Iowa’s Title V program continues to evaluate programs and processes, and strives to include family input into all activities, including the assessment of needs and priorities. Iowa’s Title V Family Delegate was a core member of the Needs Assessment team. The Title V plans and Needs Assessment process are presented for feedback from the Maternal and Child  Health Advisory Council (MCH Advisory Council) which includes multiple youth and family representatives. Additionally, the DCCH Family and Professional Partnership Program Manager provides regular feedback to ensure that the strategic plans for the Family Partnership program and the Title V CYSHCN program are aligned with the needs articulated by Iowa families. The Family Advisory Council (FAC) provides review of the block grant initiatives and members of DCCH and FAC leadership have strengthened the role of family advisors in advising all DCCH programs, including the Title V Block Grant.

Increase Internal Health Equity Capacity

During spring and summer 2022 a team from the Iowa Title V program participated in the Maternal and Child Health Workforce Development Center Accelerating Equity Learning Community, with the intent of strengthening the effectiveness and capacity of state public health workers, program leaders, family representatives, and health care providers. The team identified an equity assessment, the Bay Area Regional Health Inequities Initiative (BARHII) in order to gain a baseline understanding of the Health Equity culture in the Bureau of Family Health, as well as to identify areas where the bureau as a whole can better support health equity. The BARHII was launched February 2023 and reviewed with Bureau leaders throughout the spring. The team identified areas for growth, and have been exploring options for moving from trainings that focus on knowledge, to those that initiate action. We will also be working to build conversations about current health equity initiatives within Bureau programs, to provide technical assistance, but also to illustrate how different programs are operationalizing health equity work. This work will hopefully increase the Bureau’s capacity to engage with diverse populations through their programming that will inform the 2025 Title V needs assessment.

The Maternal and Child Health Workforce Development Center Accelerating Equity Learning Community also caused us to reevaluate our Child and Adolescent Health Equity Advisory Committee (HEAC). During Winter 2023, one-on-one interviews were conducted with HEAC members to evaluate what had been engaging about working within the HEAC, what members would like to change, what structure would work for the HEAC and their general feelings about the HEAC. With this information the program has been trying to shift power of the HEAC to the members, and to recruit new members for the team. There have also been discussions about whether the HEAC should be expanded beyond Child and Adolescent Health to ensure that we are not tapping members for multiple, but similar asks as the focus on equity and representation increases throughout public health programming.

Maternal Health

The health of women of childbearing age and access to consistent medical care continues to be a problem in Iowa due to provider shortages and social determinants of health (SDoH) associated with the many rural areas across the state, such as transportation and food deserts. Rising costs of providing care and insufficient reimbursement for OB services coupled with financial strain on hospitals following the COVID-19 pandemic have negatively impacted hospitals’ capacity to provide labor and delivery services.

These barriers, coupled with the inequities in severe maternal morbidity (SMM) and mortality statistics led to the determination that the target population for this demonstration would include all pregnant and newly postpartum persons whose household income is less than 375% of the federal poverty level (FPL). This is the criteria Iowa Medicaid uses to determine eligibility for Medicaid during pregnancy and through 60 days postpartum. This wide eligibility requirement will allow for strong data analysis opportunities to best determine which interventions are most effective in which areas. Program data can be disaggregated to identify opportunities to target specific populations such as race, ethnicity or level of rurality.  

Demographic and Economic Composition

The state of Iowa is located in the upper Midwest region of the United States. Iowa is home to 3.2 million people as of 2021, and 606,327 were women of reproductive age (Access to Obstetrical Care in Iowa: A Report to the Iowa State Legislature, 2023). The racial and ethnic makeup of Iowa is primarily White, non-Hispanic. The full racial and ethnic makeup is described below:

(U.S. Census Bureau, 2022)

The percentage of families who have recently given birth, who speak a language other than English at home has increased significantly between 2017 (7.9%) and 2021 (8.9%) (Source: Bureau of Health Statistics - Certificate of Live Birth). Spanish was the most common non-English language that families reported speaking at home in 2021 (4.0%) (Source: Bureau of Health Statistics - Certificate of Live Birth). Between the years 2000 and 2020, the percent of Iowa’s population that identifies as Hispanic or African American has increased. Hispanics now compose 6.8% of the population compared to 2.8% in 2000. African Americans represent 4.1% of the population compared to 2.1% in 2000. Likewise, these changes are reflected in births to Iowans. Statewide in 2021, 7.3% of birthing people were African American and 11.1% of birthing people were Hispanic. (Source: Bureau of Health Statistics - Certificate of Live Birth)

