Women/Maternal Health

Report for the application year: Oct 2021 - Sept 2022

NPM 1: The percent of women, ages 18-44, with a preventive medical visit in the past year

Strategy 1.1: Partner with community-based partners to provide patient navigation and health education information about women’s health to disparate populations.

During the reporting period, the Alaska Breast + Cervical Screening Assistance Program (“AK B+C”, formerly known as “Ladies First” – see more info below) maintained contracts for community outreach and screening navigation in four regions of the state with higher populations and low screening rates: Anchorage, Kenai Peninsula, Fairbanks, and the Mat-Su Valley. Unfortunately, in August 2022, the Fairbanks contractor had to leave the state. This contract will be re-procured to identify a new contractor. During the reporting period, these contractors connected with approximately 5,000 people to provide educational opportunities, barrier relief (e.g., transportation, language assistance), and assistance with accessing appointments. Over 11,000 people were also reached through events and social media.

In addition, AK B+C initiated a contract with Brilliant Media Strategies to conduct a multi-year health behavior change campaign to spread the word about the program throughout the state. To be more inclusive, the program asked the contractor to facilitate efforts to change its name. Based on the feedback and recommendations of focus groups consisting of Alaskans eligible for the program, the name was changed from Ladies First to Alaska Breast + Cervical Screening Assistance Program in July 2022. The promotional campaign development was guided by internal programmatic data as well as state and local data such as the Alaska Health Equity Index. The contractor engaged with WCFH’s outreach contractors on sharing recommendations for hyperlocal outreach, and learned from them about opportunities to reach their eligible populations to increase screening statewide.

During the reporting period, AK B+C staff provided public education about screening and the program. Staff participated in approximately 10 meetings or presentations with traditional and nontraditional stakeholders, non-profits, and other health care providers. Staff met with many non-profit organizations representing many subsets of the population including Faith Based Nursing, Department of Corrections Reentry Program, Rotary Clubs, Chambers of Commerce, Special Olympics, and many other groups.

This work is supported by data analysis and visualization through GIS technology to track screening rates, and changes based on geography, age, race, socio‐economic status, and other relevant factors. The Health Equity Index, Small Area Health Insurance Estimates (SAHIE), and internal program numbers are used to guide activities. Timeliness of screening by region has been a useful datapoint to share with the outreach contractors. AK B+C activities, which focus on increasing cervical cancer screening rates in Alaska, help connect underserved and high‐risk populations with health care providers who then can screen for and address other health concerns, including ACEs, substance use, chronic disease and other risk and protective factors in the person’s life.

Finally, AK B+C continued to expand their work with health care providers on quality improvement efforts to improve screening rates among patients seeking care at Alaska’s community health centers and private practices (see NPM 1.2 below). Also, AK B+C staff and Outreach contractors were able to engage with employers and business groups on health education and recommendation of screening‐friendly workplace policies by presenting to 34 different groups during the reporting period.

Strategy 1.2: Identify and partner with public and private providers statewide to improve and expand their preventive health services through ongoing quality improvement models.

AK B+C continued health systems interventions to increase clinic-level screening rates for breast and cervical cancer screening; this work included quality improvement (QI) projects at FQHCs and private practices throughout the state. Contracts were established with the Alaska Primary Care Association (APCA) for breast and cervical cancer screening QI projects, and with Mountain Pacific Quality Health (MPQH) for both breast and cervical cancer screening and women’s preventive health services. Many of the patients who receive care at participating clinics fall within the AK B+C priority population: women who are un/underinsured who are at or below 250% of the federal poverty level, and those who are rarely or never screened for breast and cervical cancer.

The analysis of the data submitted by the participating clinics shows mixed results, with the challenges of the pandemic still impacting screenings. Of the three clinics working with APCA during the reporting period, two saw an increase, and one saw a decrease in timeliness of cervical screening. MPQH worked with River Health and Wellness to address the number of patients due for their annual women’s wellness visit who received that service. One PDSA was completed in their efforts to improve their use of the “campaign builder” module of their Electronic Health Record (Athena) to reach at least 50% of Medicaid-eligible women in their patient population who were due for a women’s wellness visit/cervical cancer screening. There was an increase in services provided from their baseline of 55.38% of eligible patients receiving services in 2020 to 69.61% of eligible patients receiving services in 2021.

Finally, MPQH provided a webinar series titled “Alaska Women’s Wellness Mini-Series: Improving Preventative Care for Women in Alaska”, including the webinars “Reducing Women’s Barriers to Care” and “Using Data to Bring Hard-to-Reach Women in for Care.”  This webinar series was advertised for participation by public and private providers statewide via several listservs and social media.

