MCH Population Domain: Women/Maternal Health

National Performance Priority Area: Well-woman Care, with an Emphasis on Minority and Low-income Women– 2025 Annual Plan Narrative (October 1, 2024 – September 30, 2025):

Preventative women’s health, or well-woman care, is an important area of focus for North Dakota. Well-woman care is typically measured by the Behavioral Risk Factor Surveillance System (BRFSS) as a routine checkup--a general physical exam--not an exam for a specific injury, illness, or condition. In 2017, the percentage of women ages 18-44 with a routine checkup in the last 12 months, according to BRFSS data, was 58.1%. In 2021, that number had improved to 67.9% of women and in 2022, there was further improvement in North Dakota with 71.3% of women reporting having a routine checkup in BRFSS.

The North Dakota’s Pregnancy Risk Assessment Monitoring System (PRAMS) data is a complementary way to evaluate preventative women’s health. PRAMS provides a unique perspective, as it evaluates only those women who have given birth, which is an important subset of North Dakotan women. In 2020, 41.3% of women (46.6% of American Indian (AI) women, 41% of White women, and 42.3% of women of other races) reporting a routine checkup in the year prior to becoming pregnant. Progress is being made in North Dakota, as 45.2% of women reported a routine checkup in the year prior to becoming pregnant in 2021. AI women had the highest rate with 50.6%, compared to 44.7% of White women, and 47.5% of women of other races. 

While the improvement over time is encouraging, PRAMS data indicates that the percentage of women receiving a routine checkup in the period before pregnancy is much lower than the rates for women overall in North Dakota. This is particularly concerning as the period before getting pregnant is a critical time to seek preventative health services to ensure a healthy pregnancy. This is one of the reasons that in North Dakota, much of the focus of well-woman care is on the interpregnancy interval (IPI), the period between one birth outcome and conception of a subsequent pregnancy.

Further, preventative health care is not a single-step process, and aspects of preventative care can occur across a continuum. For example, managing mental health conditions is likely a prerequisite for seeking preventative health services. Similarly, accessing prenatal care or getting tested for Human Immunodeficiency Virus (HIV) are activities that connect a woman to the health care system and may lead her to engage in additional preventative services. Therefore, the Title V staff in North Dakota will continue to employ strategies that capitalize on connecting with women where they are, drawing them into the health system, particularly during pregnancy and in the months following.

Title V staff will focus on women who have given birth, women in the prenatal period, and those who plan to become pregnant, especially those who may have vulnerabilities to accessing care, such as having low income or facing stigma due to race and ethnicity.

Three strategies have been selected that will provide important steps toward helping women access preventative healthcare, with a strong focus on women in and around the pregnancy period.

1. Strategy one: collaborate with state-level organizations and entities to improve access to care. In 2024-2025, Title V staff will partner with Postpartum Support International (PSI), North Dakota chapter, to promote postpartum support to women who may need it.

2. Strategy two: intersect with women in pregnancy and the interpregnancy interval (IPI), to reach them at a time when they are most likely to contact the health care system. Reaching women when they are connected to the health care system in pregnancy or between pregnancies can optimize their health and potentially change the trajectory for their health across their lifetime. This creates a foundation of wellness.  Activities will include developing tailored prenatal care education materials, developing and enhancing group peer support programming, and increasing individualized support such as doula and family home visiting programming.  

3. Strategy three: partner with local Community Based Organizations (CBOs) and others to outreach to specific racial and ethnic groups or specific populations of high-need women in contact with other services. Within this strategy, there are multiple activities that will help Title V staff reach women in non-traditional settings and through other programs and partners, ensuring a wide reach of preventative health messaging.

Strategy one focuses on broad collaboration to impact women’s health across the state of North Dakota. Title V staff has been working on identifying ways to partner with pediatricians to increase postpartum depression screening rates at well-child visits. In 2023-2024, Title V staff developed a Continuing Medical Education (CME)-bearing webinar targeted to pediatricians and primary care physicians who provide well-child visits, to educate them about the importance of postpartum depression screening and how to integrate them into well-child visits. In 2024-2025, Title V staff will focus on helping providers improve referral and support for women who have a positive postpartum depression screen during their child’s well-child visit. Existing support services, including support groups available through Postpartum Support International (PSI), will be utilized to help support postpartum women in North Dakota. Title V staff will develop a communication plan to promote postpartum resources. This plan will include the life.nd.gov website, outreach to pediatric and family practice doctors, postpartum doulas, and labor and delivery discharge education strategies. Title V staff will also evaluate whether a crisis number should be listed at the top of the women’s health page and https://www.life.nd.gov/.

