Ongoing Needs Assessment Activities

The Bureau of Assessment and Evaluation (BAE) leads the collection, analysis, and interpretation of public health maternal child health data at the Arizona Department of Health Services. BAE’s mission is to serve as a resource to all stakeholders so that programs and partners make data-driven decisions that provide equitable opportunities for achieving optimal health for all children, women, and families in Arizona. BAE provides technical assistance and expertise on: data analytics, data management, epidemiology, program evaluation, public health assessment, and surveillance.

In addition, ongoing assessment activities help identify emerging and continuing needs for Arizona’s MCH populations:

• Maternal Mortality Review (MMR): The MMR as a subcommittee to the Child Fatality that started in June 2012 to review all identified maternal deaths in the State of Arizona. ADHS staff work hand in hand with members of the MMRC to complete maternal mortality reviews, develop recommendations to prevent maternal mortality and severe maternal morbidity, disseminate findings to the public, and implement quality improvement initiatives for clinical and non-clinical providers. Currently the committee has completed reviews on maternal deaths from 2017-2019 and have started reviewing 2020 deaths. Multiple topical reports and infographics have resulted from these activities to provide stakeholders with updated information on maternal mortality in Arizona.

• Child Fatality Review (CFR): The Arizona Child Fatality Review (CFR) Program’s goal is to reduce child deaths in Arizona by conducting a comprehensive review of all child deaths to determine what steps could have been taken, if any, to prevent each child’s death. In 2020, 838 children died in Arizona, an increase from the 777 deaths in 2019. The leading causes of death were prematurity, congenital anomalies, motor vehicle crashes, poisonings, and firearm injuries. Prematurity was the most common cause of death for neonates (infants less than 28 days old) while suffocation was the common cause of death among infants 28 days to less than 1 year of age. The program’s latest report can be found here.

• Behavioral Risk Factor Surveillance System (BRFSS): The Arizona Behavioral Risk Factor Surveillance System (BRFSS) telephone survey has been in existence since 1984 and is partially funded by the Center of Disease Control and Prevention (CDC). This surveillance collects data from Arizona adults aged 18 and over living at home. The Title V Program has supported the BRFSS in its implementations of the Adverse Childhood Experiences questionnaire, the family planning module, and the social determinants of health module. The outcome of these questions is shared with the Home Visiting programs to support their professional development and program implementation strategies.

• Pregnancy Risk Assessment Monitoring System (PRAMS): PRAMS is a collaborative research project between ADHS and the CDC.  PRAMS surveys women who have recently given birth and provides cross-sectional approach data, across Arizona’s diverse maternal population, on factors such as low birth weight, preterm birth, ante/postpartum obesity, mental health, COVID-19, breastfeeding, and starting August 2022, social determinants of health. AZ PRAMS aims to obtain data of high scientific quality on maternal behaviors before, during, and shortly after pregnancy that can be used to monitor health status as well as allow ADHS to more effectively tailor preconception, pregnancy, and postpartum services and programs to Arizona’s diverse population. This knowledge across the state population of new mothers is necessary to monitor the progress of state and non-governmental program efforts to improve the quality of maternal and infant health services. More information on PRAMS can be found in the Women’s Health domain.

• Neonatal Abstinence Syndrome (NAS): BAE performs data analysis and produces a monthly report based on available NAS data and the latest case definition provided by the Council of State and Territorial Epidemiologists (CSTE). BAE has used administrative datasets to research infant substance exposure and NAS since 2018, and the findings consistently support the need for improved surveillance and interventions in this area. BAE is part of an internal agency workgroup to implement the CSTE NAS Standardized Case Definition more broadly and build our capacity to address the suspected cases and the non-opioid cases.

