In calendar year 2021, PRAMS data indicated that the rate of attendance at postpartum visits was 90.7%. Iowa has focused on postpartum follow up for several years due to recommendations from the Maternal Mortality Review Committee and will continue these efforts into future years.
Postpartum care is important, not only to ensure that the mother’s body is healing well, but to ensure that that there are no physical or emotional complications or issues that have arisen since birth. This visit also serves as an opportunity to educate on topics such as breastfeeding and safe sleep now that the baby is born, as well as to offer support and referrals for any issues or stressors that have appeared since birth.
Title V Maternal Health clients already receive one postpartum visit; with a preference for a postpartum home visit. Postpartum visits include education around POST-BIRTH warning signs, if the client had not been seen during their pregnancy, they would be referred to services such as WIC to support them beyond the Healthy Pregnancy Program. Iowa HHS will continue to support local agencies’ efforts to provide postpartum visits and education. All client educational materials will be reviewed and approved by Iowa HHS staff to ensure proper education is provided to clients to serve their needs postpartum.
Iowa HHS Title V MH staff will include all requirements for local agencies specified in the strategies in the agency contract and will review implementation during site visits.
African American and Black identifying maternal health clients in four Iowa counties are offered Doula services. Doula clients receive up to 6 weeks of post-delivery support consisting of 3 visits. These visits include infant feeding education and support, breastfeeding consultation, referrals, postpartum care and recovery, and Infant health and well-being. This is a pilot project that will run through the FY25. This program allows Black and African American Title V maternal health clients to receive postpartum support and connection with someone who understands their perspectives and experiences.
During the 2024 legislative session, the Iowa legislature passed to expand Medicaid to provide postpartum coverage up to 12 months for mothers up to 215% FPL. The Title V program is working to identify what this would entail for our program's coverage, and what Medicaid would cover for different postpartum visits. The timing of when Medicaid expansion would become enacted is still pending but may impact our FY25 plans and goals depending on what we are able to have our Title V Maternal Health agencies offer. The change in FPL eligibility will also be a discussion that may impact our numbers on this performance measure moving forward. Iowa’s Title V program is fortunate to have a strong relationship with the Medicaid program and is included in the preparation and planning for implementation of the Medicaid state plan amendment.
Dental NPM: A) Percent of women who had a dental visit during pregnancy
According to PRAMS data, although the current FAD is 50.3% from 2020, 2021 data shows an increase to 54.6% of women with a preventive dental visit during pregnancy. This aligns with Iowa’s annual objective of 54% for 2023.
This increase can likely be contributed to increased dental care coordination and services provided by Maternal Health and Child Health contractors to pregnant women and a return to pre-pandemic dental office capacity for preventive dental care. Additionally, the 2020 rate may have been low due to COVID and its impact on public health services and dentistry.
Despite efforts to increase oral health education by MH and CAH contractors, many pregnant women remain unaware of the safety and importance of receiving dental services during pregnancy. This, along with the decreasing number of dentists willing to accept Medicaid-enrolled patients and limited availability of dentists willing to treat pregnant women, may negatively affect future rates.
The Dental NPM will be addressed by Iowa HHS Oral Health (OH) staff and through the I-Smile (Child and Adolescent Health) and Maternal Health (MH) programs. Oral Health education and access to dental services will be maintained or increased for women of child-bearing ages through HHS partnerships with the following programs/organizations: Count the Kicks (MH/OH promotion), Delta Dental of Iowa Foundation (funding opportunities), Iowa Primary Care Association (FQHC referrals), Oral Health Iowa coalition (advocacy), Molina Healthcare (Medicaid benefits), Title X/Family Planning (OH education and services), Iowa HHS Division of Behavioral Health (Tobacco/OH education), University of Iowa College of Dentistry (current science and research), and WIC (OH services for clients).
