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

1. Provide direct health care, referral services, preconception and interconception counseling, and preventive screenings for women of reproductive age in all 75 counties in Arkansas
2. Provide education and referrals for smoking cessation to women of childbearing age
3. Work with the University of Arkansas for Medical Sciences’ (UAMS) High-Risk Pregnancy Program to increase screening and consultation for high-risk women in ADH’s maternity clinics
4. Work with UAMS’s High-Risk Pregnancy Program to provide after-hours consultation services to ADH maternity patients
5. Work to reduce smoking in pregnant women, including screening during the last three months of pregnancy

The ADH has at least one local health unit (LHU) in each of Arkansas’s 75 counties. LHUs 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 programs support 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 53 LHUs covering 49 counties. Maternity services include:

• Case management
• Prenatal assessments, including risk assessments, history, physical, laboratory tests, gestational age, and fetal assessments
• Management of abnormal prenatal findings
• Prenatal counseling and education
• Women, Infants and Children (WIC) program
• Vitamins and mineral supplements
• Post-partum services

Implementation of the Affordable Care Act negatively affected the number of Arkansas women who access family planning and maternity services at LHUs. The Affordable Care Act allows women to choose a private health care provider and allows teenagers to remain insured on their parents’ policies 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 LHUs.

In 2020, a total of 27,088 women ages 18-44 received a preventive health visit at an LHU. In 2021, this total was 27,055.

Strategy 1.2: Provide fact sheets on risk factors identified to women.

Family Planning and Well Woman patients at ADH LHUs receive education and counseling on recommended preventive screenings to optimize health. Information on height, weight, body mass index, and blood pressure is gathered at each visit. 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 use, illicit drug use or abuse, human trafficking, and intimate partner violence. The ADH provides written materials on a wide variety of topics at LHUs.

There are multiple 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, supported by the Centers for Disease Control and Prevention (CDC-RFA- DP18-1801). Schools that participate in School Wellness Advocacy Groups (SWAGs) and Project Prevent Youth Coalition, funded by ADH 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, schools, community-based organizations, corporations, health care providers, hospitals, law enforcement agencies, LHUs, media companies, non-profit organizations, and other state agencies in tobacco prevention and cessation efforts.

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. 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.

Strategy 1.3: Provide referrals to community resources for identified risk factors or medical procedures unavailable at the local health unit.

In 2021, the Family Planning and Well Woman programs referred patients for a total of 6,238 health-related services not provided by ADH. The services include laboratory tests, radiology, mammography, colposcopy, social services, dental services, and referrals to other providers. The Family Planning program also made 2,667 referrals to the Special Supplemental Nutrition Program (SNAP) for the WIC program in 2021.

The ADH Be Well Arkansas program provides Arkansans with resources to improve their health and well-being. With Be Well Arkansas, TPCP staff operate a statewide call center to connect callers to tobacco and nicotine cessation services and wellness counseling for diabetes and blood pressure control. As of April 2021, Be Well Arkansas had enrolled over 7,000 participants into their tobacco cessation program. These wellness services are accessible by calling the 833-283-WELL phone number or online at the Be Well Arkansas website (www.bewellarkansas.org). In addition, the number 1-800-QUIT-NOW for tobacco cessation will route Arkansas callers to Be Well Arkansas.

The agency implemented a colposcopy pilot clinic in the Hempstead County LHU (Southwest Region) in May 2018. An additional site was added in Crittenden County (Northeast Region) in February 2019. These clinics are still actively providing colposcopy services in 2022.

Patients who received cervical cancer screening and needed further evaluation with colposcopy services were at risk for a gap in services due to cost. Four nurse practitioners were trained to perform colposcopies by experienced medical staff. In addition, telehealth services were implemented to increase access and ensure quality. The ADH Colposcopy Project performed 141 procedures in 2021.

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.

LHUs provide preconception counseling when a 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. Family planning patients without a pay source are charged based on a sliding fee scale, with no fee for families with incomes 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 ADH does not collect co-pays or deductibles.

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.

