Women & Maternal Health: Annual Report
In 2020, there were approximately 344,821 women of reproductive age (15 to 44 years old) residing in Idaho, which is just over 19% of the total state population. Idaho’s birth rate for the same year was 11.8 per 1,000 population, which is higher than the national rate of 11.0 (CDC, 2020). One half (50%) of women aged 18 to 44 had a preventive medical visit in the past year (BRFSS, 2020). In 2020, 71.2% of females aged 21 to 65 had a Pap test in the past three years. It is worth noting that Idaho gained some media attention in 2018 based on results from a study which indicated Idaho was the worst state for working moms. As of 2021, Idaho ranks 49 out of 51 states and territories. Specifically, the study ranked the state as 51st for childcare (quality and costs) and 48th for highest gender pay gap (Wallethub, 2021).
For the Women/Maternal Health domain, Idaho has selected “NPM 1: Well-Women Visits” based on the results from the needs assessment indicating the need to focus on routine care for women, including prenatal care for pregnant women. In 2018, 79.7% of pregnant women initiated prenatal care during the first trimester (PRATS). In 2020, a total of 81.4% initiated care during the first trimester and 14.7% did so in the second trimester. By July 2025, the state aims to increase the number of women who are linked to routine well-woman care, including prenatal care during the first trimester. Measurement of the objective will be based on federally available data for Idaho. Strategies to address this objective and NPM are discussed below.
During the 2019 legislative session, a bill was passed tasking the Idaho Department of Health and Welfare with implementation of a maternal mortality review committee (MMRC). The purpose of this committee is to review maternal deaths to understand the contributing factors and offer recommendations to prevent future deaths. The Idaho MCH Program has been charged with housing and coordinating the MMRC. As a result, a new objective has been added to the state action plan: By September 2025, annually implement the legislatively required MMRC to review maternal deaths in Idaho and offer recommendations for prevention.
A second new objective in the Women/Maternal Health domain has been added to support the development and implementation of a Perinatal Quality Collaborative (PQC) by September 2025. The goal is to improve quality of care for mothers and babies based on recommendations from the Idaho MMRC. The addition of this objective will provide the mechanism to act on these recommendations and then implement solutions with a group of stakeholders that can have statewide impact on maternal health outcomes.
To address these two new objectives, the existing priority of supporting “services, programs, and activities that promote safe and healthy family functioning” was used to justify the important addition of MMRC and PQC work to this domain. Based on the 2021 needs assessment, this priority is centered on results indicating the following as priorities for women of reproductive age and pregnant women: preconception health, mental health/substance abuse treatment, access to health care, self-care, parenting education, and prenatal care. Therefore, this priority and objective are linked with national outcome measures (NOMs) related to severe maternal morbidity and maternal mortality, which align with “NPM 1: Well-Women Visits.”
The MCH Program continues to partner with the Idaho Tobacco Prevention and Control Program (ITPCP) to support efforts to direct pregnant and breastfeeding women and women of reproductive age to the Idaho QuitLine. The new ESM 14.1.1 in the 2021-2025 state action plan measures the percentage of pregnant women, postpartum women, and their partners who quit smoking through participation in the local public health district cessation program.
This work aligns with the existing priority to decrease substance abuse among maternal and child health populations. The 2021 needs assessment indicated 9.1% of women smoked at any time during pregnancy statewide from 2014-2018. Furthermore, American Indian/Alaskan Native women had the highest rate of smoking during pregnancy at 16.4%. Non-Hispanic women had over two times the rate (10.1%) of smoking at any time during pregnancy than their Hispanic counterparts (4.0%). Women living in remote areas had the highest rate (14.6%) of smoking any time during their pregnancy when compared to rural (9.5%) and urban women (8.6%) in Idaho.
For the Women/Maternal Health domain, Idaho selected “NPM 1: Well-Women Visits” based on the results from the needs assessment indicating the need to focus on routine care for women, including prenatal care for pregnant women. By July 2025, the state aims to see an increase in the number of women who are linked to routine well-woman care, including prenatal care during the first trimester. Measurement of the objective will be based on federally available data for Idaho. Strategies to address this objective and NPM are discussed below.
The Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program and the Idaho Family Planning Program are administered within the Maternal and Child Health Section which allows for better alignment of home visiting, family planning, and Title V MCH priorities. In 2017, the MCH Program collaborated with the Family Planning Program to integrate One Key Question® (OKQ) into their service delivery. OKQ is an evidence-based strategy that encourages providers to ask clients the question, “Would you like to become pregnant in the next year?” as part of routine care. This process is designed to incorporate pregnancy intention screening into reproductive health and primary care settings as a proactive way to increase the proportion of pregnancies that are wanted, planned, and as healthy as possible. By asking the question, clients are supported in their decision-making, and clinicians can provide education and services that are tailored to the desires and needs of each client. Client responses, along with education and referrals, are captured in the EHR and reviewed during chart audits as a quality assurance measure. Idaho Title V funded the contract with the national model developer to offer web-based training to five family planning subrecipients which oversee Title X services at 26 services sites. In 2018, two new subrecipients added an additional 15 service sites to the Title X network implementing the OKQ approach to reproductive life planning.
From January 1 to December 31, 2021, a total of 9,200 female clients and 599 male clients were screened for pregnancy intention using the OKQ approach. Based on these data, 85% (9,799/11,515) of family planning clients were assessed for pregnancy intendedness using OKQ (ESM 1.1). Of those screened, 2.7% responded with “Yes,” 80% responded “No,” 16.3% responded that they were “Okay either way,” and 0.8% indicated they were “Unsure.” About 19.2% of unduplicated clients were not asked during the current visit about their pregnancy intention. Providers are asking OKQ within a range of frequency from every three months, every six months, or annually. It may not be appropriate or necessary to ask a client at every visit, which contributes to the 19.2% that were not asked. Additionally, while some sites are having great success with asking OKQ, one FQHC has expressed difficulty in their staff completing this assessment consistently. They have verbalized an increased effort to ensure clients are asked OKQ during each Title X visit by ensuring staff are properly trained and the electronic medical record is set up to accurately document this assessment. As of July 2021, four public health districts and two FQHCs are currently using OKQ to screen for pregnancy intention across 42 service sites. These data are not unduplicated.
The MCH block grant continued to provide funding to the Idaho Family Planning Program (IFPP) to support subgrants to four of the seven local public health districts and two federally-qualified health centers (FQHCs) which provide family planning services on a sliding-fee scale in accordance with Title X regulations to women of reproductive age, as well as adolescents and men. About 19% of clients served were adolescents under the age of 20, and about 10% were male. Family planning services at the local level include reproductive health exams, pre- and inter-conception health planning, pregnancy testing and counseling, preventive health education, and provision of contraception. It’s worth noting that three health districts have elected to no longer deliver Title X services. Therefore, client counts declined between 2014 through 2018. In October 2018, IFPP initiated subgrants with two FQHCs in southwestern and south-central Idaho to provide Title X services in areas that had family planning service gaps. These FQHCs added 15 clinic sites serving residents in 11 counties to the IFPP Title X network.
In 2021, the local family planning programs served 7,841 unduplicated clients: 7040 females and 801 males. Among these clients, 866 received pregnancy tests. A total of 263, or 30%, of these women received a positive pregnancy test, and 91, or 35%, were given a referral to prenatal care. Sixteen (16) women, or 6%, were given a referral for high risk pregnancy care. In total, 107 women who were in need of prenatal care were referred when need was indicated.
In the IFPP, women who receive a positive pregnancy test are offered a variety of information based on their disposition during the visit. If a client was planning the pregnancy, desires the pregnancy, or seems clear about wanting to continue the pregnancy, the client receives a packet which includes a list of prenatal care providers who accept Medicaid, as well as information about Medicaid and WIC. If a client seems unsure about the pregnancy, the same packet is offered with a list of prenatal care providers, Medicaid, and WIC information, and other options such as adoption and/or termination are discussed. In Public Health District 7, a program called Medicaid Ineligible Pregnancy Services (MIPS) helps pregnant women who are Medicaid ineligible navigate the prenatal process. Medicaid Ineligible women include non-residents such as international students, refugees, and those who are undocumented. Women are given a list of prenatal care providers who will accept the Medicaid rate (which would be paid out-of-pocket). These women can get their prenatal lab work through the health district, which is less expensive than through a private provider. MIPS also includes paperwork to get a Medicaid Emergency Card for post-delivery.
