The WHB develops and promotes programs and services that protect the health and well-being of reproductive age women and men, along with infants and families. The WHB’s goal is to improve the overall health of women and men, reduce infant sickness and death, and strengthen families and communities. The WHB also offers guidance, consultation and training for entities that provide health services for individuals of reproductive age.
NPM#1 – Percent of women, ages 18 through 44, with a preventive medical visit in the past year
Increasing the percentage of women with a past year preventive medical visit (NPM#1) is a critical piece of the work of the WHB. Per data from the 2019 BRFSS, 76.1%% of women ages 18 to 44 surveyed had received such a service which is higher than the national rate (72.8%), but is a bit lower than the 2018 NC rate of 77.6% (although confidence intervals overlap for the two years). Of the women who responded to the 2019 survey, those with higher income, higher educational attainment, and higher rates of health insurance coverage were more likely than other women to receive a preventive medical visit. Non-Hispanic Black women (86.4%) were more likely to have had a visit than Hispanic women (69.6%) or non-Hispanic white women (74.6%), and the confidence intervals for the non-Hispanic Black population group did not overlap with those of the other population groups. The Affordable Care Act (ACA) has ensured that the majority of health plans offer women coverage for well-woman visits without cost-sharing, but many women and/or their providers are not aware of this coverage. The ESM for NPM#1 is the following: Percentage of women enrolled in Medicaid who deliver and receive a primary care visit within 12 months of delivery. This measure is also a core indicator for Point 1 of the NC Perinatal Health Strategic Plan (PHSP): Provide interconception care to women with prior adverse pregnancy outcomes. With Medicaid paying for 54% of deliveries in 2019, an increase in this ESM will definitely affect NPM#1. For women giving birth in 2014, 21.6% of women continuously enrolled in Medicaid for twelve months after delivery received a primary care visit within twelve months of delivery; however, this percentage dropped to 16.8% for women giving birth in 2019. Data for 2019 indicate that non-Hispanic White women were less likely to receive a primary care visit within 12 months (14.7%) than Black non-Hispanic women (18.4%), American Indian non-Hispanic women (17.9%), and Hispanic women (19.1%).
To increase the percent of women with a past year preventive medical visit, local health departments (LHDs) provide family planning core services that include contraceptive services, pregnancy testing and counseling, achieving pregnancy services, basic infertility services, sexually transmitted disease services, preconception health services, and related preventive health services. LHD maternity clinics also provide maternal health services inclusive of clinical care, referral for Medicaid and WIC services, provision of tobacco cessation counseling, screening for intimate partner violence, depression screening, and provision or referral for nutrition consultation. In addition, maternal care skilled nurse home visits are provided for women with high risk pregnancies. Home visits for newborn/postpartum and newborn assessment and follow-up care home visits are also provided by nurses. LHDs are also able to provide childbirth education services.
Pregnancy Medical Home Program and Care Management for High Risk Pregnancies (CMHRP) Services
DPH continued its partnership with NC Medicaid and CCNC in implementing the statewide Pregnancy Medical Home (PMH) program aimed at improving the quality of maternity care, improving maternal and infant outcomes, and reducing health care costs. Approximately 90% of all obstetrical care providers (public and private) in NC are PMHs who provide prenatal care services to the state’s Medicaid population. All LHDs that provide maternal health services in the state are PMHs. The PMH program is an outcome-driven initiative monitored for specific performance indicators, such as the rate of low birth weight and the primary cesarean delivery rate. Participating providers receive financial incentives from Medicaid for risk screening and postpartum visit completion, ongoing collaboration with and support of a CMHRP Care Manager, local CCNC network support, data and analytics, and clinical guidance materials and resources. In turn, practices agree to work toward quality improvement goals, such as eliminating elective deliveries before 39 weeks, using 17P to prevent recurrent preterm birth where indicated, reducing primary C-section rates, and improving the postpartum visit rate. The postpartum visit must include a depression screen, reproductive life planning counseling, and completed referral for ongoing primary care. PMH Care Pathways have been developed to assist providers and care managers to follow standardized protocols of best practice. The Postpartum Care and the Transition to Well Woman Care pathway provides a thorough overview of appropriate timing of postpartum care, components of the comprehensive postpartum visit, and specific guidance for women with various complications. Other PMH pathways include: Management of Substance Use in Pregnancy, Perinatal Tobacco Use, Induction of Labor in Nulliparous Patients, Progesterone Treatment and Cervical Length Screening, Management of Obesity in Pregnancy, Multifetal Pregnancy, and Management of Hypertensive Disorders in Pregnancy. These pathways can be downloaded from CCNC’s PMH Care Pathways website.
