Needs Assessment Update

Alaska’s most recent five-year needs assessment was conducted in early 2020. A health equity priority was added in 2021, and the Title V program has been working to integrate equity considerations into ongoing needs assessment considerations. The following is an update on needs assessment approaches, findings and adjustments.

ongoing needs assessment activities

The MCH Epidemiology Unit supports ongoing primary data collection and surveillance activities and continuously analyzes data from secondary sources. Epidemiologists analyze quantitative data and produce reports to disseminate information that is accessible for internal and external audiences. This year, staff conducted analyses to examine outcomes including maternal mortality related to violence, maternal suicides, Sudden Unexpected Infant Death, and factors associated with childhood vaccination series completion.  Qualitative data is collected through survey comments as well as through Maternal Child Death Review Committee (MCDR) recommendations and descriptions of factors in mortality. Childhood Understanding Behaviors Survey (CUBS) “back page” comments on resources utilized or needed are shared by email with WCFH and DPH leadership where appropriate.

The Section also utilizes external sources of relevant data and works with internal and external partners to collaborate on needs assessment projects. Over the past year, the Title V Block Grant Coordinator worked with a University of Washington student to conduct qualitative interviews to gather public input from community stakeholders who belonged to organizations that provided services to maternal and child populations, seeking feedback on Alaska’s MCH health systems, identifying barriers in accessing care, and providing recommendations to improve services. After collecting data with key stakeholders, the student compiled a list of recommendations according to the MCH pyramid of services for consideration of Alaska Title V staff.

WCFH advisory committees, including the Alaska Perinatal Quality Collaborative (AKPQC) Steering Committee, the CYSHCN Advisory Committee, the Early Hearing Detection & Intervention (EHDI) Advisory Committee, and the Youth Alliance for a Healthier Alaska (YAHA), meet throughout the year to provide input on strategies and objectives and provide the perspective of those with lived experience on WCFH programs and population needs. Many of these committees have at least one person with lived experience or consumer participant. Professional development opportunities created or organized by WCFH, including the Home Visiting Summit, ECHOs (Home Visiting, Perinatal and Family) and the Family Engagement and Leadership Training (FELT), and the annual Maternal Child Death Review/PQC Summit conduct evaluations as part of the training. These trainings target partners, funders, providers, administration, and families.

Title X sub-recipients conduct ongoing customer satisfaction surveys and summarize the results quarterly for their advisory committees who then provide recommendations for service delivery improvement. WCFH, as the recipient of the federal funds, is responsible for assuring follow through of those recommendations. Title X services inherently include annual preventive health visits for all Title X clients, so this work is contributing to “moving the needle” on this Title V performance measure. 

Changes in Health Status and needs of the mch population

Areas of need in all population domains remain similar to those identified during the 2020 Needs Assessment. These include mitigating the impacts and drivers of substance misuse across population categories; facilitating connections to behavioral and mental health information, resources, and services; and addressing trauma and ACEs by increasing social supports and promoting safety in interpersonal relationships.

During 2019-2023, the MCDR program identified 62 pregnancy-associated deaths to Alaska residents (133.8 per 100,000 live births), ranging from 8–20 deaths per year; most of these deaths were preventable. During the most recent five years of deaths where over 85% of deaths have been reviewed (2016-2020), the MCDR Committee classified 13 deaths as pregnancy-related, corresponding to a mortality rate of 25.7 per 100,000 live births. Rates of pregnancy-associated deaths increased by 184% during 2012-2021 in rural areas of Alaska, compared to an increase of 66% in urban areas. In addition to rural residence, other sub-populations of Alaskan pregnant and postpartum people who experience high rates of pregnancy-associated mortality include Alaska Native and Asian and Pacific Islander people. During 2014-2023, Alaska Native women in Alaska experienced a pregnancy-associated mortality rate six times the rate for White women (307 per 100,000 births compared to 55 per 100,000), while the rate for Asian women was twice the rate for White women (99 per 100,000).

