Well Woman Program 

 

NPM 1: Percent of women with a past year preventive medical visit

 

ESM 1.1 - Increase the proportion of women age 15-55, who report receiving a preventive medical visit in the past 12 months by piloting Well Woman in 2 county health departments by December 2017.

 

The WW  program operates under the Office of Women’s Health and in 2018 was included as a part of the Governor’s initiative on Infant Mortality Reduction for the state of Alabama. The program allows for women to receive a preventive wellness screening, an opportunity to participate in behavioral changes regarding chronic diseases, food choices, physical activity, and referrals for smoking cessation. The WW  program focuses on women of childbearing age to improve their overall health before becoming pregnant and after the delivery of a newborn. The program reach has increased and is currently offered in six counties in Alabama (Butler, Dallas, Macon, Montgomery, Russell and Wilcox).

 

Program objectives:

The WW  program provides a well clinic visit that includes the following:

• Cardiovascular disease risk factor screenings to determine risk factors – includes blood pressure and cholesterol screening
• Risk reduction counseling to help women understand their risks
• Healthy life/reproductive health planning to include inter-conception and preconception care
• Health coaching, nutritional counseling and support to help women discover healthy lifestyle behaviors
• Vision and oral screenings
• Physical activity encouragement/incentives, such as YMCA memberships

 

Program achievements:

• Enrolled 479 participants in the program and 1,637 total WW visits made at the CHDs in FY2019 (visits include initial visits and revisits/follow-up visits)
• Hired a nutritionist to provide nutritional education to participants in Macon, Montgomery and Russell counties
• Sponsored a 2-day training course for the program’s social worker staff on motivational interviewing skills which offered 12.5 social work ethics continuing education hours
• Hosted a student intern from UAB for summer 2019 through the Pathways to Practice Scholars student fields placement program
• Referral process developed to collaborate with community partners for referrals into the program
• Incorporated Spanish version fliers/outreach material to capture Spanish speaking population
• Development of WW Alabama Facebook page/social media access
• Social media was used to survey program participants in all six counties during the summer of 2019. Four questions were asked with the following results: 75 percent of respondents learned about the program through a referral by a family member or friend; and 56 percent reported joining the program for all parts (support group, physical activity, nutritional and screenings/check-ups)

 

 

Program challenges:

• Majority of data collected manually by program coordinator. Will continue to work with the electronic health record team to resolve and solicit assistance from ADPH MCH epidemiology staff
• Staffing resources for nutritionist at state and district level is challenging for new counties participating in the WW program.

 

Oral Health Office

 

NPM 13.1 - Percent of women who had a preventive dental visit during pregnancy

ESM 13.1-Increase the proportion of at-risk pregnant women who report receiving a preventive dental visit during pregnancy by piloting the First Steps Program.

 

OHO continues its partnership with the maternity care coordination program using ADPH case managers to promote dental visits during pregnancy. In August of 2019 there was a presentation to ADPH social workers on oral health partnerships for home visitors. Dental data continued to be collected. Educational material and oral hygiene kits continued to be shipped to all care coordinators. Patients needing a dental home were referred to local dental providers. As a part of the patient assessment process, the patients were educated about the importance of accessing dental care. If specific dental needs were identified, such as locating a dental provider, social workers assisted patients with appointment scheduling, monitored appointment compliance, and linked patients to community resources to help overcome barriers in remaining compliant with oral health care services. Patients were also given access to oral health kits for themselves, children residing in the home, as well as any other member of the household. In the 16 counties targeted from October 2018 through November 2019, 1,299 maternity patients received maternity care coordination services through the ADPH social work program. A total of 1,246 Nonmedicaid/Uninsured maternity patients received care coordination services in the same counties during the same period. These services were funded through the MCH Title V Block Grant. A video conference is being planned with case managers to further develop the program.

