018. An additional site was added in Crittenden County (Northeast Region) in February 2019. The ADH plans to train additional staff as needed or when there is a need for expansion into other health units.

 

Patients who receive cervical cancer screening and were in need of further evaluation with colposcopy services were at risk for a gap in services due to inability to afford services. Four nurse practitioners were trained to perform colposcopy by experienced medical staff.  Additionally, telehealth was implemented to increase access and ensure quality. The ADH Colposcopy project has performed a total of 298 procedures, ages 21-68 years, since beginning the pilot in 2018. Overall, thirty cervical dysplasia diagnoses requiring excisional procedures were discovered and two cancer in-situ results were diagnosed.

 

Objective 2

 

Increase the percentage of women, ages 18-44, receiving preconception counseling prior to pregnancy in an ADH Family Planning clinic.

 

Strategy 2.1: Provide preconception counseling prior to pregnancy to women attending an ADH Family Planning clinic.

 

Preconception counseling is a focus of an ADH visit where the patient identifies the desire for pregnancy. However, preventive health screening services and referrals are offered at all Family Planning and Well Woman visits for identified health problems.

 

Women at risk of unintended pregnancy are a high priority population for the Women’s Health program. This population includes teens, minorities, low income women, women without insurance, and unmarried women. The ADH Health Statistics Branch created the Family Planning Needs Index, which is used to measure and rank the needs of family planning services at the county level. In this model, a score is calculated for each county by employing a weighted combination of several different health indicators. The specific indicators used in this model are: general fertility rate; fertility rate for younger teens age 10-14 years; fertility rate for teens age 15-19 years; percent births to unmarried women; percent unmarried teen births; lack of prenatal care in the first trimester; percent low birth weight births; fetal death rate; neonatal death rate; and post-neonatal deaths. The most recent needs index (2013-2017) indicated that the highest priority areas are the counties in eastern and southern Arkansas.

 

Family planning patients without a pay source are charged based on a sliding fee scale, with no fee for families whose incomes are at or below 100% of the federal poverty level. The ADH does not deny services due to inability to pay and the agency bills third party payers for family planning services. The agency does not collect copays or deductibles from patients with a pay source.

 

Objective 3

 

Increase the percentage of women receiving prenatal care in the first trimester.

 

Strategy 3.1: Monitor medical record data reports for entry into prenatal care at local health units.

 

The ADH began using the 2003 revision of the U.S. Standard Certificate of Live Birth in 2014. The 2014 data is considered Arkansas’s new baseline for this objective. In the state overall, the percentage of live births with first trimester prenatal care increased every year from 2014 (65.7%) to 2018 (70.6%, National Vital Statistics System). This increase was statistically significant.  Table 1 shows demographics for lowest use of first trimester prenatal care.

 

Table 1

Low Use of First Trimester Prenatal Care 2018

 

Category	Use of Prenatal Care
Minority (Pacific Islander)	17.7%
Uninsured	50.9%
Didn’t graduate from high school	52.1%
Born outside U.S.	56.4%
Young mothers (<20 years old)	58.6%
Minority (Hispanic)	59.4%
On Medicaid	59.8%
Unmarried	60.0%

 

Maternity patients can complete applications for Medicaid through the Arkansas Department of Human Services and non-citizens or undocumented women may apply for “unborn child” Medicaid for pregnancy coverage. Although there is variability across the state in the length of time a client receives prenatal services from the ADH, the agency is able to provide care until the patient is approved for Medicaid. Once approved, staff in the local health units work with clients to identify a local prenatal care provider. The women’s health services that ADH provides, particularly maternity services, are vital given the rural nature of the state combined with high poverty levels and the disproportionate availability of obstetric providers.

 

The ADH maternity clinics served 2,153 women with expected delivery dates in 2019.  Fifty-seven percent of these women had their first prenatal care visit at an ADH clinic within the first trimester of pregnancy.  This was a 27% increase from 2018.