Alaska continues to experience a disproportionate number of maternal deaths from violence. Suicide, overdose, and homicide are leading causes of maternal mortality, particularly among Alaska Native women. Intimate partner violence is often identified as a contributing factor across all causes of maternal deaths. Substance use is also a frequent contributing factor in maternal mortality, but MCDR case reviewers noted that substance misuse and IPV co-occur more often than not in Alaskan maternal mortality cases. MCDR case reviews also found that lack of access to perinatal healthcare or social services was identified in 44% of cases (reviewed 2016-2022), and since recent years have included improvements in identifying specific factors such as access, this is likely an undercount. These findings have contributed to the implementation of the AKPQC initiative on substance-affected pregnancies using approaches that center the need for trauma-informed, holistic interventions that acknowledge the role of maternal safety and support in recovery.

Rates of obesity, hypertensive disorders, and diabetes continued to rise among birthing people in Alaska. This increase mirrored an ongoing increase in SMM among Alaskan births from 2020 (1.6%) to 2023 (3.8%). During 2019-2023, SMM rates were highest among Alaska Native (3.7%) and Black (3.5%) birthing people. Increases in the rate of SMM over the past 4 years were most striking among residents of the Interior and Northern regions, although Anchorage and Southwest regions also had increases.

In 2022, 70% of Alaska women ages 18-44 years of age had a past-year preventive health visit (BRFSS).

In response to questions that arose during collaborations with local midwifery groups, WCFH and the AKPQC worked with Vital Records to add questions to the Alaska birth certificate in 2022 to collect information on planned place of delivery and planned attendant at birth. Among planned birth center and home births in 2023, 26% occurred at a hospital, while 99.7% of planned hospital births did occur at a hospital. In Alaska, many people living in remote villages do not have much choice when it comes to where they have their baby. WCFH staff continue to hear stories of challenges and stress on people flown into hub communities or Anchorage to deliver. We hope to continue to work with community partners to identify areas where Title V programs can alleviate some of these challenges.

Areas of need for the perinatal/infant and child populations include increasing the number of children who live in safe, stable, nurturing environments. For the perinatal/infant domain, priorities also include improving social supports to prevent and reduce the impact of Adverse Childhood Experiences (ACEs) and prevention of substance misuse among caregivers of infants and toddlers and women of childbearing age.

Alaska’s overall infant mortality rate in 2023 (preliminary data) was 7.3 per 1,000 live births, which was 30% higher than the U.S. rate of 5.6 per 1,000 births in 2022. Neonatal mortality slightly increased in 2023 compared to 2022, while postneonatal rates were similar to 2021 and 2022. The past three years have had higher annual infant and postneonatal mortality rates compared to the previous five years (2016-2020). The MCDR program is still working on conducting reviews of infant deaths that occurred since the pandemic to get a better sense of contributing factors to the higher rates in recent years, although it is suspected that social determinants of health play a large role.

For each year 2016-2020, SUID was consistently the leading cause of death among Alaskan post-neonates and ranged between 17-25% of neonatal deaths. The average disparity rate ratio (2018-2022) for Alaska Native infants compared to white infants was 2.7. The disparity rate ratio in 2022 was 2.1, which was unexpectedly low, especially following the largest disparity observed of the five years at 3.3 in 2020. Comparison of these disparity rate ratios by neonatal and post-neonatal periods reveals a substantially greater disparity for Alaska Native post-neonates (1.7 neonatal compared to 7.8 post-neonatal).

Substance misuse is tied to child maltreatment and SUID. In 2022, 6.5% of people who delivered a live birth drank alcohol during the last 3 months of pregnancy, 8.4% used tobacco, and 8.9% used marijuana at any time during their pregnancy. Prenatal cigarette use has been declining for the past decade, however e-cigarette use doubled in 2021 and 2022 compared to prior years, to 2.3% and 2.2%, respectively. Neonatal Abstinence Syndrome has increased from 9.3 per 1,000 delivery hospitalizations in 2016 to 15.1 in 2022 (HFDR).

After a decade of annual increases, the overall preterm birth rate for Alaska in 2023 indicated a slight increase compared to 2022. However, it appears the rates decreased among Alaska Native and Black people while increasing among Asian, White, and Native Hawaiian and Pacific Islander people. The rising preterm birth rate has occurred primarily among late preterm and clinician-initiated preterm births.