As of 2022, 11.1% of Iowans lived in poverty (U.S. Census Bureau). Medicaid is an important reimbursement source for maternal and newborn care in Iowa. The average percent of births reimbursed by Medicaid was 41.2% from 2017 through 2021. In 2021, 40.8% (n=15,027) of births to Iowa residents were reimbursed by Medicaid, and Medicaid reimbursed a higher proportion of births among women who self-identified as Black, Native Hawaiian, Hispanic, multiple races, or American Indian/Native American compared to women who self-identified as White or Asian. (Report to Medicaid, 2022)

Obstetrical Care in Iowa

Since 2000, 41 community level hospitals have closed their OB units. The major reasons are due to provider shortages and financial struggles. In addition, low volume OB units struggle to keep up with the ever changing clinical practices in maternity and newborn care. Iowa HHS maternal health staff have monitored the issue for several years, and while there have been many closures of low volume rural OB units, to date adverse outcomes related to OB unit closure have not been identified. For example, first trimester prenatal care initiation has remained stable (even during COVID) and birth outcomes such as low birth weight and preterm birth have remained stable. However, Iowa has seen an 18% increase in the rate of severe maternal morbidity (SMM) from combined years 2017-2019 to 2019-2021. In general, while some maternal outcomes in Iowa are better than national rates, many are trending in the wrong direction, and racial and ethnic disparities persist.

In 2021, 85.7% of mothers initiated prenatal care (PNC) during their first trimester. Mothers with Medicaid reimbursed births initiated first trimester PNC at a rate of 10% less than mothers with other payment sources for care (79.7% vs. 89.9%). By race, among mothers with Medicaid reimbursed births, the percent of those who initiated 1st trimester PNC ranged from a low of 35.8% (Native Hawaiian/other Pacific Islander) to 82.4 % (White mothers). Seventy-four percent (74%) of Black mothers initiated first trimester PNC, followed by 72.2% of American Indian/Native American mothers. Seventy-eight percent (78.5%) of Asian mothers initiated first trimester PNC. A much lower percent of Hispanic mothers initiated first trimester PNC compared to non-Hispanic mothers (72.9% vs 81.2%). First trimester PNC initiation did not differ significantly based on maternal county of residence.

Iowa HHS also has the capacity to determine the rate of adequate prenatal care, which is defined by Healthy People 2030 (HP 2030) based on the month prenatal care began and the number of prenatal visits. Overall, based on 2021 data, pregnant women in Iowa have surpassed the HP 2030 target for early and adequate PNC of 80.5% at 84.3%. However, disparities in early and adequate PNC are evident among pregnant women with Medicaid reimbursed births (84.3% vs. 78.6%) overall, and by race, ethnicity and age. Pregnant women of Native Hawaiian descent, those of American Indian/Native American and Black pregnant women obtained early and adequate PNC at the lowest percentages (respectively 33.2%, 68.5% and 72.3%) compared to White (82.2%) and Asian pregnant women (81.9%). Seventy-four percent (74.4%) of Hispanic pregnant women obtained early and adequate PNC. Mothers who resided in either metropolitan (79.9%) or rural counties (79.9%) obtained early and adequate PNC at a greater percentage than mothers who resided in micropolitan counties (77.8%). Promoting early entry into prenatal care and improving attendance at prenatal visits will be a main priority for the IMHS sites, particularly the Community Health Workers (CHWs).

Nearly 98% of pregnant women in Iowa reported having public or private health insurance during their pregnancy, whereas only 93% had insurance after their pregnancy (PRAMS 2020). Iowa Medicaid covers pregnant women for 60 days following their delivery. The proposed IMHS demonstration will provide wraparound services to participants for up to 12 months postpartum, with the goal that the Iowa Legislature will allow Medicaid to cover women for 12 months postpartum prior to the end of the grant period. According to the 2021 PRAMS, 90.7% of Iowans attended their postpartum visits. Postpartum visit attendance is not available broken down by race or ethnicity due to low numbers. If awarded, postpartum care will be tracked in the Title V Maternal Health Database, Iowa Connected, to identify opportunities for quality improvement. 

Oral health - The American Dental Association (ADA) concluded that associations exist between gum disease and preterm birth, low-birthweight babies born prematurely and the development of pre-eclampsia in pregnancy. Furthermore, diet and hormonal changes that occur during pregnancy may increase a mother’s risk for developing tooth decay and gum disease, and exacerbate existing dental infections. The 2021 Iowa Barriers to Prenatal Care survey reports that 57.1% of new mothers did not receive any oral health information from their health care provider during their pregnancy. Additionally, 45.1% of new mothers reported not having a dental visit during their pregnancy. Integrating oral health education, assessments, preventive services and dental care coordination during pregnancy and the postpartum period provides the opportunity for comprehensive care for the pregnant mother and her child.

