The 2015 Needs Assessment found that too few women ages 18‐44 have a high quality annual preventive medical visit, and Wisconsin women of childbearing age desiring contraception services do not consistently have access to and use moderately to highly effective methods. In response, the Wisconsin Title V Program selected NPM 1, and developed SPM 1 related to reproductive health access to contraception.

 

The Wisconsin Women’s Health Family Planning (WHFP) Program within the Wisconsin DHS MCH Unit has the responsibility under Wis. Stat. §. 253.07 to develop and maintain a statewide system of community‐based clinic services for quality, accessible, affordable, and confidential care. To establish a statewide system of care, Wisconsin has used a funding model of care that has included the integration of Title V funds and state general purpose revenue funds to support the WHFP Program. Historically, Title X funds have supported family planning in communities not covered by the WHFP Program. In September of 2018, DHS was awarded $3.8 million in Title X funding to continue to directly support the WHFP services, in addition to the general purpose revenue and Title V funding. This coordinated effort has facilitated an efficient use of resources, and avoided duplication of services (Figure 1).

Contraceptive, reproductive and sexual health, and early intervention care is available through this system of community‐based clinics. These community‐based clinics are available as a reproductive (health care) home for women and partners choosing to receive their family planning and related reproductive/sexual health care in a specialty care setting.

 

The implementation and evaluation model for executing the statutory responsibility under Wis. Stat. § 253.07 included active, shared leadership and partnerships between local family planning providers, the WHFP Program team, Wisconsin State Laboratory of Hygiene, DHS Adolescent Health Program, contracted technical assistance and training partner Health Care Education and Training, and the Wisconsin Sexually Transmitted Diseases (STD) Program. These partners worked together to improve, sustain, and enhance the community‐based family planning program.

 

As part of this responsibility, the WHFP Program promoted standards of care and practice that met criteria related to quality, evidence‐based, confidentiality, affordability, cost‐effectiveness, timeliness and continuity of care, and patient‐responsiveness. Standards of care were developed under the guidance of the WHFP Quality/Process Improvement Committee.

 

To address both NPM 1 and SPM 1, the WHFP Program awarded grants to enhance the quality, comprehensiveness, patient‐responsiveness, and cost‐effectiveness of WHFP services in existing community‐based clinics. Grant awards were funded with Title V and state general purpose revenue and aimed to assist in supporting approximately 20% of infrastructure costs in existing community‐based health organizations to provide family planning services as part of the statewide system of services. Grant awards were not intended to fully fund provision of services.

 

The WHFP Program had contracts with the following agencies to promote a statewide system of community‐based services: Ashland, Barron, Clark, Chippewa, Dunn, Eau Claire, Iron, Kenosha, Oneida, Pepin, Pierce, Polk, Price, Rusk, Sawyer, St Croix, Washburn, and Waupaca County Health Departments. Services to communities through these agencies were coordinated with Title X and other independent community‐based health care providers for maximum statewide services (Figure 1).

 

The WHFP Program priorities addressed the following areas:

 

1. Increase knowledge and skills among women, men, couples, and families for optimal reproductive health and pregnancy planning (Wisconsin Title V Program priority)

 

2. Normalize reproductive/sexual health for recognition and inclusion of reproductive/sexual health as a core component of public health and primary health care services

 

3. Ensure reproductive justice that all people have the right to maintain personal bodily autonomy, have children, not have children, and parent the children they have in safe and sustainable communities.

 

Program efforts were reflective of these priority areas by engaging providers and stakeholders to assess capacity and willingness to comply with the Title X Program requirements. Wisconsin’s statute governing the provision of Title X services includes some restrictions that are similar to those included in the Federal Final Title X Rule. However, the provisions in the Title X Final Rule go beyond restrictions that are currently in state law. To better understand the scope of the new provisions, the Wisconsin DHS engaged stakeholders to assess capacity and willingness to adhere with the restrictions in the Final Rule, and facilitated discussions with stakeholders on how the new restrictions will impact clients and their access to care. DHS worked with the WHFP partners to ensure essential health services are provided to individuals in need.

 

The WHFP Program engaged stakeholders throughout 2019 to assess capacity and willingness to adhere with new restrictions in the Final Rule. The Wisconsin DHS engaged all sub-recipients, with one local health agency withdrawing from receiving Title X funding in 2020. Two potential sub-recipients expressed interest in becoming Title X service providers, and negotiations took place with two local county sites who expressed interest in becoming dual protection service sites, which provide basic contraceptive services, testing/treatment for STDs, and referral to comprehensive services.

