NPM #1 Well Women Care – Improve pre-conception, prenatal and postpartum health care services for women of childbearing age

 

The health and wellbeing of the mother before, during, and after pregnancy is important not only for the woman but also for the newborn. Women who maintain a healthy lifestyle during the preconception period are less likely to experience adverse pregnancy and obstetric outcomes and are also more likely to experience better postpartum health that extends across their life span.

 

According to the 2021 Behavioral Risk Factor Surveillance System (BRFSS), 72.4% of Missouri women between 18-44 years reported having a preventive health care visit within the past year. This is higher than the national proportion of 69.7% for 2021.   There were racial differences in the proportion of women who had a preventive health care visit, with Missouri being similar to national levels (Figure 1). A higher percentage of insured women (76.5%) compared to uninsured women (41.3%) received a preventive visit. A lower percentage of those with less than a high school education (50.9%) received a preventive visit in the past year than those with more than a high school education (75.2%). The proportion of Missouri women with more than a high school education that received a preventive medical visit in the past year was also higher than at the national level (71.1%). In Missouri, 66.5% of those with a household income less than $25,000 had a preventive visit in the past year compared to 77.6% among those with a household income greater than $75,000. A slightly larger percentage of married women (72.4%) had a preventive visit in the past year than unmarried women (72.3%).

 

 

Missouri Vital Statistics (MVS) data for 2021 indicate 73.1% of women began prenatal care in the first trimester, which is slightly lower than the 73.4% observed in 2020. First trimester initiation was also lower in Missouri compared to the national level (78.3%) in 2021. There is a racial gap in first trimester initiation in Missouri, but that gap has narrowed. MVS data for 2020 showed that 77% of White Missourians began prenatal care in the first trimester compared to 60% of Black Missourians. While first trimester prenatal care initiation decreased for Black Missourians (61.4%) from 2020, it increased for White Missourians (76.5%) during that same year.

 

According to 2021 MO PRAMS, 89.4% of Missouri women received a postpartum checkup. This proportion is higher than the 85.1% reported for 2020. Women without health insurance (82.3%) had a lower percentage of receiving a postpartum checkup compared to their counterparts who were privately insured (93.8%) and Medicaid-insured (83.9%). Non-Hispanic Black women (84.7%) had lower rates of receiving a postpartum checkup compared to Non-Hispanic White women (90.9%). Women with less than a high school diploma (79.6%) had lower rates of receiving a postpartum checkup than women with a high school diploma (84.1%), some college (90.6%), and a college degree or higher (95.3%).

 

The Office on Women’s Health (OWH) continued to provide education and resources to promote well woman care, including the distribution of WOMEN: Take Charge of Your Health publication and the My Health Tracking Card and continuation of the Women’s Health Network listserv. The WOMEN: Take Charge of Your Health publication includes information on topics such as preventive health, preconception health, obesity prevention, breastfeeding, postpartum depression, and disease prevention. This resource is also available on the Department of Health and Senior Services (DHSS) website at www.health.mo.gov/womenshealth. The WOMEN: Take Charge of Your Health publication is available in English and Spanish and can be accessed online and in print. The My Health Tracking Card provides a means to track blood pressure, cholesterol, and weight. Resources were provided to the general public, local public health agencies (LPHAs), and others who contact the OWH or visit the website. The Women’s Health Network listserv comprises organizations and individuals concerned with women’s health. The network’s purpose is to provide timely information about current issues in women’s health, such as changes in services for women, changing technology in women’s health, available resources, training opportunities, events and funding opportunities. In 2022, the OWH surveyed the network and found that 89% of listserv members reported an increase in opportunities to disseminate information through the Women’s Health Network Newsletter.

 

The Missouri Women’s Health Council continued to meet quarterly. The Council is an advisory group comprised of thought leaders with expertise in women’s health and the broad range of factors that affect health outcomes and wellbeing. Council members are appointed by the Department of Health and Senior Services (DHSS) Director and reflect the geographic diversity of Missouri. The Council is charged with informing and advising DHSS regarding women’s health risks, needs, and concerns and recommending potential strategies, programs, and legislative changes to improve the health and well-being of all women in Missouri. The Council consists of women from a variety of professions, including health care providers, researchers, healthcare administrators, social workers, as well as, multiple directors of critical social service foundations serving women throughout Missouri. During FFY2022, the OWH developed a priority document for DHSS. Priorities highlighted in the document include increased access to care, improved data transparency, and support for mental health services.