CMHRP services were also available to pregnant and postpartum women enrolled in Medicaid statewide and to a limited number of low-income, pregnant women ineligible for Medicaid in some counties. CMHRP Care Managers are registered nurses or social workers. Care managers work in direct partnership with public and private prenatal care providers statewide in a collaborative team approach to patient-centered care, including supporting effective and prompt use of Medicaid eligibility determination processes and facilitating early access to prenatal care. The primary mechanism for identifying Medicaid-eligible women with priority risk factors is the completion of a pregnancy risk screening form by a PMH prenatal care provider. However, many women are identified and engaged in CMHRP via the LHDs before contacting a prenatal care provider. This gives the care manager an opportunity to assist women in applying for Medicaid coverage and selecting a prenatal care provider earlier. Using risk screening and care management data, CCNC has identified women for whom care management can be shown to make a difference in their risk of low birth weight. CCNC used this data to create the Maternal-Infant “Impactability” Score (MIIS), based on risk factors found on the risk screening form and other data sources including pregnancy assessment documentation, risk screens and pregnancy assessments from prior pregnancies, claims data that identifies various health conditions, and birth certificate data from prior pregnancies. A higher score indicates that the patient is more likely to benefit from CMHRP services. Scores range from 0-1,000, and scores ≥200 are considered priority. Based on CCNC data collected over time in the legacy Case Management Information System (CMIS), it has been determined that to be effective, most care management interventions with priority patients need to be face-to-face. The previous system of “priority risk factors” identified too many women for care management services to be effective and it gave them all equal priority, regardless of risk factor. The current system identifies fewer women to receive care management, about 30% of the total pregnant Medicaid population; however, the reduced caseload does not equate to reduced services. The priority population requires eight to ten face-to-face interventions throughout the course of the pregnancy. This equates to approximately one face to face contact every month. The non-Medicaid CMHRP program served 492 women during FY20. The non-Medicaid version of these services implements the same “Impactability” model as the Medicaid funded services which identifies fewer women and provides for higher intensity of services with those women.
Preconception Health Efforts
The WHB also works to develop and enhance preconception efforts within NC using the NC Preconception Health Strategic Plan Supplement for 2014-2019 as a guide. In partnership with the national Office of Minority Health Resource Center, the WHB implements the Preconception Peer Educator (PPE) program. Initially the PPE program focused on Historically Black Colleges and Universities (HBCUs), but the program has now expanded to other colleges and universities including community colleges. With a focus on preconception health, college students are trained on reproductive life planning, HIV/STIs, tobacco use, healthy weight, and other wellness areas. The PPEs in turn share this information on their college campuses and in surrounding communities. There are 20 two and four-year colleges on the NC PPE roster. The WHB hosted three PPE trainings during this reporting period at which students from six universities participated (,Bennet College, East Carolina University, Elizabeth City State University, Fayetteville State University, Johnson C. Smith University, and NC Central University). Students at these universities and at the other participating universities conducted a range of activities highlighting preconception health and wellness on their campuses and in the abutting communities.