 

Additionally, the WHFP Program updated their print and electronic lists of providers (WHFP, Adoption, and Prenatal Care), and disseminated guidance and provided technical assistance to providers to ensure understanding and compliance with the Final Title X Rule. Dedicated communication was established through a GovDelivery listserv for WHFP information and dissemination to all family planning providers, and a WHFP-specific email address was created and monitored by staff to more effectively communicate with sub-recipients. The position descriptions and interview questions were also finalized for the Staff Development Specialist position that will provide training and technical assistance to sub-recipients regarding program and reporting compliance, and private and public insurance billing. A billing summit was convened with clinic representatives and Medicaid staff to discuss successes, gaps, and billing challenges with a goal to increase the number of clients served and increase clinic sustainability.

 

The WHFP Program conducted contract monitoring of sub-recipients – including onsite visits to address technical assistance needs – and conducted client record reviews for quality, while continuing to implement all new and continuing requirements in Wisconsin statute, to provide an effective and broad range of family planning services.

 

Capacity in 2019 was increased at Title X clinics to offer comprehensive primary health services onsite by hiring additional staff and increasing funding to sub-recipients who currently employ Advanced Practice Nurse Practitioners. Dr. Cynthie Wautlet, MD joined the WHFP Program, serving as Medical and Clinical Practice Director. The WHFP Program also developed the scope of work and contract deliverables for a five-county consortium (Dunn, St. Croix, Pepin, Pierce, and Eau Claire) to hire a shared Advanced Practice Nurse Practitioner who will serve these counties. Eau Claire Health Department will be the employer of the Advanced Practice Nurse Practitioner, with the position being shared through all five counties on a consistent rotating schedule. Contract negotiations were finalized with three private, non-profit WHFP providers covering 15 counties to increase local capacity of their clinics, which reduced referrals to ease client burden of access and transportation challenges. These providers currently have Advanced Practice Nurse Practitioners on staff but work in a limited capacity. This contract amendment will allow the Advanced Practice Nurse Practitioners to increase their availability and clinic hours at each location.

 

An annual capacity assessment was conducted in 2019 to measure and ensure a strong primary health services referral network, and Wisconsin participated in the Reproductive Health Impact study with the Guttmacher Institute. The goal was to gather evidence on how access to affordable, patient-centered, publically funded family planning care can be harmed, benefitted, or otherwise changed as a result of various federal and state policies. The WHFP Program concluded the pilot project between the WHFP Program, Division of Care and Treatment Services, and two local county agencies to integrate the Reproductive Life Planning One Key Question into the Division of Care and Treatment Services intake process. The projects reported an increase in staff knowledge and comfort level in talking with clients about their sexual needs.

 

A plan was developed by the WHFP Program for restructuring the WHFP Advisory Committee to meet the Title X requirements, and the Quality Improvement/Quality Assurance Committee was restructured to become the Quality/Process Improvement Committee. This committee will be used to research and use evidence-based practice to update and guide program practices using the Iowa Model. The Quality/Process Improvement Committee will bring forward suggested practice and policy changes to the WHFP Advisory Committee for approval, which will then be incorporated into the Program Guidelines and disseminated to service providers.

 

A continued focus over the past five years was the promotion of collaboration and coordination between community-based reproductive health services and sexual assault service providers, to foster timely post-violence entry into care. Community partners include Sexual Assault/Domestic Violence Services, social services, the Wisconsin Coalition Against Sexual Assault, and community shelters. WHFP agencies continued to adopt and implement Trauma-Informed Care approaches and principles throughout their organizations by creating and implementing county and agency-wide Trauma-Informed Care policies. Trauma-Informed Care addresses not only post-violence care, but guides providers in delivering all-encompassing reproductive health services to patients who have experienced any traumatic event.

 

Finally, family planning projects were implemented and continued to utilize new billing codes for trichomoniasis testing, new education and counseling, HPV vaccine, and administration codes. These new coding opportunities assist family planning service providers in becoming more sustainable.

 

National Performance Measure 1: Percent of women with a past year preventive visit.

 

NPM 1 addresses the 2016 Priority Need Health Care Access and Quality. The PRAMS survey, a surveillance project of the CDC and state health departments, collects data on maternal attitudes and experiences before, during, and shortly after pregnancy. From this data, the Title V Program can identify emerging issues, and plan and review strategies and policies aimed at health care access and quality of care. The PRAMS survey provides annual preventive visit data that the Title V program uses to develop appropriate strategies that address challenges and barriers to women receiving preventive visits.

 

2018 PRAMS data indicate about 41% of women who had given birth that year reported that they did not receive either a preventive medical visit or a visit for family planning in the year prior to becoming pregnant. 24% of women who gave birth in 2018 said that they wanted to become pregnant later than they did or not at all, and 14% said they were unsure of their pregnancy intentions. Among all 2018 mothers, 81% reported that they were using a contraceptive method in the postpartum period (2-6 months at the time of the survey). Of those who were using a contraceptive method, about 33% of women were using a highly effective method (sterilization, IUD or implant) and another 30% reported using a moderately effective method. Among postpartum women who were not using a contraceptive method, about 37% said that they either didn’t want to use a method or chose not to because of side effects. Approximately 26% reported that they were practicing abstinence and another 28% said they were currently pregnant or wanted to become pregnant. Only about 1% of women not using a contraceptive method said that cost was a barrier to contraceptive use.

