Women/Maternal Health

Plan for the application year: Oct 2024 - Sept 2025

The NPM for the Women/Maternal Domain is the percent of women, ages 18 through 44, with a preventive medical visit in the past year. Areas of need for the women’s domain include prevention of substance misuse among women of childbearing age, connection to behavioral and mental health information, resources, and services, mitigating the impact of ACEs through enhanced social supports and safe, and healthy relationships. NPM 1 continues to be the best indicator for WCFH work in the women’s domain, given that much of the Section’s efforts involve supporting providers who care for women. Women who receive preventive medical care are more likely to receive screening and intervention related to priority needs including substance misuse, mental health needs, and exposure to interpersonal violence.

The ESM, among people who had Medicaid during their pregnancy and recently delivered a live birth, percentage who had a postpartum checkup for themselves, brings an equity approach to efforts to increase access to an important preventive care opportunity for women and birthing people. In addition to the importance of assessing a postpartum person’s physical and emotional recovery following birth, the postpartum visit also serves as an important opportunity to consider future preventive health needs, particularly since experiences during pregnancy can be a window to the person’s overall health (Ramos, ACOG, 2022). Collectively, strategies in this domain are expected to improve access to preventive care for women and birthing people from populations that experience inequitable access. The postpartum visit is of particular importance to promote and track due to its timing in the perinatal period and the key reproductive, behavioral health, and future preventive health care topics that should be addressed at that time in a person’s life. Additionally, Alaska's maternal mortality review program provides evidence of mortality disparities for BIPOC birthing people during the postpartum period, particularly due to violent causes including suicide. The postpartum visit is a key opportunity to prevent these deaths through screening and referrals to services, comprehensive care, and culturally safe, trauma-informed care environments that facilitate access and engagement in healthcare services by Indigenous and other minority women and birthing people who belong to historically traumatized and/or marginalized populations.

NPM Strategies:

1.1: Collaborate with community-based partners to provide patient navigation and health education information about women’s health to disparate populations.

The Alaska Breast + Cervical Screening Assistance Program (AK Breast + Cervical), the State of Alaska’s CDC-funded breast and cervical cancer screening program located in WCFH, pays for cancer screening and diagnostic services for Alaskans ages 21-64 with incomes < 250% FPL. AK Breast + Cervical maintains approximately 150 formal agreements with private and publicly funded screening and diagnostic providers to enroll and screen eligible Alaskans. The program coordinates closely with Alaska Medicaid to assure a seamless transition in coverage of costs for enrollees referred for cancer treatment. People who have not had cervical cancer screening in over five years are 60% more likely to be diagnosed with cervical cancer, and those with low household incomes are more likely to not have received a Pap test in over five years. To increase cervical cancer screening rates, AK Breast + Cervical will continue to partner with outreach and screening navigators, community organizations, and non-traditional partners.

AK Breast + Cervical maintains contracts for community outreach and screening navigation in four regions of the state that are population hubs with low screening rates. These contractors will provide educational opportunities to the public, barrier relief (e.g., transportation, language assistance), and assistance with accessing appointments. In addition, AK Breast + Cervical will continue to support Public Health Nursing’s efforts to spread the word about this program throughout the state. To support health care providers in their efforts to provide high quality care, AK Breast + Cervical is developing professional development and training opportunities in areas such as communication and trauma-informed care. Furthermore, AK Breast + Cervical will expand their work with health care providers on quality improvement efforts to improve screening rates among patients seeking care at Alaska’s community health centers and private practices (see NPM 1.2 below). Finally, AK Breast + Cervical will continue to seek opportunities to engage with non-traditional partners. Supporting all this work is data analysis and visualization through GIS technology to track screening rates, changes based on geography, age, race, socio-economic status, and other relevant factors.

AK Breast + Cervical activities, which focus on increasing cervical cancer screening rates in Alaska, help connect underserved and high-risk populations with health care providers who can then screen for and address other health concerns, including ACEs, substance use, and other risk and protective factors in the person’s life.

1.2: Identify and partner with public and private providers statewide to improve and expand their preventive health services through ongoing quality improvement models.