 

The Office of Dental Health (ODH) continued to educate mothers and children about the importance of oral health for their overall health and well-being. This included the promotion of dental visits during pregnancy. As quantities allowed, the ODH supplied infant toothbrushes and Healthy Smiles from the Start booklets to the St. Louis Safe Kids Coordinator for use during baby safety classes. The baby safety classes cover safe sleep habits, car seat safety, breast and bottle-feeding and oral care. The training reaches pregnant moms, new parents and grandparents and is presented in English and Spanish.

 

The ODH also continued to provide education to women about the importance of oral health for the mother’s overall health, during pregnancy and throughout her lifespan. This education takes place through literature developed by the ODH and the Missouri Dental Association. These materials are distributed to women via an ongoing successful collaboration with the Women, Infants, and Children (WIC) Program and the Title V MCH funded Home Visiting Program. Materials are also distributed via LPHAs, dental offices, and at community outreach events. The importance of dental visits among pregnant women is reinforced in literature distributed by the ODH via its collaboration with WIC, the Home Visiting Program, and Federally Qualified Health Centers (FQHCs).

 

As part of a pilot program, the ODH contracted with three local public health agencies (LPHAs) to provide oral health education, a dental screening and fluoride varnish to pregnant moms who seek services at their agency. The LPHAs also educated the local obstetricians on the importance of dental health during pregnancy The LPHA also set up a dental visit at a local Medicaid-providing dental clinic so the pregnant mom may have an easier time receiving dental services and this improves her dental health. Between January and September 2022, 77 pregnant women received education about oral health. Of the 77 pregnant women, 51 received a visual dental screening. Twenty-three pregnant women scheduled dental appointments but only eight of them completed their dental appointments. Thirty-five women received a fluoride varnish application at the time of the WIC visit/appointment. The LPHAs educated five local obstetricians on the importance of good oral hygiene during pregnancy. The ODH promoted this program during the 2023 Spring Regional LPHA Meetings.

 

Community Health

The MCH Services Program continued to contract with LPHAs to support a leadership role for LPHAs at the community level to promote the health of mothers and infants by assuring prenatal, delivery, and postpartum care for low income, at-risk pregnant women. Twenty LPHAs are working to improve pre-conception, prenatal, and postpartum health care services for women of childbearing age as their Priority Health Issue (PHI).

• The New Madrid County Health Department worked to increase physical activity in order to prevent and reduce obesity among women of childbearing age. Health department staff collected data regarding health behaviors of women of childbearing age as well as barriers and challenges to implementing lifestyle changes. The health department plans to use that data to implement a “Women Walk Program”. The program, which will be offered to WIC program participants, will encourage women of childbearing age to walk as a group at the health department or a local park starting with a goal of 30 minutes each week for 8 weeks.
• The Adair County, Chariton County and Perry County Health Departments are working to prevent and reduce smoking among women of childbearing age and pregnant women. These LPHAs are increasing efforts to assess smoking status among women of childbearing age and offer smoking cessation resources and programs. Outreach efforts focus on engaging community partners and providers to strengthen referral networks and increase collaborative educational efforts and resource sharing.
  • The Adair County Health Department has created a policy to screen all women of childbearing age that present to the health department for any service for smoking status. A screening and referral tool has been developed and staff have been trained on how to use it. The MCH Coordinator attended the SCRIPT (Smoking Cessation and Reduction in Pregnancy Treatment Program) training in November 2022 and plans to implement the smoking cessation program at the health department in January, 2023 to increase the number of childbearing women who are screened for smoking status and referred for cessation education and services—increasing the number of women of childbearing age who quit smoking.
  • The Perry County Health Department facilitates the Baby & Me Tobacco Free program to reduce the number of pregnant and postpartum women who smoke. The program inspires and empowers pregnant women and their families to overcome nicotine addiction and works to support communities in order to disrupt the generational impacts of tobacco. The health department created three billboard messages that are displayed on a digital billboard in Perry County and this has increased community awareness and participation in the program.

• One LPHA is working to decrease the number of women with a recent live birth who experience frequent postpartum depressive symptoms as their PHI and one LPHA is working to improve mental health care services for women of childbearing age. These LPHAs are working collaboratively to increase community awareness of postpartum depression, increase educational opportunities to providers and community members, and increase the awareness, adoption, and implementation of evidence-based postpartum depression screening tools.

