Women & Maternal Health: Annual Report
In 2017, there were approximately 328,941 women of reproductive age (15 to 44 years old) residing in Idaho, which is just over 19% of the total state population. Idaho’s birth rate for the same year was 12.9 per 1,000 population, which is higher than the national rate of 12.4 (2015). About half (50%) of women aged 18 to 44 had a preventive medical visit in the past year (BRFSS). Among pregnant women who sought prenatal care, 79% initiated prenatal care during the first trimester (PRATS). It’s worth noting that Idaho gained some media attention in 2018 based on results from a study which indicated Idaho was the worst state for working moms (Wallethub, 2018). Specifically, the study ranked the state as 51st for child care (quality and costs) and 48th for professional opportunities for women.
For the Women/Maternal Health domain, Idaho selected “NPM 1: Well-Women Visits” based on the results from the needs assessment indicating the need to focus on routine care for women, including prenatal care for pregnant women. By July 2020, the state aims to see an increase in the number of women who are linked to routine well-woman care, including prenatal care during the first trimester. Measurement of the objective will be based on federally available data for Idaho. Strategies to address this objective and NPM are discussed below.
The Maternal, Infant, and Early Childhood Home Visiting (MIECHV) and the Family Planning Programs are administered within the Maternal and Child Health Section which allows for better alignment of home visiting, family planning, and Title V MCH priorities. In 2017, the Idaho Title V Program collaborated with the Family Planning Program and the MIECHV Program to integrate One Key Question® (OKQ) into their service delivery. OKQ is an evidence-based strategy that encourages providers to ask clients the question, “Would you like to become pregnant in the next year?” as part of routine care. This process is designed to incorporate pregnancy intention screening into reproductive health and primary care settings as a proactive way to increase the proportion of pregnancies that are wanted, planned, and as healthy as possible. By asking the question, clients are supported in their decision-making, and clinicians can provide education and services that are tailored to the desires and needs of each client. Client responses, along with education and referrals, are captured in the EHR and reviewed during chart audits as a quality assurance measure. Idaho Title V funded the contract with the national model developer to offer web-based training to five family planning clinics and seven home visiting programs.
From January 1 to December 31, 2018, a total of 9,133 female clients and 919 male clients were screened for pregnancy intention using the OKQ approach. Based on these data, 99.5% (10,052/10,104) of family planning clients were assessed for pregnancy intendedness using OKQ (ESM 1.3). Those screened included 9,133 female clients and 919 male clients. Of these, 5% responded with “Yes,” 68% responded “No,” 2% responded that they were “Okay either way,” and 3% indicated they were “Unsure.” About 22% of clients were not asked during the current visit about their pregnancy intention. Providers are asking OKQ within a range of frequency from every three months, every six months, or annually. It may not be appropriate or necessary to ask a client at every visit, which contributes to the 22% that were not asked. As of June 2019, four public health districts and two federally-qualified health centers are currently using OKQ to screen for pregnancy intention across 42 service sites.
Due to competing priorities and change in data management systems, implementation of OKQ within MIECHV programs has been put on-hold.
The MCH block grant continued to provide funding to the Idaho Family Planning Program to support subgrants to four of the seven local public health districts and two federally-qualified health centers (FQHCs), which provide family planning services on a sliding-fee scale in accordance with Title X regulations to women of reproductive age, as well as adolescents and men. About 20% of clients served were adolescents under the age of 20, and about 7% were male. Family planning services at the local level include reproductive health exams, pre- and inter-conception health planning, pregnancy testing and counseling, preventive health education, and provision of contraception. It’s worth noting that three health districts have elected to no longer deliver Title X services. Therefore, client counts have declined. In 2018, the family planning programs served 10,104 unduplicated clients: 9,177 females and 927 males. Among these clients, 2,517 received pregnancy tests. Five hundred forty-four (544), or 22%, of these women received a positive pregnancy test, and two hundred seventy-nine (279), or 12%, were given a referral to prenatal care. Sixteen (16) women, or 0.6%, were given a referral for high risk pregnancy care. In total, 295 women who were in need of prenatal care were referred (ESM 1.2).
In the Title X Family Planning program, women who receive a positive pregnancy test are offered a variety of information based on their disposition during the visit. If a client was planning the pregnancy, desires the pregnancy, or seems clear about wanting to continue the pregnancy, the client receives a packet which includes a list of prenatal care providers who accept Medicaid, as well as information about Medicaid and WIC. If a client seems unsure about the pregnancy, the same packet is offered with a list of prenatal care providers, Medicaid, and WIC information, and other options such as adoption and/or termination are discussed. In Public Health District 7, a program called Medicaid Ineligible Pregnancy Services (MIPS) helps pregnant women who are Medicaid ineligible navigate the prenatal process. Medicaid Ineligible women include non-residents such as international students, refugees, and those who are undocumented. Women are given a list of prenatal care providers who will accept the Medicaid rate (which would be paid out-of-pocket). These women can get their prenatal lab work through the health district, which is less expensive than through a private provider. MIPS also includes paperwork to get a Medicaid Emergency Card for post-delivery.
