Five-Year Needs Assessment Update

Ongoing Needs Assessment Activities

Developments with the Missouri Pregnancy Risk Assessment Monitoring Surveillance System (PRAMS), Missouri Behavioral Risk Factor Surveillance Survey (BRFSS), and the Missouri Pregnancy Associated Mortality Review (PAMR) are significant components of ongoing MCH data collection and analyses. Missouri is also amongst a group of states participating in efforts to monitor emerging threats. These efforts are detailed in the Other MCH Data Capacity Efforts section.

Updates to MCH Data Collection and Analyses

1. Missouri PRAMS collected vaccination data through the COVID-19 vaccine supplement.
2. Missouri PRAMS is currently participating in the Social Determinates of Health supplement.
3. The Missouri Pregnancy Associated Mortality Review (PAMR) completed reviewing 2019 maternal deaths (see report) and is in the process of initiating review of 2020 maternal deaths.
4. Missouri is participating in the analyses of COVID-19 impact on pregnancy outcomes through the CDC “Surveillance for Emerging Threats to Mothers and Babies” (SET-NET) project.

Stakeholder Engagement

Ongoing MCH stakeholder engagement and input is sought through various opportunities and venues. Collaborative brainstorming and discussion related to the FFY 2021-2025 Title V MCH State Action Plan and other MCH priorities and initiatives for regional and statewide collective impact were facilitated through four virtual stakeholder meetings. Stakeholders participating included DHSS team members, other state agencies, local public health partners, for-profit and not-for-profit community organizations, faith-based organizations, family partners, and community members. Additional information regarding the stakeholder meetings may be found in the Public Input section narrative.

The Title V MCH core team developed a stakeholder survey to solicit further individual and organizational stakeholder input on the State Action Plan, challenges to improving MCH outcomes, emerging MCH issues and needs, and program performance metrics. The survey was disseminated electronically in June 2022, and approximately 170 individuals, representing LPHAs, state agencies, community and faith-based organizations, health care professionals, parents/caregivers of infants, children, adolescents, and/or children and youth with special health care needs (CYSHCN), and adolescents and adolescent/youth leaders, responded to the survey. A major theme emerging from the preliminary analysis is the impact of the COVID-19 pandemic on the ability to effectively deliver services due to either staff turnover or redirection of staff priorities to COVID-19 duties; this significantly impacted access to care for MCH populations. A decrease in the community’s trust in public health systems was also highlighted in survey responses. Other challenges reported include a lack of access to mental health services for adolescents and postpartum women and preventive health care, including oral health services, due either to provider shortages or lack of providers who accept Medicaid insurance. Responses also indicated the impact of lack of access to healthcare services on rural and low-income MCH populations was exacerbated by the COVID-19 pandemic and the increasing cost of living. Recommendations to meet the objectives of the state action plan included extension of Medicaid during the postpartum period to improve maternal mental health and preventive care education through schools, healthcare providers, social media and public service announcements to increase awareness of preventive practices as well as programs and services available at the local and/or state level. Emerging MCH priority needs identified were increases in Sexually Transmitted Infections (STIs) and lack of access to family planning and sexual education. More in-depth analysis of survey responses will be completed, and findings will be used to strengthen and develop strategies and activities to address the priority needs identified as part of the state action plan and develop plans to address the emerging needs of the MCH population.

