MCH Block Grant FY20 Application & FY18 Report

Women/Maternal Health

NPM-01: Well-Woman Visit: Percent of women with a past-year preventive medical visit

FY18 Annual Report

Program Activities:

This Performance Measure was not achieved. The Performance Objective was 57.0% and the Annual Indicator was 54.7%.

During FY18, the Maternal and Infant Health Program (MIHP) utilized the social media platforms Facebook and Pinterest to share information on preventive health care visits. These messages were shared under the Power Your Life logo and branding.

Educational outreach was done through numerous community events held at the University of Utah, Utah Valley University (UVU), local Bridal Fairs, a “Girls Night Out” health fair at a hospital, and a health fair through Centro Hispano, a community organization that provides health information and services to the Hispanic population in Utah County. At these events, MIHP staff handed out informational pamphlets and brochures about preventive care as well as answering the specific questions of individuals at these events.

 

MIHP staff partnered with March of Dimes of Utah to meet with and offer resources to community health centers. MIHP staff provided the clinics with copies of the Power Your Life booklet, and the Plan your Next Pregnancy brochure. MIHP staff also worked alongside the University of Utah’s Nursing program and the Utah Veterans Health Administration to see if the One Key Question® would be practical in the community health worker community and in the University Health Clinics and VA Women’s Center. An introduction and training in English and Spanish to One Key Question® was provided to community health workers, midwives, and clinicians. An additional educational opportunity was an STI presentation to a group home for women who were homeless or worked in sex industry. MIHP continued its partnership with Westminster College to implement a Preconception Peer Education program on their campus.

Finally, MIPH staff contracted with SUMA Social Marketing, Inc. to conduct focus groups on knowledge, perceptions, beliefs, and barriers associated with the well-woman exam. Four focus groups were conducted with a diverse group of women across Utah in two urban areas (Salt Lake City and Provo) and two in rural areas (Tooele and Price). Thirty-eight women ranging in ages from 18 to 44 discussed their perceptions of the well-woman visit, barriers/motivators to care, and suggestions about material creation and dissemination. Results of these groups found that women assign different meaning and different function to the terms associated with well-women visits (i.e. “routine check-up”, “well-woman exam”, and “preventive care”). These women also had varying opinions to which type of medical provider a women goes to for each check-up. Some of the women said they received preventive care with a family practitioner, others with primary care providers, and some with OB/GYNs.

SUMA offered recommendations including: determining and using only one term when encouraging and educating women to go to an annual preventive care appointment; to detail what happens at that appointment; create a dedicated website; use social media to promote activities; educate healthcare providers on the findings of the report and encourage them to use postcards or some other method to remind women about scheduling and going to their well-woman exam; and to create separate messages for younger women who most likely have not had children and may not yet be sexually active.

Accomplishments / Successes:

A strong, mutually beneficial partnership between the MIHP and two local universities, UVU and Westminster College, have assisted us reaching young college-aged women in Utah with messages about the importance of yearly preventive care, family planning, mental health awareness, and preconception health. Westminster continues to be willing and excited to create a sustainable preconception peer education program with MIHP. UVU continually invites staff from MIHP to staff a booth at a bi-annual student health fair. At each fair, we estimate that we talk to and give educational materials about preventive health to 150-200 students per visit.

A major success during FY18 was the contract with SUMA Social Marketing, Inc. and the completion of the focus groups. With the information provided by the participants and the recommendations made by SUMA, we will be able to discuss next steps.

Summary of successes and accomplishments on “Moving the Needle” in relation to NPM-01:

• Ongoing, mutually beneficial relationships with two local universities, Westminster College and UVU, has allowed the MIHP to reach college-aged women with education and information about the importance of routine preventive care.
• Contracted with SUMA Social Marketing, Inc. to hold four focus groups with a diverse group of women to assess their knowledge, perceptions, and beliefs and barriers associated with the well-woman exam. A final report was delivered upon completion of the focus groups with recommendations for future activities.

