Ongoing Needs Assessment

FY 2022 Update

The Idaho Maternal and Child Health (MCH) Program team partnered with Boise State University (BSU) for the ongoing needs assessment (ONA) of evidence-based or

informed strategy measures (ESMs) and to determine baseline information regarding the current needs for Idaho’s maternal mental health population. Findings for the following are presented in this section: stakeholder outreach survey, environmental scan of maternal mental health resources and services available throughout Idaho, and a review of maternal mental health strategies to identify best practices and evidence supported for possible replication and application in Idaho.             

 

Noted Changes in Health Status

The COVID-19 pandemic has impacted health care systems and communities globally and continues to strain state and federal governments and health care systems. The pandemic’s influence on MCH capacity and populations is ongoing. Mothers were found to have more stress during the earlier stages of the pandemic due to increased family responsibilities, especially with school and care facilities closing. Pregnant women were among the most impacted groups throughout the pandemic. COVID-19 has led to an increase in maternal deaths, stillbirth, and maternal depression. With over 104,000,000 COVID-19 cases and just over 1.1 million deaths nationally, and 525,039 cases and 5,469 deaths in Idaho as of April 19, 2023, challenges persist across the state. As of April 2023, a total of 230,467,624 Americans were listed as fully vaccinated, including 978,119 Idahoans. Idaho’s vaccination rates are among the lowest nationally, with only 59.7% of the population having received at least one dose of the vaccine (DHW, 2023).

 

The evidence reveals that since the pandemic began the percentage of Idaho adults reporting symptoms of anxiety or depression has increased. In April 2020 at the beginning of the pandemic, 33.3% of Idahoans reported experiencing symptoms of anxiety or depression within the past week. This number spiked to 45.5% at the height of the pandemic in July 2020 and has since decreased to 34.2% as of April 10, 2023 (CDC, 2023). Reports show that the prevalence of substance abuse and overdose deaths across the nation have risen during the pandemic (NIDA, 2023). Although the data is limited, provisional data from the CDC indicates that Idaho is facing similar challenges. In January of 2021, 284 Idahoans died from a drug overdose. In the same month a year later there were 361 overdose deaths. The most recent data reported 341 drug overdose deaths in November 2022 (CDC, 2023). It will take time before complete data is available to demonstrate just how impactful the pandemic was on the mental health of various populations across Idaho.

 

Youth mental health continues to be a topic of concern in the U.S. with one in six youth, aged 6-17, experiencing a mental health disorder every year (NAMI, 2021). Access to mental health care also remains a challenge with 100% of Idaho designated a mental health professional shortage area. In a recent community assessment, teen mental health was identified as an ongoing major challenge in Idaho (St. Luke’s Health System, 2022). From 2016 to 2019, the percentage of youth, aged 12-17, experiencing a major depressive episode (MDE) was 17.8% in Idaho compared to 14.0% nationally. Of the 27,000 Idaho youth who experienced an MDE during that time, only 13,000 (48.1%), received treatment for their depression (Idaho State Department of Education, 2021). Findings from Idaho’s Youth Risk Behavior Survey (YRBS) showed that suicide was the second leading cause of death among youth aged 10-19 in 2020. During 2018-2020, the rate of adolescent suicide in Idaho, at 21.5 per 100,000 adolescents, was almost double that of the national rate of 10.8 per 100,000 (America’s Health Rankings, 2022).

 

Changes is Title V Program Capacity

In FY 2022, the MCH team maintained efforts to enhance its capacity through partnerships and collaborations. The MCH Program continued to strengthen its relationship with Idaho Parents Unlimited (IPUL) and engaged IPUL staff to strengthen family engagement. The MCH team purposefully elicited feedback from adolescent mental health stakeholders. Collaboration efforts took place to explore the best options for incorporating youth voice into the ONA findings. Efforts included communications with university contacts, state program managers, and snowball networking efforts for primary data collection from a variety of partners and representatives, including: public health districts, medical associations, non-profit organizations, major hospital health care systems, state programs, mental health organizations, other public health programs, multiple MCH health care providers, tribal nations, refugee service coordinators, families, and counselors. Also, collaboration continued with the Idaho Physical Activity and Nutrition Program (IPAN), among others, to strategically work on action planning and updating ESM strategies to strengthen the evidence.

 

Partnerships and Collaboration

The MCH Program has limited staffing capacity, however, it is efficient in building relationships and collaborating with organizations with similar goals of improving services and outcomes for MCH populations. The MCH leadership team consistently strives to ensure diverse perspectives are sought throughout ONA efforts, seeking input from stakeholders, medical providers, non-profit entities, public health districts, and families that represent a broad range of geographic and demographic viewpoints.