In 2019, the Idaho Family Planning Program began a collaboration with the Sexual Violence Prevention (SVP) Program within the Division of Public Health to provide regional training opportunities for Title X providers using the Futures Without Violence curriculum, Did You Know Your Relationship Affects Your Health? This curriculum is a train-the-trainers model that addresses intimate partner violence (IPV), reproductive coercion (RC), and sexual coercion (SC). This innovative approach focuses on the crucial role of health care providers in identifying and addressing IPV, RC, and SC in the clinic setting. The curriculum provides training, tools, and resources to help health care providers address these complex and sometimes uncomfortable issues. The training demonstrates how to use a safety card to educate clients about RC and SC during Title X family planning visits to improve reproductive health outcomes and promote safe and healthy relationships. Safety cards and other resources for integrating and sustaining a trauma-informed, coordinated response to IPV, RC, and SC are provided to participants during the training.
The Idaho MIECHV Program is in the Maternal and Child Section which is directed by the MCH Director who is also the MIECHV Project Director. The Idaho MIECHV Program continues to serve at-risk communities within the seven public health districts across the state. MIECHV supports seven local implementing agencies (LIAs) to deliver evidence‑based home visiting services, which have been shown to promote positive parenting, alleviate poverty, and reduce rates of child abuse and neglect. Idaho MIECHV’s goals and objectives include:
- Supporting community based organizations to implement evidence-based home visiting programs.
- Supporting and training home visiting programs in the integration of home visiting services with services aligned with Title V Maternal and Child Health (MCH) Block Grant goals including – family-centered medical home, safe sleep education, smoking cessation, One Key Question implementation, breastfeeding, and Adverse Childhood Experiences.
- Supporting home visiting programs in implementing continuous quality improvement practices in their daily work.
The home visiting programs are voluntary and help families with infants and young children from pregnancy through age 5 years old. With Idaho MIECHV funding, the LIAs provide home visitation in twelve counties using two evidence-based programs: Parents as Teachers (PAT) and Nurse-Family Partnership (NFP). Service populations vary slightly between programs. For PAT, families may enroll at any point in pregnancy and children may enroll before they enter kindergarten. NFP serves first-time, low income mothers and infants during pregnancy and continuing until the child is two years old. A total of 6,265 home visits were provided by Idaho MIECHV programs during FY 2018.
Idaho MIECHV serves many women prenatally. In fact, a total of 210 pregnant women participated in home visiting services in FY 2018. Of these women, 92% were receiving prenatal care from a provider at enrollment. While it is highly likely the women who were not receiving prenatal care were referred to services, documentation of prenatal care referrals has been inconsistent. This is an area MIECHV is committed to improving for future reporting. Linkage to appropriate care for woman will be further enhanced by the integration of OKQ into MIECHV service delivery to assess pregnancy intention and provide proper education and referral to prenatal and preventive health care.
Smoking Cessation
Based on the Title V guidance released in 2018, Idaho re-organized the state action plan to reflect the state’s priority need of decreasing substance abuse among MCH populations in the Women/Maternal Health domain. Idaho selected “NPM 14: Smoking” to align with this priority, and efforts under this priority focus on smoking cessation for women and pregnant women. To monitor progress towards addressing this priority and NPM, Idaho developed one objective: 1) Increasing the percentage of pregnant women and women of reproductive age that have attempted to quit smoking in the past 12 months. Measurement of this objective will be based on federally available data, as well as data from the Idaho Quitline, the Behavioral Risk Factor Surveillance System (BRFSS), and PRATS.
In 2017, 8.8% of Idaho pregnant women reported smoking while pregnant (NVSS), and 14.3% of all Idaho women aged 18 and older were smokers (BRFSS, 2016). Since 2009, Idaho smoking rates during pregnancy have declined 27% from 12% to 8.8%. In 2017, Idaho ranked 27th highest in the nation among states for tobacco use among pregnant women. To address the priority need of decreasing substance abuse, specifically tobacco use among MCH populations, the MCH Program planned to leverage the partnerships that were forged during the Infant Mortality CoIIN with the Idaho Tobacco Prevention and Control Program (ITPCP).
The ITPCP was a key CoIIN partner and leads tobacco cessation efforts for the MCH population. The ITPCP has made it a priority to reach pregnant and nursing mothers who use tobacco and encourage them to make quit attempts. Most of these efforts are focused on directing this population to the Idaho Quitline and encouraging them to make use of barrier-free, evidence-based, no-cost cessation benefits. The Idaho Quitline is a telephonic-based intervention that links callers interested in quitting smoking with nicotine replacement therapy (NRT), behavioral support, and counseling. The Idaho Quitline is tracking calls for tobacco cessation counseling and referral for pregnant women and women aged 18 to 44 for ESMs 14.1.1 and 14.1.2.
