In 2020, ADHS provided funding to 12 (out of 15) counties in Arizona to provide family planning and reproductive health services to improve the health of women before, during, and after pregnancy; to promote safe sexual behavior, decrease the teen pregnancy rate, and ensure access to quality health care, particularly for low-income or uninsured individuals living in rural and other underserved areas. In addition, Title V funds Valleywise Health, a federally qualified health center, to provide these services in Maricopa County. During 2020, these 12 local county health departments plus Valleywise Health conducted 3,572 visits with 2,084 unique clients statewide.

The COVID-19 pandemic impacted the delivery of family planning and reproductive health services. Early on in the pandemic (March 23, 2020), Arizona Governor Doug Ducey issued an Executive Order clarifying that “healthcare and public health operations” are an essential service and that this category of essential services shall be construed broadly to avoid any impacts to the delivery of healthcare. However, in practice, many of the counties experienced interruptions to the delivery of family planning and reproductive health services during the pandemic. In some cases, county health departments needed to close for some time due to rising cases of COVID-19 in the county. A high number of public health nurses and other staff at the county health departments have fallen ill with COVID-19 in the course of their work in contract tracing and serving the community, and this has also forced temporary health department closures due to staff shortages and other mitigation measures. In some counties, like Pima County, their family planning program is school-based, and school closures also interrupted the delivery of services.

In spite of these challenges, the county health departments continued to find ways to adapt care (e.g., spacing out appointments, telemedicine refills, etc.) and continued to provide this essential service in their communities. There was only a small decline (15-17%) in the total number of visits and unique clients served in 2020 compared to 2019.

Health Start is a home visitation program that utilizes community health workers (CHWs) to identify women early in their pregnancy and link them to prenatal care. CHWs provide education, referrals and developmental screenings until the child’s second birthday. Health Start is authorized through state statute—with defined purpose, requirements and administration of the program—and is funded by the Arizona State Lottery. In 2020, Health Start contracted with 16 community-based agencies, including county health departments; served 2,795 unduplicated clients; and provided over 18,000 home visits. Of the population served, 43% of Health Start clients were Hispanic, 45% were White non-Hispanic, 9% were Native American, 3% were African American, and 1.5% were of Asian descent. The remaining clients identified as "Other."  In 2020, 335 Health Start families were provided with safe sleep education and signed a commitment form to adhere to safe sleep practices. Health Start provided 153 Pack 'n Plays to Health Start families that did not have a safe sleep environment for their child. All (100%) pregnant clients indicated they plan to breastfeed; however, 45% of women were breastfeeding at 6 months postpartum. Slightly more than 25% of pregnant clients self-reported at enrollment that they smoked and drank during their pregnancy. Only 7.5% of Health Start babies were born at low birth weight. Program CHWs also provided 105 classes to clients on important maternal and child health topics including parenting, nutrition, early childhood education and safety, and proper use of car seats.  

The Bureau of Women’s and Children’s Health (BWCH) continued to work on reducing severe maternal morbidity (SMM) and maternal mortality (MM) throughout the year through a multi-pronged approach that included coordination between the HRSA-funded Maternal Health Innovation Program, the Maternal Mortality Review Program, and the Alliance for Innovation on Maternal Health (AIM). Maternal Mortality continues to be an area of focus for the Governor’s Goal Council and BWCH’s maternal health work is structured around the five goals outlined in the plan: 1. Improving Knowledge and Education for Pregnant and Postpartum Women; 2. Improving Access to Care; 3. Supporting Workforce & Workforce Capacity; 4. Improving Surveillance and 5. Supporting Systems of Care.

The maternal health programs continued to collaborate with partners to reduce severe maternal morbidity and maternal mortality. A Maternal Health Task Force (MHTF), which includes its subcommittees, MHTF Steering Committee, Tribal Maternal Health Task Force, AIM Steering Committee, and Maternal Mental Health Task Force convened throughout the year to collaborate and begin developing a state-focused strategic plan that aligns with the Governor’s Goal Council and the 2020 Title V Needs Assessment.