 

The MCH Program continued its focused work on the priorities identified in the 5-year NA. Multiple collaborations took place throughout the year with staff members in the Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV), Idaho Family Planning Program, Idaho Poison Control Center, Idaho Bureau of Epidemiology, Idaho Physical Activity and Nutrition Program, Newborn Screening Program, Idaho Immunization Program, Idaho Oral Health Program, Suicide Prevention Program, Adolescent Pregnancy Prevention Program, Idaho Parents Unlimited (State’s Family-to-Family Resource Center), Idaho Tobacco Prevention and Control Program, and the Idaho Children’s Special Health Program. Additionally, the MCH Program continued to maintain a presence on the Idaho Child Fatality and Maternal Mortality Review Teams, the Emergency Medical Services for Children Advisory Board, Idaho Breastfeeding Coalition, Idaho Council on Developmental Disabilities, and the Idaho Perinatal Project.

Efforts to Operationalize Needs Assessment

A key need for women of reproductive age and pregnant women identified in the 5-year NA was access to mental health services. The BSU team provided the MCH Program with an Idaho maternal mental health resources and services report along with a review of strategies to identify best practices for possible replication in March 2022.

 

The ONA report included: 1) an extensive review of literature and environmental scan of maternal mental health services to help identify strengths and challenges within Idaho as well as evidence-informed strategies utilized successfully elsewhere; and 2) a survey of MCH stakeholders. A purposeful, snowball sampling approach was used to include a wide variety of participants and perspectives on maternal mental health. Participants were purposely drawn from the following categories: public health districts, mental health organizations, state agency program coordinators, social work, health care professionals, CSHCN program coordination, non-profit organizations, and tribal health care professionals. A health equity lens was applied to participant selection to obtain varied perspectives from traditionally underrepresented populations in Idaho, including those stakeholders representing populations at risk of health inequalities (e.g., rural, tribal). A content analysis was conducted, which identified the themes and findings summarized below. These findings are included in detail in the findings section of the ONA Report as an attachment to the MCH block grant annual report.

 

Findings: Maternal Mental Health Service Availability and Best Practices

Background

In 2019, approximately 20.6% of mothers in Idaho reported experiencing a moderate or severe level of depression within the three months following their child’s birth. Symptoms associated with depression and anxiety include items such as feelings of hopelessness and anger, losing interest and motivation, experiencing intrusive thoughts, or becoming hypervigilant with their child. Risk factors associated with postpartum depression include items such as financial and marital stress, recent major life events, inadequate support, thyroid imbalances, and complications during pregnancy, birth, or breastfeeding.

 

The effects of maternal mental illness can have far-reaching ramifications on mothers, babies, and entire families. Mothers experiencing postpartum depression may neglect their own health, feel incompetent at parenting, be less responsive to their children, and be at greater risk for substance abuse. Children of mothers experiencing mental illness are at greater risk of low birth weight, preterm birth, longer NICU stays, excessive crying and behavioral delays.

 

Maternal Substance Use

A substance use disorder (SUD) is described as “a person’s use of drugs or alcohol resulting in health issues or problems in their work, school, or home life.” The National Survey on Drug Use and Health (NSDUH) in 2018 estimated that 5.6%, 7.2 million, of women in the U.S. suffered from SUD. When women experiencing SUD are pregnant, the adverse health effects impact both mother and baby. Nationally, maternal SUD is a growing problem, with the percentage of women reporting opioid use during pregnancy increasing by 400% between 1999 and 2014. According to Idaho’s Pregnancy Risk Assessment Tracking System (PRATS), 4.3% of mothers drank and 4.0% of mothers smoked during the third trimester of their pregnancy. A 2020 study by Tufts University looked to assess the opioid vulnerability in the state of Idaho. Idaho’s opioid prescription rate of 83.8 per 100 was found to be much higher than the national average of 59.0 per 100. The study also noted that crisis services are only available in the urban areas of Idaho, limiting access to treatment for women in the rural areas of Idaho.

 

Women face the greatest risk of developing SUD during their reproductive years. Pregnant women experiencing SUD are less likely to receive appropriate prenatal care than those without SUD. Major challenges that can hinder accessing SUD resources are financial burden and stigma, along with an overall lack of basic services and specialty care availability, especially in rural areas. The cost of treatment can also be a barrier to accessing necessary SUD treatment, with some providers not accepting Medicaid, Medicare, or other insurances. Additional financial barriers include premiums, copayments, coinsurances, transportation, and other out-of-pocket costs associated with accessing treatment. In Idaho, accessing maternal SUD treatment is further complicated by the fact that only 26% of SUD treatment facilities that accept Medicaid in Idaho offer specialized programming for pregnant or postpartum women.

