Section III.E.2.c State Action Plan Narrative by Domain

MCH Population Domain: Women/Maternal Health

National Performance Priority Area: Well-woman Care, with an Emphasis on Minority and Low-income Women– 2024 Annual Plan Narrative (October 1, 2023– September 30, 2024):

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 number of women ages 18-44 with a routine checkup according to BRFSS data was 58.7%. In 2021, that number had improved to 70.9% of women. Aside from lower numbers in 2020, progress is being made toward increasing preventative care in North Dakota to reach the national average of 75.5% of women having a routine checkup.

In addition to BRFSS, the North Dakota’s Pregnancy Risk Assessment Monitoring System (PRAMS) data has been used to evaluate progress for preventative women’s health in North Dakota. PRAMS assesses women in the months after giving birth. According to 2018-2019 North Dakota PRAMS data, 37.9% of women (44.8% of American Indian women, 37.4% of White women, and 39.5% of women of other races) reported having a “routine” check-up in the 12 months prior to becoming pregnant. In 2020, this number increased to 41.3% (46.6% of American Indian women, 41.0% of White women, and 42.3% of women of other races). While the improvement over time is encouraging, the number of women receiving a routine checkup in the period before a pregnancy is much lower than the number of women 18-44 with a checkup in the last year overall. 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, particularly the months after a woman gives birth.

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 in pregnancy and in the months following.

The areas highlighted below are the strategies that the Title V team will be focusing on in Federal Fiscal Year 2024 (FFY24). To create successful strategies for the upcoming year, the team took a step back, evaluating efforts implemented over the last few years. Without changing the overall scope of the work, staff recategorized the action plan. Many of the ‘strategies’ listed in the plan in previous years were being implemented as specific activities. Therefore, the team renamed the strategies to better capture the overarching processes they reflect. Doing this, the team identified three broad strategies, under which all other work falls as activities.

Each strategy provides precursory and critical steps to preventive health care across the continuum of care and ultimately lead to improved preventative health for women:

1. Strategy one: collaborate with state-level organizations and entities to improve access to care. Activities will include promotion and evaluation of the new extended Medicaid coverage for postpartum women, developing a strategic plan with the North Dakota Maternal Mortality Review Committee (MMRC), and developing a state-wide task force to address preventative health for women.  

2. Strategy two: intersect with women in pregnancy and the inter-pregnancy interval, 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. It 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 other 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. Within this strategy, there are multiple activities that will help the team 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. Entities with state-wide impact such as Medicaid, the MMRC, and the state-level task force all have the ability to impact women’s health across North Dakota, and result in state-wide changes for women’s health. Medicaid and MMRC have been a focus of many women’s health campaigns across the nation, due to their potential to have widespread impact. The Title V team is partnering with North Dakota Women’s Network to create a state-level task force to help address preventative health care and disseminate preventative health information to women who may otherwise be difficult to reach with traditional, main-stream messaging.  

There is widespread understanding that extending Medicaid coverage is a strategic way to provide better access to preventative health care. In 2022, Medicaid financially supported 2,098 births in North Dakota, which was 22% of all babies born in the state. Moreover, Medicaid in North Dakota covers a disproportionate share of women in underserved populations. According to 2020 PRAMS data in North Dakota, nearly 69% of American Indian (AI) respondents reported utilizing Medicaid as their primary insurance; in contrast, just 17% of White respondents and 35% of “other races” respondents listed Medicaid as their health insurance. The high coverage among AI women as compared to their White counterparts suggests that extending the Medicaid postpartum coverage will also disproportionately improve the health of minority groups.

Extending Medicaid into the period after birth will allow a greater number of women to access critical preventative services during a particularly vulnerable time-period in their lives, when coverage rates are higher. This initiative was a high priority for North Dakota in the 2022-2023 plan and it was successfully implemented on January 1, 2023.

Activities that will be conducted in FFY24 related to the Medicaid extension include:

• Working closely with the Communications team to ensure dissemination of materials and efficacy of the state-wide media campaign around the Medicaid extension. With the Public Health Emergency coming to a close, and state-level changes in Medicaid administration, it will be particularly important to publicize this new coverage, to ensure all eligible women have access.
• Evaluation of the initiative to extend Medicaid postpartum. It will be important to ensure women are accessing services available to them through the enhanced Medicaid coverage.

Many of the activities throughout the plan, including those in strategies two and three, leverage the increased access to preventative services provided through Medicaid extension postpartum, and their effectiveness will be increased by this strategy within the plan.

Another activity of the Title V team in FFY24, is to partner with the North Dakota MMRC. The MMRC was officially mandated in the 2021 legislative session in North Dakota. It was created in close partnership with the Department of Health and Human Services (NDDHHS). One activity the team will conduct in 2023-2024 is creating a strategic plan with the MMRC, which will support closer alignment between the Title V team and the MMRC, enhancing its impact. The plan will create a framework for when reviews should take place, committee composition, and the dissemination of report findings annually. This activity will lead to improved impact as the root causes of poor maternal outcomes can be identified and addressed. 