• The Callaway County Health Department developed a policy to screen all consenting postpartum women that present for WIC services using the Edinburgh Postnatal Depression Scale (EPDS) screening tool. The policy was approved by the County Commission in February of 2022 and has increased the number of postpartum women who are receiving mental health resources and services to manage postpartum depression. 85 postpartum women have been screened, with 22 scoring over 10 out of 30, indicating a need for referral. Women are referred to a local provider and contacted weekly by health department staff to ensure the referral was successful. Regardless of their score on the EDPS questionnaire, all postpartum women are given mental wellness resources.
• The Atchison County Health Department hosted a “Stress Less Fest” for women of childbearing age and their children. The event included a yoga, a sensory bin, a coloring, and a stress ball making station to allow participants to explore fun and soothing ways to reduce stress and promote positive mental health. Moms received a self-care basket that included items that promote physical and mental wellness. There were 13 attendees and participants reported an increase in knowledge on strategies to reduce stress and achieve mental wellness.

• Eight LPHAs are working to ensure women of childbearing age receive an annual preventative well woman visit. Some are working to change organizational practices to include well-women care as part of the services offered at their health departments while others are collaborating with local FQHCs to screen and refer women for services.
  • Miller County Health Center designed two family rooms for use during Perinatal Program, breastfeeding support, and WIC services appointments. These rooms use a Trauma-Informed Interior Design to create a comfortable and safe space. The color scheme, furniture, and overall design facilitate an atmosphere of openness and security, allowing for more thorough and impactful appointments. The rooms also act as a central waiting location while staff members come to the room to provide services. This has increased the number of services the mother is able to receive in one visit versus having to make multiple visits (see picture below of one of the rooms). The Perinatal Program is provided by the health educator and/or certified lactation consultant at the health center. The goal of this program is to provide pregnant women with increased knowledge and resources. Once a woman obtains a positive pregnancy test, she is referred to WIC. At the time of WIC enrollment, the woman is scheduled for her first WIC appointment as well as an appointment directly after with the Perinatal Program Coordinator. During the first perinatal program appointment, the pregnant woman is screened for safe sleep environment, infant car seat, breastfeeding knowledge, accessibility to prenatal vitamins, and other resources. The health educator then connects them to these resources.                                      

 

• The McDonald County Health Department worked to increase the number of women who have an annual preventative visit and created self-care as an incentive for women of childbearing age who complete their annual preventative visit at the health department. These kits include items to promote physical and mental health, such as a water bottle to increase water intake, a pedometer to increase physical activity, and a cookbook to increase knowledge on preparing a healthy meal. (picture of self-care kit below)

 

 

• The Springfield-Greene County Health Department requires all staff to be trained in the Advancing Health Equity training series and have incorporated this training into NEST Partnership. NEST stands for NUTURE, EMPOWER, SUPPORT, and TEACH. NEST Partnership provides nurse case management for at-risk prenatal and postpartum women or families with young children. Services are delivered in the home during scheduled visits for nurse assessment, intervention, education and collaboration with health care providers. Staff have reported increased knowledge as a result of completing the training series. In addition, the health department has started a health equity committee and NEST has a staff member serving on the committee. The committee developed a health equity toolkit which will be used to evaluate internal MCH policies for equity and inclusion. This has increased staff knowledge and awareness of health equity in working with the MCH population.

• Two LPHAs are working to reduce racial disparities and ensure black women of childbearing age receive preconception, prenatal, and postpartum health care services. These LPHAs are working closely with their internal and external partners, including local hospital labor and delivery units and local universities within their medical training programs.

 

The MCH Services Program supported LPHA efforts to: provide education on the importance of adequate dental care and overall oral health, collaborate with partners to provide screening, referral and direct provision of preventive dental services for oral health needs, and increase the number of women receiving a preventive dental visit during pregnancy. LPHA and/or community partner efforts to implement education programs for pregnant women, families, and providers on the benefits of delivery after 39 weeks gestation, the risks of preterm delivery, and the risks associated with a cesarean birth are also being supported.

• Wright County Health implemented a dental varnish program where staff provide oral assessment, education, referrals and applications of fluoride varnish to pregnant women. This service increased the number of pregnant women that receive an oral health screening and fluoride varnish application. 59 pregnant women received an oral health screening and education and 36 pregnant women received dental varnish.