An HHS OH staff member has recently been assigned to serve as the MH/OH liaison. She will oversee and strengthen relationships with the MH and Title X/Family Planning programs to ensure optimal oral health remains a priority for women of child-bearing age. The MH/OH liaison will also strengthen the partnership with Count the Kicks, a program using evidence-based strategies to save babies and prevent still births, to ensure promotional materials and messaging remain relevant and useful. OH staff will continue to ensure Count the Kicks messages are shared through I-Smile oral health promotions and social media and that educational materials are distributed to MH clients and medical and dental offices while providing outreach.
The MH/OH liaison will oversee a statewide effort to increase the number of MH program participants receiving OH preventive services in partnership with the I-Smile program in FFY25. Efforts are currently underway to research promotional items and educational materials that will incentivize clients to receive OH services from the MH programs around the state. In addition, OH staff will interview I-Smile coordinators who have demonstrated success in serving MH clients to then develop a ‘best practices’ guide to share with other I-Smile coordinators.
In FFY2025, a pilot project begun in 2024 to provide enhanced oral health education within a Title X/Family Planning clinic will continue. OH staff will develop scripts for Title X clinic staff to use to provide oral health education to women who indicate they would like to be pregnant within the next year or are unsure if they want to be pregnant within the next year. Education will focus on optimal oral health before, during and after pregnancy, regular dental visits, and/or oral care for the newborn. Feedback from this project will be used to finesse protocols and messaging to ensure the maximum benefit for Title X staff and clients.
OH staff will maintain a new partnership with Molina Healthcare to increase oral health services for prenatal women and MH clients. As a Managed Care Organization for Medicaid services in Iowa, Molina offers value-added benefits for their clients to encourage optimal healthcare. Although Molina does not provide dental benefits, they are able to incentivize clients to participate in the MH program, which offers oral screenings and oral health education to encourage overall health and wellbeing during pregnancy.
I-Smile coordinators will continue to meet with the MH director for their Collaborative Service Area (CSA) on a quarterly basis to ensure local collaboration regarding improving oral health and birth outcomes for low-income women and to ensure optimal oral health for their infants. I-Smile coordinators will also be required to provide training on preventive services and dental care coordination for MH staff that provide these services to MH clients. The training ensures MH staff comprehend the significance of oral health in overall well-being and that they are equipped with the most current recommendations, policies and procedures.
In FFY25, I-Smile coordinators will make in-person visits to all dental offices in their service areas to develop positive relationships that support referrals. They will also visit all obstetrics/gynecology offices to promote optimal oral health as part of overall health. For counties that do not have an obstetrics/gynecology office, the coordinators must visit family planning clinics and/or women’s health clinics. At the dental and medical office visits, coordinators may share educational posters, promotional items and/or written educational materials to inform providers and clients on the importance of preventive dental care for the mother and baby, promote referrals to dentists and the I-Smile program, and provide education on the importance of preventive dental care before, during and after pregnancy.
Coordinators will be required to develop a health promotion initiative targeting women of child-bearing age. An example of this in past years was developing packets of materials (educational fliers, adult and infant toothbrushes, I-Smile coordinator and contact information) for medical offices to distribute at prenatal appoints to ensure the importance of oral health care during pregnancy.
OH staff will enhance the use of MH program data in FFY25 to address health equity and to better understand where targeted technical assistance or other interventions may be needed. The MH/OH liaison will use the strengthened partnership with Title X/Family Planning to identify gaps and needs throughout the state to equitably provide OH services. The data and its findings will be shared and discussed with MH contractors at annual in-person site visits and with Iowa HHS MH program staff.
Smoking NPM: A) Percent of women who smoke during pregnancy
The percent of women who smoke during pregnancy has declined. Iowa HHS has had a strong focus on maternal tobacco use over the past ten years due having a higher rate of maternal smoking than the national average (8.7 vs. 4.6, respectively). An emphasis on Iowa’s Quitline program for pregnant women and general education and screening for tobacco use likely contributed to the decline. Unfortunately, it is also possible that the reduction in smoking is in part due to an increase in other forms of tobacco, particularly vaping and other “smokeless tobacco” options that the public may have misperceptions about the safety of those products in pregnancy.