Maternity patients can complete applications for Medicaid through the Arkansas Department of Human Services (ADHS), and non-citizens, or undocumented women, may apply for Medicaid’s Unborn Child Option for pregnancy coverage. Although there is variability across the state in the length of time a client receives prenatal services, the ADH can provide care until the patient is approved for Medicaid. Once approved, LHU staff work with clients to identify a local prenatal care provider. The women’s health services provided are vital given Arkansas’s high rural population, high poverty levels, and limited availability of obstetric providers.

ADH maternity clinics served 2,153 women with expected delivery dates in 2019. The majority (57%) of these women had their first prenatal care visit at an ADH clinic within the first trimester of pregnancy. The ADH maternity visit count was 2,557 in 2020. In 2021, the ADH maternity visit count increased to 3,827.

Objective 4

The ADH Office of Oral Health (OOH) will establish partnerships with health care providers in local health units that provide maternity services to deliver oral health education for pregnant women.

Strategy 4.1: Educate health care providers about the importance of oral health during pregnancy.

The ADH OOH works with LHU nurses to provide oral screenings, risk assessments, fluoride varnish applications, oral health education to caregivers and assistance in locating a dental home if needed. Although focus is on children aged 6 and younger, anyone under 19 years of age is eligible including young expectant mothers.

In January 2022, the ADH Oral Health director retired. The director was instrumental in writing the ESMs for NPM 13.1 and helping to understand the priority. In March 2022, the ADH OOH section chief resigned. The section chief worked directly under the director and was second in command for the OOH. The overturn in staff is a challenge with fulfilling state priority needs and activities for pregnancy and Oral Health.

Strategy 4.2: Develop collaborations with obstetricians and gynecologists in the state.

The ADH OOH will present to the Arkansas Maternal and Perinatal Outcomes Quality Review Committee (MPOQRC) the Paint a Smile (PAS) program (https://www.healthy.arkansas.gov/programs-services/topics/medical-and-dental- professionals). The MPOQRC includes a diverse group of stakeholders, including representatives from UAMS, Arkansas Children’s Hospital (ACH), the Arkansas Hospital Association (AHA), the Arkansas Center for Health Improvement (ACHI), the Arkansas Foundation for Medical Care (AFMC), as well as representatives from many of the state’s 39 birthing hospitals.

Strategy 4.3: Provide education and counseling on dental health at initial or subsequent maternity visits to all women attending ADH maternity clinics.

The ADH OOH will present at the MCH Specialist meeting the PAS program. Representation from each of the five public health regions are present during the MCH Specialist meetings. OOH will present twice during these meetings.

ADH Women’s Health Section will partner with the ADH Center for Local Public Health (CLPH) to provide ADH maternity clients, and their household members a copy of OralHealthPregnancyConsensus.pdf (mchoralhealth.org) to include in the new ADH maternity visit patient packets. This publication includes a section about tips for good oral health during pregnancy.

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. 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, 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 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 percentage points. From March 2018-February 2019, the show rate was 69.7%, an increase of 4.1. From March 2019-February 2020, the show rate was 69.8%, an increase of 4.2. From March 2020-February 2021, the show rate was 74.2%, an increase of 8.6 since implementation.

HPV Prevention

The “HPV Vaccine is Cancer Prevention” Summit was held May 14, 2021 as a hybrid event. The HPV Summit is a time for medical and dental professionals to collaborate on ways to increase awareness about the benefits of the HPV (human papillomavirus) vaccine and cancer prevention as well as to increase acceptance of the vaccine. The Women’s Health section sponsored 50 maternal and child health nurse participants from all regions of the state using funds from the Title X program.

ADH partnered with the Arkansas Immunization Action Coalition to provide education on efforts to improving Arkansans’ health through immunizations at the 2021 HPV Summit. The 2021 HPV Summit was approved for 6 hours of continuing education for physicians, nurses, pharmacists, physician assistants and dental professionals. The ADH State Epidemiologist and Medical Director for Immunizations and Outbreak Response presented information on the state of HPV immunizations in Arkansas. The ADH Family Health Branch (FHB) Medical Director presented HPV and gynecological cancers education. A total of 147 participants attended the 2021 HPV “Vaccine is Cancer Prevention” Summit.