 

1. Provide training, continuing education, technical assistance, and technical support aimed at providers to assure that women are receiving annual visits. The WHFP program has developed a multifaceted approach to increase local capacity aimed at assuring that women are receiving annual visits: A DHS-employed Advanced Practice Nurse Practitioner, funded through Title X, serves several locations on a routine schedule; A locally-employed Advanced Practice Nurse Practitioner who is currently serving in a limited capacity; One shared local Advanced Practice Nurse Practitioner, where five counties formed a consortium with one county serving as the employer of record with the Advanced Practice Nurse Practitioner serving multiple clinics within the consortia service area.

 

In addition to these service models, the WHFP Program finalized the contract with the University Of Wisconsin Department of OB/GYN, and Dr. Cynthie Wautlet MD joined the WHFP Program team as a Medical and Clinical Practice Director. This contract includes access to the clinical training and other resources provided to residency students at the UW for clinicians. The DHS-employed Advanced Practice Nurse Practitioner is providing services to three clinic sites with the majority of their time allocated to provide statewide project support, updating policy and procedures, and providing programmatic expertise.

 

2. Promote and deliver a system of community‐based services for women and men of reproductive age by collaborating with WHFP providers. Several family planning agencies developed and implemented patient surveys, interviews and clinic walk through assessments. Clinics used feedback and adjusted clinic services and clinical flow to be patient-centered and adolescent-friendly. One agency that participated in the Adolescent Champion Model in 2018 expanded this model into several of their clinic sites, making them more adolescent-friendly.

 

3. Sustain a delivery system of community-based services for women and men of reproductive age by leveraging Title X, general purpose revenue, and Title V funding. Funding is denoted by profile numbers, which were created by the Wisconsin DHS fiscal services to facilitate processing of payments of blended funding to community-based projects. General purpose revenue is the main funding source for reproductive health, which includes Family Planning Services.

 

To fund the Cervical Cancer Screening and Colposcopy Services Project, another profile was created. Funds were allocated for specialized training of nurse practitioners to perform colposcopy examinations and related activities in rural areas. A portion of this funding is specifically allocated for colposcopy and other services to community-based providers in the western or northern public health regions, and at least 50% of the clients that receive Papanicolaou test, also known as a Pap test, are receiving or eligible for medical assistance.

 

A profile for the provision of dual protection service sites was developed, and fully funded through the Title V Program. Seven dual protection sites offer pregnancy testing, STD testing and treatment, initiate a birth control method, and provide referral to comprehensive service provider.

 

For the provision of Title X services, a profile was created and completely funded by the Title X Program.

 

This blended approach of funding provided a comprehensive scope of services for Wisconsin’s women and men of reproductive age, which serves 51 service sites, in 44 counties (of 72) throughout Wisconsin. The addition of Title X funding allowed for increased local capacity to provide access to services. The DHS is committed to continued cooperative and collaborative partnerships with local service providers that offer a continuum of care across public, community and health systems. In many communities, WHFP providers are the only access point to the Medicaid Family Planning Only Services benefit. The Title V Program will continue to promote access to the Family Planning Only Services benefit at all service sites.

 

4. Participate in the CoIIN to improve rates of post-partum visits through clinic messaging efforts that improve the value placed on postpartum care. Participation in the CoIIN was completed. Lessons learned will be integrated into ongoing work to support high quality perinatal care.

 

5. Increase collaboration with Medicaid to support implementing clinical best practice guidelines, through funding reimbursement and policy changes related to women’s health and adolescent health. Wisconsin Medicaid required contracted health plans to report on the HEDIS measure for postpartum visits. The MCH, WHFP, Adolescent Health, and Medicaid programs met quarterly in 2018 to discuss programmatic commonalities. These discussions were an opportunity to work with Medicaid on promoting adoption of clinical best practice guidelines in women’s and adolescent health. Based on an identified need from service providers, the WHFP Program convened a collaborative billing summit with representatives from: Wisconsin Medicaid; the WHFP Program; local community-based providers, both rural and urban; and Wisconsin Family Planning Reproductive Health Association. Goals included:

 

• Increase WHFP provider knowledge of WHFP Medicaid services.

 

• Increase comfort and competency of billing WHFP services to public and private insurance.

 

• Increase utilization of appropriate Medicaid services for eligible clients.

 

• Develop a consistent and convenient source of communication for billing questions, training and technical assistance.

 

• Increase WHFP sustainability through appropriate billing structure (i.e. public and private insurance).

 

• Evaluate progress of goals.