MCH Population: Health Status and Needs

Data indicate improvements in health markers among the Missouri MCH population. Specifically, the infant death rate decreased from 6.0 per 1,000 live births in 2019 to 5.7 in 2020. Not only is the 2020 rate 14 percent below the 2010 rate of 6.6, but the 2020 infant death rate also represents a record low Missouri infant mortality rate. Further, the percent low birth weight decreased from a record high of 8.9 in 2019 to 8.7 in 2020. The rate of inadequate prenatal care increased slightly to 21.3 percent in 2020 from 21.1 in 2019. Between 2019 and 2020, teen births continued to decrease, moving from 3,889 to 3,591 births born to mothers under the age of 20. This decrease in teen births is a 54 percent decrease from the 2010 count of 7,739. In addition, short spacing, defined as less than 18 months between births, decreased from 12.5 percent in 2019 to 12.3 percent in 2020. C-sections decreased from 30.1 percent in 2019 to 29.3 percent in 2020. Multiple births decreased from 3.5 percent to 3.4 percent of births. Notably, the rate of mothers smoking during pregnancy decreased to 11.9 percent in 2020 from 12.8 percent in 2019 and 18.9 percent in 2010. Where there have been improvements, it will be important to continue to implement appropriate efforts that will promote further progress.

Conversely, data indicate other areas where health markers among the MCH population are moving in an opposite direction. Specifically, the rate of births to obese (BMI>30) mothers increased to 30.8 percent in 2020 from 30.1 in 2019 and 23.8 in 2010. The rate of out-of-wedlock births increased from 40.4 to 41.2 percent from 2019 to 2020, respectively. Of note, the number and rate of Medicaid births increased in 2020, while WIC births decreased. Further efforts are indicated to better understand the causation of maternal obesity, out-of-wedlock births, and decreasing WIC births in contrast to increasing Medicaid births and to effectively target resources and innovation in intervention and/or program development.

Program Capacity

Shifting Title V MCH and MCH Epidemiology program capacity due to the COVID-19 pandemic and related increasing staffing vacancies presented significant challenges and necessitated flexibility and agility to maintain essential MCH functions while supporting pandemic response. All MCH epidemiology and core Title V MCH team members have had additional ongoing COVID-related responsibilities. Additional information related to program capacity can be found in the MCH Workforce Development and MCH Epidemiology Workforce section narratives.

Maintaining a strong MCH system of care and ensuring seamless delivery of MCH services is vital for achieving desirable MCH outcomes. The COVID-19 pandemic presented new and exacerbated existing challenges in accessing and continuing MCH services. MCH programs remain committed to the provision of equitable, appropriate, and quality MCH services for Missouri’s MCH population and continue to expand their knowledge, innovate and transition services to meet the needs of pregnant women, mothers, infants, children, youth, and CYSHCN, and their families. Additional detailed information related to the availability and access to and provision of health care services that impact the health status of the MCH population can be found in the MCH Emergency Planning Preparedness section narrative and State Action Plan narratives by domain.

Establishment of the Office of Early Childhood at the Department of Elementary and Secondary Education (DESE) in August 2021, per Executive Order of the Governor, created a consolidated location facilitating coordinated provision of early learning services for young children. (Refer to Overview of the State section for additional information.) The programs in the Bureau of Special Health Care Needs were reorganized from the Division of Community and Public Health (DCPH) to the Division of Senior and Disability Services in November 2021. Several programs serving the MCH population, including the MCH Director and Title V MCH Program, were reorganized as part of restructuring across the DCPH. Organizational evolutionary change is ongoing, and the stress that accompanies change and reorganization cannot be prevented. However, clear communication and planning and intentional partnership and collaboration are mitigating any stress and disruption related to the reorganizations and restructuring.

Partnerships and Collaborations

To identify the priority needs of Missouri’s MCH population, the Title V MCH needs assessment process sought input from community members and organizations, hospitals, non-profits, universities, LPHAs, and other state agencies. To address these priorities and implement effective strategies, the Title V Program continues to develop the relationships with these public and private entities as well as the specific organizations listed below.