Partnership with Sanford to develop a HRSA grant application to develop a maternity home model is an important activity for the Title V team. The Sanford Health System has a significant impact on North Dakota’s overall health and wellbeing. Nearly half of the babies born in the state are birthed through Sanford and many of the highest risk women are treated in this system. If awarded, the grant would significantly improve birth outcomes for women in North Dakota. Collaboration with Sanford is a high priority for the Title V team, and staff time will be designated to supporting their efforts. The current plan will be considered along with the Title V priorities in developing the application. Should Sanford be awarded, the Title V team will help support their project plans and will work to enhance collaboration and partnership with Sanford across the state.

The final activity the team will work on in FFY24 in strategy one is helping to develop a state-wide women’s task force. A women’s task force comprised of agencies focused on women’s health across the state will be convened by North Dakota Women’s Network. The goal of the task force is to increase the percentage of women who have an annual preventive health visit among the low income and/or minority population.

Strategy two in the FFY24 plan is to intersect with women in pregnancy and the postpartum periods. In pregnancy, as mentioned above, women may be most likely to be in contact with the healthcare system. North Dakota data also suggests that more women have insurance coverage such as Medicaid that would allow them to access preventative health services. Furthermore, the new postpartum extension initiative in North Dakota makes additional services for preventative health available and more accessible to women who have just had a baby.

North Dakota’s data suggest the importance of reaching out to women during pregnancy and the postpartum period, to build a bridge between pregnancy-related care and critical preventative services while the women may be most likely to have Medicaid coverage. Further, during the pregnancy period and when giving birth, there is a higher likelihood for women to be engaged with the medical system, offering a unique opportunity to connect women with preventative care.

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 home visiting, doulas, and prenatal advocate programs.
• Exploring the ‘hand off’ between the obstetric provider and the primary care physician.

Pregnancy is 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. Therefore, in 2022, the Title V team convened a group to begin developing prenatal education materials that were tailored to the needs of specific groups, such as new immigrants arriving from Ukraine. No materials were available that specifically addressed concerns faced by the diverse immigrant populations in North Dakota during pregnancy. The group paused their efforts due to changing staff and shifting workloads, and the work will begin again in FFY24, in collaboration with Refugee Health Services at NDDHHS. 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.

The Title V team has been excited to explore and advance the use of peer support programs to reach women during pregnancy and postpartum. Group prenatal care, partnership with family home visiting programs such as Family Spirit and Community Health Representative (CHR) programs, and postpartum/parenting groups will be explored and expanded in FFY24 to reach women. In 2023, a new group prenatal care program launched at Sacred Pipe, a nonprofit serving urban American Indian women in Mandan, North Dakota. In FFY24, this program will be evaluated. Further, Elbowoods Memorial Health Center, located at Three Affiliated Tribes in North Dakota also wishes to begin a group prenatal care program in FFY24. These programs allow women to get support in a more culturally appropriate way, from fellow women, while also getting prenatal care.

A group peer support model in the postpartum period is also an important way to ensure women stay connected to the health care system, are screened for postpartum depression, and get information about remaining healthy between pregnancies. In FFY24, the Title V team will look for ways to partner with peer support postpartum programming, such as partnering with Postpartum Support International (PSI) which has a new chapter in North Dakota. Further, the team will help launch a postpartum parenting support program at Spirit Lake Nation. This program will bring women together in a group for support and education. Screening for depression and supporting women to obtain other preventative services will be incorporated into the program.

In addition to group-level peer support, individualized support is also an important way to reach women during the pregnancy and postpartum period. As mentioned above, supporting women in the prenatal period is an important area of focus for the Title V staff, since during this time, some women wish to connect with the health care system but may be hesitant to get the support they need.

In 2022-2023, an innovative Prenatal Care Advocate program was launched for Indigenous women of the Spirit Lake Nation. The program is currently providing individualized support for pregnant women in Spirit Lake. This program aims to provide support and education to women who may be unwilling or unable to seek care through a traditional clinic. In FFY24, Three Affiliated Tribes is exploring replicating the program and the Title V team will assist.

Doulas are another way to provide individualized support. Title V staff began to explore the trainings, Medicaid reimbursement models, and partnership opportunities to expand postpartum doulas in the state in 2022-2023. Building a bridge between doulas and obstetric providers was identified as an important way to expand doula access. In particular, obstetric providers identified a gap in services between when a woman gives birth and when she returns for follow up care at about six weeks postpartum. A postpartum doula could help support a woman during this particularly vulnerable postpartum period, ensuring postpartum symptoms such as hypertension are identified and addressed, providing lactation support, and giving women the emotional support needed. In FFY24, the team will finalize and evaluate a pilot doula program, specifically working with the immigrant community to identify immigrant doulas who wish to professionalize their work. The pilot project will identify these women and train them as doulas. Obstetric providers will be identified to support the new doulas and help integrate them into the health care system. Further, the team will explore the potential to leverage doulas or other peer support in the prenatal period to specifically focus on prevention of behavioral health concerns that could develop in the postpartum period, such as the evidence-based ROSE program for preventing postpartum depression.  