Strategy two is to intersect with women in pregnancy and the interpregnancy interval (IPI). In pregnancy, as mentioned above, women may be most likely to be in contact with the healthcare system. North Dakota data also suggests that, during this period, more women have insurance coverage such as Medicaid that would allow them to access preventative health services. Further, PRAMS data indicates the importance of reaching out to women during pregnancy and IPI, to build a bridge between pregnancy-related care and critical preventative services.

The activities that will be conducted for strategy two include:

• Developing and providing tailored prenatal education to immigrants that meets their specific cultural needs, is in their preferred language, and addresses preventative care and transition to primary care.
• Enhancing and developing new peer support programs, such as group prenatal care and postpartum/parenting support groups.
• Increasing the availability of individualized support such as doulas and working closely with home visiting programs.
• Exploring the ‘hand off’ between the obstetric provider and the primary care physician.
• Exploring opportunities to incorporate men’s health, such as a family health night, to promote family-centered health.

Pregnancy provides a unique opportunity to reach women who may not otherwise connect with the health care system. During this time, women may also be seeking information to help answer their questions about pregnancy and the health care system’s process and services. Continuing activities started several years ago, Title V staff will support development of prenatal education materials tailored to the needs of specific groups, in collaboration with the Refugee Health Services program. Educational materials will help build women’s confidence in what to expect during pregnancy, can alert them to symptoms such as postpartum depression, can make them aware of resources available such as doulas and postpartum Medicaid coverage, and can remind them to make an appointment with their primary care physician for preventative care.

Title V staff will continue to support the development of group prenatal and postpartum programs, including multiple programs that were previously supported over the last two years:

1. Elbowoods Memorial Health Center, located at Three Affiliated Tribes in North Dakota began a group prenatal care program in 2023-2024, and Title V staff will continue to provide support and evaluate the number of women served.
2. In early 2024, two programs launched to serve indigenous pregnant women: the Mni Wichoni program launched prenatal health circles serving women in the Standing Rock Reservation area and Sacred Pipe, a nonprofit serving urban American Indian women in Bismarck/Mandan, launched the ‘Turtle’s Nest’ group prenatal care program. In 2024-2025, these programs will be evaluated and expanded.

During the postpartum period, support is also critical to improve women’s outcomes and increase their likelihood of getting preventative care in the year following giving birth. Postpartum doulas could be a particularly important way to support women after giving birth and could help ensure postpartum symptoms such as hypertension are identified and addressed, provide lactation support, screen for postpartum depression, and provide the general emotional support needed to move women through this particularly vulnerable period. In 2021, Title V staff began to explore training opportunities, Medicaid reimbursement models, and partnership opportunities to expand postpartum doulas in the state. In 2023-2024, Title V staff worked regularly with the Medicaid Director to identify potential barriers to Medicaid reimbursement for doulas in the state and participated in a state-level workgroup with the Foundations for a Healthy North Dakota to develop policy recommendations for doulas in North Dakota. Further, several postpartum doula programs were launched to improve the availability of postpartum doulas in North Dakota. Title V staff identified three populations that would benefit from postpartum doulas most: LGTBQ2S+ communities, immigrant populations, and indigenous people in North Dakota. Therefore, in 2023-2024, several postpartum doula training programs were launched:

1. Title V staff provided funding to the New American Consortium in Fargo, to train up to 10 immigrant community members who wish to professionalize their work with postpartum persons.
2. Title V staff partnered with the Community Engagement Unit’s BeYOU board, which advises on LGTBQ2S+ work in the state, to identify 1-3 people who would like to train as postpartum doulas as well.
3. Title V staff connected funding from a local Rotary club to the Indigenous Association to train indigenous postpartum doulas in North Dakota.

The training for these postpartum doulas is still under development. In 2024-2025, Title V staff will support the trained postpartum doulas to help them become certified. State-level workgroup participation will continue, and ways to provide funding and technical assistance to those who have already completed training to become postpartum doulas will be identified.