 

OHO provided the following items to the Medicaid Maternity Care Program

• 25 Now You’re Brushing for Two Posters (English)
• 25 Now You’re Brushing for Two Posters (Spanish)
• 250 Infant Oral Health Infographic (Spanish)
• 1,000 Infant Oral Health Infographic (English)
• 1,000 Provider Guides (English)
• 100 Provider Guides (Spanish)
• 1,000 Protect Tiny Teeth Flyers (English)
• 250 Protect Tiny Teeth Flyers (Spanish)
• 1,000 Prenatal Oral Health Infographic (English)

 

Program research was also done during this same time period to assess how maternity patients insured through private insurance companies were being educated about the importance of accessing oral health services during pregnancy. The main purpose of this research was to learn from our community partners, in the private and public sectors about successful efforts they were utilizing in educating maternity patients about the importance of accessing oral health services.

 

OHO continues to partner with ADPH internal programs, such as WIC, Perinatal Health, Women's Health, and external programs, such as Gift of Life (GOL), Head Start, and Pay It Forward, that serve or connect with pregnant women to increase oral health awareness and to promote routine dental visits, even during pregnancy.

 

OHO and ADPH marketing division staff developed floor clings, bus windows decals, and billboards advocating preventative dental visits for pregnant women during pregnancy citing the correlation between low birth weight and infant mortality with mothers exhibiting periodontal disease. The ads promoting dental visits for pregnant women continued to appear on local buses and bus stops in Montgomery throughout FY 2019. OHO also purchased Standeez promoting preventive dental visits for pregnant women and HPV that were placed in 30 Dollar General stores, grocery stores, and pharmacies around the state in August 2019.

 

Ads created to promote dental visits for pregnant women continued to be featured in "Oh, Baby!" magazine which is placed in all delivering hospitals throughout the state as well as OB/GYN offices. The 2019 ad featured two of the materials from the “Tiny Teeth” materials.

 

A new pamphlet was created to compliment the OHO fluoridation toolkit. The flyer is available online and was distributed to all public water systems along  with the toolkit.

 

The OHO director, Tommy Johnson, DMD,  presented at the Gulf Coast OB/GYN Conference on the importance of preventive dental visits for pregnant women regarding low birth weight babies. The conference was attended by approximately 125 people. Dr. Johnson gave similar presentations at various other venues including the Montgomery Area Dietetic Association, Medicaid, etc. on overall physical health and pregnancy as they relate to oral health.

 

 

The Oral Health Coalition of Alabama (OHCA) work group continued to meet to develop  Alabama’s first State Oral Health Plan. The new 5-year state plan includes an objective and strategy linked to promoting preventive dental visits for pregnant women. Alabama’s first State Oral Health Plan was completed in the late summer/ early fall of 2019. In November of 2019 OHO held a dedication and reveal program for the oral health plan.

 

ADPH's Northern Public Health District continued to partner with OHO to provide healthy habits "gifts" to children in immunization clinics and also at appropriate health fair venues. OHO provided the district with 3,500 additional oral health kits. In addition to providing a toothbrush, toothpaste, and dental floss in a "gift bag", county staff are using it as an opportunity to provide outreach, especially for WIC services, but also for other health department services such as family planning, additional immunization, breast and cervical cancer program, etc. Home health staff are also assisting in outreach by providing the "gifts" and information in homes where there are family members that may also need these services.

 

Sarrell Dental, which managed several dental clinics within CHDs, has moved those clinics to free standing buildings. While no longer connected to ADPH, these clinics continue to provide dental homes for a significant number of Medicaid children and their families. Family Health Dental operates clinics in Mobile CHD which provide dental services via community health center-managed dental programs, which included dental services for uninsured or underinsured adults. The only ADPH operated dental clinic that remains is located within the Tuscaloosa CHD. Free oral hygiene supplies, educational material, and other assistance were provided to the Tuscaloosa CHD as requested and OHO plans to assist the CHD by funding the update of its radiology equipment in 2020.  