 

The TEL-LINK Program helped improve maternal and child health by providing 2,721 health care service referrals to increase access to care for any Missourian who needs assistance. The program promotes this service through search engine campaigns to provide outreach to the underserved population. TEL-LINK provided referrals to a wide range of services such as: smoking cessation, dental care providers, WIC clinics, mental health treatment centers, health insurance providers, and many more.

 

The Newborn Health Program continued to partner with a variety of community health providers to raise awareness/educate the MCH population on resources for women of childbearing age and their families which includes preconception, prenatal, and postpartum care, as well as smoking cessation, postpartum mood disorders, and the importance of taking folic acid. The program accomplishes this through the free distribution of the Pregnancy and Beyond books and a wide variety of educational materials. All of these resources contain information to improve pre-conception, prenatal, and postpartum health care services for women of childbearing age. The program tracked the distribution of these materials and obtained feedback from partners on how they use the materials and ways to improve them. The Healthy Births and Babies (HBB) Unit continued to utilize and promote an informal maternal and child health internal work group and maximize outreach opportunities at conference exhibits, health fairs, and through the Home Visiting Programs by distributing various educational materials.

 

The Missouri WIC Program promoted the importance of depression screening utilizing the Patient Health Questionnaire-2 (PHQ-2) for prenatal, breastfeeding, and non-breastfeeding women. The purpose of the PHQ-2 is not to establish a final diagnosis or to monitor depression severity, but rather to screen for depression as a “first step” approach. Currently, 27 local agencies use the PHQ-2 screening. WIC continued the referral system to the Home Visiting Program, TEL-LINK program, the Missouri Primary Care Association, and other support programs. WIC staff also continued outreach efforts to enroll pregnant women into the WIC Program during their first trimester. For some, WIC is the first stop once they discover they are pregnant. WIC helps pregnant women by supporting a healthy pregnancy from the start; the nutritious foods, education, and resources WIC provides help to ensure the best possible outcome for mom and baby.

 

Home Visiting

The Title V MCH funded Home Visiting Program continued to share information with all contracted local implementing agencies to educate home visitors about the Affordable Care Act (ACA) marketplace enrollment process including any changes in access for enrolled participants. Home visitors accessed resources through weekly updates. As the Home Visiting Program received updates on enrollment procedures, the information was forwarded to contracted home visitors, who utilized it to assist women in applying for and accessing MO HealthNet (Missouri’s Medicaid) coverage for unborn children, newborns, and pregnant women, to assure they attained appropriate prenatal care. The Home Visiting Program also collected annual performance measure data on the percent of mothers enrolled in home visiting prenatally or within 30 days after delivery who receive a postpartum visit with a health care provider within 8 weeks of delivery. In FY22, 57.4% (112/195) of women received a postpartum follow-up visit.  With the transition of the Home Visiting Program to the Department of Elementary and Secondary Education (DESE)-Office of Childhood (OOC) in FY2021, opportunities to collaborate with partners, both internal and external, are continuing to address access to care.

 

Additional Title V MCH funded Home Visiting Program services included:

• Promotion of smoking cessation to all primary caregivers who answer yes to smoking at enrollment or at any subsequent 6 month time points. Annual performance measure data was collected on the percentage of primary caregivers who reported smoking, using tobacco, or other forms of nicotine delivery, including e-cigarettes, at enrollment and were referred to tobacco cessation counseling or services within three months of enrollment. FY22 data indicated that 42% (39/92) of primary caregivers enrolled in OOC funded home visiting programs who reported using tobacco or cigarettes at enrollment were referred to tobacco cessation services within three months of enrollment. (In addition, home visitors were provided with information and resources on tobacco cessation through the weekly update. Home Visitors shared resources such as the DHSS Missouri Tobacco Quitline and TEL-LINK with participants.
• Providing information and resources that promote the benefits of pregnancy to the full 40 weeks to all contracted home visitors to share with clients. Resources included DHSS and March of Dimes materials. Title V MCH funded Home Visiting Program Specialists assessed the receipt and use of these resources during the monthly subrecipient monitoring calls with contracted local implementing agencies and during annual trainings.
• Screening all prenatally enrolled clients for depression within three months of delivery. Primary caregivers not enrolled prenatally were screened within the first three months of enrollment. Home visitors utilized the Public Health Questionnaire 9 (PHQ-9) depression screening tool at these prescribed time points and additionally anytime home visitors recognized potential symptoms of depression. Individuals who screened positive were referred to the appropriate services. In FY22, 80% of primary caregivers (268/335) enrolled in home visiting were screened for depression within three months of enrollment (for those not enrolled prenatally) or within three months of delivery (for those enrolled prenatally). Additionally, FY22 data indicated that 13% of primary caregivers (9/69) who tested positive for depression completed referrals to services for a positive depression screening.
• Providing contracted home visitors with information on oral health resources from the ODH and the Missouri Primary Care Association to share with enrolled primary caregivers to promote the importance of receiving preventive dental care during pregnancy.

