Women/Maternal Domain: Annual Report (October 1, 2020 – September 30, 2021)

Priorities:  Mental Health/Substance Misuse

NPM 1:  Well Woman Visit:  Percent of women, 18-44, with a past year preventive medical visit

South Dakota exceeded the 2020 target of 71.8% with 77.3% of women, 18-44, having a past year preventative medical visit. South Dakota ranked 5th in the nation with a higher rate than the U.S. rate of 71.2% (BRFSS, 2020).  

MCH Needs Assessment findings (2019-2020) indicated the importance of a yearly well women visit with a Primary Care Provider (PCP) as a care coordination and referral starting point for women of childbearing age.  A well woman visit provides a comprehensive assessment of a women’s overall health including her mental health. Preventative care is important to stop diseases or conditions before they start.  Mental health screenings are a component of a well women visit and can identify women who may be suffering needlessly.  Throughout this grant year Title V continued to collaborate with Title X, the SD WIC program, and Bright Start Nurse Home Visiting to promote a medical home and annual Well Women check-up with their clients.  All three programs are located within the Office of Child and Family Services and have representatives on the National Performance Measure (NPM) #1 workgroup making collaboration easier.

Other strategies the MCH team utilized to promote annual Well Women visits included continuation of a social media campaign on For Baby’s Sake website, For Baby’s Sake Facebook page and advertising in parenting magazines.  Facebook posts related to well women and the mental health priority are included on the social media metric table below.  Information about well women visits (It Starts with You) and Perinatal Depression (You and Baby) can be found on the For Baby’s Sake website at For Baby's Sake | Healthier moms + Healthier babies (forbabysakesd.com).

The end of calendar year 2020 (or the beginning of fiscal year 2021) was a challenging time for MCH and moving the needle on this initiative.  The Office of Child and Family Services (OCFS) including the MCH program staff were emersed in pandemic response. The MCH Women’s facilitator was splitting time between active COVID investigations and regular job responsibilities as were OCFS field staff in the 74 Community Health Offices across the state.  More than half of the field staff were re-assigned to COVID investigations full time for the first half of this grant period and the remaining staff covered DOH programs to maintain continuity of care for clients.  This strongly affected activities for NPM #1 related to promotion of the well women visit and the mental health priority.  Staff were scheduled to begin Depression screening with WIC moms in July of 2021.  Instead of being a year of screening it ended up being a year of preparation.

NPM #1 Objective:  Decrease percentage of women on the SD WIC program who experience Postpartum Depressive Symptoms following a recent live birth from 17.1% in 2019 to 16.2% by 2025. (PRAMS)

Data statement: 

South Dakota did not meet the 2020 target of 16.6%. The percentage of women on the SD WIC program who experienced Postpartum Depressive Symptoms following a recent live birth rose from 17.1% in 2019 to 21.9% in 2020.

Strategies 1.1 and 1.2:  MCH Mental Health Initiative

Data to Action:  According to the 2020 SD PRAMS data, 21.9% of postpartum women on the WIC program reported experiencing Postpartum Depression versus 9.6% of non-WIC mothers.  WIC moms also reported having Depression during pregnancy at a rate of 31.6% vs.12.5% for non-WIC participants.   

Figure 1: WIC vs. Non-WIC Postpartum Depression (2020 PRAMS)

Figure 2: WIC vs. Non-WIC Depression During Pregnancy (2020 PRAMS) 

The Well Women workgroup composed of multisector partners (Strategy 1.3) utilized this data and added a depression screening initiative to the NPM #1 state action plan. The goal was to identify WIC clients who may be experiencing depressive symptoms and refer them for evaluation and possible treatment.

NPM #1 workgroup members included:

• Health Coordinator (Sisseton Wahpeton Oyate)
• Title X Coordinator
• DSS Behavioral Health Assistant Director
• OCFS Assistant Administrator/Community Health
• WIC Program Quality Specialist
• MIECHV home visiting nurse
• Maternal Mortality Abstractor/Maternal Health Consultant
• DOH’s Tobacco Program Disparities Coordinator
• DOH’s Perinatal Nurse Consultant

Title V continued to work with Hot Pink Media Agency to target messaging to our tribal communities where the largest disparities exist. (25.9% of American Indian mothers’ experience postpartum depressive symptoms vs. 9.7% of Non-Hispanic White according to 2019 PRAMS).  A Facebook post featuring a native woman was developed and added to the rotation as well as radio ads spoken by native voices. The following is an example of a 60 second radio spot focusing on Postpartum Depression:

While children are a welcome blessing, a new baby brings many emotions.  Why do some mothers feel sad or lost?  Well, baby blues are normal.  But if you are having trouble getting through the day, feel overwhelmed or hopeless – Be brave.  Reach out.  Postpartum Depression is serious.  It is a real condition, common among our people today, and - IT IS NOT.YOUR. FAULT. There are ways to treat it and build a circle of support that will help you celebrate being a mother and honor this new sacred life. You are not alone.  Share your truth with people you love and trust.  Ask for help.  If you think you have Postpartum Depression or are worried about someone else, call the Depression After Delivery Hotline – One eight hundred – nine four – four seven three or visit For Baby’s Sake SD dot com today.