• Home Visiting Data: BAE supports the Home Visiting Efforts-to-Outcome (ETO) Data System. ADHS holds the enterprise contract for the ETO which includes all demographic and programmatic data across four (4) home visiting programs (Healthy Families, Nurse Family Partnership, Health Start and High Risk Perinatal) funded across three (3) state agencies (Arizona Department of Health Services, Arizona Department of Child Safety and First Things First which is Arizona’s Early Education and Health Board). BAE supports home visiting programs at ADHS to build reports within the system, work as a liaison with the data management system TA team, and assists in identifying ways to utilize the data collected across programs. BAE also supports home visiting with the data team that assists with data entry and quality assurance for the Health Start home visiting program.  For the Maternal, Infant and Early Childhood Home Visiting (MIECHV) Program, BAE reviews the annual report data across 6 benchmarks and 19 constructs. This includes coordinating data sharing with the Arizona Department of Child Safety to access information pertaining to enrolled participants that had a substantiated case of child abuse, neglect or maltreatment for federal reporting.

• Prenatal and postnatal care assessment: ADHS's latest Maternal Mortality and Severe Maternal Morbidity Report shows that Severe Maternal Morbidity (SMM) rates were worse among Arizonan women who received late, inadequate or no prenatal care. SMM rates were also worse among women living in rural counties, with longer driving distances and times to care, and living in areas where more women are uninsured. BAE will conduct a more focused needs assessment related to access and utility of prenatal and postpartum care in Arizona.

• Healthy Smiles Healthy Bodies Oral Health Study: The Office of Oral Health led and BAE supported the implementation of an oral health study to assess the current oral health status of Arizona’s elementary school children, through a statewide stratified oral health survey of kindergarten and third grade children in Arizona’s public schools. The study was paused in 2020 due to COVID-19 and continued during the 2021-2022 school year. Data collection will continue during the 2022-2023 school year in order to complete all schools that were part of the original sample.  Information will be shared with the CDCs National Oral Health Surveillance System and used to develop recommendations and policy direction for the improvement of children’s oral health.

• Adverse Childhood Experiences (ACEs) Surveillance: BAE established an agency wide work group with prevention and preparedness epidemiologists on creating dashboards to report the prevalence of ACEs using the National Survey of Children's Health data and the Behavioral Risk Factor Surveillance System data which includes risk factors and protective factors. This includes visual representations to show groups differences of ACEs prevalence by demographics, healthcare access, subjective health status, and lifetime diagnoses. Using those data sets, the bureau also completed a trend analysis to see changes in the prevalence of ACEs in children (2016-2020) and adults (2014-2020) populations, using the aforementioned data sets. BAE is working to have a team of ADHS staff to help ADHS transition to a trauma informed agency and also collaborating with researchers at ASU and Midwestern University to develop a public report on positive childhood experiences. The office is planning to do root cause analysis to explore factors associated with ACEs in Arizona.

Changes in the health status and needs of the state’s MCH population

The following sections focus on changes to the health status of MCH populations in Arizona and presents data from two recent morbidity and mortality reports. Morbidity and mortality data provide critical health status information, highlights noticeable disparities, and provides direction for public health programming. In addition, each MCH population lead provided information on emerging issues that prompted BAE to conduct additional assessments. These emerging issues were presented to programmatic staff to update the block grant action plan.

Maternal Health

Maternal Mortality

The MMRC identified 203 maternal deaths between January 1, 2016, and December 31, 2018, of which they determined that 23% (n=46) were Pregnancy-Related deaths, with the remaining being either Pregnancy-Associated but not Related (68%, n=138) or Unable to Determine Relatedness to Pregnancy (9%, n=19). The 2016-2018 Pregnancy-Associated Mortality Ratio was 80.6 and the Pregnancy-Related Mortality Ratio was 18.3 deaths per 100,000 live births in Arizona for women ages 15-49. American Indian or Alaska Native women had the highest Pregnancy-Associated Mortality Ratio (PAMR) at 140.4 deaths per 100,000 live births (based on fewer than 20 cases; interpret with caution). The PAMR was 105.0 for White, non-Hispanic women, 116.5 for Black or African American (based on fewer than 20 cases; interpret with caution), and 41.5 for Hispanic or Latina women.