NC continued to be one of four states participating in the Preconception Collaborative Improvement and Innovation Network on Infant Mortality (PCH CoIIN) led by the UNC Center for Maternal and Infant Health (CMIH) during FY20. The overall aim of the PCH CoIIN is to develop, implement, and disseminate a woman-centered, clinician-engaged, community-involved approach to the well woman visit to improve the preconception health status of women of reproductive age, particularly low-income women and women of color. The NC PCH CoIIN consists of staff members from the WHB and the NC Chapter of the March of Dimes working in partnership with staff members from the two NC Healthy Start programs (Robeson Healthcare Corporation and Forsyth County Department of Public Health) along with Mountain Area Health Education Center (MAHEC). The metrics chosen for the project to determine if the goal/aim is met is the following: By September 2020, four states, in collaboration with the core CoIIN team and clinic partners, will develop an adaptable model to effectively integrate preconception care (PCC) into the well woman visit by: 1) working with clinics to implement validated screening tool(s) and response strategies, 2) enhancing state-level capacity to support effective implementation, 3) disseminating the model statewide and nationally. An integral part of the work of this CoIIN is to use human-centered design involving the end-users in the process of problem-solving and developing the approach to the well-woman visit. During FY20, the three NC PCH CoIIN projects, using a human-centered design approach, continued piloting their preconception health screening tool specific to the needs of their clinic and population served. The current projects include the assessment of an existing patient screening tool, along with a newly produced training video for health care providers, a dummy code embedded into the electronic medical record to prompt and record preconception health screening, and a prototype (for a tool to be developed) for women to bring to their well-woman visit.
In conjunction with other preconception health efforts, another objective of the WCHS is to promote healthy behaviors for women prior to pregnancy, including increasing the percent of women of childbearing age taking folic acid regularly. According to 2018 BRFSS, 42.8% of women responded that they took a multivitamin daily. Sub-group estimates by age and race/ethnicity are not available for that year because they did not meet statistical reliability standards. Due to changes in the weighting methodology and other factors such as the incorporation of interviews being done via cell phones, results from 2018 BRFSS are not comparable to previous years. In partnership with the NC March of Dimes (MOD) Preconception Health Campaign, during FY20, the WHB provided folic acid education to 965 public and private health care providers via in-office trainings and webinars; 1,119 health care providers during presentations at professional health care conferences and meetings; and 122 health educators and/or health care providers during an educational forum. MOD staff also trained 56 Community Ambassadors (lay health educators) about preconception health and folic acid who educated 458 peers; coordinated and conducted 25 community-based trainings – 23 in-person and 2 virtually – and educated 400 consumers in-person and 9,343 virtually about preconception health and folic acid; and conducted the Healthy Before Pregnancy curriculum in 10 high school classrooms and educated 64 students A total of 432 women were educated via the Spanish language promotora program about folic acid and preconception health, and 28,764 bottles of multivitamins were provided to low income women of reproductive age through the statewide multivitamin distribution program, which includes an online training program for health care professionals, continued to promote the folic acid message for women of childbearing age and encourage the new or continued behavior of daily folic acid consumption. The EveryWoman NC website was maintained to address folic acid and preconception health education. Also, EveryWoman NC Facebook and Twitter accounts posted press releases and electronic newsletters.
Efforts to Increase Quality Prenatal Care
In 2010, the state rolled out the 2003 Revised Birth Certificate. This update included the capturing of the actual date prenatal care was initiated as compared to the prior certificate only asking for the month. Because of this change, any data regarding prenatal care initiation prior to 2011 are not comparable. During 2011-2013, approximately 70% of infants were born to women who initiated care in the beginning of the first trimester of pregnancy. In 2018, data reflected that this percentage was at 68%, leaving opportunities for growth. Almost 75% of White, non-Hispanic women received prenatal care in the first trimester in 2018, while only 61% of Black, non-Hispanic women and 58% of Hispanic women did. In an effort to increase these rates and support improvement, LHDs continues to offer or assure access to high quality, evidence-based Maternal Health Services to all women in the state. In FY19, per reports LHD-HSA, these services were provided to 16,969 unduplicated patients. The state program team continued to explore potential mechanisms to facilitate earlier entry to prenatal care, with a particular focus on opportunities for improvements with Medicaid eligibility determination. LHDs are also required to provide Sudden Infant Death Syndrome (SIDS) Counseling to families who have experienced an infant loss.
