Good health care for a woman considers the different stages of the woman's life, from adolescence to old age. It means caring for all her needs, throughout her life course. For too many years, women’s health care meant little more than maternal health services, such as care during pregnancy and birth. These services are necessary, but they only address motherhood, a fraction of a woman's health needs.
Women’s health needs include the well-being of a woman's body, mind, and spirit. A woman's health is affected not just by the way her body is made, but by the social, cultural, and economic conditions in which she lives.
Improving women's health means addressing the "root causes" of ill health, including poverty, gender and racial inequality, and other forms of oppression. While men's health is also affected by these factors, women as a group are treated differently than men. Women usually have less power and lower status in the family and community. This basic inequality means:
- More women than men suffer from lack of access to resources like money, food, land, and mobility.
- More women than men are denied the education and skills to support and protect themselves.
- More women than men lack access to important health information and services.
- More women than men lack power and control over their lives and basic health care decisions.
- Poor women, women with darker skin, migrant women, and women from ethnic minority groups experience even more challenges than other women.
This larger view helps us to understand and work to change the underlying root causes, the many factors that influence and affect women’s health. These may not be visible, but they are important to promoting life and well-being.
Using this approach in a broader, more inclusive, and more realistic way to impact women's health and the health of the entire community, the Department has reassessed, updated, and realigned the strategies and objectives to address the state priority to improve access to health care for women to improve preconception and interconception health, specifically women who face significant barriers to better health. The national performance measure selected for this priority is NPM 1: Percent of women with a past year preventive medical visit. The realignment incorporates the Department’s State Health Improvement Plan and the Agency Strategic Plan with the MCH Block Grant strategies and objectives, providing a universal approach to addressing women’s health across the lifespan.
We have known for years that behaviors established during childhood are critical for lifelong health. Many chronic diseases are established much earlier than previously thought. For example, obese children age 5-8 already have an average of two or more cardiovascular disease markers, such as high blood pressure or high cholesterol. In addition to early disease processes, obesity predisposes children to the most severe forms of obesity in adulthood. Nearly 40 percent of obese children become morbidly obese as adults.
As women move from childhood into early adulthood, too many women of childbearing age already suffer from chronic conditions or use substances that can adversely affect pregnancy outcomes, leading to miscarriage, infant death, birth defects, or other complications for mothers and infants. According to the 2015 Pregnancy Risk Assessment Monitoring System (PRAMS), among women age 14148 who recently gave birth in Florida, approximately nine percent had asthma, five percent had hypertension, two percent had diabetes, seven percent had depression, 47 percent were overweight or obese, six percent were underweight, and 10 percent smoked before becoming pregnant.
The need to intervene early in the lives of women, for their own health and that of their babies, can best be met through the joint efforts of maternal and child health, chronic disease prevention, communicable disease, and environmental health. Working across the lifespan no longer receives the occasional puzzled look over why reproductive health work crosses with topics such as tobacco control, diabetes, cancer, and nutrition.
Today, the logic is clear. Issues of maternal and child health are recognized as being inextricably linked to the prevention and control of chronic disease. At the most basic level, the link is forged during pregnancy and the postpartum period, when health care providers can screen and treat mothers for chronic diseases, such as diabetes, and to counsel mothers on associated risk factors, such as poor nutrition and smoking. However, the links extend well beyond these obvious connections. On the one hand, the work brings heightened awareness to the importance of early intervention and its implications for lifelong health. On the other hand, expertise from diverse fields, such as tobacco control, nutrition, and diabetes, is needed to adequately address the issues of maternal, infant, and family health.
The plan for the coming year will incorporate the realignment of strategies and objectives to better address and impact the state’s progress in achieving its established performance measure targets and programmatic impacts. What follows is a summary of the past year’s programmatic activities.
The Department’s MCH Section provides oversight of the maternal and child health system of care, Florida’s Healthy Start Program, and the oversight and monitoring of the state’s Healthy Start Coalitions. Healthy Start services are available to pregnant women, infants, and children up to age three based on risks and availability of services. Healthy Start services are also available to women between pregnancies who are at-risk for a subsequent poor pregnancy outcome.