While approximately 10% of Alaskan children ages 0-17 are reported to child welfare for suspicion of maltreatment during an average year, cumulative estimates show that among children born in Alaska, approximately 43% are reported, with 14% substantiated, for an allegation of harm before age 12, and 8.3% experience a removal (ALCANLink). A study conducted by the MCH Epi Unit that used CUBS data to approximate experience of ACEs found that 47% of Alaska 3-year-old children over the past decade have experienced at least 1 ACE and a little less than 10% experienced four or more ACEs. ACEs related to financial hardship were most common, followed by substance abuse in a close family member and neglect.

Among the adolescent population, increasing healthy relationships remains a priority, as well as increasing connections to behavioral and mental health information, training, and resources for providers who serve adolescents. In 2023, 45.2% of high school students reported they would feel comfortable seeking help from three or more adults besides their parents if they had an important question affecting their life (YRBS). This was a slight decrease from 48.6% in 2019. The 2023 School Climate and Connectedness Survey (SCCS) of students in grades 6-12 found that 59% of students felt close to adults in their school and 69% were involved in their communities and felt supported by their communities. However, only 29% of students and staff reported favorable perceptions of the peer climate at their school (how respectful and helpful students are to one another and their teachers), a decline since the last survey.

Behavioral and mental health resources are a huge need for the adolescent population. YRBS data through 2019 indicated increases since 2007 in students feeling sad or hopeless, and considering, planning for, and attempting suicide in the past 12 months. At the time of this report, WCFH is still waiting to get the updated 2022 YRBS data to see how this may have changed since the pandemic. According to the 2023 SCCS survey, more students and staff indicated “0 times” for how often they observed students engage in delinquent behaviors at school and at school events within the past 12 months (81%) compared to the prior survey, as well as how often they had seen other students engaging in drug and alcohol use at school or school events in the past 12 months (84%) (SCCS).

For all Alaskan children aged 3-17 years in 2021-2022, at least 24.5% had at least one mental, emotional, developmental, or behavioral problems. Trauma and the effects of adverse childhood experiences are known to impact both short and long-term mental health of individuals. In Alaska, 1 in 3 children by the age of 7 will be reported to the Office of Children’s Services for some type of maltreatment, while Alaska’s rate for children in foster care is 150% more than the national average.

The unintentional injury-related death rate for Alaska teens has been consistently higher than the national average and has been increasing for the past decade, to 35.4 per 100,000 population during 2020-2022. Alaska’s teen suicide rate has recently declined yet is still nearly 3 times the national rate in 2020-2022 (30.2 vs. 10.5 per 100,000 population). The most common mechanism of teen suicide is firearm, while drug poisonings contributed to the largest proportion of unintentional injury deaths. (Overdose deaths among the total population continued to increase, with 2023 being Alaska’s deadliest year for opioid overdoses. Alaska’s increase in overdose deaths between November 2022 and November 2023 was the highest year-to-year increase in the nation.)

The priority identified for the CYSHCN domain is to increase or promote equitable access to medical and pediatric specialty care and family supports for CYSHCN. The 2021-2022 NSCH estimated 18.9% of Alaskan children ages 0-17, or 33,635, have special health care needs. 39.9% of Alaskan CYSHCN have a medical home, while 22.7% of 0–11-year-olds and 5.3% of 12–17-year-olds received care in a well-functioning system. However, 19.2% did not have a usual source of care when sick or when a parent/caregiver needed advice about their health. Among parents of CYSHCN, 13.9% said they were usually or always frustrated in efforts to get services for their child in the past year. Of CYSHCN who received or needed specialist care during 2021-2022, 29.3% found it somewhat difficult to obtain, while 20.9% found it very difficult to obtain. Among CYSHCN ages 3-17 years, the percent of those needing to see a mental health professional was 37.3, while 12.4% needed, but did not receive mental health treatment or counseling.  Unfortunately, many of these indicators related to access to care were worse compared to prior estimates, indicating continued efforts are needed to address these issues.

changes in program capacity and systems of care

The Section was impacted by various vacancies in administrative support positions during the past year, with three quarters of those positions in WCFH turning over in 2023. Those positions are now filled as of June 2024. Additionally, the Division and Department continue to experience reduced capacity in many support services in part due to the 2022 Department split. This includes human resources, information technology, procurement, and finance/revenue. The state of Alaska overall continues to have workforce shortages affecting multiple sectors. These vacancies and lack of capacity substantially impact the ability of WCFH staff to efficiently conduct ongoing activities within planned timelines.