 

GOL serves women, infants and children who are at a greater risk for infant mortality. They help program participants reduce barriers to success, related to economic, social and health disparities. Through one aspect of GOL, case managers and nurses provide dental health education and promote dental visits for their clients and their families. OHO provided dental health education material and oral hygiene supplies for the 500 maternity patients seen annually. The following supplies/educational material were sent to GOL:

• 1,000 toothbrushes, toothpaste, spools of dental floss
• 500 plastic promotional bags for patients
• 500 each of "Prevent Pregnancy-Related Gum Disease"  
• 500 each of "A Healthy Smile for Your Baby"
• 500 each of "Two Healthy Smiles"
• 500 each of "Healthy Habits for Happy Smiles"
• 100 each of "Healthy Habits for Happy Smiles"(Spanish Version)

 

The Pay It Forward program, administered by HandsOn River Region, was awarded a $25,000 grant from OHO in 2019 to continue its program and support the salary of a coordinator. The program is a value-based program whereas uninsured / under-insured clients can receive dental treatment by logging volunteer hours with any of more than 200 volunteer sites within the River Region. The program coordinator is responsible for recruiting new volunteer dentists, orientation of new patients who enroll in Pay It Forward, scheduling appointments, overseeing ADPH grant funds, exploring new modes of transportation for clients, and identifying additional partners for new clients. Pay It Forward originally only allowed GOL mothers to participate; fathers have since been added. Additionally, the program expanded the organizations through which clients could be vetted and enrolled. The following organizations were added:

• Hope Inspired Ministries --  Hope Inspired Ministries serves low-skilled, poorly educated, and chronically unemployed men and women by preparing them to obtain and maintain employment.
• Nehemiah Center -- The mission of Nehemiah Center is to equip and enable the children and adults they serve with lasting skills enabling them to abundantly sustain themselves physically, spiritually and emotionally.
• Communities of Transformation -- The mission of Communities of Transformation is to move families from surviving to thriving by developing personal leadership skills and building authentic relationships.
• Transformation Montgomery – Transformation Montgomery is a nonprofit organization that seeks to transform lives one person, one family, one neighborhood at a time through holistic life skills training, relational community renewal, and affordable housing.
• Aid to Inmate Mothers -- Aid to Inmate Mothers provides services to Alabama’s incarcerated women with emphasis on enhancing personal growth and strengthening the bonds between inmate mothers and their children.
• Friendship Mission -- Demonstrating love in action, Friendship Mission, Inc. provides a faith-centered place of refuge for the River Region’s homeless and poor that exemplifies compassion, promotes self-sufficiency and offers the tools to achieve this goal.

 

ADPH's collaboration with Pay It Forward is featured in the Best Practice Approach Report (BPAR) on State Oral Health Programs and Collaborative Partnerships with the Association of State and Territorial Dental Directors.

 

Each year OHO purchases and creates educational resources and promotional items with plans to distribute during oral health month and by request of its partners. Below is a partial list of those efforts in 2019.

 

OHO provided the following materials to SPP

• 1,000 Prenatal Oral Health Infographic (English)
• 1,000 Provider Guides (English)
• 20 Now You’re Brushing for Two posters (English)
• 20 Now You’re Brushing for Two posters (Spanish)

 

OHO provided the following materials to Medicaid Maternity Care Program

• 25 Now You’re Brushing for Two Posters (English)
• 25 Now You’re Brushing for Two Posters (Spanish)
• 250 Infant Oral Health Infographic (Spanish)
• 1,000 Infant Oral Health Infographic (English)
• 1,000 Provider Guides (English)
• 100 Provider Guides (Spanish)
• 1,000 Protect Tiny Teeth Flyers (English)
• 250 Protect Tiny Teeth Flyers (Spanish)
• 1,000 Prenatal Oral Health Infographic (English)

 

OHO provided the following materials to GOL

• 25 Provider Guides (English)
• 200 Prenatal Oral Health Infographic (English)
• 300 Infant Oral Health Infographic (English)

 

OHO mailed a sample of the Tiny Teeth custom materials to each of the 66 CHDs to inform them of new items that they could order for their oral health education needs.