The primary focus of Healthy Beginnings, the state’s minority infant mortality reduction program, is to improve birth outcomes specifically among communities of color. Through partnerships with LHDs, community-based organizations, and faith-based entities, Healthy Beginnings serves minority women and their families in the preconception, prenatal, and interconception periods. During FY20, the ten Healthy Beginnings program sites provided services in the preconception, prenatal and interconception periods to 481 pregnant women and women up to two years postpartum in 12 counties.
Appropriate Weight Gain During Pregnancy
Improving appropriate weight gain during pregnancy and decreasing the amount of overweight and obesity among women of reproductive age remain important to the WHB as they work to improve the health of all women. Birth certificate data for the 2015-2019 time period show that on average, 28% of pregnant women gained within the Institute of Medicine Recommended Weight Gain Ranges and 48% gained excessive amounts. In 2019, 55.2% of women giving birth were overweight or obese (BMI≥25) prior to pregnancy. In partnership with the MOD Preconception Health Campaign, healthy weight education and training continued to be offered to health care providers and consumers in offices, communities, and online. During the pandemic, the work continued virtually. The providers in North Carolina's LHD maternity clinics continued to assess gestational weight gain for all pregnant women and provided guidance as necessary in FY20, and this is actually an action step in the Perinatal Health Strategic Plan 2016-2020.
As per state mandate, North Carolina LHD family planning clinics continued to record BMI and provide education for all patients and made referrals as needed for patients who were not at a healthy weight. The Healthy Beginnings program provides education on the recommended healthy weight gain range during pregnancy based on the program participant’s pre-pregnancy body mass index (BMI). Education and support on nutrition and physical activity is provided during the prenatal and interconception period. The NC Baby Love Plus (NC BLP) program offers quarterly education/support group sessions to participants and their families on the importance of achieving and maintaining a healthy weight during the preconception, pregnancy and interconception periods. NC BLP program also provides individualized case management to participants needing additional support to achieve healthy weight goals. Due to the COVID-19 pandemic, many of the group sessions for the later part of the fiscal year had to be cancelled. Individualized support continued either via phone or virtually.
Maternal Mortality Review
North Carolina continues to conduct a formal review of maternal deaths. The focus of the review is to identify deaths determined to be pregnancy-related as well as those that are pregnancy-associated. The support of state legislation (§130A-33.52) and the cooperation of healthcare systems and professionals made the retrieval of protected health information possible to perform this mandated work. The focus of the review aligns with the recommendations of the Centers for Disease Control and Prevention (CDC) to identify potential preventable and contributing factors on the patient/family, community, provider, facility, and system levels. The overarching goal is to improve maternal health outcomes. The Committee initially met three times per year. There are nine appointed members to the Maternal Mortality Review Committee (MMRC), with additional specialty consultants in attendance by invitation, along with select staff from DPH. The Committee developed four subcommittees (1. deaths ≤42 days; 2. deaths ≥43 days; 3. substance use; and 4. trauma [suicide, homicide, motor vehicle accidents, etc.]) in order to review the cases prior to the full MMRC to ensure needed documentation was included and preliminary questions answered. The Committee reviews both pregnancy-related and pregnancy-associated deaths. The SCHS provides identified cases that meet established criteria for abstraction. During FY20, 45 cases were reviewed from 2016.
Family Planning Services and Efforts to Reduce Unintended Pregnancies
In Phase 7 of the Pregnancy Risk Assessment Monitoring System (PRAMS) survey, the question regarding pregnancy intendedness (Thinking back to just before you got pregnant with your new baby, how did you feel about becoming pregnant?) was modified to include a choice of “I wasn’t sure what I wanted” to go along with the responses that the person wanted to be pregnant later, sooner, then, or not then or at any time in the future. With this change, data prior to 2012 are not comparable to data from more recent years. Low participation has been a substantial problem for NC PRAMS from 2012 to 2019, with overall weighted response rates ranging from 50% to 57%. The 2019 PRAMS responses were similar to previous years, as 19.2% of respondents wanted to be pregnant later, 15.5% wanted to pregnant sooner, 40.3% wanted to be pregnant then, 5.8% did not want to be pregnant then or any time, and 19.2% were not sure what they wanted.
