NPM #1 Well Women Care – Improve pre-conception, prenatal and postpartum health care services for women of childbearing age.

 

The health and wellbeing of the mother before, during, and after pregnancy is important not only for the woman but also for the newborn. Women who maintain a healthy lifestyle during the preconception period are less likely to experience adverse pregnancy and obstetric outcomes and are also more likely to experience better health postnatally and across the life span. According to data from the 2018 Behavioral Risk Factor Surveillance System (BRFSS), 72.9% of Missouri women between 18-44 years of age reported having a preventive health care visit within the past year. This was lower than the national prevalence of 73.6%. A slightly lower percentage of non-Hispanic, White women (71.3%) in Missouri had a routine well woman checkup than at the national level (71.7%). The prevalence of getting a routine well woman checkup among non-Hispanic, Black women in Missouri (90.8%) was greater than for non-Hispanic, Black women at the national level (83.1%). In Missouri, a higher percentage of insured women (79.1%) compared to uninsured women (40.5%) received a preventive visit in 2018. A lower percentage of those with less than a high school education (55.6%)* received a preventive visit in the past year than college graduates (74.3%) in Missouri. However, the percentage of Missouri women who had a college degree that received a preventive visit in the last year was lower than their national counterparts (75.3%). In Missouri, fewer of those earning <$25,000 (69.7%) had a preventive visit than those earning >$75,000 (80.1%). There was no substantive difference across marital status in Missouri.

 

In 2019 (provisional data), 71.2% of infants were born to Missouri mothers who received prenatal care in the first trimester, compared to the 71.4% in 2018. Non-Hispanic Whites were more likely to receive prenatal care in the first trimester (75.9%) than, Non-Hispanic Blacks (55.7%) and Hispanics (57.5%). The U.S. prenatal care in the first trimester rate slightly increased from 77.3 in 2017 to 77.5 in 2018.

 

According to MO 2018 PRAMS, 87.5% of Missouri women received a postpartum checkup in 2018 compared to 88.9% in 2014. Women without health insurance (69.7%) had the lowest percentage of receiving a postpartum checkup than their counterparts who were privately insured (94.5%). Non-Hispanic Black women (78.7%) had lower rates of receiving a postpartum checkup compared to non-Hispanic White women (88.9%) and women with less than a high school education (72.4%) had lower rates than women with a high school education or higher (89.5%).

 

Missouri is not currently a Medicaid expansion state, however, legislation passed on August 4, 2020 to begin Medicaid Expansion on July 1, 2021. Missouri’s Medicaid system (otherwise known as MO HealthNet) has two programs which cover pregnant women, unborn children, and newborns: MO HealthNet for Pregnant Women (MPW) and Show-Me Healthy Babies (SMHB). MPW provides healthcare coverage, including sixty-day postpartum coverage, for pregnant women whose family income does not exceed 196% of the Federal Poverty Level (FPL) for their household size. Once eligible, the coverage continues through the postpartum period despite subsequent increases in income. Coverage begins the first day of the month of application. SMHB program provides healthcare coverage for unborn children and their mother whose family income does not exceed 300% of the FPL for their household size. Once eligible, the coverage continues despite subsequent increases in income. The application must be submitted prior to the delivery date. Coverage begins the date of application. Children born to a woman eligible for and receiving either MPW, SMHB, or other non-premium MO HealthNet health care coverage on the date of the infant's birth continue to be eligible for MO HealthNet coverage throughout the first year of life as long as the child maintains Missouri residence. The Extended Women’s Health Services program covers family planning-related services, pregnancy testing, sexually transmitted disease testing and treatment, including pap tests and pelvic exams, and follow-up services. Participants are covered by MO HealthNet for uninsured women who are 18-55 years of age with a Modified Adjusted Gross Income for the household size that does not exceed 201% of the FPL. The Missouri Title V Program partners with Local Public Health Agencies (LPHA) and the Home Visiting Program to assist pregnant women with enrollment for the programs listed above.

 

The MCH Services Program contracted with LPHAs to build MCH systems to promote improved preconception, prenatal, and postpartum health care services for women of childbearing age. The MCH Services Program supported LPHA efforts to: increase the number of women receiving adequate prenatal care; prevent preterm birth; reduce the incidence of preventable birth defects; increase knowledge related to and utilization of folic acid for women of childbearing age; prevent teen pregnancy; and improve access to care.

 

Ten LPHAs selected the improvement of pre-conception, prenatal, and postpartum health care services for women of childbearing age as their MCH Services contract work plan priority health issue for their FFY 2019-21 MCH work plans. The LPHAs implemented strategies including:

• Implement health promotion and education efforts to improve birth outcomes;
• ensure quality of care for all women and infants;
• improve maternal risk screening for all pregnant women;
• enhance service integration for women;
• improve access to care for women before, during, and after pregnancy;
• incorporate preconception and interconception health messages into social media campaigns;
• support folic acid campaigns to target preconception and interconception women;
• reduce use of and exposure to harmful substances such as alcohol, tobacco, and environmental teratogens;
• use data to understand and inform efforts to improve healthy birth outcomes;
• support Medicaid outreach and facilitate enrollment for pregnant women;
• implement education programs for pregnant women, families, and providers;
• engage and recruit a diverse group of community partners;
• eliminate health disparities and promote health equity to improve birth outcomes;
• provide well woman exams, pregnancy testing and counseling, prenatal case management, and routine health office visits for women of childbearing age; and
• collaborate with community partners to expand maternal health services.

 

Implementation of these strategies resulted in:

• increased utilization of community based approaches with local coalition partners to reduce known risk factors for adverse birth outcomes;
• increased number of individuals and variety of fields represented who received education on the prevention and reduction of adverse birth outcomes;
• increased number of clients that utilized the LPHA programs who received education, screening, and referral and demonstrated an increase in knowledge on the benefits of timely and adequate prenatal care and the risks of preterm delivery;

• 106 LPHAs reported providing pregnancy testing, education, and referral to OB/GYN care;
• 99 LPHAs reported providing education on the importance of prenatal care, including early entry into care, adequate number of prenatal visits, etc.;
• 67 LPHAs reported either providing direct prenatal case management or referring to prenatal case management;
• 107 LPHAs reported screening clients for insurance or MO HealthNet coverage;
• 101 LPHAs reported screening clients for having a primary care provider;
• 106 LPHAs reported providing referral to OB/GYN care;
• 71 LPHAs reported assisting pregnant women with enrollment in eligible MO HealthNet programs;
• 82 LPHAs reported providing education on the importance of postpartum follow up within the first four to six weeks after delivery, and 58 reported providing postpartum follow up within four to six weeks after delivery; and
• 86 LPHAs reported providing education on the importance of preconception and interconception care, and 50 reported providing preventive well woman visits.