The AK Breast + Cervical Program is in the fifth year of health systems interventions to increase clinic-level screening rates for breast and cervical cancer screening. The clinics participating in the quality improvement projects have shown increases in screening rates.

Staff in WCFH working in both the AK Breast + Cervical and Family Planning Programs will continue their collaborative contract with Mountain Pacific Quality Health (MPQH, a quality improvement specialist) to improve women’s access to preventive health services. In year 5 of this contract, MPQH will continue to identify additional private healthcare practices that provide services to people who are un/underinsured, whose income is at or below 250% of the federal poverty level, and those who are rarely or never screened for breast and cervical cancer. MPQH will work with those providers to better understand the populations served (addressing health equity and social determinants of health), and to identify best practices and use data to measure improvements in family planning and related preventive health services (e.g., breast and cervical cancer screening) visits. Since family planning and contraceptive needs are a main driver for individuals in their reproductive years to seek any medical services, improvements in electronic patient management systems that result in better serving all preventive health needs of these individuals when they do seek family planning services will allow providers to address other emergent health concerns (e.g., substance use, ACEs, behavioral health needs, and unhealthy relationships).

Improving connectedness between providers and their patients on an ongoing, routine basis also helps preserve the continuity of health services. Maintaining this connectedness, as well as connecting more individuals with medical homes, can help practices more quickly integrate routine preventive services for their patient populations, as well as address any emergent health needs that occur during a disaster response. See the “cross-cutting issues” section for more discussion.

1.3: Collect, analyze, and disseminate data on women’s preventive healthcare visits and other health issues among women of childbearing age (e.g. PRAMS and BRFSS).

During 2016-2022, the Alaska PRAMS Phase 8 survey collected data on receipt of health care visits by adult women in the 12 months before getting pregnant, including regular check-ups at their family doctor’s office or their OB/GYN’s office, or visits for family planning or birth control. The Phase 9 survey, which launched with 2023 births, also includes a similar question. Both the Phase 8 and Phase 9 surveys also include follow up questions about the content of the pre-pregnancy healthcare visits, in addition to questions about receipt of postpartum care and questions regarding the content of those healthcare visits. Alaska PRAMS will continue its ongoing data collection operations throughout FFY 2024-2025. Results from these questions will continue to be made available in response to individual data requests, as well as through the online PRAMS Data Visualization Tool which launched in early 2024.

As part of the annual Title V Needs Assessment update process, Alaska PRAMS and Title V epidemiologists will continue to monitor the results of the PRAMS survey questions, as well as the results of the Alaska BRFSS question related to having a preventive healthcare visit in the past year. If warranted (for example, if the rate shows a significant or sustained decline or if MCDR identifies a number of maternal deaths that may have been prevented with improved preventive healthcare) and as resources permit, the Section will disseminate information and associated public health recommendations through a variety of formats.

Using data from PRAMS, BRFSS, and other sources, the CSTE fellow will develop and publish a series of data sheets on women’s health, with each data sheet focusing on a specific topic area or indicator. The purpose of these publications will be to increase provider and public awareness and understanding of key risk factors affecting women’s health in Alaska, and current practice recommendations for improving Alaska women’s health. Key data points will include percent of women with a past year preventive health visit, unintended pregnancy, breast and cervical cancer screening rates, and key risk factors for maternal morbidity. These indicators will be stratified by relevant demographic categories, which may include region of residence, age, and race.

1.4: Engage hospitals and birthing facilities in data-driven, collaborative quality improvement focused on reducing severe maternal morbidity in partnership with the Alaska Perinatal Quality Collaborative (AKPQC).

The Substance Affected Pregnancies Initiative (SAPI) was a dyad-centered initiative that engaged Alaska hospitals in collaborative quality improvement following the Institute for Healthcare Improvement Breakthrough Series model. In December 2023, SAPI concluded data collection and transitioned into a sustainment phase over the spring of 2024.

With input from the AKPQC Steering Committee and the Alaska Maternal Child Death Review program, the AKPQC identified obstetric hemorrhage as the primary area for the next quality improvement cycle. Currently, the AKPQC is actively developing preliminary documents for a change package and a comprehensive measurement plan for this forthcoming initiative. The change package and measurement plan will undergo thorough review and refinement by Faculty Members and the AKPQC Steering Committee to ensure its relevance and feasibility. The upcoming year will focus on recruiting and launching this third initiative. The aim is to officially initiate this new endeavor in the fall of 2024.  Additional details regarding supplemental funding, both awarded and potential, can be found in SPM Strategy 1.1 of the Perinatal Domain.