Services include:
- Universal prenatal and infant risk screening
- Interconception education and counseling
- Breastfeeding education and support
- Care coordination
- Childbirth education
- Smoking cessation
- Health and parenting education for at-risk women and their children up to age three
- Education, counseling, and referrals for access to care
- Nutrition counseling
The MCH Section continued to adopt, implement, and integrate evidence-based practices into the Healthy Start program to address issues that affect the health of women and infants. The Healthy Start program uses the Department’s Health Management System and the Coalition’s Well Family System to enable the program to track the type and number of services provided to a participant for data collection purposes.
The Department uses Title V funding to provide interconception care (ICC), which is not reimbursable by Medicaid, through the Healthy Start program. The ICC services are provided to all women who participate in the program.
During the prenatal participant’s third trimester, one key question will be asked, “Would you like to become pregnant in the next year?” Based on her response, the participant will complete either the Show Your Love Baby-to-Be plan, or the Show Your Love Healthy Woman plan. The goals she sets in her reproductive life plan will be the guiding factor for the curricular education provided during face-to-face visits.
Since the Department incorporated a Coordinated Intake and Referral (CI&R) system, known as CONNECT, in 2018, ongoing technical assistance meetings have occurred to improve the process. CI&R occurs as part of the Healthy Start Program and all of Florida’s Prenatal Risk Screens and Infant Risk Screens are sent to CONNECT. The Department engages in a continuous quality improvement cycle with stakeholders examine what is going well and what needs improvement.
Title V funding was provided through Schedule C and a Statement of Work to all of 67 county health departments to provide well-woman preventative health visits; prenatal care; education for chronic disease management and prevention for pregnant women; preconception health counseling; reproductive health services; dental care services for pregnant women and children with an emphasis on children up to age six; and activities that promote access to care, health literacy, community engagement and/or establishment of policies that positively influence social and economic conditions to address the social determinants of health.
By February 2019, 83 percent of participating hospitals added LARC devices to their hospital formularies. The initiative ended in March 2019, with a total of 221 IUDs and 361 implants placed by participating hospitals. FPQC continued to work with hospitals and AHCA after the end of the initiative to resolve any billing and reimbursement issues. FPQC also collaborated with ACOG’s PCAI to discuss ongoing support for project expansion and sustainability after the LARC initiative ended.
The Department’s MCH Section contracts with the Florida Pregnancy Care Network to implement the Department’s Florida Pregnancy Support Services Program. The program is a network of nonprofit pregnancy support centers that provide support and assistance to women, men, and their families faced with difficult pregnancy decisions. Services include free pregnancy tests, peer counseling, and referrals; and most of the centers offer classes on pregnancy, childbirth, parenting, and personal finance management. Funding is provided through the General Appropriations Act through proviso language for Crisis Pregnancy Centers. Over the years, wellness services have been added to the list of services provided to include, but not limited to, smoking cessation counseling, sexually transmitted disease testing, blood pressure screenings, diabetes screenings and pap smears.
This program receives a total of $4,000,000 annually. The Department’s MCH Section promotes the availability of the services to the Florida Association of Healthy Start Coalitions and to the county health departments as a referral source. For state fiscal year 2019, the FPSSP served 41,732 women providing 134,886 services.
Reduction of maternal death is a national and state priority. Florida’s Pregnancy-Associated Mortality Review (PAMR) is an ongoing system of surveillance that collects and analyzes information related to maternal deaths to promote system improvements through evidence-based actions aimed at preventing future untimely deaths. Florida’s PAMR team is a public-private partnership. Actions of the team include reports covering multiple years of review, which are beneficial for evaluating trends and proposing recommendations for change. In addition to monitoring annual data and trends, select topics are chosen for further analysis to obtain a more complete understanding of an issue or condition and promote the development of targeted actions that may prevent future deaths. The FPQC is one method that is used for moving recommendations to action through quality improvement projects. The Department uses Title V funding for four regional part-time nurse abstractors, an epidemiology staff for data analysis, and additional staff as needed to support the statewide volunteer PAMR team.