The Acting DHSS Director and MCH Director attended a Maternal Mortality Roundtable hosted by Congressman Emanuel Cleaver and including state, regional and local maternal health partners. The roundtable discussion revolved around current trends, lead contributing factors to maternal mortality and severe morbidity, existing initiatives, and emerging needs related to maternal mortality in Missouri. Discussions with key partners identified the need for a Comprehensive Maternal Mortality Prevention Plan with targeted funding and initiatives to effect simultaneous transformation through five domains of action affecting maternal health:

1. Standardized, evidence-based maternal quality care protocols;
2. A Maternal Health Access Project with a single point-of-entry system for referrals to obstetrical and prenatal care providers and community agencies, resources, programs, and services and a hub and spoke model Perinatal Health Access collaborative, inclusive of perinatal mental health;
3. Multi-pronged strategies to expand, diversify and strengthen the maternal care workforce;
4. A Postpartum Plan of Care to plan for and optimize comprehensive postpartum care; and
5. Improved maternal health data collection, standardization, harmonization, transparency, and support to enhance data quality and access, identify poor outcomes during pregnancy and make improvements to support healthy pregnancy, delivery, and postpartum outcomes.

Adolescent Health Program partners include Wyman Center, Teen Pregnancy & Prevention Partnership, Society for Prevention of Teen Suicide, and Council for Adolescent and School Health. The Injury Prevention Program supports Safe Kids coalitions and participates on Missouri’s Injury & Violence Prevention Advisory Committee. Partners to support CYSHCN, include Assistive Technology, University of Missouri Kansas City-Institute for Human Development, and United 4 Children. The Office of Dental Health works with the Missouri Coalition for Oral Health, Missouri Dental Association, and Missouri Primary Care Association on community outreach efforts to increase access to oral health services. Newborn Health/Early Childhood initiatives connect with child care providers, Children’s Trust Fund, Home Visiting Implementation Agencies, Happy Birth Day, Inc. (Count the Kicks), and Local WIC Agencies. Statewide collaboration occurs with Missouri’s Women's Health Council, Missouri’s past and current Healthy Start grantees (Generate Health, Nurture KC, and Missouri Bootheel Regional Consortium), and the Missouri Hospital Association. Several Title V MCH programs work with local school districts and other state agencies, such as the Departments of Mental Health, Social Services, and Elementary and Secondary Education.

One of the largest partnerships is with the LPHAs who provide a strong local public health network of 115 city and county health departments. These agencies operate independently of each other and are independent of state and federal public health agencies. The LPHAs work directly with DHSS through contracts to deliver public health services to the communities they serve. These contracts include such programs as MCH Services, which comprises almost 30% of Title V block grant funding; CYSHCN Service Coordination; and Safe Cribs for Missouri. The LPHAs are typically the first point of contact for many Missourians seeking healthcare resources.

The #HealthierMO initiative provides a platform for transforming Missouri's public health system into a stronger, more sustainable, culturally relevant and responsive system that will allow public health experts to better meet the challenges of Missouri's diverse communities. The initiative advocates for long-term, systems-level change that will lead to healthier families, healthier communities, and a healthier Missouri. The initiative recognizes the value of interaction and input from a diverse group of public health system representatives across Missouri and covets feedback from all system stakeholders. The MCH Director is a member of the Executive Committee and has served on the Workforce Work group, Foundational Public Health Services (FPHS) Work group, and the Health Equity Design Team. The FPHS model defines a minimum set of foundational public health services and capabilities that need to be available in every community in order to have a functional public health system. The Missouri FPHS model highlights Health Equity and Social Determinants of Health as a lens through which all public health programs and services should be provided, and Child, and Family Health is one of the Foundational Areas included in the model. The Health Equity Design Team was formed in 2021 to develop a Capacity Building Program and FPHS Workbook to help equip public health professionals to operationalize Missouri’s FPHS model, with health equity infused throughout all the foundational areas and capabilities.

Title V MCH Program staff facilitate internal discussions within these various units and partnerships to broaden their reach through program planning, development, and evaluation. In addition, staff participate on various external Boards, Committees, Councils, and Coalitions to make sure that initiatives meet the needs of the MCH population. Additional information regarding partnerships and collaborations is included in the Public and Private Partnerships section.