 

The lack of services in rural areas further impacts the ability to access SUD treatment. Opioid prescription rates, lower median income, and crime rates related to drugs were all associated with SUD, and are all prevalent issues in Idaho, across every demographic and geographic region of our state. A Tufts University study also revealed a lack of SUD treatment and harm reduction services in Idaho.

 

The stigma associated with seeking SUD treatment is more pronounced in rural areas with a lack of anonymity noted in smaller communities. Access to SUD treatment in rural areas is further limited due to a lack of SUD service providers, with distance to treatment centers and resulting transportation challenges identified as additional barriers. Pregnant women and mothers have been found to experience a greater stigma due to ideas of selfishness and failure being associated with drug use in mothers. This has been shown to hinder one’s ability to seek services as it was reported as going against the traditional expectations of being a “good mother” and can invoke negative self-thoughts which has been shown to lead to poorer recovery rates.

 

Mental illness and SUD frequently co-occur, with an estimated 18% of adults in the United States experiencing both conditions simultaneously. With 100% of Idaho qualifying as a mental health professional shortage area, providing necessary services to those members of the maternal population suffering from mental health and/or substance use disorders is an ongoing challenge.

 

Maternal Mental Health Strategies - Other States

In Connecticut, a Perinatal Depression Screening and Referral Project focused on assessing perinatal depression among women receiving care at a Federally Qualified Health Center (FQHC) and included an evaluation of implementing a screening program to enhance referrals of women who might be dealing with depression during the prenatal and postpartum periods. Program evaluation results found that the project was successful with screening and referring women during the prenatal and postpartum periods as well as during well baby visits at FQHCs. However, barriers to receiving mental health care were found to still exist. It was noted that more than just provider access to behavioral health was needed to address perinatal depression.

 

The Moving Beyond Depression program, implemented in Ohio, is aimed at improving identification of depression among mothers enrolled in home-visiting programs and providing them with treatment. Mothers were screened for depression and, if found to be suffering from depression, were provided with in-home cognitive behavioral therapy treatment with their home visits. Participants were found to have decreased symptoms of depression, enhanced abilities to cope with stress and parenting challenges, and a higher self-reported level of functioning in everyday life activities.

 

In New Mexico a new policy, Non-Punitive Approach to Substance Use in Pregnancy, was enacted in 2019 to mitigate pregnant women being unfairly discriminated against in terms of drug use. The policy is aimed at eliminating the stigma associated with maternal drug use and implementing systems changes. The policy eliminates the mandatory child abuse reporting for drug use during pregnancy, removing the punitive approach to decrease barriers to pregnant and parenting women seeking care. Results are still being compiled, but as of early 2021 there have been 1,120 plans of care created for exposed infants.

 

Indiana’s Perinatal Quality Improvement Collaborative (IPQIC) created the Perinatal Substance Use Bundle to help provide a standard of practice to identify and screen for pregnant women using substances, as well as exposed babies. The perinatal bundle was identified as an AMCHP promising practice and offers resources to mothers, health care provider education, and avenues to address substance use among pregnant women, and works to provide consistent treatment plans for newborns with neonatal abstinence syndrome (NAS). Lessons learned from this program highlighted the need for more medicated assisted treatments (MAT) and resources for pregnant women.

 

Findings: Maternal Mental Health Stakeholder Survey

The MCH stakeholder online survey, using the Qualtrics platform, was designed to gather insights and stakeholder perspectives about the needs and resources available for the maternal population in Idaho experiencing mental health and SUD issues. Stakeholders were asked to identify what they saw as major needs and gaps in services for the maternal population experiencing mental health and SUD issues as well as to help identify organizations they currently collaborate with to address the needs for this population. Recommendations for enhancing collaborations and partnerships to optimize maternal mental health and SUD services were also sought.

 

The stakeholders were identified by the MCH leadership team and the BSU evaluation team with the intent to include those providing services to populations that may be at risk of inequalities including rural communities, low-income residents, American Indians and Alaska Natives, refugees, and CSHCN residents. A purposeful snowball approach to reach maternal mental health stakeholders throughout the state included various health and public health administrators, program directors, tribal health leaders and service providers, non-profit organization administrators and/or association administrators, health providers or administrators for refugee communities, various health care professionals, crisis center professionals, and other key stakeholders. Initial stakeholder survey recipients were invited to forward the survey to other MCH stakeholders who they thought may have valuable information to share regarding Idaho’s maternal population suffering from mental health or SUD issues. Therefore, the exact number of potential survey respondents is unknown. A total of 24 survey responses were received.

