NPM #1 Well Women Care – Improve pre-conception, prenatal and postpartum health care services for women of childbearing age

The Office on Women’s Health (OWH) will continue to provide education and resources to promote well woman care, including the distribution of WOMEN: Take Charge of Your Health publication and the My Health Tracking Card and continuation of the Women’s Health Network listserv. The WOMEN: Take Charge of Your Health publication includes information on topics such as preventive health, preconception health, obesity prevention, breastfeeding, postpartum depression, and disease prevention. It will be updated as needed to include evidence-based information, resources, and recommendations from experts and leaders in women’s health, including hotlines like 988, tobacco quitline, and the domestic violence hotline. This resource is also available on the Department of Health and Senior Services (DHSS) website at www.health.mo.gov/womenshealth. The WOMEN: Take Charge of Your Health publication is now available in English and Spanish and can be accessed online and in print. The next printing of the book will include a QR code to a survey. This survey will collect data on what participants learned and how they used the resource. The My Health Tracking Card provides a means to track blood pressure, cholesterol, and weight. Resources are provided to the general public, local public health agencies (LPHAs), and others who contact the OWH or visit the website. The Women’s Health Network listserv comprises organizations and individuals concerned with women’s health. The Network’s purpose is to provide timely information about current issues in women’s health, such as changes to services for women, changing technology in women’s health, available resources, training opportunities, events and funding opportunities. The Women’s Health Network newsletter will be distributed at least two times a month.

The Missouri Women’s Health Council will continue to meet quarterly. The Council is an advisory group comprised of thought leaders with expertise in women’s health and the broad range of factors that affect health outcomes and wellbeing. Council members are appointed by the DHSS Director and reflect the geographic diversity of Missouri. The council is charged with informing and advising DHSS regarding women’s health risks, needs, and concerns and recommending potential strategies, programs, and legislative changes to improve the health and well-being of all women in Missouri. The council consists of women from a variety of professions, including health care providers, researchers, healthcare administrators, social workers, and directors of critical social services foundations serving women throughout Missouri. The council will conduct strategic planning to align with the DHSS strategic plan. This will help focus the efforts of the council to better support the OWH.

The Office of Dental Health (ODH) will continue to educate mothers and children about the importance of oral health for their overall health and well-being during pregnancy and throughout the lifespan, including the promotion of dental visits during pregnancy. This education takes place through literature developed by the ODH and the Missouri Dental Association. These materials are distributed to women via an ongoing successful collaboration with the Women, Infants, and Children (WIC) Program and the Title V MCH funded Home Visiting programs. Materials are also distributed via LPHAs, Federally Qualified Health Centers (FQHC), dental offices, and at community outreach events.

The ODH is piloting a program to provide funding through the LPHA WIC office to provide oral health education and supplies, fluoride varnish and a warm hand off to a dental provider. The LPHA staff encourages the mother to keep the appointment by emphasizing the importance of oral care during pregnancy. The LPHA will track the referral outcomes to determine the impact of the initiative. The ODH currently has contracts with three LPHAs. As funding allows and if more LPHAs are interested, the ODH will expand the contract to grow this important initiative.

The ODH is contracting with Uzazi village in Kansas City to provide dental care to pregnant and postpartum women. Uzazi village is a non-profit organization that provides perinatal health care to racially diverse, underserved, pregnant women who are served by Medicaid. A dental provider in the area has agreed to provide dental care two days a month and will serve an average of eight women a day. ODH is coordinating the donation of the larger dental equipment needed for the clinic and the purchase of smaller equipment and supplies. Medicaid will be billed for the dental services provided..