Challenges / Gaps / Disparities:

The largest challenge faced during FY18 was determining how to use what we learned from the focus groups to create and implement evidence based programming that will result a measurable increase in women who seek out routine preventive care.

Agency Capacity / Collaboration:

Some of this work has been accomplished through the Healthy Utah Babies (HUB) partnership. HUB consists of participants representing the Birth Defects Network, WIC, MotherToBaby Utah (MTB UT), Baby Your Baby, and the Office of Vital Records.

The MTB UT program is one of our partners who has the opportunity to communicate directly with women on matters of preconception health. For example, MTB UT had a woman call their Pregnancy Risk Line concerned that she had to choose between "being sane," and being a mother because she was told that she would have to go off all her prescribed anti-anxiety medications. MTB UT reassured her that she could continue taking those medications during pregnancy and referred her to speak with her OB and psychiatrist to further talk about her concerns continuing her medications during pregnancy.

An ongoing partnership with both Westminster College and UVU will enable the MIHP to reach college-aged students with educational messages regarding routine preventive screenings and visits.

Summary Progress Report (2019) of ESMs related to NPM-01

ESM 1.1 - Formative Research: Number of focus groups conducted to understand why women are or are not receiving a yearly well-woman visit.*

*This ESM is currently inactive as the formative research has been completed during FY18.

 

ESM 1.2 - Peer preconception health: Number of institutions of higher learning partnered with to implement a peer preconception health program.

Goal/Objective:

Increase the number of institutions of higher learning partnered with MIHP.

Significance of ESM 1.2:

The Title V Maternal and Child Health Services Block Grant to States Program guidance defines the significance of this goal as follows:

A well-woman or preconception visit provides a critical opportunity to optimize the health of women before, between, and beyond potential pregnancies by receiving recommended clinical preventive services, including screening, counseling, and immunizations, which can lead to appropriate identification, treatment, and prevention of disease. For example, screening and management of chronic conditions such as diabetes and counseling to achieve a healthy weight and smoking cessation, can be advanced within a well-woman visit to promote women's health prior to and between pregnancies and improve subsequent maternal and perinatal outcomes. The annual well-woman visit has been endorsed by the American College of Obstetrics and Gynecologists (ACOG) and was identified among the women's preventive services required by the Affordable Care Act (ACA) to be covered by private insurance plans without cost sharing.

ESM 1.2 Progress Report:

During FY18 MIHP staff worked with a Public Health Master’s Student at Westminster College to create a preconception peer education training and student manual. This manual was adapted from the Office of Minority Health’s, “A Heathy Baby Begins with You” campaign.

After MIHP staff and Westminster faculty approved the content of the training and student manual, a peer education training was held in March 2018. Eleven undergraduates in public health and nursing participated in a four-hour training on what it means to be a peer educator, expectations of being part of the program, preconception health, men’s preconception health needs, contraception, and mental health. The trained peer educators were given teaching assignments for the next stage of implementation. Two weeks after the initial training, the peer educators held their first event, a class on preconception health. This class was advertised through posters placed on Westminster’s campus as well as a booth that was set up in a central location. Twenty-two students attended the class put on by the peer educators. This surpassed the goal set of fifteen attendees.

MIHP staff continued the work started by the Westminster graduate student by ongoing contact and further training opportunities with the peer educators. MIHP staff has also been working with UVU to establish a peer education program on campus. During FY19/FY20 MIHP staff will have an intern from UVU to begin work on developing a peer education program on campus. This intern will conduct research to discover the needs of the students and recruit students to participate in the program.

A continuing challenge faced by the peer education program is keeping it sustainable. We have held or attempted to hold numerous training with different cohorts of potential peer educators that seemed interested in the training and becoming a peer educator, however competition for their time and energy pulled them away. We are encouraged by the commitment to the program shown by two students at Westminster College who were trained in March 2018. They have agreed to work with MIHP staff to continue working as peer educators, create a preconception peer educator club on campus, recruit new peer educators and hold a training in FY19.
 

