Overview

The women’s and maternal health program at the Department of Health (DOH) is within the Perinatal Health unit of the Community Health Improvement Linkages section of the Office of Family and Community Health Improvement in the Division of Prevention and Community Health. Key activities of the unit include promoting, influencing, adopting, and revising policies and processes to improve the health and well-being of women and families.

 

Through our website, we offer educational materials and resources to the public on a wide range of topics, including healthy eating, physical activity, vitamins and nutrients, oral health, genetic illness, mental health and depression, safe relationships, family planning, pregnancy, sexually transmitted illnesses, and substance use. Materials are available in a variety of languages.

 

In 2020, there were 1,494,885 women of reproductive age (ages 15 to 44) in Washington, about one fifth of the total population. White non-Hispanic women made up 68 percent of women of reproductive age in 2010; this decreased to 60 percent in 2020, an 11 percent decline. The population of American Indian/Alaska Native women also decreased over this period, decreasing to 1.3 percent. Groups whose populations of women of reproductive age increased include Hispanic (16 percent), Asian (12 percent), Black or African American (4 percent), Native Hawaiian or other Pacific Islander (1 percent), and multiracial (5 percent). The largest population increases from 2010 to 2020 were to Asian (increased 37 percent), Native Hawaiian or other Pacific Islander (increased 27 percent), and multiracial (increased 26 percent). See chart below.

 

*non-Hispanic

 

 

In 2019, just over three quarters (76 percent) of adult women received a medical check-up in the past year, an increase from the 2014 rate of 68 percent, and a higher rate than men (67 percent in 2019). Ten percent of women reported 14 or more days of poor physical or mental health in the past month. More than half (53 percent) of women reported receiving a flu shot, a record high and a rate significantly higher than men (44 percent) (Behavioral Risk Factor Surveillance System [BRFSS]). As of July 17, 2021, 69 percent of women had initiated COVID-19 vaccination and 63 percent were fully vaccinated, both higher rates than men (63 percent and 58 percent, respectively).

 

The DOH Sexual and Reproductive Health Program (SRHP) works with sexual and reproductive care providers across the state to support and ensure services. In 2020, the SRHP supported services for 90,910 clients during 126,052 clinic visits across the state. An estimated 87 percent of female clients of reproductive age served in 2020 across the state had some form of contraceptive method. Contraception puts women at lower risk of unintended pregnancy, unplanned births, and abortions. The clients supported by the SRHP in 2020 were 90 percent female, 51 percent were a racial/ethnic minority, and 53 percent were at or below the poverty level.

 

Between 2010 and 2019, the overall birth rate in Washington decreased by 8 percent. This drop is most pronounced among women ages 15 to 17 (65 percent decrease), ages 18 to 19 (48 percent decrease), and ages 20 to 24 (31 percent decrease). During the same time period, birth rates increased among women ages 35 to 39 (17 percent increase) and ages 40 to 44 (32 percent increase), suggesting a shift in age among women giving birth over the past decade. Trends in births and pregnancies are not identical across racial and ethnic groups. From 2015-2018, birth rates to teenagers were highest among Native Hawaiian or other Pacific Islander, American Indian/Alaska Native, and Hispanic populations. Pregnancy rate, which includes births, fetal deaths, and abortions, decreased from 80 to 70 pregnancies per thousand women from 2010 to 2019.

 

There are also changes in how women are choosing to give birth. From 2010 to 2019, deliveries by an MD or DO decreased by 5 percent, while deliveries by certified midwives increased by 47 percent. Births in birthing centers increased by 42 percent and home births increased by 11 percent.

 

There continue to be significant disparities of first trimester prenatal care by Medicaid status at time of birth, and by race and ethnicity. The disparity by Medicaid status at birth has decreased from a 20 percent difference in 2010 to a 14 percent difference in 2019 (81 percent among non-Medicaid and 67 percent among Medicaid covered). In 2019, 78 percent of white, 78 percent of Asian, 71 percent of Hispanic, 71 percent of multiracial, 63 percent of Black or African American, 60 percent of American Indian/Alaska Native, and 41 percent of Native Hawaiian or other Pacific Islander mothers accessed care during the first trimester (WA Birth Certificates). See chart below.

 

*non-Hispanic

 

 

Access to care, particularly among Black, Indigenous, and people of color (BIPOC) populations, was the most consistent need identified among women of childbearing age during the 2020 five-year maternal and child health needs assessment. Washington did not achieve the Healthy People 2020 goal of 85 percent first trimester prenatal care for all women giving birth.