 

Environmental Health

Many persons are not aware that lead exposure can be a problem for women of childbearing age, a developing fetus and a nursing infant. The most serious effect of high levels of lead exposure during pregnancy are miscarriage and stillbirth. Other pregnancy problems such as gestational hypertension, low birth weight and premature delivery can also occur. Prenatal lead exposure impairs children’s neurodevelopment, placing them at increased risk for developmental delay, reduced IQ, hearing impairments, and learning and behavioral problems.

 

DHSS lead poisoning prevention staff continued to perform the following activities to prevent or decrease blood lead poisoning in pregnant women and their babies:

• Provided community lead education via various outreach events such as health fairs;
• Participated in updating outreach materials such as the “Pregnancy and Beyond” booklet and other pamphlets and brochures which are distributed to expectant and new parents;
• Made contact with pregnant women and their health care providers when they were known to have elevated blood lead levels (EBL) of 5 mcg/dL or higher (tracked by the ABLES staff); and
• Provided lead education and resource materials to health care providers, LPHA and health plan lead case managers, as well as WIC Program staff regarding the need to discuss lead poisoning prevention and lead testing with clients. This included providing LeadCare Analyzers and lead test kits to LPHAs that do not have the capacity to provide accurate lead screenings—allowing them to offer this service on a regular basis.

 

The Prenatal Substance Use Prevention Program promoted the importance of prenatal substance use prevention to promote healthy pregnancy and birth outcomes. The program utilized statewide community placement sites, which house substance exposed infant manikins to demonstrate the effects of drugs and alcohol during pregnancy. Despite the challenges of COVID-19 in calendar year 2021, the community placement sites demonstrated the substance exposed manikins 114 times, educating 1,683 individuals. In calendar year 2022, sites were able to utilize the manikins 125 times and educated 2,442 individuals. In addition, awareness campaigns promoted healthy pregnancy and abstaining from all substances before, during, and after pregnancy. The campaigns utilized geographic, demographic and life stage targeting. The ads ran for four months in 2021 (over 1,820,000 impressions) and three months in 2022 (over 1,480,000 impressions). (visual of geographic distribution of impressions below)

 

Impressions Map (visual of geographic distribution)
April-July 2021 (campaign period)	August 2021 (non-campaign period)	March-May 2022 (campaign period)

 

The Safe Cribs for Missouri Program continued to educate each crib recipient on smoking cessation and the consequences of smoking during pregnancy. Missouri Tobacco Quitline tip cards and MO HealthNet resources were utilized.

 

Maternal Mortality

The OWH abstracts and reviews all pregnancy-associated mortalities in Missouri. This is done to ensure that information from all maternal deaths occurring within one year of pregnancy termination is captured. Maternal mortality cases that occurred in 2020 have been abstracted and are being reviewed by the Pregnancy-Associated Mortality Review (PAMR) board. Abstraction of 2021 cases is ongoing. The reviews aid in the identification of strategies to prevent maternal mortality. DHSS published an annual report on maternal mortality with findings from the PAMR and collaborated with partners and other key stakeholders to implement the recommendations.

 

