Women/Maternal Health Annual Report
The Arkansas Department of Health’s (ADH) Women’s Health program continues to:
1) Provide direct health care, referral services, preconception and interconception counseling, and preventive screenings for women of reproductive age in all 75 counties in Arkansas
2) Provide education and referrals for smoking cessation to women of childbearing age
3) Work with the University of Arkansas for Medical Sciences’ (UAMS) High-Risk Pregnancy Program to increase screening and consultation for high-risk women in ADH’s maternity clinics
4) Work with UAMS’s High-Risk Pregnancy Program to provide after-hours consultation services to ADH maternity patients
4) Develop campaigns to increase uptake of influenza and Tdap vaccines in pregnant women
5) Work to reduce smoking in pregnant women, including screening during the last three months of pregnancy
The ADH has at least one local health unit (LHU) in each of Arkansas’s 75 counties. LHUs serve the state’s vulnerable and hard-to-reach populations, especially those in rural areas where access to medical care is limited. The ADH’s Women’s Health programs support the provision of direct health care and referral services to address the perinatal, reproductive health, well woman, and other preventive service needs for women across the state. The ADH currently offers maternity services in 57 LHUs covering 53 counties. Maternity services include:
- Case management
- Prenatal assessments, including risk assessments, health history, physical, laboratory tests, gestational age assessments, and fetal assessments
- Management of abnormal prenatal findings
- Prenatal counseling and education
- Women, Infants and Children (WIC) program
- Vitamins and mineral supplements
- Post-partum services
Implementation of the Patient Protection and Affordable Care Act negatively affected the number of Arkansas women who access family planning and maternity services at LHUs. The Affordable Care Act allows women to choose a private health care provider and allows teenagers to remain insured on their parents’ policies until age 26.
Current Activities Related to Well Woman Care
Objective 1
Increase the number of women ages 18-44 receiving an annual preventive medical visit in an ADH local health unit.
Strategy 1.1: Review medical record data reports for rates of preventive health services for women ages 18-44 provided in local health units.
In 2019, a total of 33,105 women ages 18-44 received a preventive health visit at an LHU. In 2020, this total was 27,088.
Strategy 1.2: Request Medicaid data reports on preventive health visits for women ages 18-44 provided by private providers.
It is difficult to get these data from Medicaid because ADH is not considered a primary care provider.
Strategy 1.3: Provide fact sheets on risk factors identified to women.
Family Planning and Well Woman patients at ADH LHUs receive education and counseling on recommended preventive screenings to optimize health. Information on height, weight, body mass index, and blood pressure is gathered at each visit. After interviewing the client, further education, testing, and/or referrals are provided based on identified needs. Educational topics include sexually transmitted infection screening, Pap tests, mammogram referral, hemoglobin testing, sickle cell screening, total cholesterol or cholesterol screening referral, wet mount, pregnancy testing, and fecal occult blood testing. The client is also screened for immunization status, smoking, alcohol use, illicit drug use or abuse, human trafficking, and intimate partner violence. The ADH provides written materials on a wide variety of topics at LHUs.
The ADH Tobacco Prevention and Cessation Program (TPCP) continues to support coalitions, schools, community-based organizations, corporations, health care providers, hospitals, law enforcement agencies, LHUs, media companies, non-profit organizations, and other state agencies in tobacco prevention and cessation efforts.
During the 2019 legislative session, Act 959 was created to increase coverage for medications approved by the U.S. Food and Drug Administration for tobacco cessation in the Arkansas Medicaid program. Medicaid program coverage includes nicotine replacement therapy patches, gum, lozenges, nasal spray, and inhalers. Medicaid coverage also includes the medications Bupropion and Varenicline. Prior authorization shall not be required for coverage of the medication. In addition to Act 959, Arkansas signed Act 580 into law, which now prohibits the sale of tobacco and vaping products to anyone under the age of 21.
Strategy 1.4: Provide referrals to community resources for identified risk factors or medical procedures unavailable at the local health unit.
In calendar year 2020, the Family Planning and Well Woman programs referred patients for a total of 3,191 health-related services not provided by ADH. The services include laboratory tests, radiology, mammography, colposcopy, social services, dental services, tobacco cessation, and referrals to other medical providers. The Family Planning program also made 2,810 referrals to the Special Supplemental Nutrition Program (SNAP) for the WIC program in 2020.
The ADH Be Well Arkansas program provides Arkansans with resources to improve their health and well-being. With Be Well Arkansas, TPCP staff operate a statewide call center to connect callers to tobacco and nicotine cessation services and wellness counseling for diabetes and blood pressure control. As of April 2021, Be Well Arkansas had enrolled over 7,000 participants into their tobacco cessation program. These wellness services are accessible by calling the 833-283-WELL phone number or online at the Be Well Arkansas website (www.bewellarkansas.org). In addition, the number 1-800-QUIT-NOW for tobacco cessation will route Arkansas callers to Be Well Arkansas.
The agency implemented a colposcopy pilot clinic in the Hempstead County LHU (Southwest Region) in May 2018. An additional site was added in Crittenden County (Northeast Region) in February 2019. These clinics are still actively providing colposcopy services in 2021.