 

Specific LPHA achievements included the following:

• Ray County Health Department offered free “Cooking Matters” healthy cooking classes to women and families that provided cooking demonstrations, hands-on cooking activities, recipes and nutritional education.
• Christian County Health Department established HOPE 365 (Health Outreach Prevention Education), a program that offers pre-conception, prenatal, and postpartum educational information and support, both professional and peer-to-peer, and allows for engagement of key community partners to promote healthy pregnancies.
• Atchison County Health Department maintained a mutual referral system for women’s health services between the LPHA and the community’s three school nurses, two local providers, and the community hospital.
• Joplin City Health Department created the LiveSmart Walk Initiative to increase physical activity among women of childbearing age and their families in the Joplin community, resulting in the establishment of five, active walking hubs with more being created. Community leaders are collaborating to evaluate, expand, and improve safe spaces for walking, running and bicycling resulting in the establishment of new trails and updating/improving and lengthening of old trails, the addition/updating of sidewalks and the expansion of streets to incorporate bike lanes.
• Warren County Health Department became an official vendor at both of the local farmer’s markets, held weekly, and drove the implementation efforts to establish several community garden beds. Staff continued to build their partnership with Turning Point, an advocacy group that supports survivors of domestic and sexual violence by offering exercise classes on-site and assisting them with on-site gardens and cooking/nutrition classes with the University of Missouri Extension office.
• St. Louis County Health Department, through the evaluation of internal health records of visits for women of childbearing age, determined what populations are being left out of Reproductive Life Plan (RLP) discussions; identifying such potential missed opportunities for education allows for ongoing evaluation of processes and the continued improvement of services and care to women of childbearing age.
• Nodaway County Health Department partnered with the local University of Missouri Extension office to provide free nutrition and exercise classes to women of childbearing age in an effort to prevent and reduce the prevalence of obesity.
• Phelps-Maries County Health Department surveyed 67 area women’s health stakeholders to assess willingness to collaborate to improve health care services for women of childbearing age and surveyed female LPHA consumers of childbearing age to determine educational areas of need/interest; as a result of the surveys, they have a new program of classes planned for 2020, which will include early pregnancy (4-20 weeks), late pregnancy (21-40 weeks), newborn care from birth through three months, toddler parenting, and a sibling class for children whose parents are expecting a new baby.
• Reynolds County Health Department established a Memorandum of Agreement with the Missouri Department of Social Services to begin providing temporary Medicaid enrollment to eligible pregnant women, a particular need that surfaced after the local Family Services Division stopped offering that service.

 

In FFY 19, the Section for Women’s Health (SWH) distributed 4,876 copies of the “Women: Take Charge of your Health” informational booklet. This booklet is available in both hard copy and electronically from the women’s health website. This resource is provided to the general public, LPHAs, and others upon request. The booklet provides information on topics such as preventative health, preconception health, obesity prevention, breastfeeding, and disease prevention. The Show Me Healthy Women (SMHW) program dispensed the booklet to their nurses across the state who shared them at health care events and with the SMHW providers. SMHW offers free breast and cervical cancer screenings for Missouri women who meet age, income and insurance guidelines. The SMHW providers and nurses found the booklet helpful as it includes great visuals to help women identify which screening tests they should consider. In addition, the SWH shared current issues and timely information related to women’s health through weekly updates to the statewide Women’s Health Network listserv, which comprises organizations and individuals interested in women’s health topics. Listserv recipients shared in an annual survey that the information they receive through the listserv is useful (98% of survey respondents).

 

The SWH supports the Missouri Women’s Health Council, which was re-established in October 2017. Through quarterly meetings, the Council provides input and feedback on how best to improve outcomes as the Department of Health and Senior Services (DHSS) develops and implements strategies to improve women’s health in Missouri. Members spent FFY 19 identifying key women’s health priorities, informing policy that extends Medicaid coverage for women in treatment for substance use disorders for up to one year after the birth, providing information and advice that supported Missouri in applying to become an Alliance for Innovation in Maternal Health state, and providing information and advice to support DHSS and the Department of Social Services in taking the beginning steps to developing a perinatal quality collaborative to support health care providers from across the state to drive improvement in obstetrical and newborn care. In October 2018, the Missouri Women’s Health Council co-sponsored the 16th Annual Missouri Health Policy Summit focusing on women’s health policy throughout the lifespan. The Council’s vice chair provided the keynote address on maternal mortality and morbidity, and additional Council members participated in a panel discussion on mental health, violence against women, the unique needs of women with substance use disorders, and cardiovascular and cerebrovascular health in women. In addition, the SWH provided monetary sponsorship for the event.

 

The Newborn Health program produces and distributes the Pregnancy and Beyond booklet to provide important prenatal and newborn health information. This book was developed to track and record moms’ and babies’ preventive health exams. It has the potential to improve birth outcomes for pregnant women and their infants throughout Missouri. Pregnancy and Beyond is not only a reference for health information but also a place to record the progress of a woman’s pregnancy and her baby’s development. The first section focuses on mom, the second section is for the baby, and the final section is for the toddler and preschool age child. The book is not, however, a complete health record and it does not take the place of a health care provider’s guidance and records.

 

The booklet suggests that the pregnant woman read the entire book in order to become familiar with it and bring it to all prenatal visits to help her ask questions and write down what she learned. The booklet states how early and regular prenatal care starting within the first three months of pregnancy and continuing until delivery is the most important step to assure the best possible health for the unborn child. Pregnancy and Beyond can be used to:

• Keep a record of mom’s health during the pregnancy.
• Answer questions about her pregnancy and new baby.
• Remind her of questions to ask her health care provider.
• Keep a record of her baby’s health, growth, and development.

 

The “Mom’s Section” of the booklet also includes a list of steps to improve the chances of having a healthy baby/reducing the risk of birth defects, states the importance of knowing family health history, discusses prenatal care, and shares things to know throughout the stages of pregnancy. In FFY19 35,074 Pregnancy and Beyond booklets were distributed to hospitals, doctor’s offices, LPHA’s, Birthing centers, and other partners throughout the State of Missouri. This is almost 2,500 additional booklets distributed from the previous year.

 

The Newborn Health Program also distributed over 60,000 pieces of literature aimed at improving pre-conception health and prenatal and postpartum health care in FFY19. These pieces of literature included 9 Things to Do Before Getting Pregnant (English and Spanish), Planning for a Baby, and Healthy Moms, Healthy Babies. This also included Postpartum Depression in English and in Spanish. These literature items are handed out at a variety of conferences and baby expos. The program also receives orders for literature from hospitals, LPHA’s, and doctor’s offices.

 

Text4baby is a program that provides free text messages with health information timed to a pregnant woman’s due date or a baby’s birthdate. The program can also be used to schedule a reminder for the next doctor’s appointment. Text4baby data showed that 91% of participants would recommend Text4baby to someone. Data also showed that 63% of participants reported that a text prompted them to speak with their doctor. Participants have reported 78% first trimester prenatal attendance at doctor appointments since launch of the App in 2010. Text4Baby has an average monthly enrollment of 960 participants.

 

TEL-LINK is the DHSS’ confidential, toll-free telephone line for maternal and child health care. The purpose of TEL-LINK is to provide information and referrals to Missouri residents concerning a wide range of health services. Callers requesting referrals are transferred to the appropriate agency. The TEL-LINK Program provided information and referrals on services such as WIC, MO HealthNet, prenatal clinics, community health centers, mental health services, home visiting programs, and smoking cessation for preconception, prenatal, and postpartum care. During FFY19, TEL-LINK connected 2,912 callers directly to maternal and child health services, which lead to 957 referrals for preconception, prenatal, and postpartum care services. In FFY19, the TEL-LINK Program created an advertising video to visually display how the program works and was promoted through social media and the DHSS’ main website. The Program utilizes this video and Google search ads to advertise the TEL-LINK Program’s ability to share community resources and provide access to care.

 

The Bureau of Genetics and Healthy Childhood (GHC) funded home visiting services offered in 26 counties and served 1,087 families through the Missouri Building Blocks (BB), Healthy Families Missouri Home Visiting (HFMoHV) and the Maternal, Infant and Early Childhood Home Visiting (MIECHV) programs. These programs implement the following evidence-based models:

• Nurse Family Partnership model;

• Healthy Families America model;

• Parents as Teachers model; and

• Early Head Start Home Based Option model. 