MCH Block Grant FY19 Application & FY17 Report

NPM-13A: Percent of women who had a preventive dental visit during pregnancy

FY18 Annual Report

Program Activities:

The Performance Measure was not achieved. The Performance Objective was 56.9% and the Annual Indicator was 53.6%.

With the continued collaboration of WIC, The Oral Health Program (OHP) worked on a pilot program in the Weber/Ogden area, as well as with Utah County WIC. The purpose of this collaboration was to collect data about whether pregnant moms were going to the dentist during their pregnancy. Two questions were posed in this pilot: 1) During the past 12 months, was there a time you needed dental care but could not get it at the time?; 2) Did you have your teeth cleaned during your most recent pregnancy? In Weber County, out of 568 individuals who participated in the pilot study, 119 respondents ‘Yes’ to the first question about needing dental care in the last year, but not being able to get it (21%). In Utah County, of the 409 respondents, 80 said that they needed dental care in the last year but were not able to get it (19%). To the second question of having a dental cleaning during their most recent pregnancy, of the 568 respondents in Weber County, 324 said that they did not have one (57%). In Utah County, 217 of the 409 respondents said they did not have a dental cleaning during their most recent pregnancy (53%). An additional activity planned for this project was OHP’s Oral Health Specialist (OHS) applied fluoride varnish during an education class with WIC clients in March. In-service education is also scheduled with Provo WIC staff in the future.

Several times a year the OHS and Oral Health Educator (OHE) continue to share oral health education that is posted on Utah WIC SharePoint for WIC staff and participants. The OHS and OHE strategically connected Granite Peaks Learning Center for ESL serving many refugees to Fortis Dental Hygiene School. Both were connected to the UDOH Office of Health Disparities and the OHP to provide partnerships that provide education and preventive care to ninety-five children and adults.

The OHS and OHE continuously worked with and managed public health interns to help augment and sustain the work that they did. They had two interns each semester.
 

In October of 2017, the OHE traveled to Southeastern Utah to meet with Family Spirit Home Visiting sites, WIC, Local Health Departments, and the Public Health Dental Hygienist and Head Start Staff in Cedar City, Kanab, Blanding, Monument Valley, Moab, and Price. The OHP provided educational materials for families in all of these locations, including the “12 Oral Health Messages” modules and magnets.

Since all of the home visitors in Monument Valley were licensed registered nurses, the OHE provided training on oral health risk assessment and proper fluoride varnish application. This increases access to preventive services, early detection, and appropriate referrals to dental teams.
The OHP continued to encourage, support, and partner in efforts with the Oral Health Coalition, the Utah Dental Association, and the Utah Dental Hygienists Association to increase the number of pregnant women who had preventive dental visits during pregnancy. Efforts were made to help encourage any general dentists who have concerns about treating pregnant women, to see these women, and provide appropriate care during pregnancy. An example would be sharing the National Maternal Child Oral Health Resource on Pregnancy and Dental Care with these associations.

In June 2018, at the Utah Dental Association annual leadership conference, the State Dental Director presented information on sealants and school-based sealant programs in general, as well as the Seal Your Smile program, which is operated by the UDOH’s Family Dental Plan Clinic program, to educate and encourage their support for these type programs. This program sees children from twelve elementary schools in the Salt Lake School District. The State Dental Director provided general supervision in accordance with Utah laws, for the OHP’s two public health dental hygienists, the OHS and the OHE. Periodically he provided on site supervision and visited some of the public health setting events during the year.

The OHP collaborated with the MotherToBaby (MTB) program in a survey regarding oral health for pregnant women. As MTB Utah was doing the dental survey, to see how many of the pregnant clients had received dental care during their pregnancy, those who said they had not, were asked why not. One woman said she "just knows" that she can't have any dental x-rays or anesthetic during pregnancy, so why bother going? MTB let her know she would not harm her baby by having regular dental care including x-rays and anesthetic, if needed, and that going without this routine care could increase the chance of miscarriage and prematurity.

