Overview
The Women’s Health program at the Department of Health (DOH), works to support women’s and maternal health in a variety of ways. Some of our most important work is to promote, influence, adopt and revise policies and processes that can have positive impacts on women and families.
We also offer educational materials and resources on a wide range of topics, including healthy eating, physical activity, vitamins and nutrients, oral health, genetic illness, mental health and depression, safe relationships, family planning, pregnancy, sexually transmitted illnesses, and substance abuse. Materials are available in a variety of languages.
National Performance Measure 1 – Well-Woman Visit
Percent of women, ages 18 through 44, with a preventive medical visit in the past year.
According to the Behavioral Risk Factor Surveillance System (BRFSS), the percent of women with a past year preventive medical visit was 61.1 percent in 2017. This rate has remained steady since 2009.
Women’s health staff monitored issues related to the mandated preventive services for women and worked with the Office of Insurance Commissioner and Health Care Authority (HCA), the state’s Medicaid administrative agency, when appropriate to try to ensure access to these benefits.
Culturally and Linguistically Appropriate Services (CLAS) standards have been implemented in managed care contracts. The Women’s Health Nurse Consultant and the Perinatal, Women’s and Adolescent Health Program Manager are both involved in the Office of Family and Community Health Improvement group to develop a CLAS implementation plan specific to our programs.
This past grant year, women’s health staff coordinated the immediate postpartum long-acting reversible contraception (LARC) group in partnership with the HCA to better understand the billing process for hospitals to successfully charge the provider fee and device fee that have been unbundled to make this service financially sustainable.
Since 2016, HCA has been working to integrate physical and behavioral health services. The state will fully integrate the financing and delivery of physical health services, mental health services and chemical dependency services in the Medicaid program through managed health care by 2020. As the state moves toward a regional Medicaid purchasing approach, it creates a pathway for regions to "opt-in" and fully integrate physical and behavioral health care purchasing. This initiative, called Healthier Washington, as described in the Overview of the State, is a multi-agency effort supported by federal funding to build healthier communities through a collaborative regional approach, integrate how we meet physical and behavioral health needs so that the health system focuses on the whole person, and improve how we pay for services by rewarding quality over quantity.
In an effort to address the needs of women and infants impacted by the opioid epidemic, our women’s health staff have partnered with the Division of Behavioral Health and Recovery (DBHR) and Medicaid at the HCA, the Washington State Hospital Association (WSHA) and the March of Dimes (MOD) to improve the quality of care and access to care by forming a workgroup of the state opioid taskforce. The purpose of this workgroup is to integrate mental and physical (maternal) health care services through existing agencies and programs. We aim to decrease stigma while improving standards of care and easing access to care. Additionally, we aim to decrease addiction to opiates and increase recovery for women and their families.
This past year, the Women’s Health Nurse Consultant partnered with local maternal care providers at the MOD and HCA to support local efforts in Seattle, Spokane and the Tulalip Tribes to address the maternal needs of women impacted by substance use disorder and to discuss ways to address the reduced access to services on the eastern side of the state. She will continue to provide technical assistance to local health providers through site visits during the next grant year.
WithinReach is a Maternal and Child Health Block Grant contracted provider. This private, not-for-profit organization serves as a single point of entry to the many resources a family needs to be healthy. They connect Washington families to health and food resources, promote awareness and education about specific health issues, provide insurance information and make connections in person, online, and over the phone. They provide eligibility screening and referrals to Medicaid, the Women, Infants and Children Nutrition Program (WIC), and other services. They offer referrals and health education information about pregnancy, prenatal care, maternity support, childbirth, immunizations, and family planning.
WithinReach’s ParentHelp123.org resource website had 20,826 page views with 16,720 total unique page views in calendar year 2018.
WithinReach's Family Health Hotline (FHHL) is Washington State's maternal and child health hotline. During federal fiscal year (FFY) 2018, the FHHL received and responded to 16,791 calls. Questions relating to food and nutrition resources generated the greatest number of in-bound calls, and resulted in 8,653 food assistance referrals and 6,045 referrals to WIC. 72 referrals were made to immunization clinics. Numerous additional referrals were made for pregnancy-related services, including 18 referrals for breastfeeding support.
WithinReach provides health information in a variety of languages for people who are not proficient in English. During FFY 2018, the total number of FHHL Spanish phone calls was 640. FHHL averaged 137 non-English calls per quarter. Nearly all of the call center staff are bilingual, and nearly 99 percent of Spanish-language calls are completed without a third-person interpreter.