 

The GHC Home Visiting program specifically tracks the number of prenatal women enrolled in a GHC contracted home visiting program, or women enrolled within 30 days of giving birth that remain enrolled for at least 8 weeks postpartum, who receive a postpartum follow-up visit. In FY19 the percentage of women enrolled who received a postpartum follow-up visit was 78.6% (180/229).

 

During monthly subrecipient monitoring conference calls the Home Visiting Program regularly surveilles the local implementing agencies for barriers that interfere with home visiting participants accessing needed services. In FY19, a continuing barrier to well woman care was access to Medicaid non-emergency medical transportation (NEMT). Additionally during FY19, in the southeastern region of Missouri, the closure of a local hospital and adjourning clinics resulted in home visiting clients traveling greater distances and waiting for extended periods of time to see a physician. This added two new barriers that contributed to increased challenges for accessing adequate well woman care in the most healthcare challenged region of Missouri. To help address this challenge, the following resources were sent to all GHC contracted home visiting staff through the Missouri Home Visiting Gateway Weekly Update:

• 12/17/18 - Why Rural Hospitals Are Closing- And How it Hurts Maternal Health (Recorded Webinar)
• 1/18/19 - What’s at Stake as Rural America Loses Its Hospitals (Webinar)
• 2/22/19 - For families in rural areas, doctors, support groups, counselors, and even friends and family are often many miles away. Telehealth opportunities, such as apps that connect patients with providers, virtual health events, and online communities can help families not feel so alone. - NICHQ 

 

Although not funded through the Title V program in FFY 2019, the Child Lead Poisoning Prevention Program (CLPPP) has an active role in lead assessment and education campaigns to Missouri women of childbearing age for pre-conception and prenatal lead poisoning prevention activities in the community through collaborative efforts with the DSS, DHSS, and MCH programs and through LPHA and WIC agencies. DHSS/Bureau of Environmental Epidemiology (BEE)/Adult Blood Lead Epidemiology and Surveillance (ABLES)/CLPPP programs partner with DSS (which administers the Medicaid fee for service and Medicaid/MO HealthNet Managed Health Plan programs) to require Medicaid providers and Medicaid Managed Health Plans to use a pre-natal lead risk assessment questionnaire for enrolled Medicaid women at preconception visits or for pregnant women at Prenatal Care visits. The form serves as an effective educational as well as an assessment tool for preconception or pregnant Medicaid women. Usage of this form requires initiation of direct discussions by the clinician with their clients regarding possible exposure sources and health concerns regarding lead exposure and lead poisoning and prevention. These discussions often lead to increased blood lead testing if it is discovered that lead exposure has already occurred or is suspected to have occurred in the individual’s lifetime; and it may lead to more opportunities for environmental testing of residences. When a woman of childbearing age is reported to DHSS with a blood lead level of 10 ug/dL or greater, staff contact the health care provider who ordered the blood lead test in order to determine the woman’s source of lead exposure and pregnancy status. Recommendations are given for reducing the patient’s source of lead exposure and medical management guidelines. Lead case manager and WIC trainings incorporate the CDC “Guidelines for the Identification and Management of Lead Exposure in Pregnant and Lactating Women.”

 

Elevated Blood Lead Levels in women may occur due to current exposure or to activation of bone stores of lead during pregnancy and lactation if they were lead poisoned in prior years or youth, as lead is stored in the bones for decades. Clinician’s discussions and education with clients will ideally lead to prevention of initial exposure or further lead exposure to women preconception, prenatally, and after delivery for their families and potentially their developing fetus and newborn or nursing baby. Also, many individuals and families contemplating or preparing for the birth of a child, move to a different residence or remodel their residence to provide additional or updated features or space to their current or prospective home. Pre -1978 built housing is likely to have lead paint hazards, which creates a potential lead inhalation or ingestion exposure for those individuals spending time in the older home that needs maintenance, if they participate in remodeling efforts, or stay in the home while any remodeling efforts are being carried out. Providing lead education and blood lead and environmental testing prior to conception, and prior to families making decisions to move or remodel is the ideal situation. BEE provided partial funding for another updated Pregnancy and Beyond booklet. The updated version has more references about when small children should be tested and explanations about the sources of lead poisoning in the environment. Funding received through Missouri’s participation in the Maternal Child and Environmental Health CoIIN was used to print and distribute to health care providers copies of the CDC reference book, Guidelines for the Identification and Management of Lead Exposure in Pregnant and Lactating Women. This is an excellent reference for health care providers and has current CDC recommendations.

 

Missouri’s CLPPP continued providing required home visits to families whose children under the age of 72 months had consistently elevated venous blood lead levels of 15 - 19 mcg/dL or a single elevated venous blood level of 20 mcg/dL or higher. Additionally, lead risk assessments continued to be offered to families whose child had elevated venous blood lead levels of 10 or higher in most areas of the state. Home visits are made by nurse lead case managers and by licensed lead risk assessors. Licensed lead risk assessors take samples in the home environment to discover the source of lead exposure (soil, water, dust samples inside, lead paint samples, food, cosmetics, take home occupational or hobby related sources). If any of the children’s homes included women who were pregnant or other children, the family was encouraged to have the pregnant woman and other young children’s blood levels tested. The family or home owner/landlord was then educated in interim controls and safe removal of the lead sources identified. Of note, some state or city jurisdictions in the state are able to offer lead risk assessments of the home, at a family’s request, if a pregnant woman resides at the residence. Elevated blood lead levels in women contribute to the incidence of miscarriage. The CDC recommendations encourage follow-up with any pregnant women’s elevated blood lead level of 5 mcg/dL or higher. If the pregnant woman is in an older home that is being remodeled, or has exposure through occupation or hobby or any other sources such as pica conditions or cultural or home remedies, these issues need to be addressed to provide the best health outcomes for the mother and baby.

 

The DHSS website pages were updated to reflect recent data about the incidence and risk of lead poisoning by county. Videos about lead related occupations and other lead related topics and information were posted on the website as well for the public to access.

 

The following activities are not funded by the Title V Block Grant, but still contributed to addressing the priority health need.

 

In the SWH, the Perinatal Hepatitis B Prevention Program (PHBPP) worked with three contractors (Kansas City Health Department, St Louis County, and St Louis City) and each LPHA throughout the state to identify and educate all pregnant women with Hepatitis B, enroll them in case management, follow their infants from birth through their Hep B vaccine series and Post Vaccine Serology Testing (PVST), to ensure the infant’s immunity to Hepatitis B virus. There were a total of 99 infants born from 10/1/18-9/30/19 that were followed in case management. Provider education and technical assistance was given on as needed basis. Hepatitis B surveillance was completed by the Bureau of Reportable Disease Informatics through Websurv.

 

The Bureau of HIV, STD and Hepatitis (BHSH) continued to collaborate with Ryan White Part D providers to provide access to preconception counseling and prenatal healthcare services for women living with HIV. Missouri’s two Ryan White Part D providers and their contracted subrecipients provide family-centered comprehensive care to children, youth, women, and their families.