The majority of Pregnancy-Associated deaths (50.0%) occurred between 43 days to 365 days after the end of the woman’s pregnancy; of these 85.0% were determined to be preventable. Nearly a third of Pregnancy-Associated deaths (31.3%) occurred within 42 days of the end of pregnancy, and 76.0% of deaths during this period were considered preventable. Nearly 1 in 6 Pregnancy-Associated deaths (16.4%) occurred while the woman was still pregnant; this period had the highest proportion of preventable deaths at 91.0%. Among Pregnancy-Related deaths, the majority of deaths (64.5%) occurred within 42 days of the end of pregnancy, of which 80.0% were determined to be preventable.

For Pregnancy-Related deaths, the MMRC assigned an underlying cause of death, or the disease or injury that initiated the chain of events leading to death or the circumstances of the accident or violence which produced the fatal injury. The two most common underlying cause categories among Pregnancy-Related deaths were Cardiovascular, Coronary, or Cerebrovascular Conditions (25.8%) and Conditions of Pregnancy (22.6%), which includes Amniotic Fluid Embolism, Preeclampsia, and Eclampsia.

Maternal Mental Health and Substance Use-Related Deaths

In Arizona, approximately 30-40 women die within 365 days of pregnancy each year from a mental health- or substance use-related cause.The MMRC determined that almost half (48.8%) of all Pregnancy-Associated deaths and 30.4% of Pregnancy-Related deaths were related to mental health conditions or substance use disorders. The majority (59.6%) of Pregnancy-Associated deaths related to mental health conditions or substance use disorders occurred between 43 and 365 days postpartum. The majority of deaths were among White, Non-Hispanic women (61.6%), followed by Hispanic (20.2%), American Indian/Alaska Native (11.1%) women, and Black/African American (5.1%). The biggest disparity when comparing the proportion of deaths to live births was among American Indian/Alaska Native women. Almost half (49.5%) of all deaths were among women aged 20-29 years old and 42.4% of deaths were among women 30-39 years old. The MMRC determined that 98% of deaths were preventable. The 2016-2018 substance use death (n=84), the MMRC determined that 1.9% had used at least one type of Opiate (e.g., Heroine, Fentanyl, Methadone), 54.8% had used at least one type of Sympathomimetic (e.g., Methamphetamine, Cocaine), 32.1% had used a type of GABA Agonist (e.g., Barbiturates, Alprazolam), 27.4% had used Alcohol, and 27.4% had used Marijuana.

Maternal Deaths and COVID-19 Infections

In 2020, Arizona reported a total of 29,951 COVID-19 deaths of which 41% were among females.  Recent investigations of 2020 Arizona death records have shown that 9 of 84 (10.7%) potential pregnancy-associated deaths (i.e., women 10-60 years of age who were pregnant or pregnant within 365 days) had a confirmed or probable COVID-19 infection at the time of death. An assessment of vulnerable populations, such as women of advanced maternal age, indicated that a higher proportion of women 36 to 60 years of age passed away with an indication of COVID-19 (67%) as opposed to women with the same characteristics but without an indication of COVID-19 in the death records (40%). A higher proportion of deaths also occurred among females ages 10-60 years who were either American Indian/Alaska Native or Hispanic with an indication of COVID-19 in comparison to females of the same characteristics without an indication of COVID-19 (78%, 59% respectively). 

Data from PRAMS demonstrated a high proportion of women adopting behavioral strategies to prevent COVID-19 infection in 2020. Survey results indicated that the most implemented behaviors were washing hands for 20 seconds with soap and water, covering coughs and sneezes with a tissue or elbow, masking, kept 6-foot distance from others in public, used alcohol-based hand sanitizer, and avoided gatherings involving more than 10 people, all of which were reported by more than 95% participating mothers. Although still extremely high, the least adopted preventive measure by women was the avoidance of visitors inside their own home, with 92.1% of women interviewed always or sometimes conducting this behavior.

PRAMS also indicated that healthcare-seeking behaviors among pregnant women were impacted due to COVID-19. Mothers reported canceling or delaying their prenatal care appointment because they either were afraid of being exposed to COVID-19 (10.2%), had to self-isolate due to possible COVID-19 infection (9.2%), or because the provider's office was closed or had reduced hours due to the pandemic (14.0%).

