Five-Year Needs Assessment Update
Ongoing Needs Assessment Activities
Ongoing work 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
- Missouri conducted an adolescent health needs assessment in 2022. A variety of indicators were analyzed at the county level to help the program determine areas of highest need. Indicators included teen pregnancy, high school dropout rates, and poverty levels.
- Missouri PRAMS collected social determinates of health (SDoH) data through the SDoH supplement.
- The Missouri PAMR completed reviewing 2020 maternal deaths and is finalizing the report for public distribution. The PAMR board is currently reviewing maternal mortality cases that occurred in 2021.
- 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. The team is also working to develop a means in this project to collect longitudinal data on infants over their first year of life.
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 are ongoing as part of conversations with 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 stakeholder engagement may be found in the Public Input section narrative.
MCH Population: Health Status and Needs
Data indicate improvements in health markers among the Missouri MCH population. The rate of inadequate prenatal care decreased from 21.3 in 2020 to 19.1 percent in 2021. Teen births (mothers under the age of 20) continued to decrease and moved from 3,591 births in 2020 to 3,342 births in 2021. This decrease in teen births is a 6.9 percent decrease from 2020 and a 56.7 percent decrease from the 2010 count of 7,739. Notably, the rate of mothers smoking during pregnancy decreased from 11.9 percent in 2020 to 10.1 percent in 2021, compared to 18.9 percent in 2010. The rate of out-of-wedlock births decreased from 41.2 to 40.0 percent from 2020 to 2021, respectively. It will be important to continue implementing ongoing strategies to promote further progress.
Data indicates other areas among the MCH population where markers have stayed consistent in the past year. Specifically, the infant death rate in 2021 did not change from the record low infant mortality rate of 5.7 per 1,000 live births set in 2020. This rate is 14 percent below the 2010 rate of 6.6. Of note, the rate of Medicaid and WIC births also remained unchanged in 2021.
Conversely, data indicate other areas where health markers among the MCH population are moving in the opposite direction. The percent of low birth weight in 2021 returned to a Missouri record high set in 2019, with a rate of 8.9. This is an increase from the 2020 rate of 8.7. Specifically, the rate of births to obese (BMI>30) mothers increased to 31.8 percent in 2021 from 30.8 in 2020 and 23.8 in 2010. In addition, short spacing, defined as less than 18 months between births, increased from 12.3 percent in 2020 to 12.6 percent in 2021. The rate of cesarean births increased from 29.3 percent in 2020 to 30.2 percent in 2021. To effectively target resources and innovation in intervention and/or program development, further efforts are needed to understand the causation of maternal obesity, short birth spacing, and the increased rate of cesarean births.
Program Capacity
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.
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, MCH leadership continues to develop the relationships with these public and private entities as well as the specific organizations listed below.
Discussions with key partners identified the need for a comprehensive plan for Maternal Mortality Prevention, with targeted funding and initiatives. The Maternal Mortality Prevention Plan will be implemented through partnerships with internal and external maternal health partners, with the SDoH interwoven throughout all five domains. A robust Evaluation Plan will monitor progress, measure success, ensure accountability, and inform ongoing maternal mortality prevention efforts.
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 programs such as MCH Services, which comprises almost 30% of the Title V MCH Block grant annual budget; CYSHCN Service Coordination; Child Care Health Consultation; and Safe Cribs for Missouri. The LPHAs are typically the first point of contact for many Missourians seeking healthcare resources.
Adolescent Health Program partners include the 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.
Missouri’s Foundational Public Health Services (FPHS) model describes a minimum set of foundational public health services and measurable capabilities in identified areas of expertise 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 SDoH as a lens through which all public health programs and services should be provided, and Maternal, Child, and Family Health is one of the Foundational Areas included in the model. DHSS has adopted the FPHS model as a guiding framework and is using the model to conduct a cost analysis of what it would cost to assure the provision of foundational services and capabilities at each local public health agency in Missouri. The cost analysis, anticipated to be completed in three years, will serve as a guide for a budgetary request to adequately fund public health services in Missouri.