Accomplishments / Successes:

Using the National Head Start Program Information Report (PIR), the OHS worked toward moving the needle on the National Performance Measures 13A & 13B with all the Head Starts’ statewide. These efforts include meeting with the State Head Start Collaborator, five individual Head Start/Early Head Start (HS/EHS) programs that had less than 50% of their participants visiting a dentist in the last year, and potential partner safety nets that can provide access to care.

The OHE presented to thirty-eight OB/GYN’s at the Utah Women and Newborns Quality Collaborative (UWNQC) meeting. Dental resources and Medicaid information was given.

The OHS provided maternal and infant oral health education, fluoride varnish, and referral resources to 150 refugees.

 

Summary of successes and accomplishments on “Moving the Needle” in relation to NPM-13A:

• The OHP graduate intern worked with the MTB Program on their oral health questions data. She also worked with WIC comparing our pilot data from Ogden and Provo WIC clinics. Using these two data sets, along with PRAMS, she assessed where the biggest needs are and barriers to care for pregnant women and dental care.
• The OHP intern presented a poster at the Utah Public Health Association (UPHA) for the MTB Program. She submitted a proposal on her research to speak at the 26th International Conference on Advanced Dental Care in Moscow. Her BYU Professor presented her report.
• The OHS provided an in-service presentation called Strategies for Promoting Oral Health for Pregnant Women, Infants, and Children to Cedar City EHS/HS staff. Also, a four minute long video segment on oral health for pregnant mothers and infants was made to share with staff.
• The OHS continued to coordinate KUTV Baby Your Baby segments with topics of oral health and pregnancy, baby bottle use, and other oral health topics.
• The OHP published and disseminated two Bi-Annual Oral Health Outreach Reports to stakeholders and other partners.
• The OHP continued using the “12 Oral Health Messages” created for pregnant mothers and children in collaborative efforts with WIC, HS, and the Home Visiting programs.

Challenges / Gaps / Disparities:

Limited funding resources and staff is a challenge as we try to reach all of the state to address social justice and health equities involving oral health. It is difficult to find programs to collaborate with that work with just pregnant women, so efforts continue with groups who have a significant number of pregnant women. It is also a challenge in some rural areas to find a dentist who accepts Medicaid to refer pregnant women for care. This is because all of the dentists in these areas who are Medicaid providers only see children. Language barriers are a problem for some pregnant women. Recent census data shows that about 120 languages are spoken in Utah, and about 14% do not speak English at home.

Many of the women we work with have so many other challenges they are facing including lack of employment, a child with other medical issues, being a single parent, language barriers, transportation barriers, etc. This makes dental care low on their list of priorities.

Agency Capacity / Collaboration:

The OHP’s OHS served on the Early Childhood Caries National Committee under the direction of the Association of State and Territorial Dental Directors (ASTDD). She also served as the Dental Hygiene Liaison for the State of Utah for HS. Efforts have been made to increase the number of pregnant women, as well as children, that see the dentist. Concentrated efforts were made with five local HS/EHS programs that had less than 50% of their pregnant women see a dentist. The State Dental Director collaborated with Medicaid in efforts to increase the percent of pregnant women who have preventive dental visits.

Summary Progress Report (2019) of ESMs related to NPM-13A

ESM 13.1 - Collaborate with Early Head Start (EHS): Percent of pregnant women who had a dental exam and/or treatment during pregnancy

Goal/Objective:

Increase the percent of EHS pregnant women who have a dental exam and/or treatment during pregnancy.

Significance of ESM 13.1:

Measures the number of pregnant women in the EHS program who had a dental exam and/or treatment during pregnancy.

ESM 13.1 Progress Report:

This ESM is expected to increase the number of pregnant women who visit the dentist during pregnancy in the EHS program. The pregnant women in the HS Program are a group where many of them do not make it to the dentist. Especially in some of the rural areas of Utah where there are access-to-care challenges. The OHP will collaborate with EHS to help these women make it to the dentist.