Infant and Child Health

Infant Mortality

Overall, Arizona’s infant mortality rate remained stable from 2011-2018. Arizona’s infant mortality rate has decreased 6% from 5.2 deaths per 1,000 live births to 4.9 deaths per 1,000 live births in 2020. This is the lowest infant mortality rate reported since 2016 of 5.2 per 1,000 live births. The Arizona infant mortality rate has consistently been lower than the U.S. rate. Black/African American and American Indian/Alaska Native infants have consistently had the highest rates of infant mortality from 2011-2020. In 2020, the infant mortality rates for Black/African American and American Indian/Alaska Native were 12.7 and 7.9 deaths per 1,000 live births, respectively. In comparison, the infant mortality rates for Hispanic and White infants were 4.2 and 4.1 deaths per live births, respectively. All infant mortality rates, except for Hispanic infants, increased with the highest rate increase for American Indian infants of 29.5% from 2019 to 2020.

Congenital Syphilis

In Arizona, there is an outbreak of syphilis among women and babies, a bacterial infection that is usually spread by sexual contact. Medical providers are seeing the largest increase of syphilis cases in women and newborns. Since 2015, the yearly average of syphilis cases in women has increased. The number of babies born with syphilis doubled each year. In 2020, up to 40% of untreated syphilitic pregnancies resulted in stillbirth or newborn death; of the 119 babies born with syphilis in 2020, 11 died. In the year 2021, of the 116 babies born with syphilis, 10 babies died. Syphilis in pregnant women can cause miscarriage, stillbirth, and infant death. Babies who survive can have irreversible damage to the skin, bones, joints, eyes, ears, and brain. Early detection and treatment can prevent devastating lifelong health consequences.

Developmental Screenings

Developmental screenings for infants and toddlers in well-child visits with a health care provider are an integral part of promoting healthy growth and development of children. During these visits, doctors monitor and screen for delays or problems in the child’s development. These screenings can lead to early detection of developmental disabilities, which can then lead to better treatments and improved outcomes in adulthood for children with autism or attention deficit hyperactivity disorder (ADHD). A delay in detection of developmental disorders is a missed opportunity to provide services and interventions that reduce costs and burdens associated with developmental disorders. The percentage of children ages 9-35 months whose parents completed a standardized developmental screening tool in the past 12 months (2-year estimate) decreased from 28.2% to 24.9% from the years 2018 to 2010 in Arizona. This is lower than the national average 39.9% in 2020.

Prematurity

Prematurity was the leading cause of death for infants 0-27 days while suffocation was the leading cause of death among infants 28 days to less than 1 year of age in 2020. Arizona’s prematurity mortality rate increased by 12% from 22.4 per 1,000 live premature births in 2019 to 25.2 per 1,000 live premature births in 2020. Black/African American infants made up 19% of prematurity deaths, but only comprised 6% of the total births. While there are numerous risk factors that can contribute to prematurity deaths (preterm labor, no prenatal care, hypertension), the most commonly identified risk factors were poverty (52%) and premature rupture of membranes (PROM) (34%). The Arizona Child Fatality Review Program determined that 8% (n=19) of prematurity deaths were preventable.

Sudden Unexpected Infant Deaths

Sudden Unexpected Infant Death (SUID) is the death of an infant less than 1 year of age where the cause of death was not apparent prior to a death investigation. In 2020, there were 53 SUIDs (Suffocation n=41; Undetermined n=11 and other injury n=1). While there are numerous risk factors that can contribute to SUIDs, the most commonly identified risk factors were unsafe sleep environment (100%), objects in sleep environment (92%), unsafe sleep location (85%), and poverty. Nine percent of SUIDs occurred in neonates (infants less than 28 days) (n<6), and 91% of SUIDs occurred in post-neonates (infants >28 days but <1 year of age) (n=48). The Arizona Child Fatality review program determined that 100% of the SUIDs were preventable. Black/African American infants were disproportionately affected. Black/African American infants made up 19% of SUIDs but only make up 6% of the total population. Overall, Arizona’s SUID rate decreased 20% from 0.81 deaths per 1,000 live births in 2019 to 0.65 deaths per 1,000 live births in 2020. Additionally, Arizona’s unsafe sleep environment rate and suffocation rate have decreased from 2011 to 2020.