• The KC CARE Health Center, a Missouri Ryan White Part D Recipient, and APO, a Missouri Ryan White Part D Subrecipient, provided comprehensive, coordinated Primary HIV Medical Care to 359 women and youth in CY19, including 299 women living with HIV. Of the 299 women living with HIV, the Part D Recipient provided care to 30 pregnant women.
• Of the 39 HIV+ mothers followed by Washington University’s Project ARK perinatal team that gave birth in 2019, 30 (77%) received their HIV primary medical care within the Part D network. Of these 30 women, 26 (87%) kept an HIV medical visit or had a pending appointment after delivery. The remaining 9 women that gave birth in 2019, received care from HIV providers outside of Washington University and Saint Louis University Part C/D clinics. Of these women, 100% kept an HIV medical visit postpartum or have a pending HIV appointment postpartum. Out of the 39 women followed by Washington University’s Project ARK perinatal team that gave birth in 2019, one infant was found to be HIV-infected. During the past ten years (2010-2019), only five of the 361 HIV-exposed infants delivered during that period were found to be HIV-infected. All five HIV-infected infants were immediately enrolled in medical care and all five mothers and their infants remain in medical care within the Project ARK network of medical providers.

 

NPM #2 Low Risk Cesarean Deliveries – Improve maternal / newborn health by reducing cesarean deliveries among low-risk first births.

 

Childbirth by its very nature carries potential risks for women and their babies, regardless of the route of delivery. Although cesarean sections are medically required in some instances, these births pose a greater risk of maternal morbidity and mortality, as well as neonatal morbidity and mortality, than vaginal births. According to the American College of Obstetrics and Gynecologists (ACOG), potential risks of cesarean delivery for moms and babies include a longer hospital stay, an increased risk of respiratory problems for the infant and greater complications in subsequent pregnancies, including uterine rupture, placental implantation problems, and the need for a hysterectomy. According to the 2019 Vital statistics data, there were 5,448 (24.0%) cesarean deliveries among Missouri women with low-risk first births compared to 25.6% nationwide (NVSS Provisional 2019 data). The low risk C-sections were highest among Non-Hispanic Black women (25.3%), followed by Hispanic women (23.6%) and Non-Hispanic white women (23.5%). The US 2019 provisional data also showed highest C-section rates among non-Hispanic Black women (30.0%) followed by Hispanic women (24.8%) and Non-Hispanic whites (24.7%). The low-risk cesarean delivery rate is defined as a cesarean delivery among nulliparous (first birth), term (37 or more completed weeks based on the obstetric estimate), singleton (one fetus), and cephalic (head first) births.

 

There is great variation in the rate of cesarean delivery across Missouri hospitals ranging from as low as 14% to as high as 33%. Studies have suggested that other potentially modifiable factors, such as patient preferences and practice variation among hospitals, systems, and health care providers likely contribute to the variation in cesarean delivery rates. Reducing primary cesarean deliveries among low-risk first births is critical to reducing both maternal and neonatal morbidity and mortality.

 

Conducting pregnancy-associated mortality reviews (PAMR) aims to clarify gaps in care, identify systemic service delivery issues, and make recommendations to facilitate improvements in the overall system of care. A full-time nurse abstractor position abstracts all pregnancy-associated mortalities in Missouri. Missouri was one of the states awarded the Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM) grant by the CDC. The ERASE MM initiative is a 5-year grant that will support the PAMR program by increasing capacity to conduct timely reviews, facilitate an understanding of the causes of maternal mortality, and inform prevention efforts for families and communities who need them most. To increase workforce knowledge about PAMR, the PAMR coordinator, abstractor, and one data analyst attended the two-day Maternal Mortality Review Information Application (MMRIA) User Meeting in June 2019. The training provided many opportunities for networking with other maternal mortality programs and to learn best practices for addressing perinatal mental health and substance use disorder. For example, the state of Utah developed a guidance tool for reviewing these deaths and eagerly shared this document with our program coordinator. Missouri’s PAMR board then adapted the document for use in similar case reviews. This document serves as a guidance tool to standardize the review of cases involving perinatal mental health and/or substance use. The MMRIA User Meeting also provides the latest information on the MMRIA, as well as opportunities for state input on needs related to the database. Missouri continued to use the Centers for Disease Control and Prevention’s MMRIA, which was installed locally in 2018, for abstraction of maternal mortality information.

 

During the 2018-2019 legislative session, Senate Bill 514 was passed statutorily establishing the Pregnancy-Associated Mortality Review (PAMR) Committee. The reconstitution of the PAMR board provided a unique opportunity to conduct member orientation that the PAMR coordinator completed in January 2019. The training ensured that each of the PAMR board members were using the same definitions, understood the steps of a review from start to finish, and were acquainted with the MMRIA. Many of the PAMR board members expressed that the orientation was very helpful, and the slides were shared with the CDC to distribute among other Maternal Mortality Review Committees.

 

DHSS committed to reducing maternal mortality as identified in the Department’s strategic plan. The strategic initiatives team, formed in 2018, continued to meet and develop the department dashboard. The dashboard included four department themes: reduce opioid misuse, improve the health and safety of Missourians most in need, enhance access to care, and foster a sustainable, high-performing department. Improving the health and safety of Missourians most in need included initiatives to address chronic disease and maternal mortality. DHSS’ commitment to reducing maternal mortality and improving the health of Missouri mothers and babies also included a reorganization of women’s health initiatives. The purpose of the reorganization was to bring colleagues together who work on women and maternal health initiatives to increase collaboration. Programs in the newly established Section for Women’s Health include rape and violence prevention, perinatal hepatitis B, MCH services including the Title V block grant, maternal mortality (PAMR), and WISEWOMAN and Show Me Healthy Women. Although any reorganization can cause unease among employees, it also provided programs the opportunity to share resources. For example, the WISEWOMAN program has access to a MO HealthNet (Medicaid) database, so the PAMR coordinator worked with that program to gain access to the database that assists in requesting records necessary for a comprehensive maternal mortality review.

 

Collaborative efforts continued between DHSS, MHA, MOD, MO Chapter of the American College of Obstetricians and Gynecologists (MO ACOG) and the MO Chapter of the American Academy of Pediatrics to form a Perinatal Quality Collaborative (PQC). The group leading this effort, the Maternal and Child Learning and Action Network (MC LAN), met in the fall of 2018 for their kickoff meeting, which was well attended by stakeholders from across the state. The kickoff meeting began with a general overview of infant and maternal data specific to Missouri and also at a national level. Prior to the kickoff, a survey regarding top concerns for infant and maternal health was sent to each participant to complete. The survey results were shared in a word cloud at the kickoff. The text data included some of the following key words: rural, prenatal, mental health, access, NAS, disparities and resources. The key words were then used as discussion topics as planning for next steps began. The MC LAN continues to meet on a quarterly basis and is planning to meet with stakeholders to obtain funding for a fully functioning PQC. Three members of the MC LAN, including the PAMR coordinator, attended the National Network of Perinatal Quality Collaboratives (NNPQC) 2-day meeting in November 2018 to collaborate and learn from other PQC’s. During one of the breakout sessions titled “Reducing Unnecessary C-sections,” the PAMR coordinator learned techniques from other states to gain physician buy-in, which is an important component to the success of reducing C-section rates.  

 

Of the 114 statewide Local Public Health Agencies (LPHA):

• 36 LPHAs reported providing education on the risks associated with cesarean section delivery, and 47 reported providing education on the risks associated with delivery prior to 39 weeks gestation;
• 106 LPHAs reported providing pregnancy testing, education, and referral to OB/GYN care, with interconception care education being provided with all negative pregnancy tests;
• 67 LPHAs reported either providing direct prenatal case management or referral to prenatal case management;
• 86 LPHAs reported providing education on preconception and/or interconception care, including birth spacing; and
• 99 LPHAs reported providing education on the importance of prenatal care, including early entry into care, adequate number of prenatal visits, etc.