Patients who received cervical cancer screening and needed further evaluation with colposcopy services were at risk for a gap in services due to cost. Four nurse practitioners were trained to perform colposcopies by experienced medical staff. In addition, telehealth services were implemented to increase access and ensure quality. The ADH Colposcopy Project performed 168 procedures in 2020. Overall, 30 cervical dysplasia diagnoses requiring excisional procedures were discovered, and two cancer in situ results were diagnosed.
Objective 2
Increase the percentage of women ages 18-44 receiving preconception counseling prior to pregnancy in an ADH Family Planning clinic.
Strategy 2.1: Provide preconception counseling prior to pregnancy to women attending an ADH Family Planning clinic.
LHUs provide preconception counseling when a patient identifies the desire for pregnancy. However, preventive health screening services and referrals are offered at all Family Planning and Well Woman visits for identified health problems. Family planning patients without a pay source are charged based on a sliding fee scale, with no fee for families whose incomes are at or below 100% of the federal poverty level. The ADH does not deny services due to inability to pay, and the agency bills third party payers for family planning services. The agency does not collect co-pays or deductibles.
Objective 3
Increase the percentage of women receiving prenatal care in the first trimester.
Strategy 3.1: Monitor medical record data reports for entry into prenatal care at local health units.
Maternity patients can complete applications for Medicaid through the Arkansas Department of Human Services (DHS), and non-citizens, or undocumented women, may apply for Medicaid’s Unborn Child Option for pregnancy coverage. Although there is variability across the state in the length of time a client receives prenatal services, the ADH can provide care until the patient is approved for Medicaid. Once approved, LHU staff work with clients to identify a local prenatal care provider. The women’s health services provided are vital given Arkansas’s high rural population, high poverty levels, and limited availability of obstetric providers.
ADH maternity clinics served 2,153 women with expected delivery dates in 2019. The majority (57 percent) of these women had their first prenatal care visit at an ADH clinic within the first trimester of pregnancy. The ADH maternity visit count was 2,557 in 2020.
Arkansas Act 598 authorizes hepatitis C screening during pregnancy. In addition to the testing of pregnant women required under Act 598, a physician or health care provider attending a pregnant woman in Arkansas for conditions relating to pregnancy shall take a sample of venous blood or other approved specimen as early in the pregnancy as reasonably possible. The sample must be sent to an approved laboratory for standard hepatitis C testing.
Other Programmatic Activities Related to Women’s Health
Appointment Show Rate
The ADH implemented an appointment reminder program for patients using the Vital Interaction software with Greenway PrimeSUITE patient data. The patient receives three reminders: 1) A text reminder is sent five days prior to the appointment with a requested Y/N confirmation response, 2) If the patient does not respond to the text, a voice call reminder is sent 72 hours prior to the appointment, and 3) 24 hours prior to the appointment, a text reminder is sent with no requested confirmation.
The appointment show rate for the year prior to the implementation of appointment recalls (March 2016-February 2017) was 65.6%. The show rate for March 2017-February 2018 was 68.8%, an increase of 3.2 percentage points. From March 2018- February 2019, the show rate was 69.7%, an increase of 4.1. From March 2019-February 2020, the show rate was 69.8%, an increase of 4.2. From March 2020-February 2021, the show rate was 74.2%, an increase of 8.6 since implementation.
HPV Prevention
The “HPV Vaccine is Cancer Prevention” Summit was held on May 1, 2020 as a virtual event. The Summit is a time for medical and dental professionals to come together and collaborate on ways to increase awareness about the benefits of the HPV vaccine and cancer prevention as well as to increase acceptance of the vaccine. The Women’s Health section sponsored 30 maternal and child health nurse participants from all regions of the state using funds from the Title X program.
Telemedicine to Improve Outcomes
Through collaboration with UAMS, ADH LHUs are equipped with video and peripheral equipment for real-time telemedicine consults with maternal fetal medicine providers from the UAMS High-Risk Pregnancy Program. The use of telemedicine services allows patients to save time (travel and away-from-work) and transportation costs. The system’s call center serves as an after-hours option for emergency triage consultations with ADH maternity patients.
The ADH Women’s Health section has a professional services contract with the UAMS Department of Obstetrics and Gynecology to facilitate the delivery of comprehensive and risk-appropriate maternity care to low-income women throughout Arkansas. It also supports the department in its efforts to continue to provide outpatient services to ADH high-risk maternity patients. In addition to telemedicine, the contract supports the provision of clinical services and the liaison/consultation services of a certified nurse midwife for ADH’s Lay Midwife Program. Funding for a 0.5 full-time equivalent OB/GYN physician supports the position as ADH’s Family Health Medical Director.