Community Health

The MCH Services Program will continue to contract with LPHAs to support a leadership role for LPHAs at the community level to promote the health of mothers and infants by assuring prenatal, delivery, and postpartum care for low income, at-risk women:

• Twenty LPHAs have selected to improve pre-conception, prenatal, and postpartum health care services for women of childbearing age as their Priority Health Issue (PHI).
• One LPHA has selected to prevent and reduce obesity among women of childbearing age as their PHI.
• Four LPHAs have selected to prevent and reduce smoking among women of childbearing age and pregnant women as their PHI. These LPHAs will continue to increase efforts to assess smoking and offer smoking cessation resources and programs. Outreach efforts will continue to engage community partners and providers to increase collaborative education efforts and resource sharing, and strengthen referral networks.
  • The Ozark County Health Department developed Quit Kits that include tobacco cessation education and resources and are provided to local medical providers and WIC staff to distribute to women of childbearing age that have been identified as using tobacco. The health department plans to develop a method of follow-up to measure impact.
  • The Chariton County Health Department is collaborating with the WIC office to screen and identify women of childbearing age that are smoking. All pregnant women participating in WIC are screened for smoking status. Those identified as smoking are referred to a nurse who administers the Smoking Cessation and Reduction in Pregnancy Treatment (SCRIPT) Program. SCRIPT is an award-winning, evidence-based program shown to be effective in helping pregnant women quit smoking. SCRIPT is designed to integrate into a setting that provides routine prenatal care or home visiting services and is designed to meet her where she is. A woman receives “A Pregnant Woman’s Guide to Quit Smoking” booklet, a video screening of “Commit to Quit”, and a brief 10-15 minute counseling conversation intended to spark her confidence and desire to quit smoking. The health department is coordinating with the WIC visit to minimize the number of visits the woman has to make to the office. Currently, the health department has four women actively participating in SCRIPT.
  • The Perry County Health Department is working to expand the Baby and Me Tobacco Free (BMTF) Program into their WIC Program, which screens women of childbearing age for smoking status. This will allow the health department to provide on-site smoking cessation resources for women of childbearing age. The BMTF Program is an evidence-based smoking cessation program proven to reduce the burden of tobacco on the pregnant and postpartum population. Essential elements of the program are individualized counseling using 1:1 facilitation, biomarker feedback to test for tobacco use, and contingency management with the use of vouchers toward diapers and baby wipes. Since October, 2022, 44 women have been screened for smoking status at their WIC appointment. Currently the program has two active participants. The health department will continue working to increase community awareness of this program by strategically placing billboard messaging close to a busy intersection in town as well as next to one of the largest manufacturing plants that employs over 1600 individuals. Three messages have been used so far, with analytics provided by the billboard company showing an average of 1,409 daily impressions and 157,900 impressions over the course of three months.
  • The Adair County Health Department has collaborated with the WIC Program to implement the BMTF tele-health option for pregnant and postpartum women. The WIC program screens and refers pregnant women to the BMTF Program via an online referral form. Once the referral is made, a BMTF telehealth counselor reaches out within three business days. The health department receives status updates once the referral is complete. Each telehealth participant receives a personal carbon monoxide (CO) monitor known as the iCOquit Smokerlyzer. The device connects to a user’s smartphone via Bluetooth. After the breath test is completed, the results are instantly accessed by the participant and sent to a dashboard account that allows counselors to view CO level readings in real time. Since implementation in March, 2023, 40 WIC participants have been screened for smoking status, with five being referred to BMTF telehealth support; two of those referrals are actively enrolled.
• Two LPHAs selected to decrease the number of women with a recent live birth who experience frequent postpartum depressive symptoms as their PHI and one LPHA has selected to improve mental health care services for women of childbearing age. These three LPHAs will continue to work collaboratively to increase community awareness of postpartum depression, increase educational opportunities to providers and community members, and increase the awareness, adoption, and implementation of evidence-based postpartum depression screening tools.
  • The Callaway County Health Department collaborates with the WIC Program to screen postpartum participants using the Edinburgh Postnatal Depression Scale (EPDS) screening tool and provide referral and resources to mental health services as needed. The screening tool is available in English and Spanish. If the woman scores above a 10, she is referred to a mental health provider and contacted weekly to ensure the referral was successful. The health department is planning to expand to offer screenings to all postpartum women who visit the health department for other services. So far in FFY2023, the health department has screened 59 mothers and referred 12 of them to mental health providers and services.
  • The Springfield-Greene County Health Department, NEST Partnership, began utilizing a Community Health Worker in September 2022 as part of the Community Health Advocate Program to increase the number of pregnant and postpartum women that have awareness and access to in-home case management services. NEST stands for NUTURE, EMPOWER, SUPPORT, and TEACH. NEST Partnership provides nurse case management for at-risk prenatal and postpartum women or families with young children. Services are delivered in the home during scheduled visits for nurse assessment, intervention, education and collaboration with health care providers. In addition, an online, HIPAA compliant referral form that outside agencies can utilize to refer to the NEST was implemented in November 2022 and 11 referrals have been received so far.
• Ten LPHAs have selected to ensure women of childbearing age receive an annual preventative well visit. Some will be changing organizational practices to include well-woman care as part of the services offered at their health departments while others will be collaborating with local FQHCs to screen and refer for services.
  • The Howell County Health Department is working to increase the number of women who receive an annual preventative visit. An electronic medical record was implemented in September 2022 that sends appointment text reminders immediately after the appointment is made and one day prior to the appointment. Transportation is provided at no cost using Health Tran, a service that allows the health department to schedule rides with local taxi services. In addition, to increase awareness of the importance of a woman’s annual exam and services offered at the health department, an educational flyer was created and put in a local mailer that is distributed by mail to approximately 14,200 homes, businesses, and dorm rooms, covering five zip codes in Howell County.
  • The Madison County Health Department is working to increase the number of women of childbearing age that have insurance coverage for women’s health services. Staff have been trained to screen women of childbearing age for insurance coverage and provide education on available services as well as help them to complete the insurance application process. A Community Health Worker was hired in 2023 and has been trained to assist. In FFY2023, 246 women of childbearing age have been screened for insurance coverage and 200 of these women were insured; 19 had private insurance and 181 had Medicaid. Of the 46 women uninsured women, 36 women received assistance with the Medicaid application process from nursing staff and/or the Community Health Worker.
• Two LPHAs have selected to reduce racial disparities and ensure Black women of childbearing age receive preconception, prenatal, and postpartum health care services. These LPHAs plan to work closely with their internal and external partners, including but not limited to local hospital labor and delivery units and universities within their medical training programs at the .
  • The St. Louis County Department of Public Health has developed a birth justice policy to include screening pregnant women to determine the need for doula and home visiting nursing care with the intent of building trust in the healthcare system. This may result in improved birth outcomes. This policy is currently in the editing phase and will be presented to Administration after an MCH Lived Experience Advisory Board is developed and can review and provide feedback on the proposed policy.
  • The City of St. Louis Department of Health is working to develop inclusive, culturally congruent care models and policies specific to implicit bias that OBGYN clinical staff, including physicians and nurses, will implement into practice as a required annual training.