 

The Newborn Health Program contracted with Voxiva to supply free text messages to pregnant women and new mothers up to their child’s first birthday. There were three Text4baby customized messages sent each week to Missouri specific phone numbers and websites. The message in week 36 read, “Counting down the days until your due date? It may be tempting to induce & deliver early but your baby’s brain and organs are still developing. It’s worth the wait! Go to text4b.org/088 to watch a fun video about why the end of pregnancy is important for baby’s health.” In week 38 Text4baby sent the following message, “You’re doing great, Mom! With delivery near, you may feel excited but also afraid. It’s normal! Get support from your partner, family & friends. Babies born after 39 weeks have fewer health problems than babies born earlier. The last weeks of pregnancy really count! www.marchofdimes.com/39weeks.” Over 900 participants were enrolled in the Text4baby program each month.

 

The Pregnancy and Beyond booklet is a resource distributed to medical providers and community partners throughout the state who then provide it to women to use throughout their pregnancy. Filled with a wide range of information concerning pregnancy and the first five years of a child’s life, the booklet specifically discusses why scheduling an early birth can be a problem for both mom and baby. The booklet goes on to explain that babies born between 34 to 36 weeks are considered “late preterm.” They can seem healthy at first but can later develop breathing problems, feeding difficulties, and other difficulties.

 

The Bureau of Genetics and Healthy Childhood (GHC) funded home visiting services were offered in 26 counties and served 1,087 families through the Missouri Building Blocks (BB), Healthy Families Missouri Home Visiting (HFMoHV) and the Maternal, Infant and Early Childhood Home Visiting (MIECHV) programs. These programs implemented the following evidence-based models:

• Nurse Family Partnership model;

• Healthy Families America model;

• Parents as Teachers model; and

• Early Head Start Home Based Option model. 

One goal of these programs is to increase healthy pregnancies and positive birth outcomes through home-based services. Data from FY19 indicated that 85% of infants (204/241) were born at term among mothers who enrolled in home visiting prenatally before 37 weeks gestation. 

 

Through ongoing monthly subrecipient monitoring conference calls with all GHC contracted home visiting agencies, the Home Visiting program continually reviews and provides resources on pre-conception, prenatal, and postpartum needs to help home visitors support women in having healthy full term pregnancy outcomes.  Resources were shared with all home visiting agencies via the Missouri Home Visiting Gateway Weekly Update during FY19 and included the following:

• 12/7/18 - New video features a mom who saved her baby by using the Count the Kicks app and speaking up to her provider when she noticed a change in movement.
• 6/21/19 - Support pregnant women and expectant families involved in your programs with the new Pregnancy topic area on the Early Childhood Learning and Knowledge Center (ECLKC).

NPM #14 Smoking – Prevent and reduce smoking among women of childbearing age, pregnant women.

 

From 2018 Vital Statistics data, 13.7% of Missouri women smoked during pregnancy, which more than doubles the national average of 6.5%. The prevalence of smoking during pregnancy was higher among women with less than a high school education (30.4%) compared to women with a high school diploma (22.4%), some college (12.8%) or college graduates (1.3%). Medicaid insured women (25.6%), were also more likely to smoke than those privately insured (5.6%), those who had other public insurance (9.5%) and those that were uninsured (3.8%). A greater percentage of women that were unmarried (24.2%) smoked than those that were married (6.7%) in Missouri. This nearly doubles the proportion of unmarried women who smoked nationally (13.2%). In Missouri, non-Hispanic American Indian/Alaskan Natives had the highest proportion of women who smoked (25.2%). This is higher than the rate for non-Hispanic white women (15.2%), non-Hispanic Black women (9.6%) and Hispanics (6.0%), as well as the national rate for non-Hispanic American Indian/Alaskan Natives (15.5%). Missouri women smoked during pregnancy at a greater proportion than their national counterparts across all age groups. The greatest proportion in Missouri was for age 20-24 year olds (18.4%) compared with 9.2% nationally. The percentage of women who smoked during pregnancy in Missouri was higher than for the national counterparts for every category. However, the percentage of women smoking during pregnancy has decreased from 18.4% in 2006 to 12.8% in 2019 Missouri Vital Statistics data.

 

In 2018, 728 Missouri women 18-44 years of age called the Missouri Quitline. Percentages varied by sociodemographic characteristics and pregnancy status. Among women 18-44 years of age, the callers were predominantly White (70.3%) followed by African American (27.5%). Hispanic callers were 3.1 percent. Among these women, 3.8 percent were pregnant, 2.4 percent were planning to become pregnant, and one percent were breastfeeding.

 

Smoking during pregnancy continues to be a significant public health concern for Missouri’s MCH populations. Pregnancy is a teachable moment and smoking cessation education efforts during pregnancy need to be sustained. Promoting and providing cessation resources can have a positive impact on the MCH population and increase the number of quit attempts by pregnant women who smoke. Missouri’s comprehensive tobacco control initiatives included the strategies outlined below. Strategies often addressed both tobacco cessation and the dangers of secondhand smoke.

 

The MCH Services Program supported Local Public Health Agency (LPHA) efforts to: promote tobacco avoidance and cessation among adults and youth, and identify and eliminate tobacco-related disparities among population groups. Of the 114 LPHAs, 106 reported performing maternal assessment of tobacco use and providing cessation education as indicated, 42 reported providing tobacco cessation programs, 105 reported referring clients to the Missouri Tobacco Quitline, 23 reported providing worksite tobacco programs, 30 reported participating in anti-electronic cigarette initiatives, and 9 reported implementing the evidence-based BABY & ME – Tobacco Free Program™ to improve birth outcomes by helping women quit smoking prenatally.

 

Specific LPHA achievements included:

• Lafayette County Health Department worked with local law enforcement agencies to assess and improve compliance check efforts of area businesses that sell tobacco products. Staff conducted monthly meetings with targeted area businesses and organizations to raise awareness of the increased rates of smoking in pregnant women in Lafayette County, discuss the complications that can occur as a result of tobacco use during pregnancy, and assess interest and recruit support of implementing a smoke-free ordinance in public places in Lexington, MO.
• Macon County Health Department provided free smoking cessation services to women of childbearing age that included behavioral counseling.
• Springfield-Greene County Health Department provided trainings on the evidence-based smoking cessation program, SCRIPT (Smoking Cessation Reduction in Pregnancy Treatment). Internal trainings were provided to health department social workers, nurse case managers, and WIC staff. External trainings were provided to staff at LifeHouse, a local crisis maternity residential/transitional housing program for homeless pregnant women and their infants/young children and Pregnancy Care Center staff.
• Springfield-Greene County Health Department also collaborated with Community Partnership of the Ozarks Prevention Specialists to develop a unified vape/e-cigarette curriculum/train-the-trainer program and shared it with surrounding school districts and area organizations serving adolescents.
• Camden, Linn, and McDonald county health departments have certified Freedom from Smoking® facilitators on staff to provide smoking cessation services.
• Cape Girardeau, Lincoln, Ste. Genevieve, and Stone county health departments, among others, offered the BABY & ME – Tobacco Free Program™ to pregnant women who smoke.
• Monroe County Health Department developed a screening tool to assess tobacco use in all women of childbearing age seeking health department services, assessed interest in cessation in women using tobacco products, and provided education and referral to smoking cessation resources and programs.

 

Following the AAP guidelines, the Safe Cribs for Missouri program provides cribs and two educational sessions to qualified women who have no other means to provide a safe sleep environment for their child. In FFY19, 334 pregnant and postpartum women received one-on-one educational sessions through this program. One component of the educational sessions focused on tobacco use, both the dangers of smoking while pregnant and the dangers of secondhand smoke for babies.  An evaluation report is produced each year, and the most current results showed that 44.7% of participants smoked prior to pregnancy. Of those who smoked, 41% quit smoking during pregnancy.  