Unintended Pregnancy
The ADH partners with Arkansas Medicaid, Arkansas Foundation for Medical Care (AFMC), and the Arkansas Department of Higher Education to implement strategies and distribute educational materials designed to address unintended pregnancies. Together, these partners developed a toolkit for hospitals and health care providers to use as they discuss health, sexual history, and birth control options with patients. The toolkit, TAKE CONTROL of Your Life: The choice about if or when you become pregnant is YOURS!, includes a patient education flip chart (https://afmc.org/product/larc-patient-education-flip-chart-providers) and patient education guide (https://afmc.org/product/larc-patient-education-interactive-e-book-english-download) to review the different options for family planning. The toolkit is available in English, Spanish, and Marshallese. It was distributed to campus health centers/programs at all public 2-year and 4-year colleges in the state. It was also distributed to the LHUs. Additional information for providers and individuals is available AFMC’s website at https://afmc.org/larc and https://afmc.org/?s=larc. The site also provides links to the YouTube videos developed by the Arkansas Campaign to Prevent Unplanned Pregnancy called Preventing Unplanned Pregnancy (https://www.youtube.com/watch?v=FaCyQMrSUg8).
Maternal and Perinatal Outcomes
The ADH partners with Arkansas POWER (Perinatal Outcomes Workgroup Education and Research) to develop strategies to improve perinatal outcomes in the state. POWER focuses on collaborating with 39 delivering hospitals in Arkansas to reduce maternal mortality and morbidity by implementing maternal safety bundles in postpartum hemorrhage and severe hypertension. POWER recently launched a safety bundle to reduce postpartum racial and ethnic disparities. The ADH Family Health Medical Director and Medical Director for Women’s Health provide public health information and perspective to the workgroup.
Arkansas Act 1032 authorized establishment of the Arkansas Maternal and Perinatal Outcomes Quality Review Committee (AMPOQRC). The intent of the assembly is to improve the maternal and perinatal outcomes in the state. The AMPOQRC is a multidisciplinary committee with representatives from the ADH, DHS, other perinatal and community stakeholders, representatives from participating hospitals, and the state’s only freestanding pediatric specialty hospital.
In 2019, the AMPOQRC voted to adopt a new process to assess the hospitals’ perinatal levels of care using the CDC’s levels of care assessment tool (LOCATE). The committee met seven times between 2019 and February of 2020. Meetings were cancelled in March 2020 due to the COVID-19 pandemic, but bi-monthly meetings have since resumed. Future activity will focus efforts on promoting best practices, conducting quality improvement projects, and analyzing the data gleaned to make recommendations to improve care and health outcomes for mothers and infants.
Maternal Mortality
In March 2019, Arkansas’s legislature passed Act 829 to establish a maternal mortality review committee to decrease the number of maternal deaths in the state. Leadership from the ADH Family Health Branch (FHB) was instrumental in formulating the final legislation, and the ADH was charged with establishing the committee. The Arkansas Maternal Mortality Review Committee (AMMRC) was developed and is facilitated within the FHB.
The scope of cases for Arkansas’s review is all pregnancy-associated deaths or any deaths of women with indication of pregnancy up to 365 days. At the July 2020 meeting, the committee discussed limitations on the scope for abstraction and review based on cases presented at the meeting. Based on the exclusion criteria set forth by the committee members, 10 cases were excluded from the scope of review. The remaining 30 cases were selected to be abstracted and reviewed. The cases determined to be outside the scope for review included: Not pregnant within one year of death (4 cases): Non-Arkansas resident (3), Motor vehicle accident (2), and Accident/Trauma (1).
The AMMRC is a multidisciplinary committee whose members represent Arkansas and various specialties, facilities and systems that interact with and impact maternal health. Membership consists of obstetricians and gynecologists, forensic pathologists, maternal fetal medicine doctors, anesthesiologists, nurses, psychiatrists, mental/behavioral health specialists, nurse-midwifery staff, public health practitioners, advocacy staff, and more. The AMMRC members are appointed by Arkansas’s Secretary of Health.
The ADH’s Family Health Branch developed an internal workgroup, hired a nurse abstractor, identified cases for 2018, and began case abstraction in 2019. The first orientation meeting with the full AMMRC was held at ADH on January 9, 2020, and the first committee meeting with review of abstracted cases was held on June 30, 2020.
Tobacco Prevention and Cessation
The Arkansas TPCP conducted an evaluation of the Arkansas Tobacco Quitline. The evaluation revealed that females accounted for more than half of the registrants who received intervention services through the Quitline (Table 1). A very small percent of those who registered for cessation intervention services were pregnant.
Table 1
Arkansas Tobacco Quitline Evaluation Results
|
|
FY19 Count |
FY19 Percent |
FY11 Percent |
|
|
Gender |
Male |
2171 |
34.57% |
33.90% |
|
Female |
4092 |
65.16% |
66.10% |
|
|
|
Pregnant |
17 |
.27% |
Pregnancy information is unavailable |
|
|
FY20 Count |
FY20 Percent |
FY12 Percent |
|
|
Gender |
Male |
1842 |
34.07% |
34.72% |
|
Female |
3469 |
64.17% |
65.28% |
|
|
|
Pregnant |
95 |
1.76% |
Pregnancy information is unavailable |
*Note: Percent numbers for gender do not sum to 100% due to missing and refused information.
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