 

The respondents provided valuable information about the current climate of Idaho’s maternal mental illness and SUD services. Survey participants identified population needs and gaps in services and provided recommendations for improving service provision for the maternal population suffering from mental illness or SUD.

 

Respondent Role

Survey respondents self-identified their roles which included: Nurses (RN, nurse manager, nursing director), physicians (Obstetrics/Gynecology (OB/GYN), providers, psychiatrist, pediatrician), case manager of tribal health care, childcare provider, counselor, midwife, policy analyst, public health program manager, social worker, support volunteer, parent, and survivor of perinatal depression.

 

Gaps in Service/Needs for Maternal Population Experiencing Mental Health or SUD Issues

• Lack of services
  • No available SUD treatment
  • Lack of mental health service providers
• Provider education
• Maternal fear
• Lack of supportive resources
• Stigma
• Financial constraints
• Lack of telehealth
• Lack of supportive policies
• Public awareness

 

Stakeholders identified lack of services as a top area of concern for the maternal mental health populations experiencing mental health or SUD issues. Lack of services encompassed a variety of responses, including: an overall lack of service availability in communities, no access to services, lack of inpatient care for moms and babies post-delivery, no available outpatient and inpatient treatment options for mothers in various socioeconomic statuses, limited primary residential treatment facilities, lack of perinatal resources, and difficulty finding any sort of treatment options available in particular for the Native/tribal communities.

 

Several respondents noted the challenges related to accessing services in rural areas. One stakeholder mentioned the challenges of being in a rural area, the barrier of “rurality of our area and accessibility to services that specialize in perinatal, postpartum mental health services.” Travel issues were also noted by a stakeholder as a challenging aspect to receiving services for the maternal mental health population, stating, “Traveling to Boise is not an option for moms and families.”

 

Waitlists for services were identified as a major barrier to health care for the maternal mental health population experiencing mental health or SUD issues. One stakeholder mentioned that many patients seeking mental health services tend to get discouraged because the “waiting lists are months out and therefore, many patients will seek other avenues to cope with stresses.” Waitlists for services were noted as “extremely long and unreasonable.” One stakeholder emphasized that it could take “months for this population to establish care.”

 

A lack of SUD treatment options was identified by stakeholders as a top challenge for the maternal mental health population experiencing mental health or SUD issues. Responses regarding a lack of available SUD treatment options included comments citing a lack of sober housing for families/children, a need for maternal drug court to help individuals, and a lack of parental support programs. Limited access to opioid treatment programs throughout the state was also highlighted as an issue by survey respondents. Some stakeholders mentioned that opioid treatment options were only available in the Boise area. One respondent specifically mentioned that “Moms, especially those who are incarcerated, need access to substance abuse treatment.”

 

A lack of mental health service providers was identified as a service gap for the maternal population experiencing mental health or SUD issues. Comments falling into the lack of mental health service providers category included limited providers in the area, lack of certified alcohol/drug counselors and peer recovery coaches, lack of support groups, no available facilities for women, no available long-term counseling and support options, and not enough mental health counselors in various regions of Idaho.

Respondents identified provider education regarding maternal mental health or SUD issues as a need. Responses related to the need for provider education included: the need for prescribers who are specially trained and designated for this population, a lack of appropriate understanding by professionals including doctors, nurses, and mental health care providers, lack of time and/or interest by health care providers to treat this population, the need to incorporate behavioral health with primary care services, and primary care providers having to cover maternal mental health care without being adequately trained in this area. One respondent indicated a need for provider education on utilizing medical treatments in pregnancy and the ability to evaluate the risk/benefit of treatment or stopping medications. One respondent saw a need for additional education of OB providers regarding adverse childhood experiences (ACEs) and greater collaboration across specialties.

 

Stakeholders identified maternal fear as an area of concern for the maternal populations dealing with mental health or SUD issues. Maternal fear was described in various ways including the fear of legal consequences, of having their children removed, fear of delivering in the hospital and having their baby taken from them there, and fear of seeking health care due to the concern of child protective services interference or criminalization.

 

Stakeholders identified stigma as an area of concern for the maternal population experiencing mental health or SUD issues. Responses falling into the category of stigma included a need for non-stigmatizing ways to provide prenatal care for women with SUD issues and a need for advocacy and peer recovery support to eliminate the stigma and labels for those with mental health or SUD issues.

 

Financial constraints were also identified by stakeholders as an area of concern for the maternal population experiencing mental health or SUD issues. Respondents commented on income level barriers for single non-working parents, mothers who are above the income limits but lack the financial ability to participate in private practice support groups, and lack of other community supports as barriers to service options. One respondent stated, “The cost is also a barrier for many people. Even for people who are insured the cost of seeing a provider can cost up to $60 a session which is a lot especially when you're adding up the cost to birth a child.”