Strategy 1.3: Review all pregnancy-associated deaths through the Maternal Child Death Review (MCDR), generate actionable recommendations for all preventable deaths and increase awareness about the MCDR program among the public, clinicians, and policymakers.

Funding support for Alaska’s maternal mortality review program through the CDC “Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM)” award continued during the report year, alongside new funding through the Office of the Assistant Secretary of Health. Title V funds continued to support MCDR staffing and program structure, while ERASE MM funds were utilized to support contracts with the Alaska State Hospital and Healthcare Association (AHHA), a contracted nurse abstractor, and a portion of personnel costs.

During this reporting period, MCDR began receiving additional funding support for maternal mortality through the Office of the Assistant Secretary of Health, Office on Women’s Health to prevent maternal deaths from violence. Since the maternal mortality review process is already supported by CDC funding, this award was able to be directed towards implementation of prevention recommendations. The majority of funds support culturally matched birth support services delivered by Indigenous- and BIPOC-led community-based organizations. Activities included support for the development of an Alaska-specific curriculum for cultural birth workers and doulas, outreach and educational activities using culturally grounded approaches and delivered by a Tribal organization, and direct payments to culturally matched birth doulas to support their work with pregnant and postpartum people who belong to marginalized group or experience other risk factors for violence, regardless of their ability to pay. The grant-funded doula program has been very well-received by both community members and providers. The project has introduced many rich learning opportunities related to the role of doulas and cultural birth workers within the perinatal workforce, quality improvement activities, and as a maternal mortality prevention approach in Alaska. It has also provided opportunities to increase the Section’s understanding of strengths and barriers to partnering in an effective and anti-racist manner with community partners. The OASH award also covered a small amount of personnel costs during the report period, including 10% FTE for the Alaska Perinatal Quality Collaborative (AKPQC) nurse consultant, which supports increased collaboration between the programs. This has been especially helpful during implementation of the current quality initiative on substance-affected pregnancies as universal comprehensive screening includes cofactors of interpersonal violence and provider training on trauma-informed approaches.

MCDR has continued to face a backlog of cases for review due to multiple factors including a significantly higher than average number of maternal deaths in 2021, as well as continued delays in receiving records, challenges with scheduling review meetings due to the availability and capacity of subject matter experts, and the capacity of the contracted case abstractor. Reviews have continued to occur on a rolling basis as cases become available and as meetings are able to be scheduled. The program experienced turnover of the Epidemiology Specialist position, which had previously been the team member with the most longevity and historical knowledge of the program. Due to multiple changes in databases and processes over the years, this transition will have a significant impact, but the position has been filled with a promising epidemiology professional with strong analytical skills and relevant interests and background.

Twenty maternal deaths were identified for the 2021 death year, which is higher than any other year in the program’s history, and more than double the prior ten-year average (2011-2020). Although a typical number of cases were identified in 2020, the 2019 cohort was also larger than average. These numbers are concerning, and they place a strain on the program’s staffing and volunteer resources as many hours go into the review of each case.

Number of maternal mortality cases identified by MCDR, by year:

MCDR observed that not only has the rate of maternal mortality appeared to increase, but there is also a disparity by rurality. The MCDR analyst found that rates of pregnancy-associated mortality increased by 184% in rural areas, compared to 66% in urban areas from 2012-2021. Below is a graph that is anticipated to be included in an upcoming maternal mortality fact sheet, and for which initial analyses were completed during the report period:

2012-2021 Maternal Mortality Rates by Rurality (per 100,000 live births)

Although many maternal mortality review programs report increased numbers due to improved accuracy in pregnancy identification or other issues such as overuse of the pregnancy checkbox on death certificates, our program does not believe those issues explain the increase seen in Alaska, at least in comparison with recent years. MCDR completes pregnancy identification QI, but the procedures to ascertain additional cases were also completed for recent years. The cases identified in 2021 all came to the program’s attention through the usual vital records linkages and false positives (including those identified due to errors on the pregnancy checkbox) have been ruled out. Although the case identification process is still underway for 2022, it does not appear the number of cases will be as high as it was in 2021. As these cases are reviewed, the committee will identify factors in each death and may be able to offer some insights about the increase.