Title V funding, along with Title X, TANF, state, and local funding, was allocated to 84 LHDs for the delivery of family planning services in FY20. According to the 2019 Family Planning Annual Report, 80,337 female patients were seen in these LHDs. Female patients were able to choose an appropriate method of birth control from among a range of options. During CY19, it is estimated that 21% of female patients chose a LARC method. These methods help women to create more optimal birth spacing between pregnancies, potentially resulting in healthier birth outcomes for their children. In addition, the C&Y Branch used Title V funds to support adolescent reproductive health services as part of their increased emphasis on adolescent health.
North Carolina continued to work with Upstream USA in FY20. The nonprofit is working in North Carolina over the next several years to provide sustainable training and technical assistance to health centers to ensure same-day access to birth control methods at low or no cost. To date, eleven LHDs have signed on to work with Upstream, and they are in communication with at least four additional agencies. Upstream has been working to move their trainings to a virtual platform and have completed a training with at least one LHD. NCDHHS is partnering with Upstream and providing support and guidance around the great work already happening and aiding in the expansion of more partnerships throughout the state.
The NCDHHS also helps lead a collaborative team, the Statewide Reproductive Life Planning (RLP) Stakeholders Workgroup. The workgroup has representation from 17 different agencies all focused on Reproductive Life Planning for all North Carolinians. Agencies represent: State government, local health departments, Federally Qualified Health Centers, nonprofits, private funders, hospital systems, universities, consumers, Medicaid, and substance use disorder treatment programs. This group meets at least three times per year to discuss critical issues affecting men, women, and adolescents in their reproductive years and how to improve health outcomes for this group, while ultimately improving health outcomes for future generations as well.
Through Title X funding, the WHB continued to partner with the NC DMH/DD/SAS to provide ongoing technical assistance for staff working at substance use treatment facilities and for LHD staff working in family planning clinics around RLP. Staff that were previously trained in FY19 were provided opportunities to learn more about interacting with clients and learn from other agencies on how they discuss RLP with substance use treatment clients. The technical assistance was provided through monthly virtual meetings, until the COVID-19 pandemic required staff attention. The monthly meetings were postponed in Spring 2020 with the plan to restart in Fall 2020, as well as to conduct three virtual trainings for opioid treatment programs and the LHDs in the same communities.
Teen Pregnancy Prevention Initiatives
The state teen birth rate for females 15-17 years of age reached a low of 7.7 per 1,000 women in this age group in 2019. That same year, the teen birth rate for girls 15 to 19 years old in North Carolina decreased by 22.5% from the rate in 2015 to 18.2 per 1,000, leaving North Carolina with the 29th highest teen birth rate in the nation, with the national rate being 16.6 per 1,000. The Teen Pregnancy Prevention Initiatives (TPPI) support communities across North Carolina with programs that prevent teen pregnancy and support teen parents. The Adolescent Parenting Program (APP) helps teen parents prevent a repeat pregnancy, graduate from high school, keep themselves and their babies healthy, and build skills that will help them support themselves and their babies. The Adolescent Pregnancy Prevention Program (APPP) prevents teen pregnancy by providing young people with essential education, supporting academic achievement, encouraging parent/teen communication, promoting responsible citizenship, and building self confidence among their participants. The Personal Responsibility Education Program (PREP) is designed to educate teens on abstinence and contraception to prevent pregnancy and sexually transmitted infections (STIs). PREP also addresses adulthood preparation subjects such as parent-child communication, healthy life skills, positive adolescent development, financial literacy, and educational/career preparation. TPPI also received funding from the Office of Adolescent Health (OAH) in 2015 to work with three counties (two counties in FY20) around implementation of evidence-based teen pregnancy prevention programs to scale, called Project REACH (Redefining & Empowering Adolescents & Community Health). The expected number of youth to be served in these counties is 1500 youth per year. The program provides key educational interventions to improve NC adolescents’ knowledge, attitudes, and beliefs regarding sexual health, which will impact adolescent birth rates in these counties as well as increase the number of youth seeking services at local family planning clinics.