 

Other ADPH Women/Maternal Health Programs

 

Family Planning

 

The APDH Family Planning Program provides confidential family planning and related comprehensive health care services throughout the state to women, men, and adolescents in need of reproductive health care. Services include reproductive life planning, contraceptive counseling, breast and cervical cancer screenings and follow up, and screening and treatment for sexually transmitted infections. Clients have access to a broad range of contraceptive methods, including long-acting reversible contraceptives.

 

The ADPH Family Planning Program continued providing family planning clinical services to Alabama Medicaid Plan First patients under the CMS-approved 1115 Plan First Family Planning Waiver.

 

The Family Planning Program also renewed an MOU with Alabama Department of Human Resources to continue DHR funding of non-surgical contraceptive supplies for low-income Family Planning clients.

 

To increase access to services and remove barriers to care for women in need of reproductive health care, the ADPH Family Planning Program completed a successful IUD insertion pilot in four counties (Morgan in the north, Shelby and Montgomery in central Alabama, and Baldwin in the south) that launched in October 2018. Nurse Practitioners began IUD insertion and removal training to support statewide expansion of IUD availability in every public health district over the next year, significantly increasing patient access to long acting reversible contraceptives. Family Planning physicians also began providing colposcopy services in some CHDs; clinics were strategically selected to support ease of access for patients within surrounding geographic areas comprising multiple counties. Family Planning physicians travel to these CHDs on a rotating schedule to provide the procedure. However, plans are in development for Nurse Practitioners to receive colposcopy training; upon completion, the NPs will utilize mobile colposcopy equipment and existing telehealth capability in the CHDs, giving physicians the ability to diagnose and treat patients remotely. The addition and expansion of this critical procedure greatly facilitates continuity of care for patients who require timely follow up of cervical cancer screenings.

 

In 2019, the ADPH Family Planning Program and its sub-recipients, Jefferson County Department of Health and Mobile County Health Department, served 71,415 clients in 141,515 visits. More than half of the clients served were uninsured. Almost 39,000 clients reported incomes of 100 percent or less of Federal Poverty Level.

 

FY 2019 ended with approximately 45 FTEs in the Patient 1st Program.

 

FHS expanded the use of its hotline from helping pregnant women access providers and educational materials about pregnancy, to a resource of information on all bureau services. In 2018, a total of 733 calls were received on the line.

 

Special Supplemental Nutrition Program for Women, Infants, and Children

 

The WIC Program implemented eWIC statewide during the calendar year 2019. The change to eWIC allows families to purchase their food benefits electronically in place of paper checks. One of the flexibilities of eWIC is that families may purchase foods as they need the food each month. eWIC improves the family shopping experience and reduces the stigma associated with assistance programs. Families are allowed to contact their clinic in months when they do not have a required face to face appointment, and their benefits can be loaded remotely without the parent driving to the clinic.  

 

The free Alabama WIC app is available for participants to access on Apple and Android devices. The WIC app features appointment and benefit expiration reminders, a searchable WIC approved food list, recipes, nutrition and breastfeeding education, and more. Staff are encouraged to download the app, explore what it offers and share this information with participants.

 

The WIC program continues to offer electronic nutrition education as a partner with wichealth.org. This arrangement allows low risk participants to complete nutrition education lessons via a web application. The nutrition education lessons directly interface with the Crossroads Management Information System, so that clinics can confirm completion of these lessons. Nutrition staff are also conducting nutrition education visits via telephone to reduce the number of visits that the family must make to the clinic. 

 

The WIC program has been focusing nutrition education efforts on the health benefits of WIC foods to reduce the incidence of obesity, heart disease, cancer, and diabetes for the past 2 years. The FY 2020 - 2021 Nutrition Education Plan continues to expand on these efforts. The plan includes new recipes incorporating WIC approved foods, new information about shopping tips to spread WIC benefits throughout the month and how to plan meals. Families are provided incentive items in the form of a shopping list and a nut butter scraper in an effort to educate and encourage WIC participants about the health benefits of WIC foods. The WIC program will continue to monitor food benefit redemption data to determine if the education provided regarding health benefits of the WIC food package increases redemption of WIC foods, including fresh fruits and vegetables.