No positions were eliminated from WCFH in the Governor’s FY25 state budget. The Section did receive a one-time supplement of $252,000 in FY24 to support the implementation of Help Me Grow Alaska, and this money was again included in FY25 budget. There will also be a budget increment in FY25 to support additional case slots for Parents as Teachers (PAT) home visiting services.

In April 2023, WCFH was asked by Division of Behavioral Health (DBH) to apply for the new HRSA continuation grant for the Pediatric Mental Health Access program. The CYSHCN Director is now the Project Director and provides day-to-day management for this program. WCFH contracts with the All Alaska Pediatric Partnership and Seattle Children’s Hospital to provide Alaska-based pediatric care providers working in primary care, behavioral health care, and integrated health care settings immediate access to psychiatric behavioral health consultation and whole-person care coordination for children and adolescents.

WCFH continues to lead efforts related to developmental screening, including partnering with state and community-based programs to promote the use of the online ASQ developmental screening tool and supporting the implementation of Help Me Grow (HMG) Alaska.

WCFH is also looking forward to continued expansion of evidence-based home visiting services in Alaska. In FY23, WCFH received funding from the Office of Children’s Services which doubled the amount of State funding available to support the implementation of the PAT home visiting model. In FY25, pending approval of the State budget, WCFH will receive an additional $205,000 to support the implementation of these services in Alaska. WCFH was also able to secure a state match, using Department of Education funding for PAT, that will allow WCFH to receive additional MIECHV funding to will support more PAT home visiting services in FY26.

Partnerships and collaborations

Key partnerships between WCFH and federal, Tribal, state, and local entities are listed below, with upcoming or recent changes to the partnerships described.

WCFH administers federal grants from HRSA, CDC, and others that are integrated with the work of Title V. WCFH is also one of the states receiving CDC funding to support the Alaska Perinatal Quality Collaborative.

In FY24, WCFH collaborated with the Borough of Juneau to fund nurse practitioners to offer reproductive health and well child visits in two local high schools. Using marijuana tax funds, WCFH supported school-based health centers in Anchorage, Juneau, and Bethel in FY24.

In addition to the HRSA Pediatric Mental Health Access grant (PAL PAK), WCFH partners with the DBH on the Substance-Exposed Newborns Initiative.

The Department split in 2022 resulted in the assignment of the OCS to a different department from WCFH. However, data-sharing agreements and programmatic collaborations have continued uninterrupted. Within DPH, WCFH works with other sections on breastfeeding promotion, injury prevention, cancer screening, school-based health centers, and the overdose death review. WCFH also supports Division-wide efforts such as Public Health Accreditation, the Quality Improvement team, Healthy Alaskans 2030, Workforce Development, Data Modernization, and the Scientific Review Team.

WCFH co-coordinates the Alaska Early Childhood Coordinating Council with DEED. WCFH and Medicaid organized a team to participate in a learning collaborative with the Center for Health Care Strategies, titled “Aligning Early Childhood and Medicaid (AECM).” The AECM team included staff from DPH, OCS, the Alaska Medicaid Program, the Division of Behavioral Health, and the Commissioner’s Office. The team, led by the WCFH Early Childhood Program Manager, conducted a mapping project focused on substance use disorder during pregnancy in the Yukon-Kuskokwim region.

WCFH collaborates with Tribal Health in newborn screening, he AKPQC, home visiting, pediatric clinics, and data analysis/data sharing, The Section continues to collaborate with the ANTHC Tribal Epidemiology Center to co-coordinate the Alaska Maternal Child Health & Immunization Conference which was last held in March 2024. The Title V Director, MCDR, and AKPQC staff collaborated with the Alaska Native Birthworkers Community on an AMCHP learning opportunity related to anti-racism. Through a set of contracts established last year using funding focused on the prevention of maternal deaths due to violence, WCFH partnered with four other Indigenous-led community-based organizations and service providers to deliver culturally appropriate doula services.