Pregnancy and Maternal Health Outcomes

During calendar year (CY) 2021, Iowa residents gave birth to 36,786 babies, and the median age of first time mothers was 30 years old. Among mothers with Medicaid reimbursed births the median age was 28 years old compared to 31 years of age among mothers with other payment sources for births.

Pregnancy-related deaths - (combined years of 2019 - first 6 months of 2021) Overall rate 14.2 per 100,000 live births. Due to small numbers, Iowa is unable to report disaggregated results. Iowa’s most recently published maternal mortality review committee report (2021) indicated that all pregnancy related deaths occurred postpartum, and half of the pregnancy associated deaths occurred between 42 days and 12 months postpartum. Leading causes included eclampsia, postpartum hemorrhage and suicide.

Severe maternal morbidity - The severe maternal morbidity (SMM) rate is based on 20 conditions defined by the CDC and excludes transfusions. Because the count of SMM events in Iowa is relatively low, and to support calculation of stable rates, our SMM rate is based on 3 years of data. Iowa’s SMM rate is lower than the national baseline rate (61.3 vs 68.7 per 10,000 delivery hospitalization) and has achieved the HP 2023 target rate (61.3 vs 61.8) based on 2019-2021 data. However, Iowa’s SMM rate has increased by nearly 18% in the time from 2017-2019 (52.0) to 2019-2021 (61.3). The SMM rate 2019-2021 is almost twice as high among Black women (103.1) compared to White women (54.0) and is higher among those with publicly reimbursed deliveries compared to women with private insurance (70.5 vs 56.0). Iowa’s SMM rate is the highest among mothers who live in micropolitan counties (71.9) compared to women who live in metropolitan counties (60.2) and those who live in rural counties (56.6).

Nulliparous,Term, Singleton, Vertex (NTSV) cesarean section - Based on 2021 data Iowa’s overall NTSV rate was 23.5%. The NTSV rate did not differ significantly by Medicaid reimbursement status. Iowa’s NTSV rate varies dramatically by race with a range of 19.9% (mothers of multiple races) to 42.4% (Native Hawaiian mothers). White mothers had an NTSV rate of 23.0% compared to Black mothers (27.9%). Non-Hispanic mothers had a lower NTSV rate than Hispanic mothers (21.2% vs 23.8%). The NTSV rate did not differ significantly by maternal county of residence. The rates were 23.4% among metropolitan mothers, followed by 23.3% among rural mothers, and 24.3% among micropolitan mothers.  

Mental Health - Iowa’s 2021 Maternal Health Strategic Planning process brought to light a substantial need for mental health resources. As a result, one of the three priorities in the plan was to elevate focus on maternal mental health, and a standalone Perinatal Mental Health Strategic Plan was developed in response to this. Rates for postpartum depression for Iowans are 110 per 1,000 versus 94.6 per 1,000 nationally. In Iowa, suicide and overdose were among the top causes of pregnancy-associated deaths (deaths to women during pregnancy or up to one year post-pregnancy) according to the Iowa Maternal Mortality Review Committee reports that occurred between 2015-2019

According to the 2020 Pregnancy Risk Assessment Monitoring System (PRAMS), 89% of pregnant women were asked by a provider if they were feeling down or depressed, with nearly 70% answering written questions about their mood and 84% reported their provider talked to them about postpartum depression. Statewide (Iowa) about 1 in 4 mothers who were diagnosed with depression received counseling for depression during their pregnancy (26%). Iowa’s IMHS demonstration will include a heavy focus on mental health in pregnant and postpartum women through social work support, screenings, care coordination and referrals to services.

Substance Use Disorder - Many women with untreated maternal mental health conditions also struggle with substance use disorder (SUD). In Iowa in 2020, 23.9% of women of childbearing age (18-44 years) reported binge drinking in the past month, compared to 18% overall in the U.S. During state fiscal year 2021, 55.8% of women admitted to substance use disorder treatment reported they were pregnant at the time of admission. Iowa currently has four substance use treatment centers that focus on pregnant women and women with children. The Iowa HHS Maternal Health and Family Planning programs have previously partnered with the SUD program within the Agency to improve access to services and collaboration across programs, and will continue to promote this collaboration within awarded IMHS demonstration sites. 