Local Title V agencies will be required to continue to connect with their local Tobacco Community Partnership grantees. Agencies are required to develop coalitions to address maternal health, and agencies whose service area reflects a higher rate of smoking will be encouraged to include local tobacco program staff in the coalition, and to identify local strategies the coalition can implement to reduce smoking in pregnant women. Title V nurses at local agencies will be required to complete the Treating Tobacco Use During Pregnancy training (formally known as Ask, Advise, Refer) and to utilize this process when working with clients who smoke. During chart audits and data reviews, Iowa HHS Title V staff will review documentation to ensure all clients who report smoking during pregnancy are provided education on smoking cessation and a warm referral to Iowa’s Prenatal Quitline program. This program includes an incentive, which clients will be educated on. State staff will continue to engage with the Iowa HHS Tobacco Use Prevention and Control program to identify innovative strategies to reduce smoking and ensure opportunities for collaboration continue to be explored.
SPM 1: Number of pregnancy-related deaths for every 100,000 live births
2021 maternal deaths have been reviewed, but the data is still being analyzed. The Maternal Mortality Review Committee are also unable to draw any conclusions from changes in the rate over the years due to small numbers, however continue to utilize recommendations from previous maternal mortality reviews. Due to many strategies implemented to reduce maternal deaths since Iowa adopted this performance measure, staff anticipate the rate to decrease over the years. Anecdotally, following a mass campaign on seatbelt safety, the most recent maternal mortality review cases did not include a single motor vehicle death where the pregnant or postpartum woman was unrestrained. While numbers of maternal deaths are too small for this to be statistically significant, the hope is to see a continued reduction in motor vehicle deaths where the woman was not wearing a seatbelt.
In FFY24, Iowa completed two Maternal Mortality Reviews for 2021 deaths. Results from these reviews will be available prior to FFY2025, and Iowa HHS MH staff will utilize recommendations from the committee to update direct care requirements for local Title V agencies. Local MH agencies will continue to provide postpartum home visits and include screening, education, and physical assessments based on the 2021 MMRC recommendations. A new requirement in FFY2023 was for local agencies to develop coalitions for their service area specific to maternal health, agencies will continue their coalitions in FFY2025. Agencies will share the new recommendations with their coalition and work on community-driven strategies to reduce the maternal mortality rate.
Local MH agencies were also required to identify a Maternal Health Director, who is at a minimum 0.5 FTEs. In FFY2025, Iowa HHS MH staff will work with the MH Directors to develop their skills in leading their coalitions to make changes in their community and to utilize local data to drive the change. Training and professional development opportunities will be shared with the MH Directors, and a minimum of one in-person meeting will be required to discuss ways to build up infrastructure at the local level to support pregnant and postpartum women and reduce maternal mortality.
Iowa HHS will continue to have a strong focus on health equity as a strategy to reduce maternal mortality, particularly disparities in Black and African American identifying pregnant and postpartum women. Iowa’s Title V Community Based Doula Project for African American Families will be implemented in the current four counties (Polk, Black Hawk, Dubuque, and Scott), with a focus on increasing the workforce and assisting Iowa Medicaid in implementing payment for doula services for Medicaid beneficiaries. In addition to general training on utilizing local program data, MH Directors will receive support in disaggregating their local agency data to identify disparities in their community, and will work with their coalitions to identify strategies to address any identified disparities.
Iowa HHS Maternal health will also be expanding their postpartum visits through one-year postpartum, to align with Medicaid Expansion. The details of what these expanded offerings will look like is still pending the Governor’s signature and Medicaid reimbursement guidance.
Title V MH staff will continue participating on the Iowa Maternal Quality Care Collaborative to receive updates on state level maternal health best practices as well as to share updates on Title V work. Staff will continue to collaborate with ERASE MM staff to implement statewide initiatives to address maternal mortality.
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