Arkansas Title V Maternal and Child Health Services Block Grant

2022 Report and 2024 Application

III.E.2.c.  State Action Plan Narrative by Domain

Women and Maternal Health 2022 Annual Report

Local Health Units

The Arkansas Department of Health (ADH)- Women’s Health program provides direct healthcare, referral services, preconception, inter-conception counseling, and preventive screenings for women of reproductive age in all 75 counties in Arkansas. ADH also provides education, screening, and referral for smoking cessation to women of childbearing age to reduce smoking among pregnant women. LHUs serve the state’s vulnerable and hard-to-reach populations, especially those in rural areas where access to medical care is limited. The ADH’s Women’s Health programs support the provision of direct health care and referral services to address the perinatal, reproductive health, well woman, and other preventive service needs for women across the state. The ADH currently offers maternity services in 53 LHUs covering 49 counties (Map1) including:

• Case management.
• Prenatal assessments, including risk assessments, history, physical, laboratory tests, gestational age, and fetal assessments.
• Management of abnormal prenatal findings.
• Prenatal counseling and education.
• Women, Infants and Children (WIC) program.
• Vitamins and mineral supplements.
• Post-partum services.

Maternal Health Activities 2022

Objective 1: By December 31, 2025, increase the percent of women, ages 18 through 44 with a preventive medical visit in the past year to 77%.

The state action plan that was submitted does not support NPM1. However, the following strategies aim to accomplish this objective by increasing the number of women who receive their preventive health visit:

1. The ADH Women’s Health partnered with the ADH health equity to push out family planning and maternal health information to increase preventive health visits. Flyers and educational materials about maternal health were sent to local health units.
2. Central Arkansas Alumnae Chapter (CAAC) organized its second annual Health and Wellness Fair in December 2022. CAAC partnered with the ADH, Arkansas Health and Wellness, Breast Care Program, Arkansas Minority Health Commission, Infant Hearing Program, UAMS, and Be Well Arkansas. The fair covered a wide span of topics such as, tobacco cessation, women’s health, breast cancer, heart disease, healthy eating lifestyles, and other activities for 200 attendees. The ADH Women’s Health Section distributed 30 flyers and talked to women in the community to educate them about getting their initial preventive visits and other maternal services offered at the local health units.
3. School Based Health Centers: the central region provides services at a monthly family planning clinics at Central High School. Information is provided to local colleges on family planning services and preventive annual checkups offered at LHUs. While the southeast region provides two monthly off-site family planning clinics at the university of Arkansas at Pine Bluff campus. The Jefferson County LHU also hosts a monthly clinic at the Dollarway School District’s Wellness Center.
4. The development of partnerships with local community-based health and social service providers through local Hometown Health Coalition efforts to establish a community network of services. 
5. The ADH Women’s Health section continues to work with the ADH’s Hometown Health Coalition in each region to partner with local churches, schools, and civic organizations to provide community-based educational program and activities.
6. Distribution of reproductive health and maternity information flyers through the Breastfeeding Coalition to incarcerated women to raise awareness of available services once they were released.
7. Outreach activities by the nurses in the LHUs at the grassroots level to reach out women to educate them about getting their first preventive visit:

• Visiting doctor’s offices, hospitals and sharing with them the maternity and/or family planning services provided in the health units to help patients that do not have a pay source to schedule appointment for prenatal and maternal services.
• Sharing the maternity and family planning materials with the Department of Human Services so they can refer people who do not qualify for Medicaid to LHUs services.
• Outreach visits to school nurses, youth groups, women’s shelters, health fairs.
• Asking daycares to post some of LHU flyers which list the maternal and family planning services.
• The Southwest Region distributed the flyers at influenza vaccination clinics at Tyson’s Poultry on October 2, 2022.
• The Northwest Region LHU staff attended community events hosted by the Veteran Affairs and Marshallese organizations and distributed flyers.
• The Northwest Region LHU staff participated in a local community parade, created a float (which won first place) and handed out flyers and WIC information.
• The nurses at the local health units are constantly engaging with the local community and educating them about women’s health by attending community events including: 

• Washington Regional Cancer Support Home-Fayetteville.
  • Panther Wellness Clinic-Siloam Springs.
  • Parkhill Women’s Clinic-Fayetteville.
  • Willow Creek Women’s Clinic-Springdale.
  • Creekside Women’s Clinic-Springdale.
  • Her Health Clinic-Fayetteville.
  • Division of Community Correction Reentry Service-Fayetteville.
  • The Church of Jesus Christ-Prairie Grove.
  • Sweet Home Missionary Baptist Church Nurses group- Morrilton.
  • Conway County Care Center- Morrilton.
  • UACCM continuing education center- Morrilton.
  • Conway County Library- Morrilton.
  • Community Baby Shower-Berryville.
  • Local pregnancy Center the Cradle- Berryville.
  • Community wellness committee meeting- Clinton.
  • World’s Largest Baby Fair-Harrison.