 

Diabetes during pregnancy increased 70 percent from 2019, including a 74 percent increase in gestational diabetes. Among all pregnancies, 11 percent of expectant mothers experienced some form of diabetes. Hypertension during pregnancy increased 59 percent over this same period, and also impacted 11 percent of pregnancies.

 

Postpartum depressive symptoms were reported in an estimated 13 percent of women in 2019 (WA Pregnancy Risk Assessment Monitoring System [PRAMS]). Seventeen percent of women with Medicaid coverage reported depressive symptoms, compared with 9 percent of women who did not have Medicaid.

 

National Performance Measure 1 – Well-Woman Visit

Percent of women, ages 18 through 44, with a preventive medical visit in the past year.

 

In 2019, 69.3 percent of women received a preventive medical visit within the past year. This exceeded our objective of 47 percent, but is slightly lower than the previous year. The percentage remained relatively steady between 2009 and 2017, but the survey data from those years are not comparable to 2018 and 2019 due to a change in a survey question (BRFSS).

 

Perinatal Health unit staff continued to monitor issues related to the mandated preventive services for women and worked with the Office of Insurance Commissioner and Health Care Authority (HCA), the state’s Medicaid administrative agency, when appropriate to try to ensure access to these benefits.

 

Since 2016, Washington state has been working to fully integrate the financing and delivery of physical health services, mental health services, and chemical dependency services in the Medicaid program through managed health care by 2021. This Medicaid Transformation Project is a multiagency effort led by HCA and supported by federal funding to build healthier communities through a collaborative regional approach to integrate how we meet physical and behavioral health needs so that the health system focuses on the whole person and improve how we pay for services by rewarding quality over quantity.

 

In 2020, we continued to use the DOH website and social media to disseminate messages about issues impacting women’s health, including the importance of folic acid, safe relationships, and substance use awareness. We also shared messages around special events, including Black Maternal Health Week, National Women’s Health Week, and the Centers for Disease Control and Prevention’s (CDC) Hear Her campaign.

 

Additional Work Supporting Women’s/Maternal Health

 

We continue to partner with HCA/Medicaid, the Washington State Hospital Association (WSHA), the March of Dimes (MOD), and Swedish Addiction Services in Seattle to encourage an increase in the number of providers offering group prenatal care, especially to women struggling with substance use disorder and mental health issues. MOD is working to support five clinics in Washington to begin offering this model of care of integrating substance use needs with group prenatal care. This was delayed due to the COVID-19 pandemic, but they are now resuming this work and plan to begin training for clinics to prepare for offering services later this year.

 

DOH manages contracts with four regional perinatal centers in Washington to coordinate and implement state and regional quality improvement projects to improve pregnancy and newborn outcomes.

 

WithinReach is a Maternal and Child Health Block Grant (MCHBG) contracted provider. This private, not-for-profit organization serves as a single point of entry to the many resources a family needs to be healthy. They connect Washington families to health and food resources; promote awareness and education about specific health issues; provide insurance information; and make connections in person, online, and over the phone. They provide eligibility screening and referrals to Medicaid; the Women, Infants and Children Nutrition Program (WIC); and other services. They offer referrals and health education information about pregnancy, prenatal care, maternity support, childbirth, immunizations, and family planning.

 

WithinReach’s ParentHelp123.org resource website had 24,194 page views with 19,039 total unique page views in calendar year 2020.

 

WithinReach's Help Me Grow Washington (HMG-WA) Hotline is the state's maternal and child health hotline. During federal fiscal year (FFY) 2020, the hotline received and responded to 14,468 calls. Questions relating to food and nutrition resources generated the greatest number of inbound calls, and resulted in 8,462 food assistance referrals and 5,478 referrals to WIC. Numerous additional referrals were made for pregnancy-related services and determinants of health, including 362 referrals for housing assistance.

 

WithinReach provides health information in a variety of languages for people who are not proficient in English. During FFY 2020, the total number of HMG-WA hotline Spanish phone calls was 1,184. The hotline averaged 347 non-English calls per quarter. Nearly all of the call center staff are bilingual, and nearly 99 percent of Spanish-language calls are completed without a third-person interpreter.

