Ongoing Needs Assessment Activities
Planning for the 2021-2025 Maternal and Child Health (MCH) Needs Assessment began in 2018 with the development of a project charter (Appendix A). The first MCH Needs Assessment Steering Committee meeting occurred in May 2019. The project charter was approved during this meeting. In June 2019, the MCH Unit hosted a needs assessment launch webinar.
The image below shows the process of selecting priorities beginning with selecting national outcome measures and moving backwards along a logic model continuum.
A stakeholder survey released in early 2019 asked about stakeholder needs assessment requirements. Forty-seven percent of respondents (n=24) responded that their organization had needs assessment requirements. The MCH Unit helped establish a crosswalk of needs assessment requirements including but not limited to Title V, Maternal, Infant, and Early Childhood Home Visiting (MIECHV), Mental Health and Substance Abuse Block Grant, State Primary Care Office, Child Abuse Prevention and Treatment Act (CAPTA), Head Start community-wide needs assessments, State Health Assessment, hospital community health needs assessments, etc.
The MCH Unit and MCH Epidemiology Program routinely review available performance and outcome measure data to inform programmatic decisions. Ongoing surveillance is being developed for key MCH indicators using Tableau software. Stakeholder/consumer input is important and efforts are underway to develop a youth council and parent advisory council, both of which will be useful for ongoing needs assessment.
MCH Population Needs
Women’s/Maternal
Pregnancy Risk Assessment Monitoring System (PRAMS) data indicate a continued reduction in maternal smoking. In 2017, 10% of new mothers reported smoking during the last three months of pregnancy as compared to 15.9% in 2012. This difference is not statistically significant. Despite the reduction in smoking during pregnancy, Wyoming’s rates of maternal smoking are persistently higher than the U.S. rate. Disparities in maternal smoking exist by maternal race, education, and income.
Preconception health of Wyoming women is of concern for Wyoming women and their infants. Data from the Behavioral Risk Factor Surveillance System (BRFSS) (2016) indicate that less than half (46.0%) of women of reproductive age (18-44 years) had a healthy Body Mass Index (BMI). Data from PRAMS indicate that hypertensive disorders are also of concern for Wyoming mothers. PRAMS data (2016-2017) revealed that 5.9% of respondents were diagnosed with high blood pressure or hypertension before their most recent pregnancy. When hypertension during pregnancy was examined, 11.2% of Wyoming women reported this condition. Several PRAMS respondents commented on the barriers to high-risk maternal care in their community.
In 2015, Wyoming’s severe maternal morbidity rate (108/10,000 delivery hospitalizations) was lower than the U.S. rate (144/10,000 delivery hospitalizations). Comparisons since the implementation of ICD10 are not possible. The most common severe maternal morbidity is transfusion, followed by eclampsia.
Emerging Issue - Maternal Mortality
Due to small numbers it is difficult to monitor trends in Wyoming’s maternal mortality rate; however aggregated data suggests that the Wyoming maternal mortality rate from 2013-2017 is similar to the national rate. An analysis of Wyoming pregnancy-associated deaths from 2013-2015 vital records mortality files indicates 58% of the deaths were classified as accidental with half due to overdose and half due to motor vehicle crashes. Suicide accounted for 16% of the pregnancy-associated deaths during that time. Planned development of a joint UT-WY Maternal Mortality Review will improve understanding of these causes of maternal deaths. The MCH Epidemiology Assignee is working to evaluate the pregnancy checkbox on the death certificate and participating with a CDC workgroup for maternal mortality case finding. These activities will lead to improved surveillance of maternal mortality in Wyoming.
Wyoming PRAMS data are used to track changes in the use of contraception after delivery. In 2017, 43.2% of Wyoming women reported that they use the most effective contraceptive method, which include both permanent methods such as vasectomy or tubal ligation, and highly effective reversible methods such as implants or intrauterine devices. The proportion of women who report using the most effective method increased over 2016 levels (34.6%), although the difference was not statistically significant. Another quarter (26.5%) reported the use of moderately effective birth control including birth control pills, injectables, and the patch, ring, or diaphragm.
The use of long acting reversible contraception (LARC) in 2017 was 21.9%. This total was not statistically different than use reported in 2016 (15.8%).