Strategy 4.3: Review dental Pregnancy Risk Assessment Monitoring System (PRAMS) data for rates on pregnant women’s dental visits and maternal level of education.

Telemedicine to Improve Outcomes

The ADH Women’s Health Section has a professional services contract with the UAMS Women & Infant Health Service Line (WISL) 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 nursing services, laboratory services, physician 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 FHB Medical Director.

Through collaboration with UAMS Institute for Digital Health and Innovation Obstetrics (IDHI OB) Call Center, LHUs are equipped with video and peripheral equipment for real-time telemedicine consults. ADH maternity patients are advised of the voluntary UAMS/IDHI OB telemedicine program for high-risk obstetric consults, as need occurs. The ADH does not have the providers and/or resources necessary to care for patients who may develop or present with high-risk maternity conditions. In many locations of the state, local physicians provide this support for patients from their communities. In communities without this local provider support, ADH relies on telephone and/or telemedicine consultation, co-management, and in some cases, total referral of high-risk maternity patients to the WISL.

If travel to the UAMS WISL in Little Rock is an obstacle for clients, UAMS telemedicine clinics will provide a high-risk consultation via interactive video. The telemedicine consults provide outpatient consultations, follow-up, evaluation of ultrasounds performed at site, genetic evaluation, and follow-up and emergency consults for abnormal laboratory/test results.

Unintended Pregnancy

The ADH partners with Arkansas Medicaid, AFMC, and the 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 patients. The toolkit, TAKE CONTROL of Your Life: The choice about if or when you become pregnant is YOURS!, included a patient education flip chart and patient education guide to review the different options for family planning. The toolkit was made available in English, Spanish, and Marshallese. It was distributed to campus health centers/programs at all public two-year and four-year colleges in the state. It was also distributed to the LHUs. The Arkansas Campaign to Prevent Unplanned Pregnancy also developed a YouTube video called Preventing Unplanned Pregnancy (https://www.youtube.com/watch?v=FaCyQMrSUg8). Additional information for providers and individuals is available on AFMC’s website at https://afmc.org/larc and https://afmc.org/quality/larc/.The patient education guide and interactive e-book are currently available for download at (https://afmc.org/product/larc- patient-education-interactive-e-book-english-download and https://afmc.org/?s=larc&post_type=product).

Maternal and Perinatal Outcomes

Arkansas Act 1032 authorized establishment of the Arkansas Maternal and Perinatal Outcomes Quality Review Committee (AMPOQRC). The intent of the assembly is to improve the maternal and perinatal outcomes in the state. The AMPOQRC is a multidisciplinary committee with representatives from the ADH, DHS, other perinatal and community stakeholders, representatives from participating hospitals, and the state’s only freestanding pediatric specialty hospital.

The AMPOQRC held virtual bi-monthly meetings in 2021, with four meetings during the 2021 reporting period. Due to workforce and committee participation turnover, there was a need for refocus of participants on the committee objectives.

The AMPOQRC charter approved in 2021 was developed to outline responsibilities and roles of committee members and to create a continuous quality improvement process. Also in 2021, three subcommittees were formed, with a focus on quality, education, and site visits. Written descriptions of each committee were agreed upon, including a process for regular reporting to the full committee at each meeting. In August 2021, subcommittee leads met virtually to discuss each subcommittee’s purpose and mission. Some of the key discussions included identifying co-leads from the maternity side and neonatal side, timelines, educational topics of interest, and specific quality projects.

The Quality Improvement subcommittee met during the fourth quarter of 2021. This subcommittee presented information on syphilis screening and treatment in the April 15, 2022 committee meeting.

The subcommittee is interested in forming a quality collaborative to learn and share best practices. Quality projects that are being considered include safe sleep, opioid abuse, Arkansas syphilis increase notifications, and COVID-19 surveillance and education.