This year, the ESM Performance Measure was not achieved. The Performance Objective was 36.9%, and the Annual Indicator was 25.0%. The 5-Year Annual Projected Performance Objectives have been updated according to the data trend.

Other activities in the Women’s Health domain that contribute to improvement in the National Outcome Measures 

Utah works to adhere to the three-tier framework outlined in the MCH Block Grant guidance. While the focus of most activities is the ESM →NPM→ NOM framework, activities on improving NOMs outside of the NPMs transpires in parallel. The following programmatic activities also work to improve outcomes in this domain. 

National Outcome Measures (NOM)

NOM 1: Percent of pregnant women who receive prenatal care beginning in the first trimester

The Baby Your Baby program works to get women into early prenatal care by offering temporary Medicaid coverage to women while they wait for Medicaid approval. Additionally the Baby Your Baby program runs a media campaign to encourage women to begin prenatal care in the first trimester.

During Fiscal Year 2018, MotherToBaby Utah provided 17,313 English and 1,526 Spanish Pregnancy Risk Line/MotherToBaby Utah brochures and 2,557 MotherToBaby English/Spanish Rack Cards to providers and women. MotherToBaby Utah provided education to 1,167 clients (including through their partners and relatives), 1,076 referred by their healthcare providers, pharmacists, genetic counselors, dermatologists, dentists, WIC, health insurance companies, Planned Parenthood, or other health-related providers, about receiving care during the first trimester. MotherToBaby Utah is Utah’s regional teratogen information service designated and supported, in part, by the Maternal and Child Environmental Health Network Cooperative Agreement from the Maternal and Child Health Bureau, Health Resources and Services Administration. 

NOM 2: Rate of severe maternal morbidity per 10,000 delivery hospitalizations

Utah continues to participate in the Alliance for Innovation on Maternal Health. To date, participating hospitals have implemented components of the obstetric hemorrhage and hypertension safety bundles. We continue our partnership with Wyoming joined the collaborative work and participate in learning sessions through the Project ECHO (Extension for Community Health Outcomes) telehealth system. We are now working to increase the number of facilities submitting process measures to the data portal on a quarterly basis. Work will begin in the fall of 2018 on the Obstetric Care for Women with Opioid Use Disorder bundle. Utah was invited to the Maternal Mortality meeting at the national ACOG conference to present on the use of Project ECHO to reach rural hospitals and has been invited to do a joint presentation with New Mexico on Project ECHO at the AIM national meeting in July.  

In Fiscal Year 2018, MotherToBaby Utah provided education to women, their providers, their partners, and other clients regarding the benefits and risks of medications compared to the untreated chronic and acute conditions in an effort to help women remain healthy and avoid unnecessary acute episodes or hospitalizations due to questions about continuing medication treatments.

The Violence and Injury Prevention Program (VIPP) works with the Domestic Violence Action Council to implement strategies to prevent domestic violence fatalities. 

NOM 3 - Maternal mortality rate per 100.000 live births

Utah has an established maternal mortality review (MMR) committee and all maternal deaths are brought to the committee for evaluation. Utah began entering all case information from 2015 forward into the national MMRIA data system (Maternal Mortality Review Information Application). Utah contributed maternal death data to the CDC and it was included in the 13 state MMWR report on maternal deaths. Utah was invited to present on our work related to mental health on the CDC Vital Signs Town Hall on maternal mortality. 

Utah’s MMR committee developed standard criteria to determine if maternal deaths due to suicide and accidental overdose were pregnancy related. Dr. Metz and Dr. Smid, members of Utah’s MMR who developed the criteria, made a presentation on the criteria at the MMRIA Users Meeting in June.