Other Work, 2018 to Present
Policy and Process Improvement
We have an evidence-based strategy measure (ESM) to count the number of policies and practices influenced and promoted by staff that positively impact the rate and quality of well-women medical visits for women of child-bearing age in Washington. We exceeded our 2018 goal of one policy/procedure with 12 policies/procedures, described briefly below:
- One Key Question supports women’s power to decide by helping to transform their health care experience. One Key Question asks all health providers and champions who support women to routinely ask, “Would you like to become pregnant in the next year?” From there, the provider or champion takes the conversation in the direction the woman herself indicates is the right one, whether that is family planning, preconception health, prenatal care, or other needs. We are working to improve the counseling and contraception options women receive at their well-woman visit for primary care (1). DOH has begun promotion of One Key Question through our family planning programs (2). Additionally, this year we are partnering with our HIV/STI programs to incorporate One Key Question (3).
- DOH is innovating to create partnerships between local syringe exchange sites and the family planning program to reduce barriers to contraception for men and women with substance use disorder (4). Washington has one syringe exchange site that offers all forms of contraception, one syringe exchange site that is located next to a community health clinic that offers contraception services, and one syringe exchange site that asks about pregnancy intention and provides coordination and transportation to family planning services.
- The Department of Health has partnered with WSHA to join the Alliance for Innovation on Maternal Health (AIM), which is a national organization run in partnership with the American College of Obstetricians and Gynecologists (ACOG) to improve maternal outcomes through the implementation of hospital-wide quality improvement protocols. Title V staff have participated in coordinating the kick-off meeting (March 2019) and are working with WSHA and birthing hospitals to implement protocols and report out de-identified data. (5)
- As part of quality improvement resulting from maternal mortality review (MMR) recommendations, perinatal staff led regular meetings of the state’s autopsy workgroup, which is working to ensure every woman who dies while pregnant or within 42 days of the end of the pregnancy has a quality autopsy done, has her death reported to the local county coroner’s office and has her death investigated, including autopsy. (6)
- Interagency collaboration is occurring between state agencies, WSHA, MOD, and key stakeholders to intervene for the maternal needs of women and their babies who have been impacted by the opioid epidemic. The Department of Health is leading the state opioid response team and Title V staff leads the workgroup that addresses the maternal child impact. This workgroup has several areas of work including increasing low-barrier access to contraception, improving perinatal care, addressing clinician bias, conducting community-level need analysis, linking pregnant and postpartum women to clinical and community resources, expanding access to medication-assisted treatment, expanding wraparound services, working with birthing hospitals to develop rooming-in policies for mothers and babies with withdrawal and to transition to using the eat/sleep/console tool, working with the Department of Children, Youth, and Families (DCYF) to increase consistency in child removal practices, and determining breastfeeding guidelines. (7)
- DOH is also leading two other interagency initiatives working to address the maternal/child/family impact of the opioid epidemic (8):
- In November 2018 an Association of State and Territorial Health Officials (ASTHO) interagency team led by Title V staff launched two initiatives: (1) to clarify and write policy around the federal 2016 Child Abuse Prevention and Treatment Act (CAPTA) regulations to notify Child Protective Services of all drug-affected infants, and (2) to address the needs of women who have not received substance use treatment and prenatal care during pregnancy and want to move into recovery and parent their child. This is to be accomplished by creating billing structures for birthing hospitals to treat the mother and baby together (start on medication-assisted treatment and monitor baby for withdrawal), and then transition mother and baby to residential treatment for pregnant and postpartum women. This assures the safety of the infant and supports the maternal recovery and parenting transition of the mother.
- In March 2019 an Association of Maternal and Child Health Programs (AMCHP)/ASTHO interagency team led by Title V staff was launched to address the housing needs of families impacted by the opioid epidemic through policy changes.
- Home visiting: One of the MMR panel’s recommendations was to improve follow-up care for women during the postpartum period, specifically during the first seven to ten days after the end of the pregnancy. One implementation of this recommendation is the promotion of a postpartum in-home nurse visit focused on the medical, psychosocial and emotional needs of both the mother and her infant. A small workgroup was formed around this idea and they brainstormed ways to promote and support a postpartum home visit. They learned details about what home visiting services are currently available in Washington, the populations they serve, and which of these might fulfill the very specific need of this in-home nurse visit during the postpartum period. They are also learning more about similar models elsewhere that have proven success. Currently the group’s work is on hold pending other efforts in the state surrounding home visiting, including the promotion of a postpartum in-home nurse visit as a recommendation in the Promoting Healthy Outcomes for Pregnant Women and Infants Bill (Substitute Senate Bill 5835), and as state agencies work to expand and reformulate home visiting services. (9)
- Led by perinatal contractors, the obesity workgroup met regularly with guidance from the Title V-supported Perinatal Nurse Consultant. The obesity workgroup is developing guidelines/protocols for the care of pregnant women with a high body mass index (BMI). (10)
- Maternal mortality review: This year, staff conducted presentations to providers and hospitals to share results of our findings and improve the medical care of pregnant and postpartum women. (11)
- In 2018 the Healthy Pregnancy Advisory Committee submitted to the legislature a report that outlines strategies for improving maternal and infant health outcomes in Washington State. (12)
Zika
While the mosquito that spreads the Zika virus is not found in Washington, we have residents potentially exposed via travel or sexual transmission and we are providing informational resources. Due to the increasing evidence supporting a link between Zika virus infection during pregnancy and adverse pregnancy and birth outcomes such as microcephaly and preterm birth, DOH is conducting surveillance, sending tests to the Centers for Disease Control and Prevention (CDC), conducting follow up of positive testing, providing public education about mosquito bite prevention measures, and informing obstetric and reproductive health care providers of CDC clinical guidance for testing and pregnant care content for women exposed to or infected by Zika.