The MCH Services Program will also support LPHA efforts to provide education on the importance of adequate dental care and overall oral health. LPHAs will collaborate with partners to provide screening, referral and direct provision of preventive dental services, and increase the number of women receiving a preventive dental visit during pregnancy. LPHA and/or community partner efforts to implement education programs for pregnant women, families, and providers on the benefits of delivery after 39 weeks gestation, the risks of preterm delivery, and the risks associated with a cesarean birth will also be supported.

The TEL-LINK Program will help improve MCH by providing health care service referrals to increase access to care for any Missourian who needs assistance. The program promotes this service through search engine campaigns to provide outreach to the underserved population. TEL-LINK will partner with tobacco control programs, WIC clinics, dental care providers, and more to provide referrals on a wide range of services, such as smoking cessation, dental care providers, WIC clinics, mental health treatment centers, health insurance providers, and many more.

The Newborn Health Program will continue to partner with a variety of community health providers to raise awareness/educate the MCH population on MCH resources for women of childbearing age and their families, including preconception, prenatal, and postpartum care, smoking cessation, postpartum mood disorders, and the importance of taking folic acid. The program will accomplish this through the free distribution of the Pregnancy and Beyond books and a wide variety of educational materials. All of these resources contain information to improve pre-conception, prenatal, and postpartum health care services for women of childbearing age. The program will track the distribution of these materials and obtain feedback from partners on how they use the materials and ways to improve them. The Healthy Births and Babies (HBB) Unit will continue to utilize and promote an informal MCH internal work group and maximize outreach opportunities at conference exhibits, webinars, virtual baby showers, health fairs, and through the Home Visiting programs by distributing various educational materials.