The AKPQC has been primarily hospital-based since inception, but there has been participation from midwives and outpatient providers via such channels as the Alaska Birth Transfer Initiative, the Perinatal ECHO series, and the annual AKPQC & MCDR Joint Summit. Continuing these efforts will provide an opportunity for Alaska to expand participation beyond the Labor/Delivery, Postpartum, and Neonatal time periods.  With the upcoming initiative, there is potential to extend involvement beyond birthing hospitals, particularly when considering the inclusion of other healthcare service providers in the development of the change package. This expansion could significantly enhance the reach and impact of AKPQC's efforts in improving perinatal and maternal health outcomes across diverse care settings.

The AKPQC remains committed to sustaining the Alaska Birth Transfer Initiative, which has been dedicated to enhancing the integration of midwifery services and facilitating transfers from planned community births (whether at home or in freestanding birth centers). Alaska consistently has the highest proportion of community births in the US, underscoring the importance of ensuring that community birth providers are seamlessly integrated into the broader healthcare system, with easy access to consultation, smooth transfer of care, and emergency transportation when needed. Historically, the AKPQC partnered with hospitals, freestanding birth centers, and midwifery practices to establish local transfer committees, promote standardized, evidence-based guidelines for transfers/transports, and to develop systems and processes for protected multidisciplinary case reviews. Currently, there are five communities or regions participating in this initiative – Juneau, Mat-Su, Anchorage, Homer, and Fairbanks. The AKPQC Coordinator will continue to host a quarterly meeting of the providers and hospitals who participate in this initiative. Sustained communication and collaboration are pivotal to advancing this important work, even after the conclusion of active quality improvement efforts.  Potential strategies over the coming year include hosting a repository, such as a Teams channel, to hold resources for committee members, along with presentations using public health data.

Looking ahead, the AKPQC will establish a Patient Advisory Council (PAC) by the end of 2024, aimed at engaging individuals with lived experience in enhancing all facets of care involved in the birth process. Though this effort was described in the prior year’s application plan, delays in the State procurement process prohibited progress on this work until this year.  The goal is to ensure representation from both rural and urban areas of the state, thereby guaranteeing an equitable voice in the improvement process. The PAC will convene periodically to offer input on AKPQC activities and initiatives. Embracing the philosophy of "nothing about us without us," the AKPQC places high value on the insights and perspectives of families, recognizing their integral role in shaping the future of perinatal and maternal healthcare in Alaska.  See NPM Strategy 5.3 of the Perinatal Domain for additional details regarding the AKPQC Patient Advisory Council.

1.5: Disseminate information (e.g., PSAs, presentations, fact sheets, etc.) about risk and protective factors that support behavioral health and reduce the impact of ACEs among women of childbearing age.

The ALCANLink project developed a pre-birth household challenges screening tool. This tool uses underlying predictive models derived from the PRAMS data linked to child welfare and education outcomes. Based on household experiences during approximately the 12 months before birth of a child, this was developed to be administered to pregnant people in the clinical setting. Funding to quantify accuracy, utility, and acceptability when implemented is being sought. Casey Family Programs has expressed interest and is currently reviewing a funding proposal.  (Please note - the application link above is provided for context but should not be used, shared, or considered final.)

Given the prevalence of mental health conditions and interpersonal violence as factors in maternal deaths, MCDR analysis of risk and protective factors includes those related to behavioral health and safety. MCDR will continue dissemination activities including poster presentations, live presentations, written reports, and fact sheets. The program also shares information, data, and committee recommendations upon request to help inform direct services activities and policy. Building upon a successful site visit in Fairbanks in May 2024, the new Mental Health Clinician position which supports MCDR plans to travel to communities around the state in the upcoming year to conduct maternal health listening sessions and engage with local communities on topics related to maternal mortality, which will likely include the impact of ACEs. She will also share information about risk and protective factors with statewide audiences virtually through Perinatal ECHOs, at conferences, and through other venues.