A recurring recommendation from the PAMR team is to stress the importance of a woman receiving education on preconception health and the need to have a medical home to manage chronic disease processes including maintaining optimal weight. An increasing number of maternal deaths are due to substance use disorder and mental health conditions. Florida’s PAMR data also notes that non-Hispanic black women are significantly more likely to die from pregnancy complications compared to non-Hispanic white and Hispanic women. Between 2008 and 2018, the pregnancy-related mortality ratio for non-Hispanic black women was significantly higher than for non-Hispanic white and Hispanic women. However, the gap between non-Hispanic black and non-Hispanic white has decreased from 8.7 in 2008 to 2.5 in 2018. In response to issues determined by PAMR, the MCH Section collaborated with the Bureau of Chronic Disease prevention to analyze severe maternal morbidity data that will enable the Department to identify strategies to enhance preventative services for women of reproductive age.
A PAMR Action Subcommittee was formed to develop Urgent Maternal Mortality Messages, guided by the professional recommendations of the PAMR Committee which support initiatives related to preventing maternal deaths in Florida. These messages for providers contain information on risk assessment, counseling, and treatment from preconception through the postpartum and interconception period. Distribution of the messages is accomplished through Florida professional organizations such as ACOG, District XII; American College of Nurse Midwives; FPQC; and others. The messages distributed to providers are on the topics of hemorrhage-placental disorders, peripartum cardiomyopathy, maternal early warning systems and opioid use during pregnancy.
- Collaboration Between Maternal and Child Health and Chronic Disease Epidemiologists to Identify Strategies to Reduce Hypertension-Related Severe Maternal Morbidity. Public Health Research, Practice, and Policy. Volume 16 E162, December 2019.
- Florida’s Pregnancy-Associated Mortality Review 2018 update
- Urgent Maternal Mortality Message (Maternal Early Warning System)
- Urgent Maternal Mortality Message (Peripartum Cardiomyopathy)
- Urgent Maternal Mortality Message (Placental Disorders-Hemorrhage)
The Smoking Cessation Reduction in Pregnancy Treatment (SCRIPT) curriculum, an evidence-based program for smoking cessation, has been incorporated in the Healthy Start program and coding specifications for smoking cessation have been revised to measure SCRIPT implementation. From the time SCRIPT was adopted as the tobacco cessation counseling intervention, provider training has been revised based on feedback from staff.
An emerging issue is the opioid crises. MCH Section staff are participating as team members for the Policy Academy on Pregnant Women with Opioid Use Disorders in Depth Technical Assistance project with the National Center for Substance Abuse and Child Welfare. Florida’s Department of Children and Families (DCF) serves as the lead agency, as they are the recipient of the Substance Abuse and Mental Health Services Administration (SAMHSA) grant. The goals are to:
Ensure any pregnant woman in a substance use disorder (SUD) program during their pregnancy will be care coordinated in a system of care by a maternal-child home visiting program and by DCF Child Welfare, and will enter the hospital with an initial plan of safe care. These actions will be coordinated with the hospital and Medicaid Managed Care plans as appropriate.
- Ensure any mother in SUD treatment with an infant (under the age of 1) has a plan of safe care and is working the plan including referrals to early intervention.
- Ensure women who give birth to infants who are identified as substance affected, have entry to behavioral health treatment and services and are coordinated with a maternal-child home visiting program, Medicaid Managed Care plans and/or Child Welfare as appropriate.
- Ensure treatment components of the plan of safe care for women entering behavioral health treatment after giving birth to a substance affected infant are implemented and coordinated with a maternal-child home visiting program, Medicaid Managed Care plans and/or Child Welfare as appropriate.
These goals will not only help improve Florida’s maternal and infant birth outcomes, but also aid in the state’s response to the opioid crises.
Deaths related to substance use accounted for 29.1 percent of all pregnancy-associated deaths in 2018 in Florida, a decrease from 36.0 percent in 2017. Although substance overdose deaths are not typically categorized as pregnancy-related, the PAMR team deemed it necessary to start reviewing and analyzing some of the cases where the death occurs during pregnancy and involves substance abuse. Reviewing these cases allows the PAMR case review team to make recommendations, such as the need for community services and treatment facilities for pregnant women with substance use or abuse problems. A PAMR subcommittee was formed to discuss the relation between substance abuse and mental health, as well as the need to include a mental health discipline on the PAMR case review team.