The Missouri Women, Infants, and Children (WIC) Program will promote the importance of depression screening utilizing the Patient Health Questionnaire-2 (PHQ-2) for prenatal, breastfeeding, and non-breastfeeding woman. The purpose of the PHQ-2 is not to establish a final diagnosis or to monitor depression severity, but rather to screen for depression in a “first step” approach. WIC will continue the referral system to the Home Visiting programs, TEL-LINK Program, the Missouri Primary Care Association, or other support programs. WIC will also continue outreach efforts to enroll women in the WIC Program in their first trimester.

Home Visiting

The Title V MCH funded Home Visiting programs will continue to share information with all contracted local implementing agencies (LIA) to help home visitors better understand the Affordable Care Act (ACA) marketplace changes and uncertainties. Home visiting staff will assist enrolled clients to access insurance for prenatal, postnatal, and well woman care through emails and postings within the Missouri Home Visiting Gateway resources and the Weekly Updates. Through a standard agenda topic on the monthly subrecipient monitoring and support calls with each LIA supervisor, Home Visiting Program Specialists will continue to address needs for updated resources for accessing a regular and ongoing source of healthcare, including current guidelines for accessing and maintaining insurance coverage. The Home Visiting programs will also collect annual performance measure data on the percentage of mothers enrolled in home visiting prenatally or within 30 days after delivery who receive a postpartum visit with a health care provider within 8 weeks of delivery.

Additional Title V MCH funded Home Visiting program services include:

• Promoting smoking cessation for to all primary caregivers who report smoking at enrollment and/or the subsequent 6-month visit. Annual performance measure data will be collected on the percentage of primary caregivers who report smoking, tobacco use or other forms of nicotine delivery, including e-cigarettes, at enrollment and are referred to tobacco cessation counseling or services within three months. In addition, home visitors will be provided with tobacco cessation information and resources, such as the BMTF Program, Tobacco Quitline and TEL-LINK, to share with enrolled participants;
• Providing information and resources to all enrolled pregnant women promoting the benefits of continuing healthy pregnancies to the full 40 weeks. These resources will include DHSS and March of Dimes educational materials. Title V MCH funded Home Visiting Program Specialists will assess the distribution and use of these resources during monthly subrecipient monitoring calls with the LIAs;
• Screening all clients enrolled prenatally for symptoms of depression within three months of delivery. Primary caregivers not enrolled prenatally will be screened within the first three months of enrollment. Home visitors will utilize the Public Health Questionnaire 9 (PHQ-9) depression screening tool during these prescribed timeframes and anytime home visitors recognize potential symptoms of depression, and individuals who screen positive will be referred to appropriate services. Annual performance measure data will be collected for depression screening as described above, including data on the percentage of completed referrals. Current resources on mental health are shared with contracting LIAs through Weekly Updates.
• Providing contracted home visitors with ordering information for oral health resources from the DHSS Office of Dental Health to share with enrolled primary caregivers promoting the importance of receiving preventive dental care during pregnancy and at all stages of life for both primary caregivers and their children.

Environmental Health

Many persons are not aware that lead exposure can be a problem for women of childbearing age as well as the developing fetus and/or nursing infant. The most serious effects of high levels of lead during pregnancy are miscarriage and stillbirth. Other pregnancy problems such as gestational hypertension, low birth weight and premature delivery can also occur. Prenatal lead exposure impairs children’s neurodevelopment, placing them at increased risk for developmental delay, reduced IQ, hearing impairments, and learning and behavioral problems.