During the reporting period, MCDR completed reviews of nine maternal mortality cases and prepared three additional cases for a review scheduled in November 2022. Of these twelve cases, most occurred during 2019 and 2020, but the team has begun working on 2021 cases. Review of all 2019 maternal deaths was completed during the report period. There will be four cases remaining from 2020 after the November review. Two of the remaining 2020 cases are awaiting records due to law enforcement and/or pending court proceedings. The other two are in the preparation process with the contracted abstractor and will be reviewed soon.

Although some cases are still pending review, it appears all eight deaths of the pregnancy-associated deaths identified for 2020 were the result of violence, accidental injury (including overdose), or chronic substance/alcohol use. Although COVID-19 has not been identified as a cause or contributing factor for any of the 2020 maternal deaths reviewed thus far, pandemic restrictions were identified as a potential barrier in at least one case, which may have restricted delivery of or access to certain preventive services. This information, along with the program’s prevention recommendations, helps inform selection of provider training topics, target audiences for presentations and collaboration, and prioritization of grant funding use.

The MCDR Epidemiologist, Program Manager and Committee Members delivered five live presentations and three poster presentations on MCDR-related maternal health topics at the Alaska Public Health Association (ALPHA) annual summit, the Maternal Child Health & Immunization Conference, the Second National Conference on American Indian and Alaska Native Injury and Violence Prevention, and the Alaska Statewide Suicide Prevention Conference. Topics of interest to this population domain included MCDR data on maternal mortality from interpersonal violence and suicide, suicide prevention through maternal support and reduced ACEs burden, and implementation of community-based violence prevention activities in partnership with cultural birth workers. In addition to these formal presentations, the MCDR Program Manager also delivered presentations about the program’s activities and facilitated discussion related to planning and implementation of MCDR recommendations with various audiences, including the Alaska Perinatal Quality Collaborative (AKPQC) steering committee and facility team, the Alaska Birth Transfer Initiative, the Alaska Suicide Prevention Community of Practice, the PQC Regions 8 & 10 infrastructure workgroup, and the Children’s Justice Act Task Force. At the annual MCDR/AKPQC Summit, the MCDR Program Manager co-presented alongside two other subject matter experts on interpersonal violence.

Selected slides from two presentations delivered at the Maternal Child Health & Immunization Conference by MCDR staff collaboratively with other WCFH and community partners are shared below as examples of diverse content and approaches used to share the program’s information and promote its prevention recommendations.

                                                                                                                                   Photo Credit (beadwork): Faith Cromer, Fairbanks, AK                 

In August 2022, the Alaska Hospital and Healthcare Association (AHHA) began planning to host an in-person Maternal Health Safe Table event to be held in early November 2022. AHHA partnered with WCFH to provide continuing education credits for physicians and nurses. WCFH created the registration website and provided a nurse reviewer. The MCDR Program Manager prepared a presentation and discussion related to implementation of committee recommendations that AHHA has been promoting through their contract related to comprehensive screening and holistic care. Below is an example of a slide used to prompt interactive discussion with an audience of healthcare providers and quality leads about the implementation of a recommendation.

Representation of Alaska’s diversity has been an ongoing priority for the MCDR program. The program’s interpretation of cases and the quality of recommendations are supported by contributions of cultural knowledge-bearers, lived experience, and diverse professional and personal backgrounds. Continuing to review cases in a virtual environment supports engagement of committee members and panelists throughout the state, including rural areas.

MCDR has continued QA efforts for pregnancy identification by working with the Medical Examiner’s Office, the Alaska Violent Death Reporting System (VDRS), within adolescent death records, and by researching public media sources. The new process for utilizing Medicaid data for QA that was pilot tested in October 2021 was refined and repeated in fall 2022. Several missed cases have been identified through this approach. As cases are identified, the team continues to discuss strategies to reduce missed cases through the usual identification processes.

Strategy 1.4: Collect, analyze and disseminate data on women’s preventive healthcare visits (e.g. PRAMS and BRFSS).

Both the Alaska PRAMS and BRFSS surveys continued to collect data on preventive healthcare visits among people who recently delivered a live birth and among women of reproductive age throughout the year. Although the BRFSS program is in another Section of the Division of Public Health, Title V staff collaborate closely with BRFSS staff in numerous ways to support program improvements and share best practices for data collection, analysis, and dissemination. During FFY22, the MCH Epidemiology Unit Manager provided support to the BRFSS program by serving on the BRFSS Advisory Committee, which reviews proposals for state-specific questions and makes recommendations on which questions to include on the survey each year. BRFSS, PRAMS, and CUBS staff continued discussions about online data visualization tools for analyzing and disseminating data from complex sample surveys.