 

Multiple resources were available to pregnant women and women of childbearing age including Pregnancy and Beyond, Text4baby, and TEL-LINK. The Pregnancy and Beyond booklet was available to agencies that provide services to pregnant women, such as medical providers and LPHAs. They then shared this with the women they serve. The booklet covers a variety of topics, including a section on the dangers of smoking while pregnant and the health effects of secondhand smoke on babies. Text4baby sent out customized text messages related to smoking, and women enrolled in the program received information on both the dangers of smoking and secondhand smoke. TEL-LINK is the Missouri Department of Health and Senior Services’ (DHSS) confidential, toll-free telephone line for maternal and child health care. The purpose of TEL-LINK is to provide information and referrals to Missouri residents concerning a wide range of health services. Callers requesting referrals are transferred to the appropriate agency. In FFY19, TEL-LINK connected 21 callers directly to smoking cessation services including the Missouri Tobacco Quitline.

 

The DHSS, in collaboration with partners, received $48,500 from the FY2019 general revenue budget for Missouri Tobacco Quitline (MTQ) services to Medicaid (MO HealthNet) beneficiaries who utilized the MTQ. This funding, in turn, generated an additional $48,500 in federal Medicaid match for MTQ services to Medicaid beneficiaries. In FY 2019, 6,739 Missouri tobacco users received cessation services through the MTQ. Of the 6,739 served, 899 Quitline users were Medicaid beneficiaries, equating to one-fourth (1/4) of the 2018 Quitline tobacco users. The $48,500 general revenue ($48,500 GR + $48,500 federal Medicaid match) included in the 2019 state budget paid for all 899 Medicaid beneficiary Quitline users. The MTQ served 4,250 women and 43 pregnant women during this reporting period.

 

Home Visiting

The Bureau of Genetics and Healthy Childhood (GHC) evidence-based home visiting programs promote smoking cessation for all primary caregivers who answer yes to smoking status at enrollment and at subsequent six month time points during enrollment. Data from FY19 indicated that 97% (71/73) of primary caregivers enrolled in GHC funded home visiting who reported using tobacco or cigarettes at enrollment were referred to tobacco cessation counseling or services within three months of enrollment. 

 

The following resource was shared with all GHC supported home visiting agencies during FY19 via the Missouri Home Visiting Gateway Weekly Update:

• 7/3/19 - Visit the Missouri Department of Health and Senior Services Tobacco Prevention and Control Program web pages site for information and resources.

 

State Outreach Efforts

Media Campaign

The Tobacco Prevention and Control Program (TPCP) increased efforts to reduce tobacco use among those adults who smoke at the highest rates, including low income and pregnant women. Three statewide social media campaigns targeting women of child bearing age, low income, and Medicaid members were conducted during this reporting period. The Centers for Disease Control and Prevention’s Tips from Former Smokers Campaign – Amanda Tip and Sheyda ads, a testimonial from a former smoker who successfully quit through services from the MTQ, resulted in 13,321,233 video and display impressions served and 28,251 clicks to the MTQ website. Quitline promotional materials and the cessation section of the program's web pages were revised to make it easier to navigate, access materials, and provide additional tools and resources for tobacco users and healthcare providers. TPCP added individual services to the MTQ to allow more options to help tobacco users quit, as well as, began providing services to adolescents ages 13 and older during this reporting period.

 

SPM #5 Mental Health – Percent of women with a recent live birth who reported frequent postpartum depressive symptoms.

 

Depression after having a baby can range from “baby blues” to postpartum depression (PPD). Baby blues usually last a few days or weeks, but PPD symptoms are more severe and last longer. PPD can actually interfere with daily life and caring for the baby. Based on Missouri PRAMS 2018 data, 13.7% of Missouri women with a recent live birth reported having postpartum depression (PPD); this was an increase from the 2014 rate of 12.6%. In Missouri, prevalence was highest among women with less than a high school education (20.5%) compared to college graduates (7.4%) and among unmarried women (21.2%) compared to married women (8.5%). Women who received Medicaid in Missouri (17.1%) were also more likely to report having PPD than their counterparts with private insurance (11.1%), and experienced this slightly less frequently than their national counterparts on Medicaid (17.4%). Missouri mothers less than 20 years old (23.5%) were more frequently reporting PPD symptoms than those 30-34 years old (10.6%) and 35 or older (11.9%). WIC participants in Missouri (22.1%) more frequently experienced PPD symptoms than those not participating in WIC (7.8%) and their national counterparts (17.2%). PPD is associated with not breastfeeding, earlier weening, and may affect maternal-infant relationships as well as infant behaviors. Furthermore, untreated PPD could lead to chronic mental health illness and harmful consequences for both the mother and the child. Strategies were implemented to better educate women how to identify signs and symptoms and seek treatment if needed.

 

Several resources are available to provide information about mental health care and the “baby blues.” These materials discuss possible symptoms, helpful tips, and how to seek help. One resource is the “Women: Take Charge of Your Health” informational booklet. The booklet is a free resource for all women. Mental health is addressed as a serious health problem, outlining symptoms related to eating disorders, anxiety, traumatic events, suicide and PPD. The resource reinforces the need to seek medical help and to discuss every symptom in detail with a medical provider. This resource is also available on the Department website at www.health.mo.gov/womenshealth. Another resource, the Pregnancy and Beyond booklets, are distributed to hospitals, doctor’s offices, Local Public Health Agencies (LPHA), Birthing centers, and other partners throughout the State of Missouri. New OB patients are given a booklet to be used as a reference for a wide range of information, including a section on PPD. Distribution of additional materials related to PPD occurs through conferences, baby expos and other outlets. In FFY19, 18,972 pieces of literature in both English and Spanish were distributed. The Newborn Health Program distributed literature related to PPD at 8 exhibits

 

All primary caregivers prenatally enrolled in the Bureau of Genetics and Healthy Childhood (GHC) Home Visiting Programs are required to be screened for depression within three months of delivery. Primary caregivers not enrolled prenatally are required to be screened within three months of enrollment. Home visitors utilize the Patient Health Questionnaire 9 (PHQ-9) depression screening tool at these prescribed time points and additionally anytime home visitors recognize potential symptoms of depression. Individuals who screen positive are referred to appropriate services. Data from FY19 indicated that 97% of primary caregivers (302/312) enrolled in home visiting were screened for depression within three months of enrollment (for those not enrolled prenatally) or within three months of delivery (for those enrolled prenatally).

 

The GHC Home Visiting Program has streaming rights to the postpartum depression documentary “Dark Side of the Full Moon” to provide access to all GHC contracted home visiting agencies. This streaming package includes discussion materials and depicts the importance of assisting women in being screened and then finding treatment sources when screening indicates postpartum depression symptoms. Access to the streaming channel is indefinite with continued use and sharing of this powerful documentary again encouraged in FY19 to all GHC contracted home visiting agencies.

 

During the March 2019 Annual Home Visiting Summit, a presentation titled “Recognition, Screening, and Referral for Depression” was provided to all DHSS supported home visitors during the DHSS-specific session of the Home Visiting Summit to assist in performing depression screenings accurately and without bias. Additional breakout sessions related to mental health during the Summit included: “Compassion Fatigue for the Helping Professional” and “Bringing the Trauma Lens to Home Visiting:  The Science and the Art”. Both of these presentations provided information to home visitors on the importance of self-care, the emotional and physical effects of trauma on the developing child’s brain, and the impact of trauma in families with suggestions for appropriate ways of responding to mental health situations.