 

Policy and Practice Improvement

We have developed an evidence-based strategy measure (ESM) to track the number of policies and practices influenced and promoted by staff that positively impact the rate and quality of well-women medical visits for women of childbearing age in Washington. We worked on 10 policy and practice areas:

 

• DOH has partnered with WSHA to join the Alliance for Innovation on Maternal Health (AIM), which is a national organization run in partnership with the American College of Obstetricians and Gynecologists (ACOG) to improve maternal outcomes through the implementation of hospitalwide quality improvement protocols, called “bundles.” Title V staff have participated in coordinating monthly trainings and biannual in-person trainings, and most participating birthing hospitals have access to the data system. The state began to transition from work on the hemorrhage bundle to prepare for rollout of the substance use bundle, and continues to work on integrating equity and elimination of inequities into all of their quality improvement efforts. An in-person SPEAK UP Against Racism training was planned and delayed twice due to COVID-19, so we began a planned transition to an online training (1).

 

• DOH is working on a number of interagency initiatives to address the maternal/child/family impact of the opioid epidemic:

 

• We have partnered with the Division of Behavioral Health and Recovery (DBHR) at the HCA; WSHA; MOD; the Department of Children, Youth, and Families (DCYF); and other organizations to form a workgroup of the state opioid taskforce. DOH leads the state opioid response team, and Title V staff leads the workgroup that addresses the perinatal child impact. The purpose of this workgroup is to address the needs of women, transgender, gender fluid, pregnant and parenting people who have been impacted by substance use (2).
  
  This workgroup has several areas of focus, which include:

 

• Decreasing stigma
• Addressing clinician bias
• Improving perinatal care and ease of access to care
• Linking pregnant and postpartum women to clinical and community resources
• Conducting a community-level gap analysis
• Expanding access to medication-assisted treatment (MAT)
• Expanding wraparound services
• Working with birthing hospitals to develop rooming-in policies for mothers and babies with withdrawal to stay in the same room, and transition to using the “Eat, Sleep, Console” tool
• Working with DCYF to increase consistency in child removal practices
• Supporting evidence-informed breastfeeding guidelines
• Decreasing addiction to opiates, and increasing recovery for women and their families

 

The workgroup has worked with local public health in Skagit and Snohomish counties, MOD, and Swedish Addiction Services to provide an all-day training conference on perinatal substance use.
 

• DOH continues to be involved in two initiatives launched by an Association of State and Territorial Health Officials (ASTHO) interagency team led by Title V staff: (a) to clarify and write policy around the federal 2016 Child Abuse Prevention and Treatment Act (CAPTA) regulations to notify Child Protective Services of all drug-affected infants, and (b) to address the needs of women who have not received substance use treatment and prenatal care during pregnancy and want to move into recovery and parent their child. This is to be accomplished by creating billing structures for birthing hospitals to treat the mother and baby together (start on medication-assisted treatment and monitor baby for withdrawal), and then transition birth parent and baby to residential treatment for pregnant and postpartum people. This assures the safety of the infant and supports the maternal recovery and parenting transition of the birth parent (3).

 

To address the first initiative, DOH has partnered with DCYF to look at the state’s child welfare policy that directs the reporting and notification of infants born exposed to substances. They have clarified existing policy and created definitions for infants exposed to substances, and are piloting a new system notification/report and referral to wraparound services.

Through our partnership with DCYF, we coordinated three online trainings for child welfare workers across the state:

 

• Medication Assisted Treatment during Pregnancy and Parenting – 158 people attended, and 83 percent reported that they planned on making changes to their practice as a result of the training.
• Compassionate Care and the Lived Experience – 195 people attended, and 92 percent reported that they planned on making changes to their practice as a result of the training.
• Destigmatizing Care – 210 people attended, and 95 percent reported that they planned on making changes to their practice as a result of the training.

 

To address the second initiative, in the 2019 legislative session the HCA was required to write a report and fiscal analysis with recommendations for the care and treatment of neonatal abstinence syndrome (NAS) and maternal stabilization. They are also currently working to create an administrative day rate billing code for birthing hospitals to support birth parents to room in with their infant and receive MAT after they’ve been medically discharged and their infant is being monitored or treated for NAS.

 

• In March 2019, an Association of Maternal and Child Health Programs (AMCHP)/ASTHO interagency team led by Title V staff was launched to address the housing needs of families impacted by the opioid epidemic through policy changes. This was a cohort of the national Promoting Innovation in State Maternal and Child Health Policymaking (PRISM) learning community. During the 2019 fiscal biennium, Washington allocated $35 million for housing services that prioritize people with behavioral health needs. DBHR is creating a registry for resident housing with a revolving loan fund for recovery housing and is increasing their contracts for recovery residences (housing) for people in recovery from substance use (4).