 

Summit feedback from attendees indicated technical assistance for Medicaid WHFP billing is needed at all levels. Feedback also indicated that current resources are not sufficient, convenient or clinic-appropriate, and Medicaid billing for eligible WHFP services is underutilized at all levels. As a result, the WHFP Program will continue to convene stakeholder and service providers to collect feedback and inform the DHS of priority concerns and develop a plan to meet the goals. Planning included hosting billing and coding trainings, as well as hiring a staff development program specialist to develop and train service providers on Medicaid including Family Planning Only Services, Prenatal Care Coordination and other WHFP eligible services.

 

6. Collaborate with home visiting to promote the post-partum visit. Wisconsin Family Foundations Home Visitation Program has 4 models: Nurse Family Partnership, Parents as Teachers, Early Head Start and Healthy Families America. In 2018, 73.1 % of women received a postpartum visit by a health care provider within 8 weeks of delivery. A scan of the home visiting programs revealed that each program had different standards and approaches around Reproductive Health Life Planning, as they use different resources and timelines when this information is shared with clients. The WHFP Program initiated collaboration with the Department of Children and Families to select and implement a Continuous Quality Improvement project. Home Visitors were surveyed and selected to provide education and promote reproductive life planning activities with their families in 2020.

 

7. Women’s Health Family Planning Providers were supported to increase adolescent and women’s health well visits by improving patient enrollment into Family Planning Only Services. To facilitate the enrollment process, the WHFP Program assured providers enrolled patients into Family Planning Only Services electronically. Technical assistance was provided to enhance this method of enrollment. This supported eligibility screening and enrollment assistance for health care coverage as a core service of the WHFP Program. All new Family Planning projects and staff received guidance and training on Family Planning Only Services enrollment as part of onboarding. Ideally, continued work following the billing summit in 2019 should increase the enrollment into Family Planning Only Services.

 

State Performance Measure 1: Percent of women aged 15‐20 and 21‐44 years who are at risk of unintended pregnancy and who: 1) adopt or continue use of the most effective or moderately effective FDA‐approved methods of contraception; 2) adopt or continue the use of LARC.

 

SPM 1 addresses the 2016 Priority Need Health Care Access and Quality. The Long-Acting Reversible Contraception (LARC) method of contraception and annual visits were a tandem priority within the WHFP Program. All funded projects provided access to a full range of contraceptives, such as male and female condoms, injectable, oral hormonal contraceptives, implantable, and IUDs. Each patient received the contraceptive method that best matched her preference and needs. Immediate access to contraception was a priority practice that improved the quality of the visit and outcome for the patient. Those choosing a LARC received information about the annual preventive medical visit as an opportunity to discuss other health issues, prevention of sexually transmitted diseases, and reproductive life planning.

 

According to 2018 PRAMS data, about 41% of women who had given birth that year reported that they did not receive either a preventive medical visit or a visit for family planning in the year prior to becoming pregnant. Of women who gave birth in 2018, 24% said they wanted to become pregnant later than they did or not at all, and another 14% said they were unsure of their pregnancy intentions. Among all 2018 mothers, 81% reported that they were using a contraceptive method in the postpartum period (2-6 months at the time of the survey). Of those who were using a contraceptive method, about 33% of women were using a highly effective method (sterilization, IUD or implant) and another 30% reported using a moderately effective method. Among postpartum women who were not using a contraceptive method, about 37% said that they either didn’t want to use a method or chose not to because of side effects. Approximately 26% reported that they were practicing abstinence and another 28% said they were currently pregnant or wanted to become pregnant. Only about 1% of women not using a contraceptive method said that cost was a barrier to contraceptive use.

 

The Title V Program identified six strategies to increase the use of moderate to highly-effective contraceptive use by patients.

 

1. Health Care Education and Training was funded to provide training, continuing education, technical assistance, and technical support to WHFP providers. WHFP staff were directed to the Family Planning National Training Center site for trainings and information regarding Title X requirements, core family planning services, and financial operations. Clinicians were directed to the National Clinical Training Center for Family Planning for trainings and resources on updates in contraception and updates on American College of Obstetricians and Gynecologists Committee Opinions and Practice. Health Care Education and Training conducted a training needs assessment to determine WHFP workforce priority training and educational needs. In-person and web-based opportunities were offered to meet the workforce needs for training and education, including: Rockstar Facilitation Techniques & Healthy Relationships; Improving Reproductive Health Equity; 4-part Family Planning Series, including administrative functions; documentation and billing; clinical services and billing; accelerated Title X billing; selective screening criteria for Wisconsin STD Program and the Wisconsin STD Summit.

 

2. Fund WHFP providers to promote and deliver core community‐based services for women and men of reproductive age. All WHFP projects completed a needs assessment developed and implemented through Health Care Education and Training. Based on the needs assessment findings, the following areas were included in Health Care Education and Training webinars and in-person trainings throughout 2019: Racism in sexual and reproductive health; Title X Family Planning Regulations; emotional intelligence and change.