Title V Maternal Health Clinic (MHC) Client Data - Iowa HHS transitioned to a new data system, Iowa Connected, to collect client level data for Maternal Health, Child and Adolescent Health, 1st Five Healthy Mental Development, Oral Health and Family Planning clients. Iowa has had a system in place to collect client data for more than 20 years, and makes enhancements and improvements to data collection and data quality on a regular basis. The existing infrastructure at the local MHCs to collect and report required data elements for their clients will allow the IMHS demonstration sites to rapidly implement data collection and tracking processes.

Iowa MHCs provided full maternal health services to 2,224 pregnant women in calendar year 2022. Of those women, 1,527 were screened using the Medicaid PRA, and 1,378 were determined to be high risk and eligible for enhanced maternal health services. Additionally, 91% of clients were screened for depression.

Children and Youth with Special Health Care Needs

Ongoing needs assessment activities:

DCCH assesses needs through the framework of the National Standards for Systems of Care for CYSHCN. DCCH staff are also working to align on-going needs assessment activities with the new Blueprint for Change from MCHB. The National Survey of Children’s Health is an ongoing source of population-based, family-reported data for Iowa’s Title V CYSHCN program. Other needs assessment activities include the annual Youth Services Survey for Families, sent to a sample of families who receive direct and enabling services through DCCH, conversations with members of the Family Navigator Network and the Family Advisory Council, and a review of ongoing activities of partner organizations such as the Developmental Disabilities Council, and internal programs such as the Regional Autism Assistance Program.

Changes in health status and need

The top priority needs for Iowa’s Title V program were identified in the 2020 needs assessment as:

• Infusing Health Equity in the Title V System
• Access to care for the MCH population
• Maternal, Child, and Adolescent Health systems coordination
• Dental Delivery Structure
• Safe and Healthy Environments
• Access to community-based services and supports, pediatric specialty providers, and coordination of care
• Access to support for making necessary transitions to adulthood
• Support for parenting CYSHCN with mental health or complex health needs.

Even with the Public Health Emergency ending COVID-19 exacerbated the need to address all of these priority areas, especially access and parent support. Iowa’s Title V program including CYSHCN continued to provide support in all of these areas, including expanded access to in-home telehealth direct services and supports for families. For a large portion of 2020 and 2021, many Title V local and state program staff provided this care while working from home, or in reduced density work environments.

DCCH collects information from the Family Navigator Network about changes in issues and needs from families they are working with. The Family Advisory Council also provides information about the needs of families of CYSHCN. Mental health issues continue to be an issue for Iowa’s CYSHCN and provider shortages make access to care especially challenging, especially for children and youth in more rural areas of Iowa.

A family survey is part of the annual process for this 5-year Title V cycle for DCCH programs. The Youth Services Survey for Families is a questionnaire that includes 26 questions with a 5-level Likert-type response scale ranging from ‘Strongly Agree’ to Strongly Disagree.’ Respondents are also given the option ‘Does not apply.’ The items in the questionnaire are grouped into 6 domains that pertain to the direct and enabling services provided through DCCH: Access, Participation in Treatment, Cultural Sensitivity, Satisfaction, Outcomes, and Social Connectedness. Domains contain between 2 and 6 questions, which are combined into a mean domain score. Additional questions cover basic demographic information: Gender, age-category, and race/ethnicity. Additionally, there are 3 open-ended questions, asking 1) What has been the most helpful thing about the services you and your child received as a result of DCCH services? 2) What would improve services for families who need support? and 3) Any other comments? The survey is administered annually in the spring. The table below shows the results from the 2021,2022, and 2023 surveys. A review of the data showed that scores were relatively high overall and have remained steady over time.

Youth Services Survey for Families, mean domain scores,2021, 2022 and 2023 surveys

DCCH is in the early planning stages for the 2025 Needs Assessment. During FFY2023, DCCH worked with AMCHP to develop a comprehensive evaluation plan for the Family Navigator Network. Implementation of this plan is expected to occur during FFY2024

Changes in capacity and MCH systems of care

Essential services for MCH priority populations were enhanced in several ways during the 2022 Iowa legislative session. For people with disabilities, including CYSHCN, more funding is now available for direct support staff wages, to reduce the length of Home and Community Based Services waiver waiting lists, increase vocational rehabilitation services, and ensure that special education for children disabilities in private schools are provided.