The SD Department of Health’s strategic plan Goal #1 is:  Enhance the accessibility, quality, and effective use of health resources.  Objective A of this goal states Increase the percentage of mothers on the SD WIC Program who are screened for depression using a validated tool within 3 months of child’s birth from 98% to 100% by 2025. The strategies added to the NPM #1 state action plan were designed to do just that. 

The SD WIC team consists of RNs, LPNs, Licensed Dieticians, Nutrition Educators and Public Health Assistants (PHA) located in 74 Community Health Offices across the state. There are over 100 staff providing WIC services.  One of the challenges faced early on was the determination that scoring, counseling, and referring someone with a positive PHQ-9 was not within the scope of practice for a licensed dietician, nutrition educator, or PHA in SD.  The MCH team had to pivot and change the way screening would be initiated. 

The team collaborated with DSS’ Behavioral Health program and their SAMHSA SBIRT grant to provide training to all WIC staff.  The rationale for including all staff was that all staff could benefit from training even if they weren’t able to administer the PHQ-9, counsel, or refer.  The first training Applying Screening, Brief Intervention & Referral to Treatment to Perinatal Health Screenings was provided by Dr. Maridee Shogren and Dr. Christine Harsell at Mountain Plains ATTC over ZOOM.  The objectives included:

• Identify the symptoms of perinatal depression
• Recognize the need to screen women for perinatal depression
• Recognize the need for substance use disorder screening for women in the perinatal period
• Demonstrate knowledge of the SBIRT intervention
• Discuss a brief intervention utilizing the FLO algorithm

OCFS nurses participated in a second ZOOM training I’ve Screened, Now What? Perinatal Depression Screening and Response provided by Mountain Plains Mental Health Technology Transfer Center Network (through the SBIRT grant).  Objectives for this training included:

• Best practices when screening perinatal populations for depression
• How to implement a team-based response to patients expressing thoughts of suicide
• Examine unique barriers experienced by perinatal persons when seeking care
• Discuss the importance of referral pathways for connecting individuals to care

The following Depression Screening Algorithm was designed for nurses as an equitable and accessible referral pathway for clients with a positive PHQ-9 screening:

OCFS field office resource guides were updated to include a listing of DSS Mental Health Centers for referral purposes, teaching tools on perinatal depression and informational materials for clients.

At the end of this grant year an email was sent to OCFS nursing staff to initiate depression screening using the PHQ-9. For this reason, the MCH team is unable to assess the overall effectiveness of the depression screening initiative or measures. While we couldn’t initiate depression screening this grant year as intended, we laid the groundwork for it to happen next fiscal year.

Other MCH activities related to Women’s Domain:

Maternal Mortality Review: The South Dakota Maternal Mortality Review Committee (MMRC) formed in calendar year 2021 and conducted their first meeting in July 2021.  The committee is a multi-disciplinary group of volunteer health care providers and public health practitioners who review maternal deaths (deaths that occur up to one year after pregnancy).  Vital records, hospital and law enforcement records, and informant interviews give a complete picture of the circumstances surrounding the maternal deaths.  The committee discusses prevention strategies and shares their findings with the Statewide Preventable Death Committee to put data into action.

Pregnancy Care Program:  The Office of Child and Family Services’ Pregnancy Care Perinatal Services Program provides a risk assessment and subsequent modified case management for those found eligible for services. The risk assessment is comprised of chronic, and pregnancy induced risk factors as well as social determinants of health.  Modified case management involves registered nurses providing ongoing assessment, education, and support throughout the pregnancy and up to 3 months postpartum.  Other services include screening for depression, safe sleep education, breastfeeding education and referrals to community-based resources based on the mother’s identified risks and factors as they arise. 

Referrals for medical insurance coverage:  Community Health Offices across the state promoted Medicaid and Marketplace enrollment for clients that initiated services and were uninsured.  Staff utilized available translating services (Language Link or Lutheran Social Services translators) if a client ‘s primary language was other than English.   Clients were referred to DSS Economic Assistance or Navigators if more assistance was needed to promote equity in accessing insurance.

Mental Health/Suicide Prevention resources:  The MCH Adolescent Health Coordinator attended the Suicide Prevention in Rural Primary Care two-part webinar series. One take away was that people who die by suicide are likely to have been seen by a Primary Care Provider in the previous month before their death. This is especially true in rural areas where behavioral health resources are fewer and stigma around mental health is greater. The training walked through strategies for primary care providers and provided a step by step Suicide Prevention Toolkit.  One activity mentioned was putting materials in office waiting rooms to create an environment that the patient feels comfortable sharing concerns and to share what types of services are available in the community. The Title V team began brainstorming ways it could coordinate efforts in the 74 Community Health Clinic/WIC offices across the state.  At the same time, the NPM 1 Well Women workgroup was beginning to look at how to initiate depression screening in Community Health offices. The NPM 1 and NPM 7.2 coordinators collaborated to develop two mental health/suicide prevention resources:

1. Suicide Prevention and Mental Health rack card-provides South Dakota resources and mental health/suicide prevention apps.
2. Mental Health poster that could be posted in waiting rooms or exam rooms. (see below)