 

WIC continued to increase public awareness of the importance of breastfeeding. The WIC Programs in Dallas and Walker counties were recipients of the Loving Support Award of Excellence for exemplary breastfeeding promotion and support activities. The WIC Breastfeeding Coordinator provided breastfeeding information for ADPH's Alabama's Health newsletter. The Breastfeeding Coordinator and other members of the Alabama Breastfeeding Committee (ABC) participated in CDC's State Breastfeeding Coalition teleconference calls. The WIC Breastfeeding Coordinator continued training WIC staff and offering breastfeeding education to staff from Alabama hospitals. She served on the board of the Alabama Lactation Consultant Association, which continued to meet. Also, the coordinator served on the board of ABC, which continued to meet. Nurses, doctors, lactation consultants, and various other health professionals are members of ABC, which focuses on encouraging, supporting, and protecting breastfeeding in Alabama. The WIC State Breastfeeding Coordinator participated as a member of the Central Alabama Breastfeeding Task Force.

 

The Breastfeeding Resource Guide was updated for ADPH's website. Materials were distributed to CHDs to promote Breastfeeding Awareness Month. As of September 2019, there were a total of 70 active peer counseling sites. Training was provided for the Breastfeeding Peer Counseling Program. Expansion of the Breastfeeding Peer Counseling Program continues.

 

A WIC Alabama Breastfeeding Enrollment Report is available for Public Health District Nutrition Directors. The report provides breastfeeding initiation and duration rates for each clinic and district.

 

Pregnancy Risk Assessment Monitoring System

 

The PRAMS Project began collecting data in 1992 and was designed to help state health departments establish and maintain a surveillance system of selected maternal behaviors and experiences. The Centers for Disease Control (CDC) collaborated with Alabama, other states, and the District of Columbia to implement this system. The Alabama PRAMS Project was transferred to the FHS from the Center for Health Statistics (CHS) on May 1, 2016. The CHS continues to provide the required data to the BFHS to carry out the PRAMS grant activities.

 

Through the relocation of the PRAMS Project to the BFHS, staff now have direct access to Alabama PRAMS data. Alabama PRAMS is positioned to collaborate with other partners and key stakeholders for maternal and child health in the state. Alabama PRAMS works with the Alabama MCH Title V Program, which fosters relationships with programs both internal and external to the BFHS and with many statewide and community groups and governmental and private organizations to address various issues. As such, Alabama PRAMS works to collaborate with WIC, Medicaid Maternity Care Providers, birthing facilities, health care providers (obstetricians/gynecologists, pediatricians, nurses, etc.), Healthy Child Care staff, the Alabama Chapter of March of Dimes (MOD), other BFHS and ADPH program staff, and other key stakeholders, as deemed appropriate. These collaborations provide opportunities to promote the awareness of and benefits of participating in the survey, if selected.

 

The Alabama PRAMS Project seeks to help improve the health of mothers and babies in Alabama. To perform these tasks, the PRAMS questionnaire asks mothers questions about their behaviors and experiences around the time of their pregnancy to determine why some babies are born healthy and some are not. Each year, approximately 1,450 Alabama mothers are randomly selected from the state birth certificate registry to receive the questionnaire, via mail or phone, for completion. In 2018, 811 Alabama mothers participated in PRAMS.

 

In the future, there will be an option to answer the PRAMS survey via a web application, which the Alabama PRAMS Project will seek to implement once available. With improved rewards and increased brand recognition, Alabama PRAMS improved recent response rates, which have exceeded the CDC response rate threshold. Maternal behavior and pregnancy outcomes have been strongly associated, thus, the impetus for seeking to improve efforts to understand contributing factors to infant mortality and low birth weight. Topics of PRAMS questions include, but are not limited to, the following: breastfeeding, contraception, infant sleep environment, prenatal care, and maternal mental health.