Pregnancy and Oral Health Activities 2022

NPM 13.1:  By December 31, 2025, increase the percentage of women who had preventive dental visit during pregnancy to 44%.

The following strategies are implemented to increase the number of women receiving preventive dental visit during pregnancy:

1. Develop collaborations with obstetricians and gynecologists in the state to offer Paint a Smile (PAS) program. PAS trains medical professionals to perform oral health risk assessment, oral health screenings, education, and apply fluoride varnish in clinical settings to close the gap that might exist for people who do not have regular access to comprehensive dental care. The

dental care during pregnancy is safe and recommended. All women should be encouraged to continue their regular dental visits or to see a dentist during any trimester of their pregnancy. Physical changes during pregnancy increase the mother’s risk for oral problems such as gingivitis, tooth mobility, tooth erosion, tooth decay, and gum disease. Additionally, the bacteria responsible for dental cavities can easily be transmitted from the mother to the infant or toddler.

2. The ADH OOH works with LHU nurses to provide oral health education to caregivers and assist them in locating a dental home if needed. Although the focus is on children aged 6 and younger, anyone under 19 years of age is eligible including young expectant mothers.
3. The Arkansas Department of Health used social media platforms to inform and motivate pregnant women to maintain good oral health and see their dentist regularly. In 2022, they reached 4715 people on Facebook, 185 on Instagram, and 795 on Twitter.

Future activities might include partnering with Healthy Birth Day Inc. (HBD), ADH Women’s health, ADH OOH, and Delta Dental to launch a campaign to educate women about the importance of practicing good oral hygiene while pregnant. HBD/ Count the Kicks could be integrated not just with traditional healthcare settings like OBGYNs or Midwives, but also with Dentist, Hygienist, and Dental Assistants. The connection between poor oral health and poor birth outcomes is undeniable. That is, by creating a systems protocol for Dental Clinics and educating Dentists on the importance of talking about not just oral health but also touching on the importance of tracking fetal movement is just one more touch point expectant women will have in their lives that will ultimately make a difference.

Challenges in Implementing Title V Activities

• The implementation of Affordable Care Act affected the number of women receiving family planning services at the health units, as it allowed woman to choose private health care provider and permitted teenagers to remain insured under their parents’ policies until age 26.
• The overturn in staff represents a challenge with fulfilling state priority needs and activities for pregnancy and Oral Health. In January 2022, the ADH Oral Health director retired. The director was instrumental in writing the ESMs for NPM 13.1 and helping to understand the priority. In March 2022, the ADH OOH section chief resigned from the position. The section chief worked directly under the director and was second in command for the OOH. Furthermore, the MCH director retired as of January 2023 and the Women’s Health section chief has resigned in May 2023. Currently, the new staff operates to revise the old programs and establish new strategies and partnerships (i.e., Delta Dental and ADH OOH) associated with maternal health to better serve women across Arkansas.  

Local Health Unit Activities

The following strategies aim at serving women at the health units rather than increasing the number of visits:

1. Review medical record data reports for rates of preventive health services for women ages 18-44 provided in LHUs. In 2022, a total of 14,162 women ages 18-44 received a preventive health visit at the LHU.

2. Family Planning and Well Woman patients at LHUs receive education and counseling on recommended preventive screenings to optimize health. Educational topics include sexually transmitted infection screening, Pap tests, mammogram referral, hemoglobin testing, sickle cell screening, total cholesterol or cholesterol screening referral, wet mount, pregnancy testing, and fecal occult blood testing. The client is also screened for immunization status, smoking, alcohol use, illicit drug use or abuse, human trafficking, and intimate partner violence.

3. Provide referrals to community resources for identified risk factors or medical procedures unavailable at the local health unit. In 2022, Family Planning and Well Woman programs referred patients for a total of 3,191 health-related services not provided by ADH. The services include laboratory tests, radiology, mammography, colposcopy, social services, dental services, tobacco cessation, and referrals to other medical providers. The Family Planning program also made 2,856 referrals to the Special Supplemental Nutrition Program (SNAP) for the WIC program in 2022.