 

Other Programmatic Activities Related to Women’s Health

 

Appointment Show Rate

 

The ADH implemented an appointment reminder program for patients using the Vital Interaction software with Greenway PrimeSUITE patient data in March 2017. The patient receives three reminders: 1) A text reminder is sent five days prior to the appointment with a requested Y/N confirmation response, 2) If the patient does not respond to the text, then a voice call reminder is sent 72 hours prior to the appointment, and 3) 24 hours prior to the appointment, a text reminder is sent to the patient with no requested confirmation.

 

The appointment show rate for the year prior to the implementation of appointment recalls (March 2016 - February 2017) was 65.6%. The show rate for March 2017 – February 2018 was 68.8%, an increase of 3.2%. From March 2018 - February 2019 the show rate was 69.7%, an increase of 4.1% since implementation in March 2017. From March 2019 – February 2020 the show rate was 69.8%, and increase of 4.2% since implementation in March 2017.

 

HPV Prevention

 

The HPV Summit was a virtual event held on May 1, 2020. The Summit is a time for medical and dental professionals to come together and collaborate on ways to increase awareness about the benefits of the HPV vaccine and cancer prevention as well as increase acceptance of the vaccine. The Women’s Health section sponsored 30 maternal and child health nurse participant from all regions of the state using funds from the Title X program.

 

Telemedicine to Improve Outcomes

 

Through collaboration with the University of Arkansas for Medical Sciences, ADH local health units are equipped with video and peripheral equipment for real-time telemedicine consults with maternal fetal medicine providers from the University of Arkansas for Medical Sciences High Risk Pregnancy Program. The use of telemedicine services allows patients to save both time (travel and away-from-work) and transportation costs. In addition, the system’s call center serves as an after-hours option for emergency triage consultations with ADH maternity patients.

 

The ADH Women’s Health section has a professional services contract with the University of Arkansas for Medical Sciences Department of Obstetrics and Gynecology to facilitate the delivery of comprehensive and risk-appropriate maternity care to low-income women throughout Arkansas. It also supports the department in its efforts to continue to provide outpatient services to ADH high-risk maternity patients. In addition to telemedicine, the contract supports the provision of clinical services and the liaison/consultation services of a certified nurse midwife for ADH’s Lay Midwife Program. Funding for a 0.5 full-time equivalent OB/GYN physician supports the position as ADH’s Family Health Medical Director.

 

Unintended Pregnancy

 

The ADH partners with Arkansas Medicaid, Arkansas Foundation for Medical Care (AFMC), and Arkansas Department of Higher Education to implement strategies and distribute educational materials designed to address unintended pregnancies. Together, these partners developed a toolkit for hospitals and health care providers to use as they discuss health, sexual history, and birth control options with their patients. The toolkit, TAKE CONTROL of Your Life: The choice about if or when you become pregnant is YOURS!, includes a patient education flip chart (https://afmc.org/product/larc-patient-education-flip-chart-providers/) as well as a patient education guide (https://afmc.org/product/larc-patient-education-interactive-e-book-english-download/) that reviews the different options for family planning. The toolkit is available in English, Spanish, and Marshallese. It was distributed to campus health centers/programs at all public 2-year and 4-year colleges in the state. It was also distributed by the AFMC staff to ADH central office and 73 local health units in 63 counties. Additional information for health care providers and individuals is available on the Foundation’s website: https://afmc.org/larc/ and  https://afmc.org/?s=larc. The site also provides links to the YouTube videos developed by the Arkansas Campaign to Prevent Unplanned Pregnancy called Preventing Unplanned Pregnancy (https://www.youtube.com/watch?v=FaCyQMrSUg8).

 

Maternal Mortality

 

The ADH partners with Arkansas POWER (Perinatal Outcomes Workgroup Education and Research) to develop strategies to improve perinatal outcomes in the state. POWER is an initiative with a focus of collaborating with 39 delivering hospitals in Arkansas to reduce maternal mortality and morbidity by implementing maternal safety bundles in postpartum hemorrhage and severe hypertension. POWER has recently launched a safety bundle to reduce postpartum racial/ethnic disparities. The ADH Family Health Medical Director and the ADH Medical Director for Women’s Health provide public health information and perspective to the workgroup.