 

The WHFP program restructured their Advisory Committee to meet Title X requirements, which included realignment of existing Quality Improvement/Quality Assurance Committee to the Quality/Process Improvement Committee. The Quality/Process Improvement Committee began plans to use research and bring evidence-based practice to update and guide program practices using the Iowa Model. Planning also included bringing suggested practice and policy changes to the WHFP Advisory Committee for approval, before being incorporated into program guidelines and disseminated to service providers for implementation.

 

The WHFP program continued to work with Ancilla, an outside vendor to assist local clinics with extracting data from their electronic health records. Projects with electronic health records had client encounter data directly pulled to meet reporting requirements, and those without will continue to use the REDCap database to directly report required data. The WHFP Program epidemiologist worked closely with Ancilla to assure the most accurate data capture and retrieval. Two additional agencies selected to use an electronic health record. A DHS epidemiologist worked with agencies and Ancilla to onboard staff assisting with the transition to an electronic health record.

 

3. Implemented the Dual Protection Model of Service in Local Health Departments. The WHFP Program conducted a new partner capacity assessment, and as a result, one new agency expressed interest in becoming a Dual Protection Service site. WHFP Program staff worked with local agency staff to set up clinic sites and develop dual protection policies and procedures, and train staff. Dual Protection sites provided family planning services following the guidance from the CDC’s Providing Quality Family Planning Services: Recommendations to men and women throughout the contract year. Services included STD testing, treating and re-testing, providing the first three months of primary contraceptive method, reproductive life planning, pregnancy testing, education, and Dual Protection kits. Referrals were made as indicated. Dual Protection services supported the following preconception health prevention and promotion of Title V Program goals:

 

• Reproductive health promotion and risk reduction and skill development

 

• Protection of fertility through early detection and treatment of STDs

 

• Supporting a patient’s reproductive life plan decision of when to become pregnant and choice of a primary birth control method

 

Dual protection services provided a point of entry and re‐entry into reproductive health care, intended to increase access to family planning services, and provided referral to comprehensive community‐based reproductive health. A program review template was utilized at mid-year visits to monitor accountability and quality improvement of services. Capacity-building technical assistance was provided by the WHFP Program staff and their partners, such as the Wisconsin STD Program.

 

5. Collaborate with the Division of Care & Treatment to incorporate One Key Question into contracts with community comprehensive services agencies and connect women to family planning. The pilot project concluded between the WHFP Program, Wisconsin Division of Care and Treatment Services, two local county agencies, and the Reproductive Life Planning One Key Question has been integrated into their intake processes. The projects reported an increase in staff knowledge and comfort level in talking with clients about their sexual needs.

 

4. Collaborate with the University of Wisconsin Department of OB/GYN. Through this collaboration, findings were disseminated from a provider survey on the usage of LARC and 17 alpha‐hydroxyprogesterone caproate (17P, a hormone treatment used to prevent premature births), and a plan was developed for active change. In 2015, the Title V Program collaborated with the University of Wisconsin School of Medicine and Public Health, Department of OB/GYN to survey women’s health providers. Results were disseminated via conference presentations and publications, and highlighted the need to improve the comfort level among Family Medicine providers to promote LARC as a contraceptive method and to prescribe 17P where appropriate. This collaboration with the university continued through active participation in the Wisconsin Contraceptive Access Network.

 

7. Collaborate with Wisconsin Contraceptive Access Network to improve statewide access for all women to receive their contraceptive method of choice. Wisconsin Contraceptive Access Network consists of a network of diverse organizations with representatives from statewide professional associations, local public health, health care systems, advocacy groups, community based organizations and academic institutions. The vision of Wisconsin Contraceptive Access Network included assurance of the full range of safe, effective (FDA-approved) contraceptive health care that is available, affordable and accessible to women across the state; which is provided with inclusivity, culturally appropriateness and without coercion. In collaboration with Wisconsin Contraceptive Access Network, the first Contraceptive Care Summit was held in 2019, for practitioners and stakeholders to learn about evidence-based strategies in contraceptive care and patient-centered counseling. The goals of the summit were to expand capacity to practice reproductive justice, and improve equitable access to contraceptive care. Hands-on skills training was offered for clinicians to learn or strengthen insertion and removal of an IUD. The Wisconsin Contraceptive Access Network created the Wisconsin Contraceptive Access Network News Digest, which contains Wisconsin and national news related to contraceptive access.

 

The WHFP Program partnered with Wisconsin Contraceptive Access Network to create a document defining and addressing access which identified several dimensions: Proximity to Clinical Care; Timing of Clinical Care; Acceptable Clinical Care; and Affordable Clinical Care.