Child Mortality

In 2020, the Child Fatality Review reported that a total of 838 child deaths took place. The child mortality rate in Arizona saw an increase by 8.1% for the children ages 0 to 17 years. The mortality rate of the children ages 1 to 17 and 15 to 17 also saw an increase of 24% and 19% respectively. In 2020, CFR teams determined 396 child deaths were probably preventable. The data shows that 8% of natural deaths (n=39), 100% of accidental injury deaths (n=232),100% of suicides (n=49), 100% of homicides (n=53), and 79% of undetermined deaths (n=23) were preventable. The CFRP determined that there were 12 direct COVID-19 deaths in 2020 and 29 indirect COVID-19 deaths in 2020. While 58% of direct COVID-19 deaths occurred in children ages 0-11 years, 79% of indirect COVID-19 deaths occurred in children ages 12-17 years. Of the COVID-19 direct deaths, in 83% of the deaths, the manner of death was natural, while 8% were accidental, and the remaining undetermined. The majority of indirect COVID-19 child deaths were among White (38%) and Black (31%) children.

Overall, the child mortality rate for all racial groups increased from 2019 to 2020. American Indian/Alaska Native and Black/African American children have consistently had the highest rates of child mortality from 2011-2020. In 2020, the child mortality rate for American Indian/Alaska Native children was 57.4 deaths per 100,000 children and among Black/African American children was 53.2 deaths per 100,000 children.

Adolescent Health

Adolescent Mortality

The adolescent mortality rate in 2020 was 19.7. and 53.5 deaths per 100,000 for children between the ages of 10 to 14 and 15 to 17, respectively. The adolescent mortality rate for children ages 15-17 increased by 19% from 44.8 deaths per 100,000 children in 2019 to 53.5 deaths per 100,000 children in 2020. The majority of male adolescent deaths are between age 15 to 17 (17%) compared to females of the same age (6%). In adolescents 10 to 14 years of age, motor vehicle crashes were the leading cause of death (21%) and poisoning was the leading cause of death for the adolescents ages 15 to 17 years.

In 2020, there were a total of 49 suicides death reported. This was a 30% increase in suicide rate from 2019 to 2020. Of the suicides, 71% were male and 29% were females. CFR reported that the majority of suicides 65% (n=49) occurred in children ages 15 to 17. Among suicides, strangulation (51%) was the leading cause of death for children ages 10-17 years followed by firearm injury deaths (37%).

American Indian/Alaskan Native, Black/African American and White children were disproportionately affected. American Indian/Alaskan Native, Black/African American and White children made up 16%, 8% and 43% of suicides but only make up 6%, 5% and 41% of the total population, respectively. The leading causes of suicide deaths among children ages 10 to 17 were strangulation (51%), firearm injury deaths, poisoning, suffocation and motor vehicle crash. While there are numerous risk factors that can contribute to the 2020 suicide rate, the most commonly identified risk factors were relationship problems (69%), access to firearms (37%), history of maltreatment (37%) and child mental health disorder (37%).

The Title V Program will consider creating an interagency taskforce for adolescent health so state agencies can bring awareness to mental health disorders, discuss, align and coordinate as applicable. This includes tracking the schools/demographic of the schools that training is provided for professionals on bullying prevention to make sure that the most vulnerable are being reached. There is also planning to expand Mental Health First Aid to include Mental Health First Aid for Youth mental health certification training for youth, not just adults, and expand ADHS trained mental health first aiders to be trained in youth mental health first aid and offer training to schools and youth. There is also a plan on increasing mental health providers who are focused on youth mental health in areas with low access making sure they are familiar with cultural norms surrounding these areas and mental health.