Florida’s Department of Health, AHCA, and the Department of Children and Families joined the Opioid use disorder, Maternal outcomes, Neonatal abstinence syndrome Initiative (OMNI) Learning Community to learn how other states are engaged in a variety of policies and strategies aimed at addressing opioid use disorder. This learning collaborative is being facilitated by the Association of State and Territorial Health Officers (ASTHO).
In addition to contracting with the state Healthy Start Coalitions, the MCH Section provided oversight and monitoring of the following contracts to address maternal and women’s health priorities:
- Contracts with 11 Fetal Infant Mortality Review (FIMR) projects through Healthy Start Coalitions to provide for the implementation of FIMR services to address the behavioral, environmental, and structural processes that may impact fetal and infant deaths, to learn more about why infants die and to propose recommendations for change. These contracts are funded with Title V.
- Contract with the Family Health Line to provide counseling, information, and referrals related to women, pregnant women, and child health issues for all callers in Florida through a toll-free hotline. Services will be consistent with the individual needs of each caller. This contract is funded through Title V.
- Contract with the Ounce of Prevention Fund of Florida to identify, fund, and evaluate innovative prevention programs for at-risk children and families and to raise awareness of maternal and child health initiatives such as Text4baby, safe sleep, and Reach Out and Read campaigns throughout the state, with a focus on television and radio advertisements. This contract was funded through general revenue.
- Contract with the Florida Pregnancy Care Network to establish, implement, and monitor a comprehensive system of care through subcontracts that provide pregnancy support services that solely promote and encourage childbirth to women who suspect or are experiencing unplanned pregnancies. Services will include employability skill training to clients through the Win at Work program, a program that addresses work equity. This contract was funded through general revenue.
- Contract with the FPQC to engage perinatal stakeholders to improve maternal and infant health outcomes through design, implementation, and evaluation of processes, and to enhance quality improvement efforts. This contract was funded through Title V.
- Promoting tobacco cessation to reduce adverse birth outcomes and secondhand smoke exposure to children is the second priority that falls within the Women’s Health Domain. We selected NPM 14.1 percent of women who smoke during pregnancy to address this priority.
In Florida, 11.9 percent of women reported smoking in 2018 (BRFSS). Smoking during pregnancy increases the risk of miscarriage and certain birth defects such as cleft lip or cleft palate. It can also cause premature birth and low birth weight and is a risk factor for SIDS. Secondhand smoke exposure doubles an infant’s risk of SIDS and increases a child’s risk of respiratory infections and common ear infections. Children with asthma who are exposed to secondhand smoke are likely to experience more frequent and more severe attacks, which can put their lives in danger.
The MCH Section continues to collaborate with the Bureau of Tobacco Free Florida (BTFF) on the promotion of program services to reduce tobacco use. To advertise the website, the BTFF Media Agency Team uses a mix of digital advertising platforms and social media in addition to traditional broadcast advertising. These digital advertising platforms in 2019 included Google Search Ads, YouTube, Facebook, Twitter, and more, with a spend of $1,194,000. The BTFF Media Agency Team also operated social media communities on Facebook, Instagram, and Twitter. Ads and social media posts in 2019 included videos, images, and messages describing the dangers of smoking and encouraging users to quit.
On Facebook, the BTFF had 119 posts resulting in 404,807 organic impressions and 4,284 engaged users. On Instagram, the BTFF had 51 posts resulting in 19,085 impressions and 326 engagements. There were 657 tweets on Twitter resulting in 722,172 impressions and 9,490 engagements. More than four in five adult smokers in Florida recalled seeing one or more campaign advertisements in 2019. Awareness levels for the campaign exceed the guidelines for exposure for effective media campaigns. The specific advertisements originally created for CDC’s Tips From Former Smokers campaign and aired in Florida as part of the Tobacco Free Florida campaign were most widely recognized among Florida smokers.
The Florida Association of Healthy Start Coalitions continued to promote SCRIPT as the primary smoking cessation program for pregnant women in Florida. Program specific revisions that increased the emphasis on practical application knowledge and skills in tobacco cessation and in using the curriculum with clients were implemented to the train-the-trainer guidelines. As a result, 82 percent of survey respondents indicated they now know enough about the SCRIPT curriculum to feel confident in supporting families with smoking cessation. Family Health Line staff have been trained on the SCRIPT program to increase referrals to Florida’s Healthy Start Program and SCRIPT.
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