Through a contract with the Alaska Hospital and Healthcare Association (AHHA), the AKPQC and MCDR continued to support partnerships with birthing facilities around the state. WCFH collaborates with perinatal health providers and facilities statewide on the AKPQC and Perinatal ECHO series. This includes partnership with pediatricians, obstetricians/gynecologists, maternal fetal medicine specialists, neonatologists, nurse midwives, nurses, mental health clinicians, and doulas statewide.

Operationalization of five-year needs assessment

In FY21, the following priority was added to increase strategic focus on health equity:

Promote health equity, improve social determinants of health, and identify and deconstruct systems of institutionalized oppression for maternal and child health populations.

Four strategies were added in the Cross-Cutting/Systems Building domain to address this priority. Staff have participated in numerous trainings and have been translating theoretical knowledge into practice. Equity topics are emphasized at the annual AKPQC/MCDR Joint Summit and the MCH and Immunization Conference. WCFH staff provided leadership in developing guidelines for inclusive language for the Division’s information products. The strategies are designed to promote deeper staff development and supervisory techniques, address equity impacts of current Title V strategies, promote equitable use of resources, and leverage data and information in partnership with marginalized communities to raise awareness and drive action.

changes in organizational structure and leadership

In 2021, the Governor proposed to bifurcate DHSS into the Department of Health and the Department of Family and Community Services. Public and stakeholder sessions were held to inform implementation, with the Title V Director serving as a department representative at these sessions. The proposal was resubmitted in 2022 as Executive Order 121. After no formal vote to reject the order was conducted by the legislature, the EO went into effect July 1, 2022. There are no major programmatic or leadership changes to DPH, however many support services staff were split between the two new Departments, leading to reduced capacity in the areas of procurement, IT, and human resources.

In 2023, Lindsey Kato became the new Director of DPH. She is located in the state capital of Juneau and brought both her experience in Public Health and the private sector. Dr. Anne Zink, who had been the Chief Medical Officer (CMO) for the Department since 2019, left her role in April 2024. Dr. Robert Lawrence is now the CMO for DOH and comes to the Department after working the past several years as the CMO for the Department of Corrections.

In 2024, after a multi-year planning process which crossed all sections of the Division, DPH received accreditation from the Public Health Accreditation Board. 

emerging public health issues

Opioids and substance use continue to impact overall population health. As mentioned previously, in 2023 Alaska experienced the steepest increase in overall overdose mortality compared to all states according to CDC data. The Anchorage School District announced 10 overdoses among high school students in less than a month in April 2023. The OSHS and WCFH School Nurse Consultants continue to distribute information related to the fentanyl crisis, and the MCDR team has continued working with the overdose review committee program in the Section of CDPHP to assist them in operationalizing their reviews. The MCDR program is planning to coordinate with this review team in the next year on the review of maternal overdose deaths.

Alaska’s syphilis outbreak was first declared in early 2018 and case counts have continued to increase. As of January 16, 2024, 10 suspected or probable CS cases were reported during 2023, for an estimated annual incidence of 105 cases per 100,000 births (January 2024 Epi Bulletin). As part of the Governor’s Healthy Families Initiative, a key focus in FY24 was on congenital syphilis. An increment of general funds was given to DPH to work on this important health issue. This involved a collaborative effort between the Sections of WCFH, Epidemiology, Laboratory, and Public Health Nursing. WCFH has supported efforts around data analysis, provider education and establishment of a congenital syphilis review board over the past year. WCFH’s knowledge and experience in conducting the MCDR Committee was valuable in the planning efforts.

In spring 2024, both houses of the Alaska state legislature passed a bill to revise language in the state statute governing review organizations, which include MCDR. It is expected that the Governor will sign the bill later this summer. This bill became a priority for the Division because the language modifications that were proposed and eventually passed are expected to make committees such as MCDR as well as the overdose fatality review and new congenital syphilis review board operate more efficient and effectively. A key provision will also allow them to include a more multidisciplinary membership than under the current statute. As future public health threats emerge, the changes will hopefully make it easier for public health reviews in Alaska to be established and operationalized.