 

6. Collaborate with Home Visiting to promote Reproductive Life Planning. Wisconsin Family Foundations Home Visitation Program has 4 models: Nurse Family Partnership; Parents as Teachers; Early Head Start; Healthy Families America. In 2018, 73.1 % of women received a postpartum visit by a health care provider within 8 weeks of delivery. A scan of Home Visiting programs revealed that each program had different standards and approaches around Reproductive Health Life Planning, as they use different resources and various timelines when this information is shared with clients. The Title V Program collaborated with the Wisconsin Department of Children and Families to select and implement a Continuous Quality Improvement project. Home Visitors were surveyed, and selected to provide education and promote reproductive life planning activities with their families in 2020.

 

National Performance Measure 14: A) Percent of women who smoke during pregnancy and B) Percent of children who live in households where someone smokes.

 

Wisconsin smoking statistics from 2018 show 10% of women used tobacco during pregnancy in Wisconsin (Figure 2), compared to the national average of 7%. It is also important to recognize that significant disparities exist among different populations (Figure 3). According to 2018 PRAMS data, approximately 22% of women who gave birth in Wisconsin in 2018 had smoked a cigarette in the two years prior to pregnancy, and 19% had smoked in the 3 months prior to pregnancy. About 11% of mothers smoked in the last 3 months of pregnancy.

 

While 81% of Wisconsin women were non-smokers, an estimated 8% of women overall quit smoking during pregnancy, and another 7% reduced the number of cigarettes they smoked on an average day. However, 14% of Wisconsin mothers were smoking in the months following the birth of their child. About 3% of Wisconsin women who gave birth in 2018 used electronic vapor products in the 3 months before pregnancy while less than 2% reported using e-cigarettes in the last 3 months of pregnancy.

2018 PRAMS data showed that over 96% of Wisconsin women reported that a provider talked with them about the health effects of smoking during prenatal care, however, only 68% of women who received a postpartum visit reported that their provider asked them if they were smoking. The most commonly reported barriers that made it difficult to quit smoking were cravings, having no other stress coping mechanisms, being around other people who smoke, and underlying anxiety that worsens without cigarette use.

 

National and statewide efforts support work on NPM 14 in Wisconsin. CDC’s TIPS™ campaign connected smokers with resources to help them quit, including a quit line number (1-800-QUIT-NOW) to route callers to their state quit line. The Wisconsin quit line provided free cessation services, including counseling and medication. This service was effective in improving health outcomes and reducing healthcare costs. The campaign, along with additional outreach, generated a total of 13,496 calls to the Wisconsin Tobacco Quit Line in 2019, 730 enrollments in services via Fax to Quit, 850 e-Referrals, and 321 enrollments online. Wisconsin also implemented a statewide smoke-free worksite policy in 2010, which has proven to be very effective in the prevention of secondhand smoke exposure in the worksite.

 

Recent Federal policies raised the legal age to purchase tobacco to 21 in the U.S., meaning tobacco retailers cannot sell tobacco products, including e-cigarettes, to those under the age of 21. The FDA is responsible for the law’s enforcement. Another FDA policy prohibits the use of fruit, candy, and mint flavors for pods or cartridge-based e-cigarettes (tobacco and menthol flavors for those products are exempted). The policy also exempts e-juice flavors for open systems like mod and tank-based e-cigarettes.

 

To further support efforts in Wisconsin, Governor Evers' Tobacco-Related Policy Package included four bills:

 

• Vape shop licensure

 

• Mandate to include e-cigarettes in all tobacco-free school policies

 

• Expanded the definition of public health emergency

 

• Increased funding for tobacco prevention and control

 

The Title V Program continues partnership with the DPH Tobacco Prevention and Control Program. Both programs provided funding to the Wisconsin Women’s Health Foundation (WWHF) for support of the First Breath program. First Breath is an intervention and referral strategy to assist pregnant & postpartum women in stopping smoking. There are 255 (15 are new) First Breath sites, located throughout Wisconsin’s 72 counties, and is offered by prenatal care providers in multiple settings including public health providers and Home Visitors. Intervention includes monthly phone and text support from a Health Educator and Certified Tobacco Treatment Specialist, personalized counseling sessions and quit plans, educational materials, up to 5 home visits, 3 carbon monoxide breath tests, and other services based on availability.

 

First Breath offers services to partners, fathers, grandparents, caregivers, and women who are not pregnant or postpartum. These services include text message support, smoking assessment, and education from a Health Educator. If interested, participants are referred to the Wisconsin Tobacco Quit Line for counseling and nicotine replacement therapy.

 

The Medicaid Prenatal Care Coordination benefit supported public health and community agencies in delivering this service. WWHF provided 12 recruitment activities and 3 communications/educational opportunities about the BadgerCare Plus tobacco cessation benefit, and hired a graduate of First Breath to be an advocate and health educator for their smoking cessation programs. This young woman participated in First Breath during her 2nd pregnancy and quit smoking. She was motivated to succeed by the outcome of her first pregnancy that resulted in a preterm delivery. She is now a spokesperson for the CDC's TIPS Campaign and is seen in Wisconsin public service announcements and television commercials. Another component of this work focused on households with people who smoke and have young children.