The Education subcommittee met several times during the fourth quarter of 2021 to discuss educational information needs to be shared on an ongoing basis. The Education subcommittee presented information to the AMPOQRC on COVID-19 trends, pregnant women, and educational campaigns in the June 17 and August 19, 2021 committee meetings. Current and future educational activities include:

• Providing approved educational offerings on the ADH AMPOQRC website. The material would be for health care providers as well as consumers. An example of health consumer information would be to include a hospital locator with level of care designation
• Developing a process to collect and create distribution lists for educational offerings (e.g., Nursery Alliance, the Perinatal Outcomes Workgroup Through Education and Research (POWER) program, ADH, Arkansas Medical board)
• Developing monthly or bi-monthly newsletters

Risk-appropriate care is a strategy developed to improve health outcomes for pregnant women and in infants. A level of care assessment was conducted by introduction of the CDC Levels of Care Assessment Tool (LOCATe). LOCATe helps to assess birthing facilities based on the level of risk-appropriate care and offers a standard process for assessment that aligns with the most recent guidelines and policy statements issued by the American Academy of Pediatrics (AAP), the American College of Obstetricians and Gynecologists (ACOG), and the Society for Maternal-Fetal Medicine (SMFM). In 2021, the results revealed a discrepancy in 50% of maternal and 43% of neonatal self-reported level of care and their LOCATe-assessed level of care.

Future activity will focus on quality improvement projects, educational activity, full implementation of the levels of care assessment tool, and site visits.

Maternal Mortality

In March 2019, Arkansas’s legislature passed Act 829 to establish a maternal mortality review committee to decrease the number of maternal deaths in the state. FHB leadership 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 FHB.

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, with the exception of out-of-state residents who die in Arkansas. At the July 2020 meeting, the committee discussed limitations on the scope for abstraction and review based on cases presented at the meeting. Based on the exclusion criteria set forth by the committee members, 10 cases were excluded from the scope of review for the 2018 deaths. The remaining 30 cases were selected to be abstracted and reviewed. The cases determined to be outside the scope for review included: Not pregnant within one year of death (4 cases): non-Arkansas resident (3), Motor vehicle accident (2), and Accident/Trauma (1).

The 2018 reviews were completed in 2021, and the MMRC made recommendations on all pregnancy-related cases and most pregnancy associated cases. The data from the 2018 case abstractions and committee recommendations were used in the 2021 legislative report and a Fact Sheet (both available on the AMMRC website). For 2019, 31 cases were identified for review. Based on the exclusion criteria set forth by the committee members, seven cases were excluded from the scope of review for the 2019 deaths. The cases determined to be outside the scope for abstraction included: Not pregnant within one year of death (2), non-Arkansas residents (2), and motor vehicle accidents (3). The committee met five times in 2021 and reviewed 13 of the 24 cases (2019) in 2021. The 2019 case reviews were completed in 2022.

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 and behavioral health specialists, nurse-midwifery staff, public health practitioners, advocacy staff, and more. The AMMRC members are appointed by Arkansas’s Secretary of Health. Four members resigned from the committee, and four new members were approved during 2021.

The AMMRC internal workgroup successfully launched a website for the AMMRC in 2021, developed a tool for committee members to use while reviewing the cases, and developed a list of stakeholders to assist with the action phase of recommendation. The FHB medical director made five presentations during 2021 to increase awareness about the AMMRC. He also met with the Arkansas Legislative House and Senate Public Health Committee to discuss the AMMRC 2021 legislative report.

Nurse-Family Partnership

The FHB partners with Arkansas’s Nurse-Family Partnership (NFP) home visiting program to improve pregnancy outcomes by helping women be involved in good preventive health practices. The following link provides information regarding the NFP program: https://www.nursefamilypartnership.org/locations/arkansas. NFP nurses conduct in-person visits to provide education and support to reduce preterm births and other poor maternal and child health outcomes.

Paint a Smile (PAS)

The ADH Office of Oral Health (OOH) offers a Paint a Smile (PAS) program. Improving maternal and infant health is a vital educational segment of the program.

OOH staff visit medical and dental offices statewide and deliver PAS toolkits, 1st Checkup by 1st Birthday folders, and oral health presentations.