 

Since Healthy People 2020 goals and objectives include numerous maternal and child health indicators, Alabama PRAMS data will be used to measure the status of the maternal and child health related indicators, as applicable. Alabama PRAMS data will also be used by Alabama’s Title V MCH program to monitor progress related to the National Performance Measures selected for programmatic focus during the current funding cycle.

 

The Alabama PRAMS Project is currently participating in the supplemental opioid research that began in May 2019 and will continue until further notice. The main goal of the Alabama PRAMS Opioid Supplement is to use the existing PRAMS methodology to assess maternal behaviors and experiences related to opioid use among women before, during, and after pregnancy in the United States.

 

Office of Women's Health

 

The Office of Women's Health (OWH) was created by Alabama Legislature Act 2002-141 to be an advocate for women's health issues. The purpose of the office as described in the legislation is as follows:

• To educate the public and be an advocate for women's health by establishing appropriate forums to educate the public regarding women's health, with an emphasis on preventive health and healthy lifestyles.
• To assist the state health officer in identifying, coordinating, and establishing priorities for programs, services, and resources the state should provide for women's health issues and concerns.
• To serve as a clearinghouse and resource for information regarding women's health data, services, and programs that address women's health issues.
• To provide an annual report on the status of women's health and activities of the office to the Governor and the Legislature.

 

The law provides for an advisory committee for the office. The Steering Committee consists of the following:

• Three physicians appointed by the Medical Association of the State of Alabama
• Three nurses appointed by the Alabama State Nurses Association
• Three pharmacists appointed by the Alabama Pharmacy Association
• Three employers appointed by the Business Council of Alabama
• One consumer appointed by the Governor, one appointed by the Lieutenant Governor, and one appointed by the Speaker of the House
• Three members appointed by the Alabama Hospital Association
• Three registered dietitians appointed by the Alabama Dietetic Association

 

Women on Wellness

The Women on Wellness (WOW) Speakers Bureau was developed by the OWH Steering Committee to promote the health of women throughout the state by facilitating and coordinating evidence-based information and education about women's health. The WOW Speakers Bureau features great public communicators who are experts in women's health and focus on specific issues affecting women's health through the lifespan. WOW speakers are physicians, nurses, dietitians, pharmacists, social workers, community health advocates, and other healthcare providers who are qualified expert speakers available for any audience interested in learning more about specific women's health issues.

 

Single Mothers Empowerment Conference

Single mothers were invited to the Sixth Annual Single Mothers Empowerment Conference on Saturday, June 22, 2019, at the McWane Science Center in Birmingham. The theme was "Revive & Refresh , Stronger Together!" and topics included finances, healthy relationships, life transitions, legal concerns, and much more. The event provided a constellation of information, resources, mentorship, a strong network of support and motivation for single parent women of all walks of life. It was designed to empower single mothers to address the challenges and obstacles they face as family leaders while helping them to renew their hopes, dreams and goals.

 

Women's Health Update

The OWH Twelfth Annual Women's Health Update was held Friday, August 2, 2019, at the Grandview Medical Center Auditorium in Birmingham, Alabama. The theme was: Innovations in Women's Health: A Focus on Technology. The event was a continuing education offering for registered nurses, nurse practitioners, pharmacists, social workers, dietitians, and other health care providers. The purpose of the annual conference is to disseminate scholarly work that is aimed at improving the health status of all women. Topics included Telehealth, cardiovascular health, weight management, nutrition, complementary and alternative medicine, preconception care, mental health issues, community involvement, and health policy; each topic included the use of technology for assistance with health care needs across communities. The conference provided a venue for scholars from various disciplines to share their latest projects and research findings with colleagues.

 

Opioids

 

The Alabama OMW/NAS Taskforce continues to meet quarterly in March, June, September, and December. The goal of the taskforce, formed through an ADPH Office of Women's Health partnership with the AAP, Alabama Chapter, is to target the misuse of opioids in Alabama among women and address the growing trend of infants born addicted to drugs (NAS), by introducing preventative strategies and proposing standardized screening protocols to address early identification in women, and in babies exhibiting NAS after delivery. Midyear 2018, the three core subcommittee teams - legal, protocol, and education - were expanded to include the treatment, resources & recovery committee. The target population continues to be girls/women (including incarcerated women) and NAS infants.