 

Lack of available telehealth services was mentioned by respondents as a barrier to services for the maternal populations experiencing mental health or SUD issues. Responses regarding lack of telehealth included the need for more access to services via the internet, access to telehealth in general, and telehealth as an option to “access telehealth services for maternal care management and outreach.”

 

Suggestions to Enhance Collaborations and Partnerships to Optimize Services Provided

• Offer more services
• Increase awareness
• Increase training opportunities
• Systemic and policy changes
• Collaboration suggestions
• Increase access to health care professionals
• Enhance telehealth options

 

Respondents suggested offering more services as a way to optimize care for the maternal populations suffering from mental illness or SUD. Responses regarding offering more services included the need for more direct service providers and higher quality of services, more services for incarcerated moms, more options for services in general, specific and free support groups, easy access to services, one-stop access to a variety of services, and incorporating home visits.

 

Stakeholders identified increasing awareness to help enhance collaborations and partnerships to optimize services. Responses related to increasing awareness included making available resources “very public” for individuals and “simple to understand” and access, providing handouts for the patients to see where and how to seek help, providing information and resources to front line staff in the doctor’s office and hospital nurses, offering a database with all support groups and resources available, and providing information that is easy to find.

 

Respondents identified a need to increase training opportunities as a way to optimize services for the maternal populations suffering from mental illness or SUD. A variety of responses included a suggestion to focus on the clinic relationship (primary care before hospital care), provide free weekly case consultations for providers, and offer funding and time for trainings for postpartum providers on appropriate screenings and treatment. One respondent emphasized the need for providers to appropriately refer patients for whom they are not adequately trained to care for. Another noted the need to educate providers of the positive impacts to pregnant women specifically if referrals are made to those that specialize in working with this population because pregnancy can be a “time of motivation and success for the long-term of both mother and baby.”

 

Stakeholders identified a need for systemic and policy changes as a way to optimize services for the maternal populations suffering from mental illness or SUD. Eliminating barriers and removing the need to “have to jump through many hoops to get approved for services” was suggested. Some stakeholders’ comments regarding the need for systemic or policy changes addressed the need to move away from criminalizing SUD and approaching it as a public health issue rather than a criminal issue. Another spoke of the need to address systemic issues such as health care, education, affordable housing, parental leave and social services and identified these as underlying contributors to maternal mental health and SUD issues.

 

Respondents suggested improving the partnership between larger tertiary centers and critical access hospitals to provide better care, incorporation of cross payor collaboration to improve the overall behavioral health system, integration of case management with health care professionals to help provide women with the resources they need, and the establishment of a statewide perinatal collaborative that involves providers, third party payors, and local health departments.

 

Active collaborations/partnerships identified to address the maternal population’s needs related to mental health or SUD

 

Many stakeholders noted existing collaborations and partnerships, however, multiple respondents did not report any active collaborations or partnerships, which could indicate an area of focus for future efforts to improve service provision to the maternal population suffering from mental health or SUD issues. A total of 41 organizations were listed by stakeholders demonstrating active collaborations or partnerships aimed at addressing the maternal population’s mental health or SUD needs. These organizations represented an array of hospitals, behavioral health providers, community organizations, local and state public health, among others. These collaborations not only occur in Idaho, but across parts of Washington, Montana, and Wyoming.

 

Changes in Organizational Structure and Leadership

Since March 2020, all MCH Program staff have transitioned to hybrid schedules with office time and remote telework as a permanent, operational change due to the COVID-19 pandemic. Many staff have selected the same day of the week for their in-office time, which provides opportunities for connection and collaboration on MCH projects.

In March 2022, KD Carlson was promoted to health program manager for the Children’s Special Health Program (CSHP) and Newborn Screening (NBS) Program. She provides administrative, planning, and budgetary oversight for these programs and monitors the Washington State Public Health Laboratory contract for services. KD previously fulfilled the MCH Health Program Specialist role.

In May 2022, Claudia Coatney joined the MCH Program as the new MCH Health Program Specialist. Her responsibilities include oversight of child health initiatives, including oral health and physical activity and nutrition strategies. She supports perinatal and infant health strategies such as the MMRC and CMV education. Claudia fulfills a key role in preparing and coordinating the MCH block grant submission.

In June 2022, Aarika Adams joined the CSHP and NSB Programs as a TRS II. Her responsibilities include CSHP membership renewal, claims adjudication, PKU and NBS kit orders, and data tracking.