The #HealthierMO Initiative led creation of Missouri’s FPHS model, and the #HealthierMO Health Equity Design Team developed a Capacity Building Program and FPHS Workbook to help equip public health professionals to operationalize Missouri’s FPHS model. (https://www.healthiermo.org/capacity-building)
Title V MCH team members facilitate internal discussions within these various units and partnerships to broaden their reach through program planning, development, and evaluation. In addition, MCH staff participate on various external boards, committees, councils, and coalitions to ensure 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, the Judicial, and the Executive Branch, which is headed by the Governor. Within the Executive Branch are 16 executive departments, including Health and Senior Services. The DHSS is the designated state agency for the administration of the Title V MCH Block Grant and allocation of grant funding. The Department Director was appointed in March 2022. DHSS is organized into the Office of the Director, including the State Public Health Laboratory (SPHL), and five divisions: Administration, Regulation and Licensure, Senior & Disability Services (DSDS), Cannabis Regulation, 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 Block Grant. The new full-time CYSHCN Director role, which is currently vacant, is also organized with the MCH leadership team in the DPCH Director’s Office. The CYSHCN Director role was previously housed within the Bureau of SHCN. This shift will increase the capacity of Title V MCH programming 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-DSDS in November 2021. The transfer was formalized through the State FY 2023 budget process. The move to DSDS was a seamless transition for participants and families served through SHCN program and resulted in increased communication/coordination of Home and Community Based Programs (both Medicaid and the associated non-Medicaid services) and improved continuity of services. The work of the Bureau of SHCN aligns 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 Leaders
- Martha Smith, MSN, RN, Missouri MCH Director/Public Health Nursing Manager and interim CYSHCN Director, has over 37 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. She has served as the interim CYSHCN Director since June 2023.
- Lisa Crandall, Bureau Chief, Bureau of Special Health Care Needs (SHCN), has worked for DHSS, Bureau of SHCN Needs since 2004 and has been the Bureau Chief since 2012. Lisa served as Missouri’s Title V Children with Special Health Care Needs Director from 2016-2023 and will provide mentorship to the new CYSHCN Director.
- 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.
- Andrea Tray, MPH, Senior Research/Data Analyst, has been with DHSS since 2021, serving in her current role since December 2022. She is currently conducting an analysis on racial disparities in breastfeeding as a benchmark for evaluating regional health equity initiatives.
- Andra Jungmeyer, MPH, State Adolescent Health Coordinator, has over 20 years of experience in public health, with over eight 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, MCH Services Program Manager, has over 15 years of state and local public health experience and served as the Central MCH District Nurse Consultant for two and a half years before becoming the MCH Services Program Manager in 2021.
- Nina Nganga, MPH, 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 Program provides resource information and peer support to families of CYSHCN. The Program 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. 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.
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 2021, with 113 of 115 LPHAs reporting, 16 reported reducing the number of days open to the public, and 27 reported laying off staff and closing internal home health services due to decreased funding. The COVID-19 pandemic was cited as the primary reasons for changes in staffing, hours of operation, and provision of services. In addition, these LPHAs noted that recruitment of new staff has been significantly challenging due to the increasing demand for nurses across healthcare overall, as well as higher wages and sign-on bonuses available from other organizations.
Operationalizing Process and Findings
The Title V MCH Block Grant 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). Title V MCH leadership 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 Title V MCH 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, infant, child, and adolescent health and CSHCN), 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 have been identified as public health issues of increasing severity and/or significance. These topics include the increased incidence of mental and behavioral health issues and suicide among adolescents, untoward impacts of children with and without a special health care needs without a medical home, the need for multipronged and innovative approaches to prevent maternal mortality and reduce severe maternal morbidity, and the need for a strong, reliable, resilient and well-prepared MCH workforce.
Suicide among Missouri adolescents between the ages of 10-19 is the third leading cause of death for this age group (9.1 per 100,000). In 2018, 94 Missourians aged 10-19 died of suicide, making up approximately 7.6% 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 20.4% in 202021. The percentage of high school students who say they have made a plan about how they will commit suicide has also increased from 11.3% in 2009 to 16.8% in 2021. 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 Governor’s final approved state fiscal year 2024 budget includes $4.35 million to implement a Maternal Mortality Prevention Plan and effect simultaneous transformation through the following five domains of action affecting maternal health:
- Standardized, evidence-based maternal quality care protocols;
- 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;
- Standardized maternal care provider trainings, using creative modalities, on trauma--responsive and culturally and linguistically appropriate care and screening, referral, and treatment of mental health conditions during and after pregnancy; SUD during and after pregnancy; cardiovascular disorders associated with pregnancy; and gestational diabetes and other endocrinology disorders associated with pregnancy.