In 2019, Utah began collaboration with the CDC Foundation to contribute to enhanced surveillance and understanding around opioid related maternal deaths. Utah will be providing data on maternal opioid related deaths and working to improve data collection related to these deaths. In 2019, Dr. Marcela Smid published a study using Utah MMR data titled “Pregnancy-Associated Death in Utah, Contribution of Drug-Induced Deaths”. The study generated a great deal of press coverage in Utah.

In May 2019, Utah submitted an application for the CDC Maternal Mortality grant opportunity. In our application, Utah proposed to become the MMR committee for the state of Wyoming. Regardless of funding, Utah and Wyoming will work towards implementing this process in 2019, building on our cross-state collaboration on maternal safety bundles.

The MMR data continues to inform the work of the Utah Women and Newborns Quality Collaborative (UWNQC) safety bundle workgroup (AIM). The goal of the AIM project is to reduce maternal deaths and severe maternal morbidity, so the actions described above contribute to mortality prevention as well.

VIPP works with the Domestic Violence Action Council to implement strategies to prevent domestic violence fatalities. The program also works to prevent excessive alcohol and opioid use and runs a suicide prevention program.

NOM 29 - Percent of women who experience postpartum depressive symptoms following a recent live birth

There continues to be a focused effort in this area. The Policy group of Postpartum Support International Utah, a stakeholder group co-chaired by Utah's MCH Director, built on the momentum from last year’s concurrent resolution on maternal mental health and successfully lobbied for three years of funding for maternal mental health efforts in Utah. The appropriations amount of $220,000 will allow the Maternal and Infant Health Program to keep the new Maternal Mental Health Specialist position as well as fund development of a resource and referral website for the public and providers and support other perinatal mental health projects. Events to support this effort this past year included: putting on a Perinatal Mood and Anxiety Disorders Conference Training 170 providers, getting February designated as Utah's Maternal Mental Health Awareness Month through the Governor's office, and including a Film Circuit in the State (over 100 members of the public attended), and coordinating a Climb Out of the Darkness Event in three Utah cities for survivor moms, families, and clinicians to attend.

The maternal mental health sub-committee of the UWNQC worked to develop screening and referral protocols for clinicians. The committee will begin pilot testing of the algorithms in 2019. 

In 2018, the MIHP supported a public health student from the University of Arizona. The student, who was a practicing Ob/Gyn, implemented a series of focus groups and surveys among Utah’s refugee populations to assess the mental health concerns among women of reproductive age. Findings of her study were that refugee women did not seek out mental health services for the following reasons: 

When asked for recommendations to improve services/resources for mental health among refugee women, they noted better translators, better access, better cultural competency, a better network among organizations that serve the refugee community, and more education about mental health in the refugee community. The women also noted that while telehealth and the internet were good ideas, many in their community needed more education on how to use the technology. The study findings will be incorporated into the 2020 MCH Needs Assessment.

During FY18 4,805 English and 962 Spanish Postpartum Depression brochures were distributed to families and providers to help screen for depression and identify local resources. During FY18 MotherToBaby Utah provided education to clients and their providers about medications regarding the treatment of postpartum depression including the risk of untreated postpartum depression.

Other activities of note in the Maternal Health Domain:

The Utah Birth Defect Network (UBDN) provides health education to the community on birth defect prevention, preconception health, Zika Virus, and other health topics. For the period (7/1/2018 to 6/30/2019), the UBDN had 77 events, reached potentially 51,939 people, and distributed 5,021 bottles of prenatal vitamins and 2,745 Power Your Life bags. The UBDN also distributed 2,828 pens with 6 rotating messages, 5 of which are directly related to the MCH block grant. Those messages include ‘Take 400mcg of folic acid everyday’ ‘Birth Defects: Common, Costly, Critical’, ‘Mental Health Matters - Ask for Help!’, ‘Pregnant? Schedule a dental appt’, and ‘Schedule your yearly well-woman visit’.   The health education efforts conducted through UBDN promote preconception and interconception health for women of reproductive age, which has been recommended to reduce risk of negative maternal and pregnancy outcomes.