In 2019, the IFPP began a collaboration with the Sexual Violence Prevention (SVP) Program within the Division of Public Health to provide regional training opportunities for Title X providers using the Futures Without Violence curriculum, Did You Know Your Relationship Affects Your Health? This curriculum is a train-the-trainers model that addresses intimate partner violence (IPV), reproductive coercion (RC), and sexual coercion (SC). This innovative approach focuses on the crucial role of health care providers in identifying and addressing IPV, RC, and SC in the clinic setting. The curriculum provides training, tools, and resources to help health care providers address these complex and sometimes uncomfortable issues. The training demonstrates how to use a safety card to educate clients about RC and SC during Title X family planning visits to improve reproductive health outcomes and promote safe and healthy relationships. Safety cards and other resources for integrating and sustaining a trauma-informed, coordinated response to IPV, RC, and SC are provided to participants during the training.
COVID-19 Impact on Well-Women Care
Over the course of 2021, the IFPP saw a decline in the number of unduplicated client visits. Subrecipients reported feedback from Title X clients that clients perceived it was unsafe to access Title X services during the COVID-19 pandemic. This impact was also evident in the increase of “no show” numbers during 2021. Increased spacing between appointment times was used to allow for social distancing in waiting rooms. Access issues and delays in getting patients in with some referral partners due to the COVID-19 pandemic were also reported. Walk-in clinics, including walk-in teen clinics, and services provided to correctional facilities, including juvenile detention centers, were suspended at the beginning of the pandemic. Initially, services such as initial birth control, pregnancy testing, and symptomatic STD appointments were prioritized and non-priority appointments that could be rescheduled were rescheduled.
Title X family planning service delivery for 2022 has slowly started to increase as clinics start to see more patients in-person. Many clinics continue to use telehealth to reach clients, especially in rural regions of the state. Providers have developed telehealth policies, conducted telehealth visits for clients that did not require a physical exam, developed ways to complete curbside visits, and extended contraception prescriptions when that was an acceptable option. These services will continue to be offered post-pandemic.
The Idaho MIECHV Program and Project Director, housed in the MCH Section, is supervised by the MCH Director. The MIECHV Program supports seven local implementing agencies (LIAs) to deliver evidence‑based home visiting services, which have been shown to promote positive parenting, alleviate poverty, and reduce rates of child abuse and neglect. Idaho MIECHV’s goals and objectives include:
- Supporting community-based organizations to implement evidence-based home visiting programs.
- Supporting and training home visiting programs in the integration of home visiting services with services aligned with Title V Maternal and Child Health (MCH) Block Grant goals including – safe sleep education, smoking cessation, breastfeeding, and Adverse Childhood Experiences.
- Supporting home visiting programs in implementing continuous quality improvement practices in their daily work.
The home visiting programs are voluntary and help families with infants and young children from pregnancy through age 5 years old. With Idaho MIECHV funding, the LIAs provide home visitation in twelve counties using two evidence-based programs: Parents as Teachers (PAT) and Nurse-Family Partnership (NFP). Service populations vary slightly between programs. For PAT, families may enroll at any point in pregnancy and children may enroll before they enter kindergarten. NFP serves first-time, low income mothers and infants during pregnancy and continuing until the child is two years old. A total of 5,066 home visits were provided by Idaho MIECHV programs during FY 2021.
Idaho MIECHV serves many women prenatally. In fact, a total of 212 pregnant women participated in home visiting services in FY 2021. Of these women, approximately 89% were covered by health insurance and 100% of women in need of prenatal care were referred to prenatal care. Approximately 49% of enrolled prenatal women breastfed their infants for at least six months, a 16% decrease from 2020 data. The MIECHV data specialist attributes the drop to an algorithm error in the NFP database and high home visitor turnover rates at the local level. The program expects the FY 2022 data to more closely mirror previous years.
COVID-19 Impact on Home Visiting
The MIECHV Program continues to see challenges persist two years into the pandemic. These include challenges such as lack of technological readiness, family disengagement, caseload maintenance, and home visitor burnout and turnover. Along with overcoming these significant challenges, MIECHV has been impressed with home visitors’ resilience and creativity during the pandemic, with a steadfast dedication to supporting families and keeping them engaged in services.