Adverse Childhood Experiences (ACEs)

Adverse Childhood Experiences refer to specific kinds of adversity and traumatic events during childhood and adolescence (0-17 years). ACEs impact the health, wellbeing, and quality of life for children, families, and communities in Arizona. The number of Arizona children with two or more ACEs is significantly higher than in the U.S. as a whole. In Arizona children ages 12 to 17, 44.4% have experienced two or more ACEs, compared to the national average of 30.5%. As children age, the number of those who have experienced two or more ACEs increases. It is estimated that nearly 70,000 Arizona children have more than five ACEs. The growing body of knowledge about ACEs offers suggestions about how Arizona can respond and make a positive impact on its citizens' lives.

Children and Youth with Special Health Care Needs (CYSHCN)

CYSHCN are children who have a chronic medical, behavioral, or developmental condition that has lasted or is expected to last 12 months or longer and need prescription medications and/or specialized therapies. Approximately 1 out of 5 children in Arizona is CYSHCN. Based on findings from the 2020 Title V Needs Assessment, and in collaboration with statewide MCH partners, Arizona defined two priorities above to focus the programmatic efforts over the five-year reporting cycle. The priorities are to strengthen systems of care to advance inclusivity and promote equitable and optimal outcomes for children and youth with special health care needs, and to engage individuals, families, and communities as partners in the development and implementation of programs and policies to create people-centered programs that promote health equity. Using data for 2019 and 2020 from the National Survey of Children’s Health, we determined the prevalence and predictors of flourishing among Arizona children and adolescents ages 6–17. A three-survey question included indicators of flourishing: children’s interest and curiosity in learning new things, persistence in completing tasks, and capacity to regulate emotions. The rate of CYSHCN that meet all three flourishing items was 35.4% compared to 28% for their non-CYSHCN counterparts and 36.6% for CYSHCN who meet 2 and 1 flourishing item respectively. This shows that 67.4% of families of non-CYSHCN report their child is flourishing compared to 35.4% of families of CYSHCN children.

Components of a well-functioning health care system include family partnerships, medical home, early screening, early access to services, and preparation for adult transition. In 2019-2020, the percentages of CYSHCN (6.2%) and Non-CYSHCN (15.9%) receiving well-functioning system care were lower. The rate of CYSHCN that did receive care in a well-functioning system in 2020 (6.2%) decreased from the 2019 rate (13%). The vast majority of children and youth with special health care needs (CYSHCN) in Arizona (93.8%) did not receive care in a well-functioning health care system.

Cross-Cutting

Oral Health

The percent of women who had dental work during their pregnancy was at 34% during the year 2020 which is slightly lower than 2019. In order to achieve that, there has been an increase in the number of inter-agency partnerships implemented to coordinate dental services for pregnant women and children and also a number of medical, dental and other healthcare professionals who receive perinatal oral health education. Since 2015, the state of Arizona has seen a decrease in percent of children, ages 1 through 17, who had a preventive dental visit (75.6%). This indicates that 3 out of 4 children in Arizona (age 1 to 17 years) had a preventive dental visit. The goal is to get that percentage increased to 81% by year 2025. The percentage of children ages 0 through 17, who are continuously and adequately insured in 2020 was 62.5% in Arizona compared to 64.9% in the U.S. During the years 2019-2020 in Arizona, there was a higher percentage of children ages 6 to 11 years old that received one or more preventive dental care visit (86.5%) in the past 12 months compared to the older and younger kids who were 63.2% and 80.4% for the children age 0 to 5 years of age and 12 to 17 years of age respectively.

Future Assessments

BAE will continue to collaborate with the Title V Program and the Bureaus of Nutrition and Physical Activity and the Bureau of Chronic Disease and Health Promotion to identify leverage points for collaboration and to better understand the intersectionality of Arizona’s MCH populations. In addition to the MCH epidemiology workforce BAE’s structure includes epidemiologists in violence and injury and chronic disease along with the PRAMS, BRFSS, and YRBSS programs. The structure of BAE will allow for more robust and integrative assessments to inform the Division of Prevention Services and the Title V Program.