Through a competitive grant process, DHSS was selected for a 5-year grant awarded through the Centers for Disease Control and Prevention’s (CDC) Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM) Program. This funding directly supports agencies and organizations that coordinate and manage Maternal Mortality Review Committees (MMRC) to identify, review and characterize maternal deaths and identify prevention opportunities. The OWH is wrapping up year three of the grant and planning for year four activities. The OWH improved internal processes to expedite maternal mortality case identification, abstraction and review by working with the Bureau of Vital Records to use provisional death files. Furthermore, maternal mortality cases were grouped by date of death for abstraction and review. For example, if at all possible, deaths that occur at the beginning of the year are abstracted first and brought to the PAMR Board for review. In addition, a Patient Abstract System (PAS) linkage was developed during year two of the grant to identify additional hospitalizations and/or emergency room visits to aid in case abstraction. The PAS linkage was further refined by developing a linkage to identify cases of early pregnancy in hospital discharge data where there would be nothing else to indicate a pregnancy from the death certificate (i.e. early miscarriage). This looks at all women of birthing age (10-60) who died in a given year and uses the diagnostic and procedure coding to identify women who had an ICD-10 O code (or A34). This code is used in maternal records for pregnancy and childbirth. It uses a combination of name/date of birth and social security number/date of birth to identify such cases. As this is a newly developed linkage, further information on outcomes will be forthcoming. Through the ERASE MM grant, the OWH contracts with the Missouri Hospital Association (MHA) to implement patient safety bundles in Missouri birthing facilities, clinics and critical access hospitals. Implementation of the “Care for Pregnant and Postpartum People with Substance Use Disorder” (CPPPSUD) bundle began in 21 facilities. The bundle was implemented in response to the June 2021 PAMR report that identified maternal overdoses as a leading cause of maternal death.

 

Soon after launching the Missouri Maternal-Child Learning and Action Network (MC-LAN) in 2018, DHSS and the MHA partnered to join the American College of Obstetricians and Gynecologists (ACOG), as funded by the Health Resources and Services Administration, Alliance for Innovation on Maternal Health - AIM. Through this effort, MHA takes the lead on implementation of maternal safety bundles in Missouri birthing facilities. As the first initiative, Missouri implemented the AIM “Severe Hypertension in Pregnancy” patient safety bundle. In response to the Centers for Medicare and Medicaid Services “Birthing Friendly” hospital designations rule, MHA opened up Missouri’s AIM collaborative to allow facilities to implement the Severe Hypertension in Pregnancy (SHP) bundle or Obstetric Hemorrhage (OH) bundle in addition to the CPPPSUD Bundle. Facilities implementing the SHP or OH bundles have online access to bundle resources, including recordings from previous webinars. While facilities are expected to report data on some bundle elements, they do not receive intensive support as the active CPPPSUD collaborative. The OWH and the MCH Director collaborated with MHA and other key stakeholders through the MC LAN to provide guidance, knowledge sharing and peer support as the initiatives continue. The MC LAN provides strategic guidance and focus of high-value opportunities to improve clinical, operational and outcome performance, and to develop collaborative partnerships to achieve these aims. In addition, the committee partners with the communities it serves to achieve better communication, and educate the public on quality and safety initiatives of the health care community. This committee meets three times a year with additional virtual meetings as needed.

 

Other Title V MCH Activities Related to the Women/Maternal Health Domain

 

The OWH supported several initiatives to assist women of child bearing age. While these initiatives were not funded by Title V MCH, staff funded by Title V MCH leveraged Title V MCH support to ensure adequate response to emerging issues. First, the OWH supported the Uninsured Women’s Health Services Program. With the Missouri Department of Social Services (DSS), the OWH reimbursed medical providers for women’s health services. These included: approved methods of contraception; testing and treatment of sexually transmitted diseases, including pap tests and pelvic exams; family planning, counseling, education on various methods of birth control; and drugs, supplies, or devices related to the women’s health services described above, when they are prescribed by a physician or advanced practice nurse. During the 2022 state fiscal year 26,728 individuals were enrolled in the program. The estimated cost savings to the state due to unintended pregnancy was $25,701,576. Second, the OWH maintained a public listing of pregnancy assistance information and ultrasound providers. The OWH sends a survey annually in order to develop a listing of private and public agencies available in the state to help pregnant women. This listing of assistance and ultrasound providers is indexed geographically and is available online. Third, the OWH represented the Department in several statewide task forces and commissions, including the Missouri Rights of Victims of Sexual Assault Task Force and the Combatting Human Trafficking and Domestic Violence Commission. Additionally, the OWH supported the statewide Sexual Assault Nurse Examiner Telehealth Network. This network is in the beginning stages and will expand access to forensic exams across the state. Finally, the OWH led the start of several new initiatives to improve the health of women in the state. These included a tobacco cessation program for pregnant women, a doula training initiative, a free prenatal care program in Kansas City, Missouri, and a perinatal quality collaborative for the prevention and treatment of opioid abuse disorders among pregnant and postpartum women.