Organizational Structure and Leadership

Missouri’s state government is organized into three branches: the Legislative Branch, the Judicial Branch, and the Executive Branch, which is headed by the Governor. Within the Executive Branch are 16 executive departments, including Health and Senior Services. The Department of Health and Senior Services (DHSS) is the designated state agency for the allocation and administration of the Title V MCH Services block grant funds. The Acting Department Director was appointed in March 2022. DHSS is organized into the Office of the Director, including the State Public Health Laboratory (SPHL), and four divisions: Administration, Regulation and Licensure, Senior & Disability Services, and Community and Public Health (DCPH). DCPH is the largest of the four divisions and is responsible for supporting and operating more than 100 programs and initiatives addressing public health issues.

DCPH is organized into bureaus, offices and units by types of programs and services provided and overseen by a Division Director, an operations director, two deputy directors and four assistant deputy directors. DCPH serves as the umbrella agency that facilitates access to numerous MCH-targeted programs and provides a majority of services to the MCH population. Structurally, the MCH Director and the Title V MCH Services Block Grant are now located within the Division Director’s Office, and the MCH Director oversees coordination of overarching MCH initiatives and administers the Title V MCH Services Block Grant. The CYSHCN Director also serves as the Chief of the Bureau of SHCN located within the Section for Home and Community-based Services in the Division of Senior and Disability Services. Steps are being taken to create a full-time CYSHCN Director position, with the hopes of filling the position in the near future. This will increase the capacity of the Title V MCH Program to address the needs of CYSHCN beyond the population served by the programs and services in the Bureau of SHCN, strengthen statewide efforts to promote a medical home for all children with and without SHCN in Missouri, and implement family-centered, community-based, systems of coordinated care for all children with and/or at risk for special health care needs.

The functions of the Bureau of SHCN were transferred from the DHSS DCPH to the DHSS Division of Senior and Disability Services (DSDS) in November 2021. The transfer was formalized through the State FY 2023 budget process. This was a seamless transition for participants and families served through SHCN programs. The move to DSDS will result in increased communication/coordination of Home and Community Based Programs (both Medicaid and the associated non-Medicaid services) and improved continuity of services. In addition, the move to DSDS will give SHCN programs, and the services available to families, greater attention. The work of the Bureau of SHCN aligns perfectly with the mission of DSDS, “to be the leader in advocating, partnering, protecting and supporting seniors and individuals with disabilities to be safe, healthy and independent.”

State and Federal MCH funding supports the following programs:

• Community Health Services (injury prevention, adolescent and school health)
• Environmental Health (childhood lead poisoning prevention)
• Epidemiology (vital statistics, analytics, surveillance systems)
• Healthy Children and Families (home visiting, newborn health, TEL-LINK, safe cribs, WarmLine, MCH Navigators)
• Genetics (newborn screening)
• Early Childhood (developmental monitoring, child care health consultation, inclusion specialists, parent advisory council (PAC))
• Oral Health (preventive services, community outreach)
• Special Health Care Needs (family partnership, care coordination, assistive technology)
• Women’s Health (MCH services, infant & maternal mortality, maternal substance use and mental health, health services for incarcerated women)
• Nutrition & physical activity (breastfeeding, obesity prevention)
• Crosscutting (immunizations, communicable disease prevention, health equity)