 

Committee members participated in a panel discussion with the Executive Director of the Alabama Office of Prosecution Services/Alabama District Attorneys Association in 2019, at the AAP, Alabama Chapter meeting, to discuss the Alabama child endangerment law and criminalization of mothers who use illegal substances during pregnancy. Mothers continue to be charged with chemical endangerment of the child. Discussions are ongoing for the development of a position statement that would include decriminalization for women in treatment programs. The taskforce hopes to develop the basis for a communication piece for the State of Alabama that stresses, that if the mother gets treatment during pregnancy, she will not be charged. The document would carry logos of the Attorney General, the AAP, Alabama Chapter, and ADPH. Draft language for the position statement flyer was submitted for literacy level review by staff at UAB.

 

The taskforce is working to address universal testing of all mothers in labor and delivery units and reduce variation in treatment of opioid exposure. Data is needed for comparison of outcomes and translation into better care. A comparison of three years of data from Huntsville/Madison hospitals (which test all mothers), to UAB and St. Vincent's data (which do not test all mothers), is being explored. Challenges include the fact that providers keep circling back to fear of prosecution if the baby tests positive for opioids.

 

Maternal Mortality Review Program

 

ADPH established the Maternal Mortality Review Program (MMRP) in March 16, 2018.  The purpose of the Program is to understand how a wide array of social, economic, health, educational, environmental, and safety issues relate to maternal death.  The goal is to do an in-depth look into the circumstances of each case of maternal death to understand how to prevent them.  An additional goal is to promote change among individuals, communities, and health care systems in order to improve the well-being of women of childbearing age, infants, and families.  The maternal mortality review process begins with the ADPH nurse abstractor gathering information about a maternal death and synthesizing the information into a case summary.  The de-identified case summary is presented to the Maternal Mortality Review Committee (MMRC).  The MMRC is a multidisciplinary team which reviews cases of maternal death that occur during pregnancy or within one year of pregnancy and makes recommendations that will lead to a more effective and efficient statewide maternal care system.

 

The Alabama MMRC convened for the first time on December 7, 2018 for a mock case review.  ADPH and a team from the Centers for Disease Control and Prevention (CDC) provided information on the importance of conducting maternal death reviews and oriented members about the role they each play on the committee.  The MMRP has consulted and collaborated with the Division of Reproductive Health National Center for Chronic Disease Prevention and Health Promotion Centers for Disease Control and Prevention in the implementation and operations of the Alabama MMRP.  On Friday, February 8, 2019, the Alabama MMRC conducted its first case review meeting with more than 45 professionals from across the state in attendance.  During the year, the MMRC met quarterly and reviewed all of the 36 maternal deaths selected for review out of 56 maternal deaths that occurred in 2016.  Support for the MMRC was provided by the American College of Obstetricians and Gynecologists.

 

Currently, the MMRP staff is abstracting 2017 maternal deaths.  The MMRC is meeting quarterly to review the 2017 case summaries and make recommendations.  An abbreviated report of the 2016 findings is being prepared and scheduled to be published by the end of 2020. 

 

In FY 21, the MMRC will continue to meet quarterly to review cases. The MMRP will be provided state funds through the general fund budget.  These funds were secured through the efforts of the March of Dimes and the Medical Association of the State of Alabama.  The funds will be used to hire additional MMRP staff and provide funding for autopsies.  The program will incorporate interviews from family members, a process similar to FIMR, to gain a better understanding of the factors that contribute to maternal deaths.  Maternal deaths that are COVID-19 related will be reviewed, abstracted and presented to the MMRC.  So that, prevention efforts can be disseminated to mitigate these deaths.