 

Through participation in the Association of State and Territorial Health Officials (ASTHO) and the Association of Maternal and Child Health Programs (AMCHP) Promoting Innovation in State & Territorial MCH Policymaking (PRISM) Learning Community, DHSS partnered with the University of Missouri Kansas City Institute for Human Development (UMKC-IHD) to organize, convene and facilitate a statewide Maternal Health Multisector Action Network (the Network). Focused on a life course framework, the Network promotes a coordinated, multidisciplinary system of care for women of childbearing age and pregnant and parenting mothers to assure health equity, racial/social justice, and a comprehensive continuum of care, including prevention and treatment efforts, for women/mothers with mental health and substance use disorders (SUD). The Network used a landscape scan of State Policy Options for Perinatal Women with Substance Use Disorders provided by AMCHP to inform its priorities, goals, strategies, and future policy initiatives and aims to address risk and protective factors that influence health disparities within families and communities through the Life Course Perspective.

 

The Network was established in 2022 and has over 200 individual stakeholders; 40 of whom are active participants. A diverse, multi-sectored group of MCH, public health, mental and behavioral health, SUD treatment, social services, and other community stakeholders, including LPHAs, were invited to participate in the Network efforts. Two groups oversee the work of the Action Network: 1) the Moms’ Self-Advocacy Network, comprised of mothers with lived experience, and 2) the Planning Committee, comprised of content experts and key stakeholders with expertise in MCH and SUD. The Mom’s Self-Advocacy Network is being developed.

 

To incorporate the lived experiences of mothers of young children affected by substance use and mental health challenges, the Network promoted partnerships with individuals, families, and family-led organizations to ensure family engagement in decision-making, program planning, service delivery, and quality improvement activities. The UMKC-IHD conducted six focus groups or “mapping sessions” to better understand the facilitators and barriers to accessing high quality and equitable services for mothers affected by substance use and mental health disorders. The UMKC-IHD recruited two groups of individuals for focus groups: Mothers of young children affected by substance use throughout the state and service providers or individuals who work at organizations/agencies that provide services to mothers affected by SUD and mental health disorders before, during and/or after pregnancy. Understanding the lived experience is crucial to guiding the development of future services and support systems available to address maternal substance use and mental health, resulting in improved health outcomes for mothers and their children. Focus group discussions identified the following themes:

• Facilitators to care included:

• Practitioners who listen wholeheartedly to their patients and learn about their patient/their lives;
• Childcare available with treatment or other recovery services;
• Access to transportation, phone, and internet; and
• Advocates, such as doulas, community health workers, and home visitors.

• Barriers to care included:

• Long wait times between the decision to access SUD treatment/detox and admission;
• Lack of a recovery community with shared experiences of motherhood;
• Access to care-organizations and agencies only provide services and treatment during business hours, which is when many mothers work or provide care for their children;
• Fear of being vulnerable and the possible repercussions of disclosing substance use; and
• Stigma and biased care from providers, clinicians, child welfare, legal system, and community.

 

UMKC-IHD facilitated three Action Network meetings in March, July, and September of 2022. By incorporating the voices of mothers with lived experience, the Network identified the following five priority areas associated with maternal substance use and mental health:

 

1. Social Determinants of Health/Stigma/Justice/Equity;
2. Wraparound Services/Team Birth Approach;
3. Medicaid Expansion;
4. Child and Family Support Services; and
5. Criminal Justice Issues.

 

Work groups were formed around the five priority areas, and the landscape scan helped identify areas of strength, opportunities, gaps in services, and policy options. The workgroups serve to develop strategic action plans for Missouri-specific priorities, as decided by the Moms’ Self-Advocacy Network, Planning Committee and the Action Network.

 

As the state’s chief maternal child health strategist, the MCH Director worked to broaden the scope of MCH partnership beyond DHSS and other state agencies. As a convener of multidisciplinary, cross-sector collaborations and facilitator of meaningful and diverse partnerships, Title V MCH brings MCH partners and programs together across programmatic siloes and organizational boundaries to promote the health of the MCH population and address social determinants of health and health inequities. For example, the MCH Director facilitates collaboration with the two Healthy Start grantees (Nurture KC, and Missouri Bootheel Regional Consortium) and their partners to facilitate sharing of information and resources, shared learning and identification of opportunities for alignment and collective impact. The MCH Director is actively engaged in statewide collaborative efforts to promote the health of women of childbearing age, including but not limited to participation in PAMR, MC-LAN, Women's Health Council, the DSS Maternal/Infant Health Efforts coordination meetings, the Uplift Connection, the ParentLink Advisory Council, and the Missouri Association for Infant and Early Childhood Mental Health.