 

Home visitors were also provided professional development on mental health topics through attendance at the 2019 Children’s Division Trauma Summit, which was made possible through a collaboration between DHSS, the Department of Social Services, and Children’s Trust Fund. Strategies shared during presentations included: dealing with resistance and engaging families struggling with trauma, practical implementations and techniques for working with families through a trauma lens, de-escalation strategies, and information to assist home visitors in developing goals with families dealing with trauma and crisis.

 

A number of other resources were shared with GHC supported home visitors through the Missouri Home Visiting Gateway Weekly Update and included:

• 11/23/18 - Moving Postpartum Care from Screening to Treatment and Beyond. (Webinar)
• 12/14/18 -Though not all women with symptoms of depression will be diagnosed with clinical depression, screening and appropriate care should be provided during prenatal care. (MIHA Data Brief)
• 1/11/19 - New Maternal Depression Issue Brief - NICHQ.
• 2/8/19 - Leveraging Advances in Science to Achieve Breakthrough Impacts at Scale for Children Facing Adversity. (Webinar)
• 3/15/19 - Are the Words "Toxic Stress" Toxic? Rethinking the Narrative About Early Life Stress. (Webinar)
• 3/22/19 - 2019 Missouri Infant and Early Childhood Mental Health Summit, April 12, 2019, 9:00 am – 4 pm. (Conference opportunity)
• 3/28/19 -Turning the Tide on Mental Health Trends. (Webinar)

• 6/7/19 - Research Review: Dr. Bart Klika explores emerging research on adverse childhood experiences (ACEs).
• 7/26/19 - Case studies that highlight three states (South Carolina, Virginia, and New Hampshire) that have each successfully created a system for screening for maternal depression and providing appropriate follow-up treatment.
• 8/16/19 - Experts from the Brookings Institution, the U.S. Preventive Services Task Force, the Medical University of South Carolina, and Postpartum Support Charleston analyze the impact of maternal depression on children and families, and describe concrete steps health professionals can take to ensure that more mothers are screened and referred to support and resources. 

• 9/6/19 - Adult Mental Health and Perinatal Depression is a two-part training series from the Institute for the Advancement of Family Support Professionals designed to teach strategies to identify women and families at risk for mental health issues.  
• 9/13/19 - In the past decade, researchers have pinpointed a phenomenon in children who have experienced adversity or trauma that can have negative health effects well into adulthood. It is called toxic stress. Outlined here are the possible physical effects of early childhood stress through the lifespan. 

WIC agencies screen for and assign the nutrition risk factor 361 Depression, which is defined as clinical depression and includes PPD, for women participants. The risk factor is assigned when a prenatal, breastfeeding, or non-breastfeeding woman indicates she has clinical or PPD as diagnosed, documented, or reported by a physician, clinical psychologist, or someone working under a physician’s orders. The diagnosis may also be self-reported by the applicant/participant/caregiver. In FFY19, risk factor 361 was assigned to 812 prenatal women, 285 breastfeeding women, and 594 non-breastfeeding women. Assigning this risk factor has grown from 1,195 women in FFY16 to 1,691 women in FFY19. Several WIC agencies also utilize the Patient Health Questionnaire 9 (PHQ-9) depression screening tool to assist in identifying PPD.  

 

The MCH Services contract supported LPHAs providing screening and referral for PPD. Of the 113 LPHAs, 78 reported providing screening and referral for PPD, 71 reported having community partners who provide screening and referral for PPD, 58 reported providing postpartum follow-up within 4-6 weeks after delivery, and 73 reported having community partners providing postpartum follow-up with 4-6 weeks after delivery. Several LPHAs collaborated with behavioral health partners and/or the University of Missouri Extension Services to participate in and/or provide Mental Health First Aid education. Christian County Health Department used MCH Services contract funding to help cover the salary expenses for a full-time Licensed Professional Counselor for their MCH population, with individuals seeking counseling for suicide contemplation, unwanted pregnancy, rape, child abuse, parenting guidance, and a variety of other topics. Callaway County Health Department partnered with Central Missouri Community Action (CMCA) to form a Maternal Mental Health Coalition which has brought trainings and awareness on postpartum mental health to area health care providers and community members, including the showing of the documentary "The Dark Side of the Full Moon" to highlight the tragedy of PPD. Seven agencies in Callaway County are willing to treat women with PPD and many groups including Parents as Teachers and some healthcare providers are routinely screening postpartum women with evidence-based screening tools such as the Edinburgh Postnatal Depression Scale (EPDS) and conducting subsequent referrals as needed. Columbia-Boone and Callaway County health departments partnered together to establish a work group to enhance screening for PPD, implementing a referral list of providers/services, creating an awareness campaign, and providing trainings for those providing support or services for women. Springfield-Greene County Health Department launched the Maternal Mental Health Network, an interdisciplinary group of key stakeholders from both the public and private health sectors that meets quarterly to help guide change and increase promotion of maternal mental health in the Springfield community.  

 

The CCHC Program provided 1 hour of specialized consultation and 32 hours of stress management for adults and children through continuing education to child care providers. These trainings discussed stressors, the effects of stress on the body and mind, the difference between acute and chronic stress, how stress affects children, stressors in children’s lives, stress management (including techniques and methods of relaxation), and modeling healthy stress management for children. As a result of this training, child care providers are better able to manage their stress, model healthy stress management, as well as guide children in managing their own stress.

 

SPM #6 Oral Health – Percent of women who had a preventive dental visit during pregnancy.

 

A preventive dental visit during pregnancy is recommended because changing hormone levels can result in increased plaque, leading to pregnancy gingivitis. This can lead to bleeding and sore gums. Left untreated, gingivitis can become periodontal disease, which is a serious form of gum disease. Morning sickness may lead to vomiting, which can also damage the teeth. A visit to the dentist during pregnancy can help monitor for pregnancy gingivitis, periodontal disease, or other oral health problems. During regular dental visits, the patient can have their teeth professionally cleaned and receive education on good oral health. For example, a dental hygienist may educate a patient about proper brushing techniques, how to floss, and the importance of eating a healthy diet.

 

Based on PRAMS 2018 data, 42.3% of Missouri women had a preventive dental visit during pregnancy, which was slightly lower than the 2014 proportion of 47.0%. In Missouri, mothers 20-24 years old (27.0%) were less likely to have had a preventive dental visit than those 30-34 years old (52.7%) or those 35 years or older (65.0%). In addition, Medicaid enrollees (32.2%) were less likely to have a preventive dental visit than their counterparts with private insurance (50.8%) in Missouri. A greater percentage of college graduates (59.8%) had a preventive dental visit in Missouri than any other educational level (the highest percentage nationally was 62.7% for college graduates) while pregnant. Married Missouri mothers (49.0%) were more likely to have had a visit than unmarried mothers (32.8%). This trend follows the national estimates of 53.9% for married and 35.9% for unmarried mothers. Missouri WIC recipients less frequently (34.2%) had a preventive dental visit during pregnancy than those who were not WIC participants (47.9%).