After observing a decline in the prevalence of women who had a preventive health care visit in the past year in 2020 compared to 2019, the MCH Epidemiology Unit Manager reached out to the BRFSS Analyst to confirm whether this drop was statistically significant or not, prior to developing any public messaging. When told the decline was not significant, efforts to create social media messages or other publications to make the public and providers aware of this drop were paused until more information could be gathered. However, in response to the data request, the MCH Epi Unit Manager began discussions with the BRFSS analyst and coordinator about collaborating on a presentation for the January 2023 Alaska Public Health Summit on changes in health behavior during the pandemic, given that the PRAMS and CUBS surveys also collect information on receipt of care.

Another example of collaboration between programs was the BRFSS Coordinator provided information to the PRAMS and CUBS Coordinators about the process the program uses to charge for questions on the survey to inform PRAMS and CUBS as they explored this option. Increased funding would be used to increase the value of incentives and thank you gifts offered to PRAMS respondents, which would hopefully increase response rates and data quality for all questions, including questions about health care received and barriers to care.

In February 2022, the PRAMS Coordinator presented 2020 PRAMS data on accessing perinatal care (prenatal and postnatal) at the Maternal Child Health and Immunization conference. The PRAMS Steering Committee met multiple times throughout the year to discuss the transition to the Phase 9 survey and to prioritize topics and questions for Alaska. Despite the length of question, the committee prioritized asking about barriers to prenatal care and had a rich discussion about why it is important and worth the cost/time and space in the survey. With timely prenatal care an ongoing priority as an indicator for Healthy Alaskans 2030, this PRAMS question is a key measure for identifying strategies to address this issue.

Strategy 1.5: Engage hospitals and birthing facilities in data-driven, collaborative quality improvement focused on reducing severe maternal morbidity in partnership with the Alaska Perinatal Quality Collaborative (AKPQC).

During this reporting period, the AKPQC launched its second initiative focusing on substance use during pregnancy (Substance-affected Pregnancies Initiative, or “SAPI”). Due to the high number of maternal mortality cases involving substance use as a cause or factor in maternal deaths in Alaska, and many MCDR committee recommendations related to this topic, this initiative has provided an opportunity to deepen existing collaboration between AKPQC and the MCDR programs. Please refer to the Perinatal Domain for additional reporting on this initiative during the reporting period.

The annual AKPQC & MCDR Summit was held virtually in April 2022. This summit convened obstetric and pediatric providers, nurses, certified nurse and direct entry midwives, doulas, behavioral health professionals, quality and process improvement specialists, Alaska Medicaid representatives, and child welfare and injury prevention professionals. Summit sessions focused on addressing key clinical practice areas and root causes of maternal health disparities in Alaska to improve health equity. MCDR, PRAMS and other data sources were used to inform the selection of topics and to provide background information to presenters. Local and national speakers presented on topics of cultural safety, intimate partner violence, COVID-19 in pregnancy, substance use in pregnancy, and substance use disorder services and the 1115 Medicaid waiver. Eighty-three individuals registered for the two-day conference; 64% of respondents to the post-summit survey indicated that the overall rating of the summit was “excellent” with another 33% selecting “good”.

The AKPQC continued to partner with the University of Alaska Anchorage Center for Human Development to host a monthly Perinatal ECHO. Topics presented during this reporting period include COVID-19 and Pregnancy, Mental Health and Pregnancy, Refugee Health and Pregnancy, Infant Formula Shortage, and Environmental Health and Pregnancy.

The AKPQC compiled a grant submission packet for the funding opportunity through the Centers for Disease Control and Prevention (CDC) Statewide Perinatal Quality Collaboratives Cooperative Agreement. In August 2022, the AKPQC received a notice of award for the new 5-year funding cycle beginning September 30, 2022. A portion of this funding will be used to support contracts for a data manager and a quality improvement manager. The data manager will assist with data collection and analysis for the AKPQC, including efforts to improve equity in perinatal health outcomes. The quality improvement manager will focus on supporting facilities (participating hospitals) in best practices for quality improvement work and in development of actionable data collection plans, tracking and/or reporting. Special focus will be on engaging rural hospitals with limited resources to mitigate data challenges.