While supporting postpartum doula training in the state, Title V staff will also continue to look for opportunities to support upskilling and cross-training for family home visitors, peer support specialists, and community health workers, who can all provide important support to postpartum persons.

The third and final strategy Title V staff will use is to partner with local CBOs, Title X Family Planning, other Title V initiatives, and additional partners to expand the reach of preventative messages, conducting outreach to specific racial and ethnic groups or specific populations of high-need women in contact with other services.

Activities in strategy three will include:

• Partner with community-based organizations (CBOs) to reach women belonging to specific racial and ethnic groups, to pilot ROSE (Reach Out, Stay Strong, Essentials for mothers of newborns), a postpartum depression prevention program.
• Develop a plan for working better with other partners in the Healthy and Safe Communities Section (HSC) office, including Women’s Way, Title X Family Planning, Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and the Alternatives to Abortion program. In 2024-2025, Title V staff will submit a request for technical assistance to develop a strategic plan across all entities that work with maternal child health in the Healthy and Safe Communities Section.
• Partner with Title X Family Planning on two efforts:
  1. Providing funding and technical assistance for Upper Missouri District Health Unit (UMDHU) for regular outreach clinics in Dickinson.
  2. Conducting a large quality improvement project beginning in Spring 2025, to improve postpartum depression screening and referral.

Title V staff has worked closely with ethnic-led CBOs every year to reach specific racial and ethnic groups and to support increased preventative screening. Title V staff has found that these organizations are highly effective at tailoring messaging and methods to improve women’s care among racial and ethnic groups in North Dakota. Postpartum depression has not been addressed specifically among racial and ethnic groups in North Dakota, despite the possibility that it is impacting these women at a higher rate. The ROSE program (Reach Out, Stay Strong, Essentials for mothers of newborns) is an evidence-based program that has been shown to reduce cases of postpartum depression by half among low-income women. In 2024-2025, Title V staff will provide Title V funding to 1-3 organizations to pilot this program. This work will set a foundation for the new Title V plan, which will include a postpartum-related priority starting in 2025-2026.

In 2024-2025, Title V staff will develop a strategic plan to ‘work as one’ across partners addressing maternal health. For example, other Title V partners, Title X Family Planning, the Alternatives to Abortion program, WIC and Women’s Way are providing programming to improve maternal health in North Dakota, often by partnering with the same grantees and with overlapping objectives. By being more intentional in partnering with these existing programs, Title V staff can expand its reach. A Title V Technical Assistance Request will be developed to fund a facilitator for a day-long workshop that will bring partners together to develop a strategic plan.

In 2024-2025, Title V staff will collaborate closely with Title X Family Planning staff and identify ways to enhance the existing PHQ2 and PHQ9 screenings to identify clients who may have depression. To ensure accurate diagnosis, effective treatment, and follow-up, an Internal Medical Audit (IMA) will be completed in Spring 2025. Any findings from the IMA will be shared at the Fall 2026 Subrecipient Directors’ meeting. The findings will be used to make changes and improve quality by offering optional "mini grant" application for service sites to apply for in 2026-2027.  

Title V staff will provide training to Title X staff on setting up a referral program to decrease barriers and challenges in clients accessing services. For example, a regular Lunch and Learn series and continuing education will increase staff knowledge and ensure high-quality bidirectional referrals. Title X staff will continue to improve their assessment skills of clients’ circumstances and potential barriers and assist clients in problem-solving, therein increasing their ability to access referral services. 

In addition, UMDHU will continue providing family planning services in the southwest corner of the state, utilizing Title V funds and technical support. UMDHU will provide an outreach clinic in Dickinson at least once per month, adding an additional day per month if the need arises. UMDHU will also offer outreach and support throughout the community by attending community events and meeting with local providers and clinics.

Title V staff will use these strategies to improve women’s preventative health care across North Dakota. The team will include a state-level approach, collaborating with a variety of partners to improve preventative health statewide. In particular, the team focuses on pregnancy and postpartum, to reach women at this particularly vulnerable time period when they are most likely to contact the health system. The broad state-level strategies will be combined with more targeted efforts to reach specific subpopulations in North Dakota. Many of the activities in the plan focus on postpartum depression, which will create a foundation for this new priority area, to be developed in the next five-year Title V plan.