 

1. Increase referrals to smoking cessation services for postpartum women and family members who smoke. WWHF created a streamlined, centralized process for First Breath referral and enrollment by creating a new position to coordinate referral and enrollment procedures, policies, new tools, and a pathway to manage all First Breath referrals and enroll into texting and Quit Coaching services. This streamlined Ask-Advise-Refer model quickly identified at-risk pregnant, postpartum, and other household smokers, and connected them with personalized, evidence-based tobacco treatment services through First Breath. This new Enrollment Specialist processed 1,425 referrals (site enrollment=91%, self-referral=5%, e-referral=2%, Quit Coach=1%) conducted text message enrollment procedures for 1,084 pregnant and postpartum women, and conducted Quit Coaching enrollment and consent procedures for 522 pregnant and postpartum women. For those 522 pregnant and postpartum women:

 

• 1843 phone counseling sessions were conducted

 

• 579 in-person counseling sessions were conducted

 

• Participant Short-Term Outcomes (6 months postpartum)

 

• 26% passed CO (Carbon Monoxide) + 7-day abstinence

 

• 34% passed CO

 

• 75% reported smoke-free home

 

• 70% achieved zero infant exposure to tobacco smoke

 

 

First Breath Quit Coaching means equal opportunity to succeed. There was no significant difference in quit rates among women based on age, relationship status, or educational level.

 

Quit coaching services were also provided to other caregivers such as partners, grandparents, and household members. With regard to caregivers, 168 received tobacco-related education and brief intervention, as well as 100% receiving information about the Tobacco Quit Line.

 

Along with this new process, WWHF developed print and digital content for women and other caregivers to self-refer to the First Breath program. This was highlighted through 3 self-referral promotional activities. The Title V Program funded the WWHF to build a system of evidenced based cessation and treatment for high-risk individuals and their families beyond the perinatal period addressed by First Breath. WWHF also created an online training for the new streamlined First Breath Ask-Advise-Refer model. This training was distributed to sites via a webinar. All providers who implemented First Breath were required to complete this webinar training to maintain their First Breath provider status and submit service referrals to WWHF. There were 255 First Breath sites that completed the training and 1012 First Breath providers at these sites completed this training. As of December 31, 2019, 1664 referrals were made to WWHF: 1425 pregnant and postpartum women and 239 support persons.

WWHF First Breath statewide reached 22% of all pregnant smokers in Wisconsin (Figure 5).

WWHF continued to use the Environmental Tobacco Smoke GrapeVine train the trainer model to address household smoke exposure to infants and children. GrapeVine is specific to WWHF and trains nurses to lead health education sessions in communities to educate Wisconsin women about disease prevention and healthy lifestyle changes. Content focused on multigenerational tobacco use and reducing Environmental Tobacco Smoke exposure for infants and children, and included a PowerPoint, speaker scripting, materials, and attendee posttests. This education of families and community groups also highlighted the importance of breastfeeding as a protective factor, safe sleep practices, and having the home smoke free to reduce the incidence of sudden unexpected infant death. The education reached pregnant and postpartum women, partners, fathers, grandparents, caregivers and support people in contact with infants and young children. WWHF continued to be a strong partner for tobacco cessation, providing this education throughout the state.

 

In 2017, WWHF began working with an electronic health record system and a physician champion to address electronic/system referral and follow up. Efforts continued to incorporate First Breath referral questions into UW Health’s clinical electronic health record system. They worked with Redox for software and support. This year was spent developing e-Referral policies, procedures, training materials and tools for clinic staff to use and train online. In July 2019, the UW Health Clinic’s e-Referral pilot was launched. All UW Health Clinics have access to the First Breath e-Referral through the UW Health Link. If a patient is pregnant or postpartum, has documented recent tobacco use (less than 6 months), and has interest in quitting, a Best Practice Advisory will appear within their electronic health record, prompting the health care provider to ask if they would like a referral to First Breath. WWHF engaged in outreach to other health systems in the state regarding e-referral options for their clinics.

 

2. To support local agencies in the implementation of the objective, a statewide smoking Learning Community was established for stakeholders including funded Title V partners. This strategy was completed at the end of 2018. In 2019, the strategy was modified and WWHF began to focus on medical providers who see pregnant/postpartum women and their infants and children to make a wider reach and greater impact to women, infants and children in the state. Local support was offered to local agencies through WWHF programming.