Family home visiting is an important way to provide individual support to women across the state.  Family home visiting programs across the state reach hundreds of women that may not otherwise be contacting the mainstream health care system. Further, evidence-based programs are available to provide culturally appropriate materials to specific women; for example, Family Spirit is designed for American Indian women. These programs offer an important place for postpartum depression screening and promotion of preventative health. The Title V team will continue to look for opportunities to partner more closely with existing home visiting programs in FFY24. One opportunity may be to integrate Family Spirit training/curriculum into existing programs, or to explore partnering within an incarceration setting to bring better support to pregnant women in the North Dakota penitentiary.

The third and final strategy Title V staff will use is to partner with local CBOs, Title X Family Planning, other initiatives within Title V, and other 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:

• Work with the Women’s Task Force to develop/disseminate information through non-traditional settings.
• Partner with ethnic-led CBOs to reach women belonging to specific racial and ethnic groups.
• 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 and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).
• Encourage Pediatricians to screen and refer more women for postpartum depression, when they bring their child for well-child visits.

The impact of strategy two relies on strategy three, as the most women will be reached during pregnancy and interpregnancy interval if effective strategies are used for outreach. Strategy three leverages other Title V partnerships, projects within Title X, and other community partners to reach women wherever they are.

Reaching women in non-health-related settings may be an important way to inform them about preventative health. One goal of the new Women’s Task Force is to develop communication strategies and materials to increase the understanding of importance and availability of preventive health care resources in North Dakota. The task force will strategically partner with pilot sites to assist in disseminating materials to women via non-traditional routes for preventative women’s health education, such as food banks, ethnic grocery stores that reach specific groups of women, and shops such as thrift stores and Dollar Stores. The percentage of women receiving women’s preventative health educational materials is measured as Evidence-Based Strategy Measure (ESM) 1.4. This year, it is expected that this number will be improved dramatically from last year, as this extensive collaboration will allow many more organizations to help the Title V team reach more women.

The Title V team has worked closely with ethnic-led CBOs every year, to reach specific racial and ethnic groups, to support increased preventative screening, ESM 1.3. The last three years, the team has used participatory grant making, a process where applicants divide grant money among themselves after orally sharing their project proposals with one another. Over the last three grant cycles, participants have built on the projects of the year before, adding complexity to their project design, improving their follow-up with participants, and enhancing their partnership with local resources, such as health centers. In FFY24, the Title V team may choose to do this strategy again or may collaborate with the same partners as the past, to continue to expand the success of current grantees.

In FFY24, the Title V team will identify partners that are reaching women through other programming. For example, other Title V partners, Title X Family Planning, WIC and Women’s Way are all providing programming that reaches women in North Dakota. By being more intentional in partnering with these existing programs, the Title V team can expand its reach.

The team will explore partnerships and relationships between Family Planning Clinics, Women’s Way agencies and WIC offices across North Dakota to ensure a collaborative approach to greatly enhance well women care across the state.

North Dakota state staff will present to program and clinic staff with information on programming and set up a referral program to decrease barriers and challenges to improve knowledge and linkage about programs. The Title V team will work with other programs to provide high-quality bidirectional referrals by assessing individual clients’ circumstances, identifying potential barriers, and helping them to problem-solve and reduce all barriers, therein increasing their ability to access referral services. 

In addition, in FFY24, the Title V team will request technical support to build a strategic plan for reaching women through other programs. This strategic plan will provide a roadmap for intentional partnership across existing programs in the Healthy and Safe Communities Section (HSC) at NDDHHS. In future years, this plan could be expanded to include other programs outside of the HSC, including other programs within the Division of Public Health, and even programs in other Departments, such as the Department of Commerce or Department of Transportation which reach hundreds of women across the state.

The Title V team has been working on identifying ways to partner with pediatricians to increase postpartum depression screening rates at well-child visits. Studies revealed barriers for pediatricians to integrate postpartum depression screening in well-child visits including the lack of time and inadequate knowledge. The team is developing a webinar targeted to pediatricians to educate them about the importance of postpartum depression screening and the process to integrate the screening into the well-child visits. The team also will be working with the University of North Dakota (UND) to develop Continuing Medical Education (CME) credits for the webinar. This webinar will be an important tool to overcome the lack of knowledge barrier among pediatricians and to help them identify ways to integrate the screening and referral into the well-child visit more easily. The goal is to place the webinar in some upcoming local conferences with medical and public health attendance. Previously, referring women with positive screens may have been challenging, as time-limited Medicaid coverage may have prevented a woman from following up. With new extended coverage postpartum, follow up and treatment will be more possible.

In the FFY24 plan, the Title V team will use three strategies and a variety of activities to improve women’s preventative health care across North Dakota. The strategies are all interconnected and intertwine to reach the women who most need improved preventative care. Strategies impact women from a variety of angles, including state-level, local/community level and individual level. The team focuses on collaboration and strategies that impact women across a continuum of care, particularly in pregnancy and the postpartum periods. Diversity among populations of women in North Dakota is increasing, and the strategies used by the team will ensure all women are reached.