Breadth of Partnerships with other entities that serve the MCH population

Iowa’s Title V program works extensively with organizations such as the Iowa Departments of Management, Education, and with the now combined Humans Services. Coordination of services and ensuring Iowa’s most vulnerable families are receiving the needed services to succeed has been a cornerstone of these collaborations. The MCH program, including CYSHCN, has strong linkages within HHS Bureaus of Immunizations, Oral Health Section, Chronic Disease Prevention and Management, Vital Records & Health Statistics and Substance Abuse Prevention and Treatment programs. HHS’s Office of Disability, Injury & Violence Prevention supports state and local efforts to improve services for victims of domestic and sexual violence. HHS and DCCH appreciate many public-private partnerships with organizations such as Delta Dental of Iowa Foundation, the Iowa AAP, ChildServe, Blank Children’s Hospital, the Iowa Primary Care Association, the National Alliance on Mental Illness Iowa Chapter, Child and Family Policy Center, ASK Resource (Family Voices affiliate), the Autism Society of Iowa and a number of other health care providers and systems. Opportunities range from funding for school-based dental sealant programs, participation on health advisory councils, and evaluating program data.

The CYSHCN section of Title V also works with the Iowa Developmental Disabilities Council (DD Council) and is co-located and meets regularly with the University Center for Development and Disability (UCEDD), and the Iowa Leadership Education in Neurodevelopmental and Related Disabilities Project (LEND) programs. The Iowa Title V CYSHCN program has active collaborations within the University of Iowa Stead Family Children’s Hospital and Department of Pediatrics, including the Division of Developmental Pediatrics and the Division of General Pediatrics. Other University of Iowa programs that Title V actively collaborates with include the Carver College of Medicine Departments of Psychiatry, Family Medicine, and the College of Public Health.

Operationalizing the 2021 Needs Assessment

FHB is currently in the process of reviewing and rewarding the FY2023 Title V Request for Applications (RFAs) The Title V Block Grant State Action Plans directly affect and dictate the development of requirements and activities outlined in the funding opportunity. Staff continue to use and update the 2021 Needs Assessment to ensure the needs of Iowa’s population are continuing to be met and continue to reduce barriers faced by families.

In order to further operationalize the Needs Assessment state Title V staff are continuing to utilize the findings to inform and programmatic changes including but not limited to the Maternal Health Strategic Plan and the CSAs discussed previously.

DCCH updated the strategic plan in 2021 with a focus on alignment between the needs of CYSHCN and families and the work that is carried out by DCCH. Title V Priority areas are used as a basis to direct efforts within DCCH as well as to advocate with other organizations with shared goals.

Changes in organizational leadership

Iowa’s Title V MCH program is housed in the Family Health Bureau within the Wellness and Preventive Health Branch which falls under the Division of Community Access.

Juliann Van Liew, Director, Wellness & Preventive Health, the WPH Branch manages much of the agency’s maternal and child health portfolio, including maternal and reproductive health, oral health, child and adolescent health, WIC, and healthy eating and physical activity work. Prior to joining the agency in March of 2023, Juliann was the Director for the Unified Government Public Health Department in Wyandotte County, Kansas where she oversaw the department’s accreditation process, Community Health Improvement Plan, and led the county’s COVID-19 response. In previous work, Juliann led population-health strategies for a larges safety net health system in Minneapolis, Minnesota, including home visiting and community-based mental health programs. Juliann earned her Bachelors of Arts from Drake University and her Master’s in Public Health from the University of Minnesota with a concentration in maternal and child health.

Mykayla (Micki) Beard, Bureau Chief, Child and Adolescent Health Section, has worked for the State of Iowa for over 25 years, most recently with legacy DHS as a Quality Program Manager. Ms. Beard led the team responsible for the development of Iowa's new Quality Rating and Improvement System -- Iowa Quality for Kids (IQ4K) and served as the project manager for numerous statewide contracts, responsible for developing contract scope of work, tracking contractor performance and managing the overall contract budget.

Tracy Rodgers, Bureau Chief, Oral Health Section, has worked in public health for over 20 years, most recently managing the I-Smile program. Ms. Rodgers has also served as project director for several HRSA oral health grants, including the current oral health workforce grant which has included development of the I-Smile Silver project for Iowa adults.

Sylvia Navin, Bureau Chief, Reproductive Health Section, has over ten years of experience with Iowa HHS, working in a variety of public health areas. Ms. Navin started as an intern with the Early Hearing Detection and Intervention Program, worked with Iowa's Children's Health Insurance Program as the State Hawki Outreach Coordinator, and spent a few years working in healthcare payment reform with Iowa's State Innovation Model grant. Most recently, Ms. Navin worked in Title V Maternal Health, Title X Family Planning and was the project director for Iowa's Maternal Health Innovation (MHI) grant. In her new role, Ms. Navin will remain the project director of the MHI grant and will oversee programs related to reproductive health. Programs within the Reproductive Health Section include Title V Maternal Health, Title X Family Planning, Violence Prevention, PRAMS, ERASE MM and Iowa's Title V Doula Project.