 

The ODH has an ongoing initiative to educate mothers and children about the importance of oral health for their overall health and well-being. This includes the promotion of dental visits during pregnancy. This was accomplished via continued collaboration with the Missouri Primary Care Association (MPCA) to provide educational brochures to women about the importance of dental visits during pregnancy. The MPCA also assisted the ODH to educate dentists, dental hygienists, and dental assistants about dental care during pregnancy. This was done at quarterly meetings with all Federally Qualified Health Center (FQHC) dental directors, at the MPCA’s annual conference, and by assisting the ODH to distribute messages via its FQHC Listserv. This was often counter-intuitive for women, and even some medical and dental professionals, who assumed that dental cleanings during pregnancy were harmful to mother and/or child. The ODH provided education to women about the importance of oral health for the mother’s overall health, during pregnancy, and throughout her lifespan. This education took place through literature, including the “Healthy Smiles from the Start” booklet developed by the ODH and the Missouri Dental Association (MDA). There were 2,200 of these booklets distributed last year. These materials were distributed to women via an ongoing successful collaboration with the Women, Infants, and Children (WIC) Program and the Bureau of Genetics and Healthy Childhood Home Visiting Program. The education provided by all home visitors to women enrolled in home visiting programs included information about the importance of addressing their oral health as well as education about activities to support good oral health for their children.

 

MCH funds support ODH maintenance of an Oral Health webpage filled with oral health information for anyone with oral health questions. The website includes a link to the Centers for Disease Control and Prevention’s (CDC) Water Fluoridation Reporting System, which displays Community Water Fluoridation (CWF) statistics for each Missouri county and water system. The ODH provided CDC with Missouri’s water fluoride levels quarterly in order to update the state data. The ODH also maintained the Missouri Oral Health Surveillance System. This included posting updated fact sheets compiling oral health statistics and related information on the ODH website. The ODH’s Five-Year State Oral Health Plan is also posted on the ODH website. During the FY19 year, there were 16,392 visits to the website from people seeking more information on oral health.

 

MCH funds also pay for ODH to print and disseminate educational resources and literature to members of the public via dental offices and at community outreach events. WIC agencies were able to order a limited amount of toothbrushes for the agencies who requested it. From October 1, 2018 to September 30, 2019, ODH shipped out 260,871 toothbrushes, toothpaste, and floss to participants in Preventive Services Program (PSP) events, Baby Safety classes, and other oral health events. In that same time period, ODH shipped out 327,461 pieces of literature to people participating in the same above-mentioned oral health events. Information learned about the importance of dental health can only be implemented when community members have the appropriate knowledge and resources to take action.

 

ODH provided infant and adult toothbrushes along with oral health literature for distribution to parents attending Baby Safety Classes. The Baby Safety Classes are held regularly in different regions throughout Missouri to underserved clients. The class trainer focuses on several different aspects of baby care but also assists the new/expectant mother with oral hygiene care for the baby. Participants receive various educational information, which includes the Healthy Smiles pamphlet and oral care items. 

 

Fluoride protects against tooth decay at any age, and water fluoridation is the least expensive method to reduce cavities. Increasing awareness of this benefit is a key factor in dental education. ODH provided education to the public, city officials, dental and medical professionals, and public health authorities about the safety and effectiveness of CWF for the prevention of dental caries. ODH contracted with the Missouri Coalition of Oral Health (MCOH) to educate and promote to community members and stakeholders the importance of oral health, including water fluoridation. MCOH presented to dental hygiene students, the Show Me School Based Alliance, and Community Caring Partners to discuss oral health and the Oral Health Progress and Equity Network. MCOH also made connections with local oral health advocates who work with Community Health Workers and LPHAs in order to educate those stakeholders on the importance of oral health among their community.

 

On August 16, 2019, staff from ODH participated in the Missouri Mission of Mercy (MOMOM) event in St. Joseph, MO. MOMOM is a large-scale dental clinic that provides free oral healthcare to patients of all ages who cannot otherwise afford or access care. The total value of the dental care provided was $631,000 to 500 people. An additional 500 people, including dental health professionals and community volunteers, provided care. Patients were triaged and provided the care they needed from routine cleanings to fillings to extractions.

On September 1, 2018, ODH became the recipient of two new grant awards, one from the Health Resources and Services Administration (HRSA) and the other from CDC. These grants were used to begin developing Teledentistry training, Teledentistry sites at nursing homes and schools, and a Teledentistry program to promote and apply dental sealants. Grant efforts also included providing education about CWF, updating the State Oral Health Plan, and providing fluoride varnish at some LPHA sites. These grants continue, and ODH is working diligently across Missouri to raise awareness of the importance of oral health through these grants.

State statute 640.136.1 was agreed upon by the Missouri legislature in 2016 and states that any public water system or public water supply district, which intends to make modifications to fluoridation of its water supply shall notify the Department of Natural Resources, the MO Department of Health and Senior Services, and its customers of its intentions at least ninety days prior to any vote on the matter. This gives community members and organizations such as the MDA and MCOH the opportunity to educate decision-makers and the public about the safety and importance of CWF. ODH regularly meets with MDA and MCOH to discuss CWF issues and plans of action. In Jefferson County, MO, the water board continues to debate the water fluoridation issue in the Festus area. The community water system is currently fluoridated, but members of the board are considering removal of the fluoride. Many oral health stakeholders (MDA, MCOH, local dentists, CWF experts, and volunteers) came together to educate the water board about the benefits of CWF. So far, the water board has decided to look into this issue further and not bring it to a public vote. Of the Missouri community water systems continuing to provide fluoridated water, there were 15 that received CDC’s Water Fluoridation Quality Award for maintaining their fluoride at optimal levels in the water system.

Through screening, referral, and participation in the provision of preventive dental services, the LPHAs worked to increase the number of women who had a preventive dental visit during pregnancy. Of 114 LPHAs, 95 reported screening clients for an identified dental care provider and providing dental referrals as indicated, and 91 reported having community partners who provided oral health screening and referral. A total of 35 LPHAs reported providing dental screenings and/or services. The MCH Services contract supported LPHAs providing oral health education and dental services to the MCH population within their communities. Dallas County Health Department has a Bright Smiles Program in which MCH contract funds were utilized to pay a part-time coordinator to conduct regular brushing and oral health education to students in kindergarten through second grade at a local elementary school. Joplin City Health Department partnered with a local dental school in which dental students provided education on oral care once a week to WIC participants. Howard County Health Department WIC staff provided toothbrushes to participants and referrals as needed. Vernon County Health Department has a nurse on staff that helped provide fluoride treatment to uninsured women and children in the Miles for Smiles mobile dental unit. Clay County Health Department has registered dental hygienists who provided dental screenings, oral health education, and fluoride varnish applications for children enrolled in the WIC program. Multiple LPHAs collaborated with community partners to host mobile dental vans at health departments, schools, and other community sites.

 

During FY19, ODH received Title V funding to promote water fluoridation through a multi-media campaign. Nine counties in southeast Missouri were targeted to receive the campaign. These counties were selected to counteract a recent anti-fluoridation movement to remove fluoride from the public drinking water in a nearby community. The goal of the campaign was to educate these communities about the benefits of fluoride in an attempt to dispel myths and prevent additional anti-fluoridation efforts. The media campaign included two 30-second radio spots and a newspaper insert. The radio spots highlighted the importance of drinking fluoridated water, receiving regular dental check-ups, and practicing good oral hygiene. One radio spot specifically targeted pregnant women and encouraged good dental hygiene during pregnancy. Not only were the radio spots aired throughout the nine targeted counties, but the Missouri Broadcaster’s Association offered to air the spots statewide at no additional cost. The result was a total of 8,598 radio spots aired throughout the state. The newspaper inserts were included in 14 different community newspapers and reached approximately 20,000 homes over three months. One local newspaper only agreed to include the insert for one month, so the remaining inserts were redirected to a community outside of Kansas City where dental professionals had been advocating for the inclusion of fluoridation in the Independence water system. The insert was an infographic created by the American Academy of Pediatrics that used simple language to describe how fluoridated water benefits people of all ages and helps prevent tooth decay.

 

* Interpret with caution due to sample size limitations.