Core Title V MCH Program Staff at the DH SS

• Martha Smith, MSN, RN, MCH Director/Public Health Nursing Manager, has over 35 years of experience in nursing and MCH and has served in these roles since March 2019, previously serving as the Interim Director of the Center for Local Public Health Services and the MCH Services Program Manager.
• Lisa Crandall, Bureau Chief, Bureau of Special Health Care Needs/CSHCN Director, has worked for DHSS, Bureau of Special Health Care Needs since 2004 and has been the Bureau Chief since 2012. Lisa has served as Missouri’s Title V Children with Special Health Care Needs Director since 2016.
• Karen Harbert, MPH, Lead MCH Epidemiologist, has worked for the DHSS, Office of Epidemiology since 2014 and has served as the lead MCH epidemiologist since December 2020. Previously, she was a Senior Epidemiology Specialist and served as the lead for data-related issues for the MIECHV, Title V, and Children’s Trust Fund Home Visiting Programs.
• Karyn Stewart, PHD, Senior Research/Data Analyst, has been with DHSS in this role since August 2021. Her background includes undergraduate teaching and research in health disparities, health equity and MCH.
• Andra Jungmeyer, MPH, State Adolescent Health Coordinator, has over 20 years of experience in public health, with over seven years in this position.
• Jami L Kiesling, BSN, RN, Chief, Bureau of Genetics and Healthy Childhood, has worked in state public health over ten years, with a focus on maternal and child health. She has served in her current role since 2018, overseeing the TEL-LINK, Newborn Screening, Newborn Blood Spot Screening, Prenatal Substance Use Prevention, and Newborn Health programs.
• Sara Gorman, MSN, RN, Maternal Child Health (MCH) Services Program Manager, has over 11 years of state and local public health experience and served as the Central MCH District Nurse Consultant before becoming the MCH Services Program Manager in 2021.
• Nina Nganga, MPH, Title V MCH Program Coordinator, has been with the DHSS in this role since August 2021. Her background includes a MPH in Global Health and a certificate in Global Women’s, Adolescent and Children’s Health and MCH-related research in the US and Kenya.

Family Leaders

The Family Partnership provides resource information and peer support to families of CYSHCN. The Family Partnership employs four part-time professional Family Partners who are parents of individuals with special health care needs. Each serves a region of the state to assist families as well as plan, schedule, and facilitate all Family Partnership events. One Family Partner also participates on the early childhood PAC, a group of family leaders from across the state. These leaders have experience in their own communities working with agencies that provide services to at-risk families with young children and have demonstrated leadership skills. Title V provides financial support for the PAC through the contract with the DESE.

Local Public Health Agency Workforce

LPHAs protect and improve community well-being by preventing disease, illness and injury and impacting social, economic and environmental factors fundamental to optimal health. LPHAs are the foundation of the local public health system, comprised of public- and private-sector health care providers, academia, business, the media, and other local and state governmental entities. In 2020, with 104 of 114 LPHAs reporting, 16 reported reducing the number of days open to the public, nine reported laying off staff, and 42 reported not replacing open staff positions, with decreased funding and the COVID-19 pandemic being cited as the primary reasons for changes in staffing, hours of operation, and provision of services.

Operationalizing Process and Findings

The Title V MCH Program used the conceptual framework provided by HRSA/MCHB as part of its needs assessment process, and followed guidance for integrating the needs of stakeholders and Missouri’s diverse population through a health equity lens. The needs assessment and its activities were guided by the social ecological model (SEM). The Title V MCH Program initiated the statewide Missouri Five-Year Needs Assessment in the fall of 2018. The needs assessment timeline included capacity for the DHSS contracting process (planning), qualitative and quantitative data collection and analysis (spring 2019 – fall 2019), and stakeholder input (winter 2019 – spring 2020) before identification of the final state priorities in spring 2020.

The needs assessment was designed to enable the Title V MCH Program to assess its activities and services in relation to the state’s MCH needs identified though qualitative and quantitative data sources. Selected MCH stakeholders participated in a virtual convening in April 2020, where they were briefed on the MCH block grant and an overview of findings. After reviewing additional fact sheets, stakeholders were invited to participate in an online discussion board segmented into each of the Title V domains (maternal health, infant health, child health, adolescent health, SHCN), as well as cross-cutting/SDOH. Comments were recorded from stakeholders, particularly regarding the most pressing issues affecting each population domain and the MCH system’s capacity to address those issues. After two weeks of discussion, stakeholders were invited to nominally rank each potential priority option in three ways: (1) by the number of individuals impacted, (2) by the capacity of existing resources to address the issue, and (3) by political and social will to address the issue. Additionally, nearly 100 indicators were reviewed and analyzed for the needs assessment process. When numbers permitted, each indicator was broken down among multiple axes, including race, ethnicity, geography, and poverty. Trend analysis was performed on current national and state performance and outcome measures, as well as indicators of population/community health status and health system capacity.