After the annual summit, interest in follow-up training on Intimate Partner Violence (IPV) was expressed by some attendees and by the AKPQC Steering Committee, based on the prevalence of violence and trauma among women who use substances. In response, the MCDR Program Manager met with the AKPQC Steering Committee to discuss an MCDR recommendation for provider training about strangulation identification and response, which has surfaced in both maternal and pediatric mortality cases and based on the input of forensic medical experts within the MCDR committee, is a common training gap with significant potential for impact due to the strong association between strangulation and IPV lethality. MCDR data regarding the high prevalence of IPV histories in maternal mortality cases from substance-related causes (as high as 74%, based on an analysis of MCDR-reviewed cases from a recent five-year review period) was also shared with this group. This presentation and discussion resulted in an agreement to offer training on strangulation at the next SAPI Learning Session in January 2023. Dr. Cathy Baldwin-Johnson will provide this training. Dr. Baldwin-Johnson is an MCDR committee member and one of the state’s leading forensic medical experts. Prior to practicing in forensic medicine, Dr. Baldwin-Johnson’s background was in family medicine. She has extensive experience providing training on the assessment and diagnosis of traumatic injuries from abuse and violence, including pediatric and maternal strangulation for clinical and non-clinical audiences and her insightful and trauma-informed presentation style is well-known and appreciated by many Alaskan professionals. The MCDR Program will co-present a portion of the training to integrate data and information from the maternal mortality review process, as well as to co-facilitate discussion about strangulation as it presents within the context of power and control dynamics and other family stressors, as this is a subject area of expertise this staff member has prior experience working and providing professional training on. During the reporting period, the MCDR Program Manager and Dr. Baldwin-Johnson met to collaboratively develop an outline and draft materials for the training.

In September 2022, a guest presenter from an Alaska-based doula service attended the Alaska Birth Transfer Initiative meeting, after which a rich discussion occurred within the group about the process and importance of doula services, what they bring to a birthing person, and the services doulas provide before and during the birthing process. This led to a group decision to have further discussion about how to better integrate doula services into the birthing process.

Strategy 1.6: Disseminate information (e.g. PSAs, presentations, fact sheets, etc.) about risk and protective factors that support behavioral health and reduce the impact of ACEs among women of childbearing age.

Throughout the year, the PRAMS and CUBS programs received and responded to several data requests related to indicators of behavioral health and risk and protective factors that support behavioral health and reduce the impact of ACEs.

• In February 2022, the CUBS program shared a research dataset with a contractor hired by the Alaska Division of Behavioral Health to evaluate the 1115 waiver demonstration: “Alaska Substance Use Disorder and Behavioral Health Program”. Data from CUBS were included in the evaluation as part of a broader mixed-methods approach utilizing administrative claims data, survey data, and key informant interviews. Specifically, the evaluators were interested in CUBS data on trends since 2012 on experience of stressful life events, symptoms of maternal depression, experiences of violence, maternal substance use, social supports, and receipt of treatment for behavioral health concerns for both the Medicaid and non-Medicaid populations in Alaska. The CUBS Coordinator and Senior Epidemiologist reviewed the initial study proposal and provided extensive feedback, working with the evaluators and the DBH liaison to help them understand the data limitations and possibilities.
• The CUBS program shared results for measures related to maternal mental health, treatment, and experiencing a close relationship with someone who was depressed, mentally ill, or suicidal with Onward & Upward, a nonprofit organization in the Mat-Su Region that uses experiential learning, adventure, and the outdoors to strengthen youth, families, and the community. The data were requested to use as part of a One Health Education Curriculum Project.
• PRAMS provided updated data on people who have 5 social supports during the postpartum period for a Scorecard of Key Issues Impacting Alaska Mental Health Trust Beneficiaries. The Scorecard provides evaluation measures for the Alaska Division of Behavioral Health’s Comprehensive Integrated Mental Health Program Plan 2020-24. Part of this plan is a focus on prevention and early intervention efforts that build resilience and address trauma in individuals who are at risk of developing disabling conditions. As stated in the Scorecard, “Research shows that social support is a major buffer of postpartum depression and can improve outcomes for infants, young children, and their families. The presence of social supports, as reported by mothers after giving birth, can help predict early childhood experiences and provide an opportunity to increase individual and community-level supports at a critical developmental period.” In 2020, 75.2% of postpartum Alaskans stated that they have access to all five social supports asked about on PRAMS, which included measures of financial support, physical support, and emotional support. The PRAMS Coordinator and other MCH Epi staff had worked closely with the Mental Health Trust to craft this measure, which is also now being used as one of Alaska’s Title V SPMs.
• PRAMS data for several behavioral health measures were also shared with the Alaska Mental Health Board/Advisory Board on Alcoholism and Drug Abuse staff to present to their advisory boards for planning and advocacy purposes.
• CUBS data on ACES/stressful life events were shared with a grant writer at a local hospital who requested the data for a grant application.