After being accepted to become an Alliance for Innovation on Maternal Health (AIM) state in the fall of 2019, BWCH provided funding through MHIP and MMRC to implement the Hypertensive Disorders of Pregnancy patient safety bundle in birthing hospitals that wished to enroll in the Arizona AIM Collaborative. The Arizona AIM Collaborative is led by the Arizona Hospital and Healthcare Association (AzHHA). AzHHA formed a steering committee made up of key partners which includes the Arizona Title V MCH Director, Office Chief for Assessment and Evaluation, Office Chief for Women’s Health and program staff in the maternal health field to inform the direction of the implementation. Unfortunately, the pandemic caused delays in the roll-out of the initiative, as hospitals were focused on the overwhelming care needed for COVID-19 patients. However, the steering committee continued to meet, discuss, and plan for the kickoff of the project, which was rescheduled and held in April 2021.

BWCH was awarded the CDC “Preventing Maternal Deaths: Supporting Maternal Mortality Review Committees” (ERASE MM) grant in 2019, which is intended to enhance the current processes of the Arizona Maternal Mortality Review Program (MMRP). The fiscal and technical resources have allowed BWCH to assign dedicated staff to implement the “Review to Action,” evidence-based processes to review and take action to prevent future maternal deaths in Arizona. In 2020, BWCH released the Maternal Mortality and Morbidity in Arizona report, which summarizes incidence and causes of maternal mortality and severe maternal morbidity in Arizona and provides recommendations to improve maternal health outcomes at various levels of the health system (e.g., patients/families, providers, facilities, systems, communities). In addition to this report, BWCH staff conducted multiple presentations to maternal health stakeholders and, in coordination with the MHIP, hosted a statewide Maternal Mortality Summit in August 2020 with over 300 virtual attendees—all with the intention of increasing awareness of maternal mortality as a public health issue and the role different sectors have in preventing these deaths. In an effort to reflect the data emerging from maternal mortality reviews, the MMRP supported over 200 maternal health professionals to participate in an Implicit Bias Training and actively recruited new and additional members to the MMRC representing sexual/domestic violence prevention, lactation consultants, indigenous care providers, doula support, and mental and behavioral health.

AZ PRAMS (Pregnancy Risk Assessment Monitoring System) is a research project between the Arizona Department of Health Services and the Centers for Disease Control and Prevention (CDC). It is a survey about a woman's health and life experiences before, during, and after pregnancy. It is the only surveillance system that provides data about pregnancy and the first few months after birth. Randomly selected mothers who delivered a live birth in Arizona may be eligible to participate in the mail and/or telephone questionnaires. CDC PRAMS has a minimum overall response rate threshold policy for the release of data, which is a 55% response rate.  Currently, AZ PRAMS has a response rate of 52%, so AZ PRAMS is not releasing data at this time. AZ PRAMS has worked on multiple strategies to increase response rates; for example, adding Amazon or Bashas (needed for rural communities) cards as an option for rewards and increasing the rewards amount from $20 to $30. The Amazon gift cards strategy was a success, as the response rates increased shortly after. The $30 gift rewards will be available in mid-May, 2021. AZ PRAMS also implemented a strategy of using colored envelopes to easily identify the survey for participants when it arrived in the mail. AZ PRAMS receives $45,000 in Title V funding to supplement CDC funding for this work.  AZ PRAMS will most likely meet the CDC PRAMS threshold by 2021 and will be able to offer publicly available reports from the surveillance.

The Preconception Health Alliance has been meeting virtually throughout 2020 and has been focused on developing a strategic plan for the next five years.  The Alliance continued to convene planning meetings, distribute preconception health information from reputable sources, and promoted the use of reproductive health plans.  The Alliance is utilizing preliminary data from Arizona PRAMS to guide their focus of preconception health needs in the state and funding from Arizona Title V to support printing and distribution of materials and other small needs.

The Sexual & Domestic Violence Program, now located in the Bureau of Chronic Disease and Health Promotion, awarded new five-year contracts that became effective November 2020 with sub-recipients represented from the Northern, Eastern, Southern, Western, and Central regions of the state, including the state domestic and sexual violence coalition, university systems and county community health services, using funding from the CDC-funded Rape Prevention Education grant and the Public Health and Health Services Block Grant. The program continued to collaborate with and support the Office of Women’s Health, providing technical assistance as needed. The program also has representation on the Maternal Health Task Force. The Health Start program integrates domestic and sexual violence screening into the scope of service provided to clients and CHWs screen clients using the Relationship Assessment Tool adapted from the Women's Experience with Battering (WEB) scale after the client has been in the program for three (3) months. In 2020, 78 women from the Health Start Program were screened for risk of domestic violence.