Pregnancy registry is in place to follow up with all pregnant women and infants who test positive. Title V staff will assist with registry follow-up if called upon. As of March 2019, there are 84 confirmed and probable travel-associated cases in Washington. Our Women’s Health Nurse Consultant is also the point of contact for cross-referrals of families relocating to our state and between health officials in Puerto Rico (PR) and Virgin Islands (VI), and the state Title V agency.
Maternal Mortality Review
In March 2016, the legislature passed Engrossed Second Substitute Senate Bill 6534 (codified at RCW 70.54.450) creating the Maternal Mortality Review Panel (MMRP) to conduct multidisciplinary review of all maternal deaths in Washington. The law set out to identify factors associated with the deaths and make recommendations for system changes to improve women’s health care services in the state. The law requires a report outlining the findings of the review and recommendations to be submitted to the health care committees of the Washington State House of Representatives and Senate every two years. The inaugural review was completed in spring 2017 and reflected the review of maternal deaths from 2014 and 2015. The subsequent Maternal Mortality Review Report was released in August 2017.
The MMRP reviews each maternal death case (death of a woman during pregnancy or within the first 365 days after pregnancy from any cause), and distinguishes which deaths were pregnancy-related (the death occurred during the woman’s pregnancy or within 365 days after the end of her pregnancy from a cause that was complicated by pregnancy, a chain of events initiated by pregnancy, or the aggravation of an unrelated condition by the physiological effects of pregnancy). Feedback from members of the MMRP and key partners led to an expansion of the scope of work of the MMR, and suicide and substance-use related deaths are now included in the reviews, with some of these deaths now classified as pregnancy-related.
Maternal mortality reviews of deaths from 2016 were completed in August 2018. Findings from the review of 2016 deaths, as well as suicide and substance-use-related deaths from 2014-16, will be published with recommendations on prevention in the mandated legislative report in October 2019.
In 2019, Substitute Senate Bill 5425 concerning maternal mortality reviews was signed into law. This revises and extends the state’s previous maternal mortality review panel law, which is due to expire in June 2020. It authorizes DOH to include more diverse membership on the panel and requires tribal representation. It also contains new requirements for hospitals and birthing centers, which must now report deaths of women who have died within 42 days of the end of pregnancy, and new requirements for coroners and medical examiners, who must conduct death investigations and autopsies on those reported deaths. The state budget allocated $265,000 each year for 2020 and 2021, which will cover basic infrastructure to conduct the review process and write the report. MCHBG provides support to oversee the review program.
Messaging
Women’s health staff continued to use the DOH website and social media to disseminate messages about issues impacting women’s health, including the importance of folic acid, safe relationships, substance use awareness, and around special events, including Women’s History Month, Black Maternal Health Week and National Women’s Health Week.
We continue to partner with HCA (Medicaid), WSHA, and MOD to encourage increase in the number of providers offering group prenatal care, especially to women struggling with substance use disorder and mental health issues.
WSHA has begun updating their safe delivery bundles, beginning with the pre-pregnancy bundle. The Women’s Health Nurse Consultant is a member of the steering committee and regularly participates in the communications. She is also working with DOH Environmental Health staff to assess the possibility of integrating lead and mercury screening into the pre-pregnancy and prenatal bundles.
One of the strategies recommended by the Healthy Pregnancy Advisory Committee in their 2018 report to the legislature is enhanced reimbursement for group prenatal care. Our Women’s Health Nursing Consultant has also partnered with MOD and perinatal health providers to integrate substance use and parenting content specific to the needs of women with substance use disorder into MOD’s group prenatal care model.
We work with partners, including the Department of Corrections (DOC) and medical providers, on ensuring availability and accessibility of all women to LARC. Women’s health staff are collaborating with the DOH Family Planning program to support DOC in offering Nexplanon and intrauterine device (IUD) access for female inmates. We are also working with Title X partners to assist with training. The Women’s Health Nurse Consultant also connected with Upstream (a new non-profit to our state) to assist providers, billers, schedulers, medical assistants and nurses in training for same-day LARC insertion. The objective is to integrate family planning into primary care and to increase access for all women who want a LARC. Another goal with DOC is to increase provider training for IUD insertions.
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