4. Provide preconception counseling prior to pregnancy to women attending an ADH Family Planning clinic. LHUs also provide preventive health screening services and referrals at all Family Planning and Well Woman visits to identify health problems. Family planning patients without a pay source are charged based on a sliding fee scale, with no fee for families with incomes at or below 100% of the federal poverty level. The ADH does not deny services due to inability to pay, and the agency bills third party payers for family planning services.

5. Track medical record data reports for prenatal care entry at local health units. In 2022, ADH maternity clinics served 1,265 women with expected delivery dates. Maternity patients can apply for Medicaid through the Arkansas Department of Human Services (ADHS), while non-citizens or undocumented women can apply for Medicaid’s Unborn Child Option for pregnancy coverage. The ADH can provide care until the patient gets Medicaid approval, which varies across the state in terms of duration. After approval, LHU staff help the clients find a local prenatal care provider. The women’s health services are crucial given Arkansas’s high rural population, high poverty levels, and limited availability of obstetric providers.

Other Programmatic Activities

Appointment Show Rate: The ADH implemented an appointment reminder program for patients using the Vital Interaction software with Greenway PrimeSUITE patient data. The patient receives three reminders: a text reminder is sent five days prior to the appointment with a requested Y/N confirmation response, a voice call reminder is sent 72 hours prior to the appointment If the patient does not respond to the text, and a text reminder is sent with no requested confirmation 24 hours prior to the appointment. The appointment show rate had notably increased from 65.6% during program implementation in March 2016. The show rate for March 2017 to February 2018 was 68.8%, an increase of 3.2 percentage points. From March 2018 to February 2019, the show rate was 69.7%, an increase of 4.1. From March 2019 to February 2020, the show rate was 69.8%, an increase of 4.2. From March 2020 to February 2021, the show rate was 74.2%. From January 2022 to April 2023, the show rate was 79.6%, an increase of almost 9% since implementation.

Promote Maternal Health: Arkansas Maternal Mortality Review committee (AMMRC) works to quantify and understand pregnancy-associated deaths to create actionable and comprehensive recommendations to prevent future deaths. This is accomplished through epidemiological surveillance and multidisciplinary case review led by the committee members. The committee is working toward a partnership with the Center of Disease Control and Prevention to launch Hear Her Campaign in Arkansas. The campaign will be promoted though major social media platforms to reach the target population who are pregnant women, women who have given birth within the last year (postpartum), and their support network (including partners, family, and friends). The main objectives are to raise awareness of urgent maternal warning signs during and after pregnancy, improve communication between patients and their healthcare providers, empower pregnant and postpartum woman to speak up and raise concerns, and provide tools for pregnant and postpartum women and healthcare professionals to better engage in life-saving conversations.

Count The Kicks Campaign: ADH partnered with Healthy Birth Day, Inc. (HBD) in 2022 to release a statewide launch of count the kicks, a stillbirth prevention public health campaign. The nonprofit provides the ADH with social media content and free digital tools for use on all social media platforms. HBD prints Count the Kicks educational materials with ADH logo, including brochures, posters, and app reminder cards in English and Spanish for all maternal health professionals and birthing hospitals in Arkansas. Count the Kicks is a one-of-a-kind stillbirth prevention campaign directed at pregnant women. The success of the public health campaign comes from partnering with maternal health providers to ensure that all women in the third trimester are aware of the importance of counting their baby’s kicks, learning what are normal movement patterns for their baby, and telling their provider right away if they detect any changes. During the first quarter of 2023, the number of CTK app downloads among expectant parents was 118 users, the number of Arkansas hits to the CTK website, and social media was 635 people, and the number of CTK materials sent to healthcare professional was 20,965 pieces for 65 orders placed. 

Nurse-Family Partnership: The Family Health Branch partners with Arkansas’s Nurse-Family Partnership (NFP) home visiting program to improve pregnancy outcomes by helping women be involved in good preventive health practices. The Nurse-Family Partnership (NFP) Program gives first-time moms first-rate help, right from the start. This free, evidence-based program partners first-time moms who meet low-income requirements with specially trained Registered Nurses. Through home-based visits, these nurses educate moms on prenatal and newborn care and teach them how to help their children develop emotionally, physically, and mentally. NFP helps moms prepare for birth and gives both mother and child the support to reach their goals. During home visits, NFP nurses answer questions about pregnancy, childbirth and how to care for a newborn. Nurses help moms set personal and family goals, then link them with resources in the community so they can achieve them. Nurse-Family Partnership/Arkansas Home Visiting Network (arhomevisiting.org).