Qualitative and quantitative data in combination with the stakeholder meeting feedback led to the identification of 8 MCH priority needs for Missouri, including 5 National Performance Measures (NPM) and 3 State Performance Measures (SPM).

Emerging Public Health Issues

Four salient topics are relatively new public health issues or public health issues of increasing severity. These topics include increased incidence of mental and behavioral health issues and suicide among adolescents, proportion of CYSHCN compared to children without a special health care need with a medical home in Missouri, ongoing impacts from the COVID-19 pandemic, and Medicaid extension for postpartum women.

Suicide among Missouri adolescents between the ages of 10-24 is the second leading cause of death for this age group (15.5 per 100,000). In 2018, 172 Missourians aged 10-24 died of suicide, making up approximately 15.2% of all suicides that year. According to Missouri’s Youth Risk Behavior Survey (YRBS), the percentage of high school students who say they seriously considered attempting suicide has increased from 15.4% in 2009 to 17.4% in 2019. The percentage of high school students who say they have made a plan about how they will commit suicide has also increased from 11% in 2009 to 14% in 2019. Addressing suicide among the adolescent population is of tremendous significance. The Adolescent Health Program (AHP) addresses various health topics such as positive youth development and teen pregnancy prevention, and is instrumental in addressing suicide prevention. The AHP team provides consultation, education, training, technical assistance, and resources for health professionals, school personnel, parents, adolescents, state agencies, and community organizations. The AHP team coordinates the Council for Adolescent and School Health (CASH) to help the DHSS identify health priorities for adolescents, promote strategies to reduce health risks, and promote healthy youth development. The AHP partners to provide evidence-based suicide prevention trainings to schools and has developed a crisis toolkit for distribution to families.

Well-child visits provide important opportunities to support the whole child and address physical, behavioral, mental and emotional wellbeing, as well as conduct routine screenings, administer routine immunizations, and make early referrals to needed specialized services. The rates of well-child visits and routine childhood immunizations decreased during the COVID-19 pandemic. A patient-centered medical home facilitates patient-provider relationships to provide comprehensive primary care. In collaboration with the Missouri Chapter of the American Academy of Pediatrics, the Show-Me School-Based Health Alliance, Missouri Managed Care, and other partners, the Title V MCH team is pursuing new partnerships and strategies to ensure every child in Missouri has an identified medical home. Establishing a full-time CYSHCN Director position will play a key role in ensuring all children with and without special health care needs have a medical home. Ensuring coordinated, comprehensive and ongoing health care services for children with and without special health care needs is addressed further in the State Action Plan CSHCN Domain narrative.

The DHSS has made strides in monitoring the potential impact of COVID-19 on mothers and children. The Missouri PRAMS has collected COVID-19 data from mothers through the COVID-19 supplement since March 2021. The new Missouri PRAMS dashboard is accessible at https://health.mo.gov/data/prams/prams-dashboard.php. Missouri is one of 31 jurisdictions participating in the Surveillance for Emerging Threats to Mothers and Babies, which collects information on pregnant people and their children through the first 3 years of life. Related to participating in this surveillance opportunity, Missouri is linking COVID-19 case data to vital statistics files to assess the impact of COVID-19 infection on adverse pregnancy outcomes such as infant death, low birth weight and preterm births.

With the implementation of Medicaid Expansion in 2021, it is important to monitor and respond to any impacts on the MCH population. While increased access to health care may also increase the likelihood of preventive care visits among women, ensuring those eligible for care are enrolled and receive quality care are two separate issues of importance for consideration and monitoring. Medicaid Expansion also reinforces the importance of leveraging the Title V and Medicaid partnership to advance the patient-centered family medical home, ensure equitable access to care and address the social determinants of health and health inequities. It will continue to be important for the Title V MCH Program to be proactive in engaging with partners to facilitate Expansion efforts.