DHSS lead poisoning prevention staff will continue to perform the following activities to prevent or decrease blood lead poisoning in pregnant women and their babies:

• Provide community lead education via various outreach events such as health fairs;
• Participate in updating outreach materials such as the “Pregnancy and Beyond” booklet and other pamphlets and brochures which are distributed to expectant and new parents;
• Make contact with women and their health care providers when pregnant women have elevated blood lead levels (EBL) of 5 mcg/dL or higher (tracked by the Adult Blood Lead Epidemiology and Surveillance staff); and
• Provide lead education and resource materials to health care providers, LPHA and health plan lead case managers, as well as WIC Program staff regarding the need to discuss lead poisoning prevention and lead testing with clients. This will include providing LeadCare Analyzers and lead test kits to LPHAs that do not have the capacity to provide accurate lead screenings, allowing them to offer this service on a regular basis.

The Prenatal Substance Use Prevention Program will promote the importance of prenatal substance use prevention to promote healthy pregnancy and childbirth. The program will partner with statewide community-based partners to house substance exposed infant manikins to demonstrate the effects of drugs and alcohol during pregnancy. In addition, awareness campaigns will promote healthy pregnancy and abstaining from all substances before, during, and after pregnancy.

The Safe Cribs for Missouri Program will continue to educate each crib recipient on smoking cessation and the consequences of smoking during pregnancy. Information shared includes the BMTF Program, Missouri Tobacco Quitline tip cards and MO HealthNet resources.

Maternal Mortality

The OWH will continue to abstract and review all pregnancy-associated mortalities in Missouri. This will be done to ensure that information from all maternal deaths occurring within one year of pregnancy is captured. These reviews will aid in the identification of strategies to prevent maternal mortalities. DHSS will report findings from the Pregnancy-Associated Mortality Review (PAMR) and collaborate with partners and other key stakeholders to implement PAMR recommendations. The OWH will continue to identify new ways to share recommendations, such as data dashboards, one-pagers, and briefs.

DHSS was selected through a competitive grant process for a 5-year grant awarded through the Centers for Disease Control and Prevention’s (CDC) Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM) Program. This funding directly supports agencies and organizations that coordinate and manage Maternal Mortality Review Committees (MMRC) to identify, review and characterize maternal deaths and identify prevention opportunities. The OWH continues to improve internal processes to expedite maternal mortality case identification, abstraction and review by working with the Bureau of Vital Records to use provisional death files. Furthermore, maternal mortality cases are grouped by date of death for abstraction and review. For example, deaths that occur at the beginning of the year are abstracted first if possible and brought to the PAMR Board. These process improvements will continue to be refined during year three of the grant. In addition, a Patient Abstract System (PAS) linkage was developed during year two of the grant to identify additional hospitalizations/emergency room visits to aid in case abstraction. Through the ERASE MM grant, the OWH contracts with the Missouri Hospital Association (MHA) to implement patient safety bundles in Missouri birthing facilities, clinics and critical access hospitals. MHA will continue implementing the “Care for Pregnant and Postpartum People with Substance Use Disorder” (CPPSUD) bundle. According to the PAMR reports published in June 2021 and June 2022, mental health conditions were the leading underlying cause of pregnancy-related deaths, followed by cardiovascular disease—highlighting the need for this work. The Maternal/Infant Mortality Coordinator will work closely with the PAMR Board and MCH leadership to implement the initiatives in this grant.

Soon after launching the Missouri Maternal-Child Learning and Action Network (MC-LAN) in 2018, DHSS and MHA partnered to join the American College of Obstetricians and Gynecologists (ACOG), as funded by the Health Resources and Services Administration, Alliance for Innovation on Maternal Health - AIM. Through this effort, MHA is taking the lead on implementation of maternal safety bundles in Missouri birthing facilities. As the first initiative, Missouri began implementing the AIM “Severe Hypertension in Pregnancy” patient safety bundle. Since the start of implementing these initiatives, the MC-LAN has become the Perinatal Quality Collaborative (PQC). The PQC has since started implementing the AIM CPPSUD patient safety bundle. The OWH will continue collaborating with MHA and other key stakeholders through the PQC to provide guidance, knowledge-sharing and peer support in developing strategic quality initiatives based on the Triple Aim principles of improving and evaluating perinatal quality and population-based programs. The PQC provides strategic guidance and focuses on high-value opportunities to improve clinical, operational and outcome performance, and to develop collaborative partnerships to achieve these aims. In addition, the committee partners with the communities it serves to achieve better communication, and educate the public on quality and safety initiatives of the health care community. This committee meets three times a year with additional virtual meetings as needed. Missouri birthing facilities enrolled in the AIM will be required to report data metrics into the AIM data portal. DHSS and MHA will work together to assist birthing facilities with data submission to minimize burden on the facilities and leverage key stakeholders to assist with the implementation AIM bundles.