- A Postpartum Plan of Care to plan for and optimize comprehensive postpartum care; and
- 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.
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 SDoH and health inequities. It will continue to be important for Title V MCH leadership to be proactive in engaging with partners to facilitate expansion efforts.
With the end of the federal Public Health Emergency (PHE), all Medicaid enrollees, including children, must be re-determined for eligibility within a one-year period, beginning April 1, 2023 and ending March 31, 2024. More than 1.4 million Missourians have healthcare coverage through MO HealthNet and will be impacted by the return of annual renewals. Eligible individuals—especially pregnant and postpartum women, people of color and children—are at risk of losing coverage during the unwinding process. Despite remaining eligible for Medicaid or becoming eligible for other types of low-cost coverage, children and families may lose coverage due to procedural reasons (such as not responding to a mailed request for verification by the state that may have gone to the wrong address). The Title V MCH team is pursuing collaborative strategies to increase awareness and ensure that internal and external stakeholders can spread the word to keep Missourians informed about the unwinding process. This includes sharing resources highlighting practical ways that MCH professionals and advocates can support families through this uncertain time and ensure MCH populations have continuity of coverage through the Medicaid redetermination process. The MCH Director shared resources such as a letter from Dr. Michael Warren, Associate Administrator of the Maternal Child Health Bureau, a related AMCHP Fact Sheet and DSS outreach materials.
The MCH Director facilitated a discussion between DHSS, the Missouri Hospital Association and 8 hospital systems in rural Missouri. The meeting aimed to: 1) identify the challenges related to recruiting and retaining clinicians that provide maternal health services in rural hospitals and communities and 2) discuss practical solutions to address the challenges. A common thread from the discussions was that many rural hospitals are “a car wreck away” from closing their OB/GYN services. Closure of rural hospitals is an ongoing challenge in Missouri where 50% of rural hospitals do not provide maternity care services. Between 2022-2023, Missouri saw the closure of three more rural birthing facilities: First Breath Birth and Wellness, Cox Monett Hospital, and Hedrick Medical Center. One of the hospital partners posited that labor and delivery is the backbone of any community, and “closing obstetric services won’t only affect maternal and infant health and mortality - it will kill the soul of the community.” Additionally, rural hospitals in Missouri are responsible for most maternal health care services for incarcerated women, including labor and delivery. The challenges being faced were broken down into several themes:
- Shortage of OB/GYN physicians available to work in rural hospitals (residency to attending physician pipeline, lack of support and mentorship for new physicians, lack of OB/GYN residency slots, etc.);
- System-level/structural challenges (majority of rural patients are Medicaid recipients and associated lower reimbursement rates; lengthy Medicaid credentialing process for physicians - 90-120 days average; high rate of turnover due to rural physician isolation, workload and on-call commitment; extended delays in Medicaid reimbursement for services; etc.); and
- Non-physician related challenges (nursing workforce shortage, challenges in collaborating with LPHAs, etc.).
A Rural Maternal Health Care workgroup, led by the new DHSS Chief Medical Officer, has been formed, and discussions with rural maternal health partners have continued. The work group will identify barriers to care, including but not limited to provider/workforce availability, payment and coverage issues, supportive infrastructure, and patient trust, and strategize approaches, engage stakeholders, and identify appropriate entities to address barriers and design potential solutions. The goal is for Missouri mothers to have access to the continuum of care from pregnancy through one year postpartum that is: in hospital, outpatient, and/or community settings; within 50 miles of their home; inclusive of maternal health providers and workforce members with comprehensive and diverse educational backgrounds; centered on the needs of patients and communities, in a manner that authentically garners trust; and appropriate for all acuity levels of maternal health care needs.
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