Emerging Issue - Maternal Mental Health and Substance Abuse
As with other states, opioid use in pregnant women and neonatal abstinence syndrome (NAS) are emerging concerns in Wyoming. Although NAS rates have been increasing, the NAS rates and numbers are relatively low, especially compared to U.S. rates and rates in states ravaged by the opioid epidemic. Wyoming PRAMS recently added fifteen questions about opioid use before and during pregnancy to better track this emerging issue.
Postpartum depression is similar to the U.S. at 12.7% of new moms reporting postpartum depression in 2017 (PRAMS data). Suicide and drug overdoses are a leading cause of maternal mortality in Wyoming.
Perinatal/Infant
Infant mortality in Wyoming was 4.9 deaths per 1,000 live births during the period of 2014 - 2018, slightly lower than the U.S. rate. Despite the overall lower rate, disparities by maternal educational attainment and race persist. Neonatal mortality (death within the first 28 days of life) accounted for 63% of Wyoming infant deaths in 2017. As noted above, preconception health is one contributing factor to infant mortality in Wyoming. Wyoming infant mortality data indicate an increase in the rate of sleep related sudden unexpected infant (SUID) death in 2016-2017. PRAMS data from 2017 indicate that 77% of infants always or often sleep alone in a crib and 86% of infants are put to sleep on their backs.
Wyoming’s 2017 preterm birth (<37 weeks) and low birth weight (LBW) rates have not significantly changed since 2009, and in 2017 were 8.9% and 8.7%, respectfully Both are similar to the national rate. LBW rates are highest among women over 35 years old, in non-metro areas, and who are uninsured. Preterm rates are highest among women with less than a high school education, over 35 years old, and who are Native American.
Child
Unintentional injury remains the leading cause of death for children 1-11 years in Wyoming and rates are significantly higher than the U.S. rates. Because of Wyoming’s small population and small number of childhood deaths, data on childhood injury outside of fatalities is vital to informing programmatic efforts. We rely on state hospitalization and outpatient discharge data for non-fatal injury information. There are challenges in collecting accurate and consistent non-fatal injury data. In addition, the switch from ICD-9-CM to ICD-10-CM in Wyoming hospitals led to difficulty in classifying injury hospitalizations. MCH Epidemiology is working with a subcontractor to survey hospitals to understand how the change from ICD-9-CM to ICD-10-CM impacts surveillance efforts, and to work to improve data quality for injury surveillance efforts.
Twenty seven percent of Wyoming children (6-11 years) were active for 60 minutes every day, similar to the U.S. rate (NSCH, 2016-2017). Due to small numbers, Wyoming was unable to observe any disparities in physical activity based on sex, special health care needs, race, ethnicity, or income.
Only 31.7% of Wyoming parents reported that they completed a developmental screen for their child (9-35 months old) in the last year (NSCH, 2016/2017). This low screening rate and the rate of Early and Periodic Screening, Diagnosis and Treatment (EPSDT) screening in Wyoming (41.4% of 1-14 years old eligible in FY18 received a screen) are concerning.
Adolescent
As seen nationally, the Wyoming teen birth rate continues to steadily decline. However, the Wyoming teen birth rate (24.6 births per 1,000 women aged 15-19, 2017) remains higher than the national rate (18.8 births per 1,000). In addition to an overall decline in Wyoming teen birth rates, racial disparities in Wyoming teen birth rates have also decreased. In 2007, Native American and Hispanic teen birth rates were three and two times higher compared with the White rate. In 2017, the Native American birth rate (44.2 births per 1,000) was just over twice as high as the White rate (19.8 births per 1,000) while the Hispanic rate has declined to 31.5 births per 1,000.
The Wyoming adolescent suicide rate of 31.1 deaths per 100,000 during 2015 - 2017 (15-19 years old) is more than two times the national rate (10.5 per 100,000) and has increased slightly since 2012. Additionally, Wyoming has a high rate of motor vehicle crash fatalities among teens. Other risky behaviors among teens have remained fairly constant over the last eight years, including reports of bullying (70% reported no bullying in 2016, 68% in 2018) and marijuana use; in both 2014 and 2016, about 78% of youth report zero occasions of lifetime use and in 2018, 77.5% reported zero occasions of lifetime use. We have seen an increase in teens that have never used cigarettes; up from 73% in 2012 to 79% in 2018 (Wyoming Prevention Needs Assessment).