The Section will continue to support Division-wide effort to implement activities to address high rates of congenital syphilis in Alaska. Some of these efforts overlap with efforts to address the impact of ACEs, including disseminating information about factors that support behavioral health and social determinants of health.

1.6: Support the development of a comprehensive, trauma-informed, culturally responsive workforce.

WCFH will support workforce development that promotes responsiveness to the needs of communities – particularly those experiencing disparities - through partnerships with persons with lived experience and community-based organizations serving populations that experience disparities.

Funds from the Office of the Assistant Secretary for Health’s (OASH) award to implement MCDR recommendations to prevent maternal mortality from violence channels resources to community-based organizations will focus on the provision of culturally matched birth support. Through conference presentations, the AKPQC and other contacts, MCDR and other WCFH staff promote shared understanding of and support for the role of doulas – particularly culturally matched birth support persons - as a part of a comprehensive perinatal care team.

The Alaska Perinatal ECHO series and the AKPQC & MCDR Joint Summit educational opportunities are instrumental in equipping professionals with the knowledge and skills needed to provide sensitive, culturally competent care. By actively promoting and participating in these events, WCFH will contribute to fostering a workforce that is well-prepared to address the diverse needs of our community, particularly in the perinatal and maternal health spheres. The next summit will take place in spring 2025.

The Title V MCH Director continues to be the lead Section Chief related to workforce development activities for the Division of Public Health. In partnership with the University of Alaska-Anchorage, the Division partnered to create the Alaska Clearinghouse of Continuing Education (CACHE). Continued promotion of this resource for continuing education will continue, including women’s and maternal health providers. 

WCFH will continue to request HRSA TA funds to support provider and staff training as appropriate, including topics which support development of workforce capacity to serve patients who belong to all of the diverse and intersecting cultures and identities found within the Alaska perinatal population.

1.7: Continue to partner with Medicaid and department leadership on extending postpartum coverage to one year.

On February 1, 2024, Medicaid postpartum coverage was extended from 60 days to 12 months noting an important achievement in access to care related to maternal health. WCFH will continue to leverage connections with providers and community partners to widely share up-to-date information to educate all impacted groups about the extension and how it will be operationalized. Additionally, through partnership with Medicaid and the MCH Epidemiology Unit, maternal and infant health outcome measures must continually be monitored over time to assess utilization and impact. The MCH Epi unit will continue to include variables on Medicaid eligibility/enrollment, including when analyzing maternal health outcomes, PRAMS data on postpartum healthcare visits, and NPM performance. Findings will be shared with Medicaid partners, providers, and others to provide information about implementation of postpartum Medicaid extension and any observable impacts on maternal health.

MCDR will continue to use Medicaid data to supplement vital records information for maternal mortality case ascertainment efforts. In addition to identifying issues causing cases to be missed, this quality assurance activity helps to ensure that all pregnancy-associated deaths among Medicaid beneficiaries receive a multidisciplinary case review. When available, MCDR will provide data about Medicaid access in maternal mortality cases and share recommendations which support or suggest improvements as relevant to implementation of extended coverage.

1.8: Promote access to sexual and reproductive health services for all Alaskans in their communities.

WCFH awarded Title X Family Planning Services Grant funds to two sub-recipient agencies for the SFY24-28 grant cycle (7/1/23-6/30/28): Kachemak Bay Family Planning Clinic (KBFPC) serving the Central and Southern Kenai Peninsula, and Identity Health Clinic serving the greater Anchorage area. Both agencies will provide comprehensive sexual and reproductive health and related preventive health services to individuals within their respective service areas and collaborate with other local health and social services providers and agencies to assure wrap-around care and reciprocal referrals to meet their clients’ specific needs, including behavioral/mental health support services, substance use screening and referral, and preventive and primary health care services.

MCDR’s OASH award for the prevention of maternal mortality from violence supports workforce development for doulas, with an emphasis on doulas culturally matched to populations who experience violence and mortality disparities. The care from full spectrum doulas encompasses prenatal, birthing, and postpartum support and includes information and support to increase access to postpartum healthcare services. Culturally matched doula support can increase access for people who have experienced medical trauma, oppression, or other barriers to care.