 

The AFMC developed educational materials on maternal mortality and post-delivery warning signs as part of the initiative to decrease maternal mortality and morbidity. The materials include algorithms to help clinicians recognize urgent warning signs for women up to a year after delivery. Materials for patients include information on urgent post birth warnings signs and information about when a pregnant or post-partum woman should seek treatment with a medical provider.

The materials have been distributed to Medicaid providers at the hospital and clinic practice level across the state. The materials can be downloaded from: https://afmc.org/quality/maternal-mortality/ or https://afmc.org/quality/maternal-mortality/.

 

According to the Centers for Disease Control and Prevention’s Pregnancy Mortality Surveillance System, the maternal mortality ratio for Arkansas for 2011-2015 is 25.0:

 

• Non-Hispanic White: 18.6
• Non-Hispanic Black: 54.6
• Hispanic: 15.4

The maternal mortality ratio is the number of maternal deaths per 100,000 live births. A maternal death is a death during or within 42 days of the end of pregnancy or its complications. In 2019, Arkansas ranked 46th worst in the nation in maternal mortality (Health of Women and Children Report, 2019 ). This is possibly related to the fact that Arkansans often face disparities regarding poor socioeconomic status and rurality, and maternal mortality rates are significantly higher among these groups.

 

In 2017, the Arkansas Legislature passed an interim study proposal requesting a review of maternal mortality in the state and recommendations for solutions to lower maternal mortality. The proposed plan was developed using information and resources on a maternal mortality review provided by the Centers for Disease Control and Prevention Foundation; Association of Maternal and Child Health Programs; and the Centers for Disease Control and Prevention’s Division of Reproductive Health (http://reviewtoaction.org/).

 

An increasing national and state trend in maternal mortality indicates the need to conduct maternal mortality review in order to gain insight into the medical and social factors leading to these events and to prevent future occurrences of maternal mortality.

 

In March 2019, the Arkansas Legislature passed Act 829 to establish a maternal mortality review committee to decrease maternal deaths in the state. Leadership from the ADH Family Health Branch was instrumental in formulating the final legislation and the ADH was charged with establishing the committee. The Arkansas Maternal Mortality Review Committee (AMMRC) was developed and is facilitated within the Family Health Branch.

 

The scope of cases for Arkansas’s review is all pregnancy-associated deaths or any deaths of women with indication of pregnancy up to 365 days, regardless of cause (i.e. motor vehicle accidents during pregnancy, motor vehicle accidents postpartum, suicide and homicide). Deaths are identified from review of death certificates with a pregnancy check box selection and linkage of vital records by searching death certificates of women of reproductive age and matching them to birth or fetal death certificates in the year prior. The AMMRC is a multidisciplinary committee whose members represent Arkansas and various specialties, facilities and systems that interact with and impact maternal health. Membership consists of obstetricians and gynecologists, forensic pathologists, maternal fetal medicine doctors, anesthesiologists, nurses, psychiatrists, mental/ behavioral health specialists, nurse-midwifery staff, public health practitioners, advocacy staff, and more. The AMMRC members are appointed by the Arkansas Secretary of Health.

 

The ADH’s Family Health Branch developed an internal workgroup, hired a nurse abstractor, identified cases for 2018, and began the case abstraction process in 2019.  The first orientation meeting with the full AMMRC was held at ADH on January 9, 2020 and the first full Committee meeting with review of abstracted cases was held on June 30, 2020.

 

Tobacco Prevention and Cessation

 

The Arkansas TPCP conducted an evaluation of the Arkansas Tobacco Quitline. The evaluation revealed that females accounted for more than half of the registrants who received intervention services through the Quitline (Table 2). A small percent of those who registered for cessation intervention services were pregnant.

 

 

Table 2

Arkansas Tobacco Quitline Evaluation Results

 

*Note: Percent numbers for gender do not sum to 100% due to missing and refused information.