Maternal Mortality Review and Perinatal Quality Collaborative
Since 2005, Idaho’s maternal mortality rate increased from a low of 17.0 per 100,000 live births for 2008-2012 to a high of 23.8 per 100,000 live births for 2012-2016. In 2017 and 2018, the MCH Program was engaged by the Idaho Medical Association (IMA), the Idaho Perinatal Project, the Idaho chapter of the American College of Obstetricians and Gynecologists, and provider champions to discuss maternal mortality review committee legislation. MCH assisted stakeholders with outlining other states’ efforts, reviewing legislation and processes from other states, exploring possible barriers, participating in training, and creating a plan for what maternal mortality review will look like in Idaho. The MCH Program supplied the team with example legislation, provided state-level data, participated in regional ACOG webinars related to the CDC’s MMRIA data system, and shared funding opportunities related to maternal mortality review teams. During the 2019 legislative session, the IMA presented House Bill 109 which authorized the creation and implementation of a Maternal Mortality Review Committee (MMRC) for the state. The bill passed and was signed by the governor, and MMRC work is now being led by the Idaho MCH Program.
In 2019, the Maternal Mortality Review (MMR) Program developed policies and procedures based on the Review to Action resource center, created notification letters to build awareness of the presence and function of a MMRC, and established a fully functioning committee. The MMRC is comprised of 15 members from a variety of specialties and regions in the state and meets annually. The first MMRC meeting was held in March 2020 with all members in attendance and reviewed deaths from 2018. Since its first meeting the MMRC has successfully reviewed all cases for 2018, 2019, and 2020. Committee recommendations and data were presented in the Annual Idaho Maternal Mortality Reports for 2018 and 2019, with combined data in the appendices of the 2019 report. This report is provided to the legislature each year to share the MMRC’s findings and recommendations. The MMR Program also maintains a webpage on the DHW website to share contact information, resources, and reports with providers and the public.
With the MMRC established and currently operating, the MCH Program recognizes that the next step in reducing maternal mortality and morbidity is the establishment of Idaho’s Perinatal Quality Collaborative (PQC). In 2021, the MCH program manager met with other states’ PQC leaders to discuss their structure, funding sources, project selection and adoption processes, and membership. The MCH Program determined that partnering with an external entity will provide more sustainability for establishing Idaho’s first PQC. The MCH Program began the subgrant solicitation process for the Idaho PQC in February 2022. Next steps for developing the PQC are outlined in the FY 2023 application plan.
The MCH Program partners with the Idaho Tobacco Prevention and Control Program (ITPCP) to address substance abuse among MCH populations in the Women/Maternal Health domain. The ITPCP has made it a priority to reach pregnant and nursing mothers who use tobacco and encourage them to make quit attempts. Most of these efforts are focused on directing this population to the Idaho QuitLine and encouraging them to make use of barrier-free, evidence-based, no-cost cessation benefits. The Idaho QuitLine is a telephonic-based intervention that links callers interested in quitting smoking with nicotine replacement therapy (NRT), behavioral support, and counseling. The Idaho QuitLine is tracking calls for tobacco cessation counseling and referral for pregnant women and women aged 18 to 44 for ESM 14.1.1.
According to the Association of State and Territorial Health Officials (2013), offering pregnancy specific and postpartum QuitLine services to women is a recommended strategy to improve smoking cessation. In 2015, the Idaho QuitLine implemented a Pregnancy Cessation Program, which offers up to 10 calls during pregnancy and postpartum for women who want to quit smoking compared with the 5 calls for the general population. This program also provides participants with a $5 incentive card for each session they participate in before birth and $10 for each session after the baby is born. This enhanced program includes several intervention calls in the two-week period following a quit attempt, one just before the due date and two calls within two months after the baby’s delivery. These calls help the participant to develop skills to remain tobacco free and to reduce the health risks to the baby from exposure to secondhand smoke. Pregnant women may request nicotine replacement therapy (NRT), however they must obtain approval from their primary care provider. Up to 8 weeks of free NRT is offered through the Idaho QuitLine, if approved through their primary care provider. Any pregnant or new mother that expresses interest in quitting tobacco through the QuitLine is automatically referred to the 10-call Pregnancy Program. For FY 2021, data show a total of 247 women, including 27 who were pregnant or breastfeeding, aged 18 to 44 years called or completed a web intake to the Idaho QuitLine for cessation services. From April 2021 to April 2022, a total of 338 pregnant, postpartum women, or household members quit by using NRT, quit without NRT, or reduced the number of cigarettes smoked as a result of support from the QuitLine.