State of Alabama Infant Mortality Reduction Plan

 

In December 2017, Governor Kay Ivey convened the Children’s Cabinet to address the issue of infant mortality in Alabama. A subcommittee was created to develop an action plan. This subcommittee was comprised of leaders and staff from DECE, DHR, DMH, ADPH, Medicaid, and OMA. Title V funded program managers and MCH Epi staff developed and implemented strategies and data support for governor’s initiative.

 

Home Visiting

DECE contracted with two programs to provide evidence-based home visitation, using the Parents as Teachers and Nurse-Family Partnership (NFP) models of service delivery. Newly hired staff were required to complete NFP required and DECE required new home visitor trainings. Following the training period, recruitment ensued. Though the narrow eligibility requirements of NFP proved to be a challenge, the team met half of their year 1 targets in the first three quarters. By the end of quarter three, more than 50 families (across all pilot counties) were enrolled in the program, illustrating rapid growth of participant enrollment. This upward trend is anticipated to increase by the end of year one. Funding from a variety of sources, in addition to matched funds by Medicaid, allowed home-visiting services to be expanded to 66 of 67 counties in Alabama. The strategy team will continue to use the two models as a basis for continuous program growth and advancement.

 

Screening, Brief Intervention, Referral to Treatment (SBIRT) Tool

The SBIRT tool can be a useful instrument in identifying, reducing, and preventing substance use, domestic violence, and depression. Research has been completed on best practices in providing services among pre-pregnancy, prenatal, and post-partum women. Additionally, training strategies and outreach models have been explored to determine the optimal ways to effectively provide screenings. In this way, a training program and support for providers may increase the number of screenings that take place. The SBIRT committee began meeting to develop a working plan as to how to accomplish the goal of implementing SBIRT in the designated counties. After developing the plan, the lengthy contractual process further delayed plan implementation; thus, significantly delaying the progress in the team’s proposed objectives. However, the team selected a project coordinator, who began in September 2019, to provide oversight for the anticipated activities. The integral role of the project coordinator in the activities throughout the remaining years in the initiative will be imperative to the program’s success. The lead agency for SBIRT was the Alabama Department of Mental Health.

 

Preconception and Inter-Conception Care

The WW program provides preconception and inter-conception care to women of child- bearing ages (15-55 years), as a foundation for wellness, identification of chronic diseases, and the adoption of a healthier lifestyle. In the first year of the initiative, a referral process was developed and initiated for enrollment into the program. The program boasts a 45 percent increase over the target enrollment of participants (total number by August 26, 2019 = 291). Of those enrolled in the program, at least 78 percent had controlled blood pressure at nearly the end of year one and 93 percent had blood glucose levels controlled inside the target range.

 

This program continues to be encouraged throughout the pilot counties and nearly seven thousand promotional materials have been distributed, in addition to social media postings. Community partnerships established in year 1 with organizations, such as GOL and Small Wonders, is projected to increase participant enrollment and improve health outcomes of women.

 

Perinatal Regionalization

Enhancing perinatal regionalization is a priority of the State of Alabama Infant Mortality Reduction Plan. For several years, the team has been working and continues to work to implement a fully coordinated system of perinatal regionalized care in Alabama. The foundation for such a system will be dependent upon relevant data that the workgroup began collecting in year 1. Furthermore, the workgroup, in collaboration with the Alabama Hospital Association and the State Health Planning and Development Agency (SHPDA), has worked to identify the level of neonatal care of delivering hospitals through self-declaration of the facilities. Baseline data for self-declared neonatal level of care was received from the SHPDA, and pertinent data was requested from the Center for Health Statistics. In March 2019, a conference call was convened with Dr. Wanda Barfield, OB/GYN and Rear Admiral with CDC, to discuss recommendations for engaging providers. In May 2019, Dr. Whit Hall, Neonatologist at the University of Arkansas, traveled to Alabama and met with staff and providers at the three delivering hospitals in Montgomery to discuss opportunities, options, challenges, and barriers. Review of the aforementioned data and support from CDC and experts will further advance the efforts underway to develop a perinatal regionalization system in the state.