The last available year for Wyoming Youth Risk Behavior Surveillance System (YRBSS) in Wyoming is 2015 as the state has not applied for the grant. As a result infrastructure and capacity for data surveillance among the adolescent population remains low. Wyoming has worked to identify data sources and systems that will fill the gaps in monitoring the health and wellness of the adolescent population left after the loss of this data source.
Children with Special Health Care Needs
Wyoming Children with Special Health Care Needs (CSHCN) continue to experience disparities in overall health and access to necessary services. Based on data from the NSCH, only 17.9% of Wyoming adolescents with special health care needs received the necessary services to transition to adult health care, which is similar to the National number of 17%. Less than 12% of Wyoming CSHCN received care in a well-functioning system compared to 14.8% of all CSHCN nationally.
Crosscutting
Insurance Coverage
Wyoming’s premiums are the highest in the nation according to an Urban Institute report from the Robert Wood Johnson Foundation on Premium increases. Some premiums in Wyoming increased by more than 70% between 2017 and 2018. The 2017 American Community Survey data reports that 9.9% of Wyoming children are uninsured, as compared to 4.8% of U.S. children. Proportions are higher for children with a reported disability (defined as activity limitations) at 11.2%; for those who do not speak English (18.5%); and for children who are non-Hispanic American Indian/Alaskan Native (32.5%).
Title V Program Capacity Updates
In FFY18, the MCH Unit filled 3 vacancies including two program managers and an administrative assistant. As of June 15, 2019, the MCH Unit has two additional vacancies. A new Women and Infant Health Program Manager (WIHPM) will start August 1st and MCH leadership is in the process of redesigning the MCH administrative assistant position to provide additional Title V grant coordination support.
Currently, MCH does not have a family/parent representative on staff. However, a statewide youth council is in development.
Title V Partnerships and Collaborations Updates
In an effort to better support MCH collaborations, the Wyoming MCH Unit Collaboration Survey launched in early 2018. Through this survey, staff hoped to learn how to improve partnership activities like communication, and understand our current level of stakeholder partnership. Sixty-six (66) individuals completed the survey, representing a 63% response rate. A summary of the comments received through the MCH Collaboration Survey is attached as Appendix B.
Other MCH Bureau investments
Two graduate student interns joined the MCH team in May/June 2018 as part of the MCH Workforce Development Center’s MCH Title V Summer Internship Program. The student interns worked with MCH, Medicaid and other key stakeholders to develop a plan to implement Bright Futures, 4th Edition as part of a broader cross-division goal of improving statewide EPSDT rates. See Appendix C.
MCH continues to partner with Parents as Teachers National Center (PATNC), the Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) grantee in Wyoming, to build and support a network of home visiting organizations. In FFY18, the MCH Unit and PATNC met several times to discuss development of a Memorandum of Understanding (MOU) between organizations and coordination of the MIECHV and Title V needs assessments. A MOU will be established in 2019. To assure coordination of needs assessment activities, the MCH Unit Manager sits on the MIECHV Needs Assessment Steering Committee and the Wyoming MIECHV Director sits on the Title V/MCH Needs Assessment Steering Committee.
Other Federal investments
MCH continues to partner with Wyoming’s Title X grantee, WHC, to ensure optimal coordination of activities related to family planning. A new WHC Executive Director began in June 2019 and monthly Title V/Title X partnership meetings are scheduled to continue to maintain and strengthen partnerships.
Other HRSA programs
The Wyoming Primary Care Association (WYPCA) is a key partner in MCH priority activities. Specifically in FFY18, the WYPCA supported promotion of adolescent well visits through participation in the AYAH CoIIN project. Currently (FFY19), WYPCA provides leadership and support to identify and respond to challenges related to reimbursement for LARCs in rural health clinics, federally qualified health centers, HIS clinics, and hospitals.
The Genetics Clinics offered through Title V works closely with the Mountain States Regional Genetics Collaborative, funded through HRSA’s Genetics Services Branch, to improve services to Wyoming patients requiring genetics care.
Tribes
MCH tribal nurses serving both the Northern Arapaho and Eastern Shoshone tribes offer gap-filling financial assistance and care coordination services as part of the CSH Program. CSH Benefits and Eligibility Specialists provide training and support to the nurses to improve and sustain programming.
The Wyoming PRAMS project continues to sample all births to Native American women. Wyoming PRAMS staff attend tribal health fairs and work with leadership of the tribal health programs to provide data for review and use in tribal programs.
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