Other Title V MCH Activities Related to the Women/Maternal Health Domain

The OWH supports several initiatives to assist women of childbearing age. The Office supports the Uninsured Women’s Health Services Program. With the Missouri Department of Social Services (DSS), the OWH reimburses medical providers for women’s health services. These include: approved methods of contraception; sexually transmitted disease testing and treatment, including pap tests and pelvic exams; family planning, counseling, education on various methods of birth control; and drugs, supplies or devices related to the women’s health services described above, when they are prescribed by a physician or advanced practice nurse. The OWH continues to work with DSS and the Women’s Health Council to identify areas for improvement in the program, such as application processes and eligibility. The OWH maintains a public listing of pregnancy assistance information and ultrasound providers and the list is indexed geographically and available online. The OWH sends a survey annually in order to develop a listing of private and public agencies in the state to help pregnant women. Common services provided include food, clothing, supplies related to pregnancy, parenting skills and educational programs, and adoption assistance. The OWH supports a prenatal care program in Kansas City to provide free group prenatal care. The OWH supports tobacco cessation for pregnant and postpartum women and their households through telehealth with the BMTF Program. The OWH works with BMTF to publicize the program and offer it at no cost to participants across the state. The OWH leads a doula training program to increase the number of doulas and doula training organizations across the state. The OWH also represents the Department on several statewide task forces and commissions, including the Missouri Sexual Assault Response Team and the Combatting Human Trafficking and Domestic Violence Commission. Finally, the OWH supports the statewide Sexual Assault Nurse Examiner Telehealth Network. This network is in the beginning stages and will expand access to forensic exams across the state.

The Missouri Maternal Health Multisector Action Network (the Network) will continue its effort and dedication in connecting stakeholders with existing resources and toolkits and fostering partnerships amongst stakeholders. The Network will work closely with the key partners in the state to: evaluate the gaps in the support system for mothers and their young children affected by maternal substance use and mental health, and make sure that the Network is positioned to fill the gaps in the support system. This involves a strategic plan for sustaining the Network in the long term. With that in mind, the Network will continue to connect stakeholders in order to increase collaborations and decrease siloes. The Network workgroups will continue focusing on actions to address the evolving needs of the mothers and their children. In addition, the Network will recruit mothers to participate in the Mothers’ Self-Advocacy Network, which will be launched in FFY 2024. A major goal of the Advocacy Network will be to prepare mothers to testify in the Missouri legislature during the 2024 legislative session.

As the state’s chief maternal child health strategist, the MCH Director works to broaden the scope of MCH partnership beyond DHSS and other state agencies. As a convener of multidisciplinary, cross-sector collaborations and facilitator of meaningful and diverse partnerships, DHSS brings MCH partners and programs together across programmatic silos and organizational boundaries to promote the health of the MCH population and address social determinants of health and health inequities. The MCH Director will continue to actively engage in statewide collaborative efforts to promote the health of women of childbearing age, including but not limited to engagement in PAMR, MC-LAN, Women's Health Council, the DSS Maternal/Infant Health Efforts coordination meetings, the Uplift Connection, the ParentLink Advisory Council, and the Missouri Association for Infant and Early Childhood Mental Health. The MCH Director will continue to collaborate with the two Healthy Start grantees (Nurture KC, and Missouri Bootheel Regional Consortium) and their partners to facilitate sharing of information and resources, shared learning and identification of opportunities for alignment and collective impact.