High Risk Pregnancy Program: the ADH Women’s Health Section has a professional services contract with the UAMS Women and Infant Health Service Line (WISL) to facilitate the delivery of comprehensive and risk-appropriate maternity care to low-income women throughout Arkansas. It also supports the ADH in providing outpatient services to ADH high-risk maternity patients. In addition to telemedicine, the contract supports the provision of nursing services, laboratory services, physician services and the liaison/consultation services of a certified nurse midwife for ADH’s Lay Midwife Program.

COVID-19 Vaccination in Pregnancy: Women’s Health partnered with ADH Surveillance for Emerging Threats to Mother and Babies Program to create a survey for providers to fill out covering possible concerns they might hear from pregnant and breastfeeding women or those trying to get pregnant about the COVID-19 vaccine or COVID-19 in general. In July 2022, the ADH developed a Pregnancy and COVID-19 webpage involve information for the community and health care providers https://www.healthy.arkansas.gov/programs-services/topics/covid-19-and-pregnancy. The webpage also includes resources from CDC for patient education to promote awareness and encourage women to make inquiries to protect their health against COVID-19.

HPV Prevention: The “HPV Vaccine is Cancer Prevention” Summit was held May 16, 2022, as a hybrid event. The HPV Summit creates a platform for collaboration among medical and dental professionals to increase awareness about the benefits of the HPV (human papillomavirus) vaccine and cancer prevention as well as to increase acceptance of the vaccine. ADH partnered with the Arkansas Immunization Action Coalition to provide education on efforts to improving Arkansans’ health through immunizations at the 2022 HPV Summit.

Long-Acting Reversible Contraceptives (LARC): LARC is an important service provided by ADH Family Planning Title X Program. The Women/Maternal Health Domain work closely with Title X staff to expand knowledge of, and access to, all forms of contraception, especially LARC services. In calendar year 2022, 3,571 LARC insertions including Nexplanon and Intrauterine Device (IUD) were performed. 

Congenital Syphilis testing, prevention, and treatment: Every region in Arkansas is seeing an increase in the number of syphilis cases, especially among women. From 2017 to 2021 there was a 164% increase (from 562 to 1,482) overall in early syphilis cases and a 285% increase (from 155 to 597) among women of reproductive ages (15-44 years). Syphilis among pregnant women is especially a concern due to the potential of congenital syphilis, which happens when a mother with syphilis passes the infection to her baby during pregnancy. Untreated syphilis during pregnancy can lead to stillbirth, preterm delivery, and other congenital abnormalities. Congenital syphilis is preventable by early detection of maternal infection and appropriate treatment prior to delivery. The State of Arkansas requires testing of all pregnant women at the first prenatal care visit and 3rd trimester (between 28-32 weeks gestation). Furthermore, testing at delivery is required if not done during the pregnancy. Local health units across the state provide Syphilis testing and treatment for free or at low-cost according to income verification. The number of Syphilis test by visit at the maternity clinics was 1070 visits in 2021 and 1051 visits in 2022. On the other hand, the visit counts with patient count at the maternity clinics across Arkansas’ five regions was 1243 patients for 2021-2022 and 1266 patients for 2022-2023.

Unintended Pregnancy: The ADH partnered with Arkansas Medicaid, AFMC, and the Arkansas Department of Higher Education to implement strategies and distribute educational materials designed to address unintended pregnancies. Together, these partners developed a toolkit for hospitals and health care providers to use as they discuss health, sexual history, and birth control options with patients. The toolkit, TAKE CONTROL of Your Life: The choice about if or when you become pregnant is YOURS!, included a patient education flip chart and patient education guide to review the different options for family planning. The toolkit was made available in English, Spanish, and Marshallese. It was distributed to campus health centers/programs at all public two-year and four-year colleges in the state. It was also distributed to the LHUs. The Arkansas Campaign to Prevent Unplanned Pregnancy also developed a YouTube video called Preventing Unplanned Pregnancy (https://www.youtube.com/watch?v=FaCyQMrSUg8).

Maternal regionalization site visits: ADH leads the perinatal regionalization efforts in Arkansas. Towards this aim, ADH will coordinate site visits to birthing hospitals as a part of its perinatal regionalization work. ADH will recruit volunteer clinical providers to conduct the site visits and provide an incentive to participating clinical providers using funds from this subaward. Volunteer providers will conduct in-person site visits and complete the “Levels of Care Assessment Tool” (LOCATE) from the Centers for Disease Control and Prevention. ADH will coordinate site visits, collect, and analyze assessment data, and provide results of the LOCATE assessments to UAMS (e.g., confirmed levels of care for each hospital) for inclusion in the state maternal health dashboard.