 

• Led by perinatal contractors, the obesity workgroup met regularly with guidance from the Title V-supported Perinatal Nurse Consultant. The obesity workgroup is developing guidelines and protocols for the care of pregnant women with a high body mass index (BMI) (5).

 

• DOH is working on a number of interagency initiatives associated with maternal mortality review and prevention:

 

• Washington’s second Maternal Mortality Review Panel (MMRP) Report was released in October 2019 and covered deaths from 2014-2016. This report included data and findings related to deaths from suicide and behavioral health conditions. Staff continue to disseminate findings from that report through presentations and communications materials to providers, hospitals, and other partners and interested groups. Staff continue to coordinate and support the maternal mortality review process and panel to review deaths of Washington residents that occur within a year of pregnancy (6).

 

• As part of quality improvement resulting from the maternal mortality review recommendations, perinatal staff worked to have the state’s maternal mortality law amended to require birthing hospitals and licensed birth facilities to report deaths that occur during pregnancy or within 42 days of the end of the pregnancy to the local county coroner or medical examiner’s office. Upon reporting, county offices are required to conduct a death investigation, and autopsy is strongly recommended using the Guidelines for Maternal Death Autopsy as developed by the workgroup. The law went into effect on July 28, 2019. Perinatal staff continued to monitor the number of autopsies reported and performed as outlined by the law. In addition, in-service training sessions took place when requested by partners (7).

 

• In 2020, Washington state policymakers cited the MMRP report in Senate Bill 6128 to extend Medicaid coverage to 12 months postpartum. This bill passed in the House and the Senate; however, it was vetoed by the governor due to budget cuts related to the COVID-19 response. In 2021, the bill was active again as Substitute Senate Bill 5068 and was passed and signed by the governor (8).

 

• In 2021, Washington state policymakers amended a law, Second Substitute House Bill 1325, to permanently fund a perinatal psychiatric information line at the University of Washington (UW) Psychiatry and Behavioral Sciences called Partnership Access Line (PAL) for Moms. This “warm line” allows all types of providers to easily contact and access a perinatal psychiatrist for consultation, and to receive written documentation of consult and resources. Funding this line was one recommendation submitted to policy makers in the 2019 MMRP Report to increase access to perinatal behavioral health providers and information (9).

 

• DOH explored the feasibility of amending Revised Code of Washington (RCW) 43.70.442 to require that suicide training standards for licensed health care professionals include content on risk factors and intervention for pregnant and postpartum people. Significant barriers made this amendment unfeasible at this time. However, we developed a collaborative partnership with the DOH Injury and Violence Prevention team to increase awareness and educational opportunities for health care providers and other key partners on suicide risk during and after pregnancy. Furthermore, the revised Washington State Suicide Prevention Plan, scheduled for release in 2021, will include an appendix with information on suicide among this population (10).

 

Maternal Mortality Review

 

Background

In March 2016 (amended in 2019), the legislature passed Engrossed Second Substitute Senate Bill 6534 (codified at RCW 70.54.450), creating the Maternal Mortality Review Panel to conduct multidisciplinary review of all maternal deaths in Washington. The law set out to identify factors associated with the deaths and make recommendations for system changes to improve women’s health care services in the state. The law requires a report outlining the findings of the review and panel recommendations to be submitted to the health care committees of the Washington State House of Representatives and Senate every three years.

 

The MMRP is a diverse and multidisciplinary group of over 70 people from around the state. This group includes clinicians and non-clinicians, physicians, midwives, social workers, behavioral health experts, pathologists, prosecuting attorneys, advocates for people affected by domestic violence, doulas, community health workers, Indigenous perspectives, patients, and patient advocates. With staffing and support provided by DOH, the MMRP reviews pregnancy-associated deaths (death of a woman during pregnancy or within the first 365 days after pregnancy from any cause), and distinguishes which deaths were pregnancy-related (the death occurred during the woman’s pregnancy or within 365 days after the end of her pregnancy from a cause that was complicated by pregnancy, a chain of events initiated by pregnancy, or the aggravation of an unrelated condition by the physiological effects of pregnancy) and which deaths are preventable. The MMRP then makes decisions on the factors that contributed to preventable deaths and what recommendations are needed to prevent them.

 

Report of Findings

In October 2019, we published the second report of findings and recommendations. The report included recommendations for improving health equity and reducing stigma and bias; supporting hospitals and providers to implement evidence-based and recommended quality improvement activities; improving postpartum care; and improving and increasing access to perinatal behavioral health care, treatment, support, resources, and knowledge for patients and providers.