The MCH Program has strengthened collaboration with the ITPCP to implement a smoking cessation program tailored for pregnant and postpartum women, their partners, and households with young children (under the age of one year) in the seven public health districts and one tribal health center. This homegrown program, modeled from the evidence-based program “Baby and Me – Tobacco Free,” offers diaper incentives for pregnant women, postpartum women, and household members who quit smoking. Program participants who quit smoking during pregnancy, or up to one year after the baby is born, are eligible to receive one box of diapers per month for up to twelve months in order to promote a sustained quit.
When an individual is referred to the Diapers and Wipes Program they are also referred to Health District cessation classes and the Idaho QuitLine to receive counseling support to help them quit smoking or vaping. Once a program participant quits smoking, they are eligible to receive a box of diapers. The participants are tested for nicotine or carbon monoxide, and upon results indicating the person has quit, they receive a box of diapers. If the participant has a positive test, then they will continue to work with the Health Educator until they finally quit. Tobacco Control grant funding supports staff time to promote and implement the program while MCH funds the testing and diaper incentive. Evaluation of the expanded program tracks the percentage of pregnant women, postpartum women, or their household members who quit smoking through participation in the program (ESM 14.1.1). From April 2021 to April 2022, a total of 445 pregnant or postpartum women and their household members participated in the incentive-driven cessation program. The program supported 338 participants to successfully quit smoking or vaping as indicated by a negative test.
COVID-19 Impact on Smoking Cessation
Some of the prime participants for the Diapers and Wipes Program include those attending in-person cessation classes and people coming to the health district for Women, Infant, and Children (WIC) services. For much of the pandemic, those programs were offered virtually, impacting marketing of, and enrollment in, the program.
Due to the ongoing circumstances of the COVID-19 pandemic, and with approval from the MCH Program, the ITPCP made small modifications to the smoking cessation program on a case-by-case basis. As a result of the escalating COVID-19 cases in Idaho and the challenges associated with conducting saliva nicotine tests, ITPCP sought legal advice from the Office of the Attorney General and was able to waive the nicotine test during the COVID-19 epidemic. The priority was to keep staff, partners, and the community safe during this time.
In the absence of the saliva nicotine test, tobacco coordinators were asked to monitor and keep records on the following:
- Confirmation from the QuitLine vendor that participants were completing all coaching calls.
- Development of next steps if participants were not completing all coaching calls and when program operations should resume normal practice.
- Maintenance of brief notes on modifications due to COVID-19.
Despite the COVID-19 pandemic, Project Filter worked creatively to maintain the Diapers and Wipes Program with implementing partners. This is attributed to an ability to remain flexible, a rigorous marketing campaign including social media outlets, TV ads tailored to reach Hispanic audiences, and the gaining popularity of the program. Several of the health districts developed new materials, conducted comprehensive media and communications campaigns, and did direct mail outs, which they believed helped maintain program enrollment.
Other Activities
The Reproductive and Adolescent Health Unit, housed in the MCH Section, oversees state-mandated activities related to pregnancy education for women seeking abortion services. By Idaho law, the Idaho Department of Health and Welfare is required to develop and distribute packets of fetal development materials for women contemplating abortion which must be provided within 24 hours of the procedure. This activity was tasked to the MCH Program in 2013. The three booklets in the packet include information on fetal development, the abortion procedure and associated risks, and a directory of pregnancy and child health services. During the 2016 legislative session, the law was amended to add a list of providers that would provide a free ultrasound to a woman contemplating abortion. This list is maintained and distributed by the MCH Program. During the 2018 legislative session, the law was amended requiring that information regarding abortion reversal (for medical or chemical abortions) be included in the packet. In 2018, the MCH Program translated the packet materials into Spanish to be more accessible. The Spanish version is available in hard-copy and online. In 2021, the bill was further amended to provide information about the development of children with Down syndrome and resources available in the public and private sector to assist parents with the delivery and care of a child born with Down syndrome. Electronic copies of these booklets and lists are maintained at www.abortioninfo.dhw.idaho.gov.
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