 

3. Provide training and technical assistance to providers and Title V-funded agencies working on smoking. Local and tribal health agencies noted capacity barriers, so this strategy was modified to allow WWHF to work more closely with medical providers who see pregnant/postpartum women and their infants and children. WWHF continued to support First Breath sites by developing, distributing and promoting sustainable training content; including quarterly continuing education opportunities such as webinars, on-site consultations, and technical assistance to First Breath sites. To engage providers, WWHF offered continuing education opportunities and maintained regular communication with current First Breath providers. Twelve First Breath e-newsletters were created and disseminated, with an average read receipt of 300. All sites received a quarterly, site-specific report on First Breath referral and enrollment, and offered additional technical assistance as requested. WWHF conducted regional training and technical assistance sessions for First Breath providers and partners throughout the year. Almost all (99%) of attendees agreed that these regional sessions provided them with information, tools, and/or techniques that can be applied to their work.

To assess quality improvement and quality assurance, WWHF developed, conducted and analyzed an annual provider survey, and updated and distributed implementation materials for First Breath providers. There were 214 providers that completed the 2019 First Breath Provider Survey, and 95% agreed that First Breath materials and services are appropriate for community and demographic. Forty-seven (47%) reported seeing an increased use of Electronic Nicotine Delivery Systems, of which users were identified as priority target groups, and WWHF worked with the Multi-Jurisdictional Coalition to address this. Print and online promotional materials were updated due to requests for different languages and new tools.

 

All WWWF Quit Coaches participated in monthly quality assurance check and received skills-coaching from a supervisor and 100% of files were HIPAA-compliant. Quit Coaches maintained their Tobacco Treatment Specialist Certification and attended at least one professional development opportunity (Figure 6).

4. Develop and evaluate resources to support smoking cessation for postpartum women and their families. In the fall of 2018, WWHF conducted a statewide Health Equity Assessment to identify population-related needs and gaps in the current First Breath prenatal smoking cessation program. This assessment involved pregnant and postpartum women, health/social service providers, and community partners joining together to review data, identify priority groups, and discuss strategies to better reach and help underserved women. Data from all attendees were compiled and analyzed in 2019. Top themes emerging across all groups and regions included:

 

• Priority Populations

 

• Single Moms

 

• Women with a Mental Health Disorder

 

• Women with a Substance Use Disorder

 

• Native American Women

 

• Strategies for Reaching Priority Populations

 

• Current First Breath providers provide more education about First Breath

 

• Partner with behavioral health providers

 

• Promote First Breath at non-health care/community settings

 

• Focus Areas to Better Serve Priority Populations

 

• Greater focus on stress management and self-care

 

• Increased contacts with First Breath Quit Coach

 

• More emphasis on “You Are Not Alone”

 

• New Materials & Tools for Priority Populations

 

• More vaping/e-cigarette information

 

• Videos and greater presence on social media

 

• Target group specific materials Based on this information

 

WWHF provided Regional Sessions “The Bucket Approach: Tailored Smoking Interventions for Individuals with Mental Health Challenges” in 7 regions of the state. There were 103 providers and partners who attended these sessions, and 99% agreed that this session provided them with information, tools or techniques that they needed to apply to their work in this area.

 

WWHF continued the First Breath Families texting campaign based on feedback from Striving to Quit and First Breath participant focus groups. This text messaging campaign also included input from breastfeeding, safe sleep, and mental health groups. Promotional postcards were available to providers to send to clients or families. WWHF conducted annual Participant Advisory Groups focused on program development and expansion, and 74 (a record high) enrollees or program graduates participated through in-person groups or one-on-one meetings. Meetings focused on program development and how WWHF could provide more support to women around the state enrolled in First Breath. The group came up with the First Breath Support Group, Mom Café. Among current smokers, 89% (54/61) stated they would attend. Former Smokers were asked if they would have attended when they were trying to quit, and 75% (6/8) said yes. Participant satisfaction survey results showed 100% would recommend First Breath to a friend, and 87% rated First Breath as “very good” or “excellent”.

 

Multi-jurisdictional tobacco control coalitions identified new community partners to provide training and education to implement routine practices that encouraged smoke-free homes. Referrals to WWHF for triaging to cessation services for pregnant/postpartum women, partners, fathers, grandparents, caregivers and support people in contact with infants and young children were identified as a priority based on the 2018 Health Equity Tool Assessment.

 

5. Collaborate with Home Visiting to increase smoking cessation services. Home Visiting Program models funded by Wisconsin’s Family Foundation’s Home Visiting Program provide educational and informational support surrounding approaches to smoking cessation. Local and state entities offer trainings and referral resources such as First Breath and the Wisconsin Quit Line. The Home Visiting agencies continued to use tool kits, educational resources, and referral services to support smoking cessation with the families served throughout 2019.

 

In 2019, local Home Visiting agencies assessed tobacco use of newly enrolled clients and found that 147 clients reported using tobacco, and 23.1% of these clients accepted referrals to tobacco cessation counseling such as First Breath or the Wisconsin Quit Line.