According to the Association of State and Territorial Health Officials (2013), offering pregnancy specific and postpartum Quitline services to women is a recommended strategy to improve smoking cessation. In 2015, the Idaho QuitLine implemented a Pregnancy Cessation Program, which offers up to 10 calls during pregnancy and postpartum for women who want to quit smoking compared with the 5 calls for the general population. This program also provides participants with a $5 incentive card for each session they participate in before birth and $10 for each session after the baby is born. This enhanced program includes several intervention calls in the two-week period following a quit attempt, one just before the due date and two calls within two months after the baby’s delivery. These calls help the participant to develop skills to remain tobacco free and to reduce the health risks to the baby from exposure to secondhand smoke. Pregnant women may request nicotine replacement therapy (NRT), however they must obtain approval from their primary care provider. Up to 8 weeks of free NRT is offered through the Idaho QuitLine, if approved through their primary care provider. Any pregnant or new mother that expresses interest in quitting tobacco through the QuitLine is automatically referred to the new 10-call Pregnancy Program. To measure the success of this strategy, the MCH Program is using the ESM of the number of pregnant women and the number of women aged 18 to 44 who called the Idaho Quitline for cessation services. For CY 2018, data show 24 pregnant or breastfeeding women and 522 women aged 18 to 44 called the Idaho Quitline for cessation services.
The MCH Program has strengthened collaboration with the ITPCP to implement a smoking cessation program tailored for pregnant and postpartum women, their partners, and households with young children (under the age of one year) in the seven public health districts. This homegrown program, modeled from the evidence-based program “Baby and Me – Tobacco Free,” offers diaper incentives for pregnant women, post-partum women, and household members who quit smoking. Program participants who quit smoking during pregnancy, or up to one year after the baby is born, are eligible to receive one box of diapers per month for up to six months.
When an individual is referred to the incentive program they are also referred to Health District cessation classes and the Idaho QuitLine to receive counseling support to help them quit smoking or vaping. Once a program participant quits smoking, they are eligible to receive a box of diapers. The program participants are tested for nicotine or carbon monoxide, and upon results indicating the person has quit, they receive a box of diapers. If the program participant has a positive test, then they will continue to work with the Health Educator until they finally quit. Tobacco Control grant funding supports staff time to promote and implement the program while MCH funds the testing and diaper incentive. Evaluation of the expanded program includes number of participants enrolled in the program, number of participants who participate in the first test, number who receive the incentive at the first test, and number who stay quit throughout the program. From the inception of the program in August 2018 to May 2019, 238 pregnant women, postpartum women, their partners, and other household members participated in the incentive-based smoking cessation program (ESM 14.1.3).
Other Activities
The Reproductive Health Unit, as part of the Idaho Maternal and Child Health Section, includes Title X Family Planning and Adolescent Pregnancy Prevention Programs and oversees state-mandated activities related to pregnancy education for women seeking abortion services. By Idaho law, the Idaho Department of Health and Welfare is required to develop and distribute packets of fetal development materials for women contemplating abortion which must be provided within 24 hours of the procedure. This activity was tasked to the Maternal and Child Health Program in 2013. The three booklets in the packet include information on fetal development, the abortion procedure and associated risks, and a directory of pregnancy and child health services. During the 2016 legislative session, the law was amended requiring a list of providers that would provide an ultrasound to a woman contemplating abortion for free be included in the packet of information. This list is maintained and distributed by MCH. During the 2018 legislative session, the law was amended requiring that information regarding abortion reversal (for medical or chemical abortions) be included in the packet. In 2018, the MCH Program translated the packet materials into Spanish in an effort to be more accessible. The Spanish version is available in hard-copy and online. For more information, visit abortioninfo.dhw.idaho.gov.
Since 2005, Idaho’s maternal mortality rate increased slightly from a low of 17.0 per 100,000 live births for 2008-2012 to a high of 23.8 per 100,000 live births for 2012-2016. In 2017 and 2018, the MCH Program was engaged by the Idaho Medical Association, the Idaho Perinatal Project, the Idaho chapter of the American College of Obstetricians and Gynecologists, and provider champions to discuss maternal mortality review committee legislation. MCH assisted stakeholders with outlining what was happening in other states, reviewing legislation and processes from other states, exploring possible barriers, participating in training, and creating a plan for what maternal mortality review will look like in Idaho. The MCH Program supplied the team with legislation and information from other states, provided state-level data, participated in regional ACOG webinars related to the CDC’s MMRIA data system, and shared webinar and funding opportunities related to maternal mortality review teams. During the 2019 legislative session, the Idaho Medical Association presented H.B. 109 which would authorize the implementation of a Maternal Mortality Review Committee (MMRC) for the state. The bill was passed and signed by the governor, and MMRC work is being led by the Idaho MCH Program. Please see the “Women and Maternal Health – Application Plan” for more information and changes to the state action plan for FY2020.
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