 

Dissemination

After publishing the report, we spent much of late 2019 and early 2020 on a “road show” presenting the report in person and virtually to a variety of audiences, including perinatal providers and partners. Some well-known audiences included the Washington State Hospital Association, the Washington State Obstetrics Association annual conference, and the UW obstetric grand rounds.

 

Tribal Collaboration

In December 2019, we presented the findings and recommendations from the 2019 report to the American Indian Health Commission. The commission works on behalf of 29 federally recognized tribes and two Urban Indian Health Organizations in Washington to improve health outcomes for American Indian and Alaska Native communities and people. After our presentation, we received invaluable feedback and realized there was an opportunity to collaborate with the commission on the maternal mortality review and reduction work. As a result, we have been working with the commission to coordinate a listening session to learn more about what tribal communities want us to know about maternal mortality in their community, and if and how they want to engage with the department and Perinatal Health unit in the maternal mortality review and reduction work. This listening session is being led by the commission. Perinatal staff will provide support and consultation as needed for planning and will attend the session, which will take place sometime in early 2022. We hope the session will result in a product or a plan to contribute information and recommendations to the next MMRP report, scheduled for release in early 2023.

 

Second-Generation MMRP

Publishing the second legislative report in October 2019 marked the end of the initial MMRP’s service period. In January 2020, a new MMRP was established. This second-generation MMRP comprises over 70 clinical and non-clinical disciplines from all over Washington. In addition, the new panel includes more non-clinical members and more perinatal support providers, perinatal advocates, and patients or patient representatives.

 

Health Equity

We continued work to center health equity into our maternal mortality review process as well as the work we produce. To start, we developed a plan to provide health equity resources and training for the MMRP to apply not only during their role on the panel, but also in their own lives. We recruited more non-clinical members to join the MMRP, and also worked with our partners at the CDC to better identify evidence and incidences of discrimination, bias, and stigma during the maternal mortality review process.

 

Expanded Scope of Review

In addition to adding review of deaths related to suicide and accidental overdose, we have continued expanding the scope of the review to now include deaths from homicide where domestic violence and/or behavioral health conditions were also involved, as well as deaths that occurred to Washington residents out of state. This expansion came following feedback from the MMRP and the CDC, as well as our partners and constituents. We now review all these maternal deaths to determine if they are pregnancy-related and preventable. We have been recruiting additional subject matter experts in the fields of domestic violence and law enforcement to assist us with the review of homicide deaths.

 

To date, the new MMRP has successfully reviewed maternal deaths from 2017 and 2018, and deaths that occurred out of state from 2014-2018. We are preparing to review maternal deaths from 2019, and will review 2020 deaths by mid-2022. Our next report will be published in early 2023 and will include data on 2017-2020 maternal deaths, as well as information and recommendations related to COVID-19 impact on maternal deaths (based on the maternal mortality review findings).

 

Funding

Funding for basic infrastructure and staffing for the maternal mortality review and report was largely provided by state funding and MCHBG in 2020. In 2019, DOH was awarded $375,000 annually for five years as part of the CDC’s Preventing Maternal Deaths Grant, Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM). These funds have been used to enhance the review process to identify deaths in a more timely way, and to increase activities around implementing the MMRP’s recommendations as outlined in reports. These activities included hiring a program coordinator, prioritizing which recommendations to focus on for the next year, planning a stigma and bias training for perinatal care providers, and continuing work on a Centers of Excellence for Perinatal Substance Use certification program.

 

COVID-19

The Women’s and Perinatal Nurse Practitioner has convened a perinatal COVID-19 workgroup that includes representation from DOH, WSHA, HCA, birthing hospitals, and many different types of inpatient and outpatient perinatal providers. We met regularly to hear from community members and partners, and discussed what supports were needed to address the maternal/infant impacts and needs associated with the COVID-19 pandemic. Patient education materials were developed and released in many languages. A website was created with content for people who are pregnant and parenting, and for health care providers offering perinatal care. DOH also received a grant from the CDC for case tracking measures for COVID-19 in pregnancy, and for looking at maternal/infant outcomes longitudinally.

 

During the first months of the pandemic, the University of Washington partnered with several birthing hospitals and clinicians to track birth outcomes, and they reached out and connected with the DOH Perinatal Health Program Manager and Epidemiologists to discuss this work. Later during the pandemic, DOH received a CDC grant to track and measure perinatal outcomes through case review of everyone in Washington who tested positive for COVID-19 during pregnancy. Both UW and DOH have shared information about their work and perinatal/COVID-19 measures to a variety of audiences.