In FY20 through Title V, TPPI funded SHIFT NC (Sexual Health Initiatives for Teens) to provide information, education, resources, consultation and training to professionals and stakeholders working to reduce teen pregnancy in the state. SHIFT NC usually holds a statewide teen pregnancy prevention conference in May, but was unable to with the COVID-19 pandemic. SHIFT NC did create a statewide youth engagement plan with the goal of creating a statewide youth advisory group to start in FY21. Through Title V, TPPI also funded the North Carolina School Health Training Center that is housed at East Carolina University. The Training Center provided professional development and skill-building for program facilitators funded through other TPPI programs. This included: a networking conference held for primary and secondary education programs around Youth Engagement, Reproductive Justice, as well as contraceptive and STI updates; training on Racial Equity; training on making curricula observations of facilitators meaningful; training for facilitators in the evidence-based programs – Making Proud Choices! (21 facilitators trained), Reducing the Risk (18 facilitators trained), and Be Proud! Be Responsible! Be Protective! (17 facilitators trained); and training was held on high quality facilitation. The networking conference was held in March 2020 with 75 attendees.
In addition to the teen pregnancy prevention work funded through Title V in FY20, TPPI funded 55 agencies to implement adolescent pregnancy prevention programs or adolescent parenting programs. Through the 29 primary prevention programs funded in 26 counties, 8,393 youth participated in an evidence-based or evidence-informed teen pregnancy prevention program. TPPI funded 25 secondary prevention programs in 24 counties. A total of 612 participants were served with monthly home visits using the Parents as Teachers program and offered a minimum of a quarterly peer to peer group instruction. Of the 582 female participants, 1% had a repeat pregnancy and 45% reported using a LARC. Of the 612 total participants, 2.3% reported dropping out of school that year.
Be Smart Family Planning Medicaid Program
The NC Be Smart Family Planning Medicaid Program (Be Smart) is designed to reduce unintended pregnancies and improve the well-being of children and families in the state. Family planning/reproductive health services are provided to eligible men and women whose income is ≤195% of the federal poverty level. The Be Smart program covers annual exams and physicals, laboratory procedures, FDA-approved contraceptive methods, STI testing and treatment, and family planning counseling. One Be Smart program manager is housed in the WHB and works collaboratively with staff in Division of Health Benefits.
The North Carolina “Be Smart” Family Planning Medicaid Program Strategic Plan was developed as a five-year (2018 – 2023) internal guide for the DPH and NC Medicaid. It guides the implementation of the “Be Smart” Program by identifying and addressing six key strategies/goals that assist DPH and its partners in implementing changes that will have the greatest impact on NC residents and program participants. The six key strategies are:
- Expand agency and stakeholder partnerships that offer program services.
- Increase training opportunities for all agencies implementing the program.
- Provide training and outreach opportunities to program enrollees and potential recipients.
- Improve and clarify the process of determining eligibility for current and future beneficiaries.
- Create an easy access and enrollment process for consumers.
- Provide automatic transitions from existing Medicaid programs for beneficiaries, caseworkers, and providers.
In April 2020, the Be Smart Family Planning Medicaid Program Manager conducted a Reproductive Life Planning webinar with the March of Dimes with 95 participants. The webinar gave an overview of the Medicaid program and allowed open discussion among participants for creating innovative ways to market family planning during the COVID-19 pandemic.
Focusing on the second strategy of the Be Smart Family Planning Medicaid Strategic Plan, a Train the Trainer Toolkit Committee was created to develop and market a toolkit to assist local agencies in promoting the Be Smart Family Planning Medicaid program within their local communities. The toolkit will include provider scenarios, educational resource lists, outreach and education strategy examples, and marketing ideas. The committee started this work and plans to have the toolkit completed in 2021.
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