County Public Health Department (CPHD) Activities

The overarching themes of the CPHD activities for FFY 2023 are partnerships and collaboration.  Since a well-woman visit is clinical in nature, the three CPHDs working on NPM 1 are all meeting and consulting with many types of organizations and providers, i.e.: Title X Family Planning, Montana Women, Infants, and Children (WIC), hospitals, family-practice clinics, and colleges.

In 2017, Johns Hopkins University Women’s and Children’s Health Policy Center published a brief on how to Strengthen the Evidence Base for Maternal and Child Health Programs.  “Scientifically Rigorous” evidence was identified for “Patient Reminder/Invitation.”  The brief stated: “There is strong evidence to suggest that patient reminders/invitations are effective, both on their own and in combination with other strategies.”  As an example of this strategy, Beaverhead CPHD is currently implementing a patient reminder and invitation activity.  Their focus is specifically on HPV vaccine and cervical cancer screenings, and is targeting Family Planning and WIC clients.

According the Johns Hopkins brief, the evidence rating one step down from Scientifically Rigorous is “Moderate Evidence.”  At this level, it states: “Other interventions targeting the patient/consumer that appear to be effective are community-based group education and patient navigation…(and) on the provider/practice-level reminder/recall systems, provider education, and implementation of a designated clinic/extended hours appear to be effective.”  Richland CPHD is currently implementing examples of these strategies: 1) working with Family Planning (co-located with the CPHD) to increase the percent of women in their county who receive annual well-woman visits over the 2019 baseline, as pertains to improving their client services process; and  2) meeting with and educating local providers, and creating a plan that will encourage patients to seek annual visits.

In FFY24, the FCHB will contract with two CPHDs who have chosen to focus on NPM 1: Beaverhead, and Silver Bow.   They will implement and evaluate at least two community-level activities during the fiscal year.  The FCHB will provide these counties with training, resources, and support on evidence-informed or best-practice activities, goal setting, and evaluation.

State-Level MCHBG Activities

Interim Needs Assessment: Phase One Survey Analysis

The state-level MCHBG Program is conducting an interim needs assessment with the assistance of the University Montana Rural Institute for Inclusive Communities (UMRIIC).  Phase One of this work is taking place during FFY 2023.  One of the deliverables is analysis of the wellness visit module from a survey looking at maternal health care experiences in Montana. The module on well-women visits gathered information on patient access to, and experiences with, the wellness visit.  The initial survey work was supported by the Montana Obstetric and Maternal Support (MOMS) Program, a HRSA Maternal Health Innovation Grant.

The wellness visit survey module gathered information on healthcare utilization (annual wellness visit, and having a wellness visit the year before pregnancy), services included (physical exam, health history, health screening(s), reproductive life planning), health screenings (cervical cancer, depression and/or anxiety, sexually transmitted infections, substance use, breast cancer, and other screenings), patient satisfaction, and an open ended question on areas for improvement.

Data collection occurred from July 26, 2022 – September 14, 2022. The online survey targeted Montanans who have been pregnant in the last five years. UMRIIC used convenience and purposive sampling methods. Participants were recruited through social media platforms Facebook and Instagram via six custom images. The social media campaign included sponsored posts facilitated by the UM Rural Institute for Inclusive Communities platforms. A postcard was also sent to all WIC participants, totaling 8,800.  Additional data analysis on this survey module is underway, with completion expected by the end of September 2023.

MCHBG-Proposed PRAMS Survey State-Added Question

In March 2022, the Montana PRAMS Steering Committee chose, and the CDC and IRB approved a state-added question that was proposed by the MCH Program Specialist. The PRAMS 2022 survey, which closed out on 6/9/2023, included this question:

Here is a list of problems some women can have getting prenatal care. For each item, circle Y (Yes) if it was a problem for you during your most recent pregnancy or circle N (No) if it was not a problem or did not apply to you.

• I couldn’t get an appointment when I wanted one
• I didn’t have enough money or insurance to pay for my visits
• I had no way to get to the clinic or doctor’s office
• I couldn’t take time off from work
• The doctor or my health plan would not start care as early as I wanted
• I didn’t have my Medicaid card
• I had no one to take care of my children
• I had too many other things going on
• I didn’t want anyone to know I was pregnant
• Other – Please tell us:

The data collected from this question will provide additional public input data for the upcoming needs assessment.  It will also offer insights into regional differences across the state.

Montana Statewide Syphilis Symposium and Public Awareness Campaign

In response to syphilis spreading faster in Montana than it has in decades, a new partnership was formed with the Public Health and Safety Division (PHSD) STD/HIV/Viral Hepatitis Section.  Montana’s data indicated that during 2022, there were 602 cases of syphilis (all stages), with women of child-bearing age accounting for 281 of these cases, and there were 41 pregnant women.  Preliminary 2022 data shows 15 cases of congenital syphilis, with three stillbirths.

The FCHB collaborated with the STD/HIV/Viral Hepatitis Section to sponsor a Montana statewide Syphilis Symposium held June 19-23, 2023.   In partnership with the Native American Development Council (NADC) and the Montana Public Health Institute (MTPHI), four cross-sector community meetings were held in Tribal communities across the state, in addition to a full day clinical training hosted by Dr. Melanie Taylor, Medical Epidemiologist at the Centers for Disease Control & Prevention (CDC).

Nearly 300 providers and community partners, including Tribal Health, County Public Health, Indian Health Services (IHS), Urban Indian Health Centers, Tribal Councils, and social service providers were trained on syphilis testing, staging, and treatment. The next steps following the symposium include: providing more clinical training to healthcare providers across the state; increase public awareness; improve access to 340B drug pricing across the state; provide information regarding the Bicillin shortage to healthcare providers; provide recommendations to Fort Peck Tribal Council regarding their tribal code which impacts women seeking prenatal care; and the creation of the Congenital Syphilis Case Review Board to review all cases of Congenital Syphilis and provide prevention recommendations. 

To increase public awareness, MCHBG funds were utilized to support the continuation (from July 1- Sept 30, 2023) of an existing Syphilis public awareness campaign.  The campaign is focused on increasing awareness of Syphilis, and encouraging prenatal care, testing and treatment for the condition in the most impacted communities in the state. Outreach is through billboards, social media, radio Pubic Service Announcements, and digital ad placements.

Montana Obstetrics and Maternal Support (MOMS) Program NPM1 Activities

The MOMS Program contracted with the University of Montana Rural Institute for Inclusive Communities (UMRIIC) for data collection and analysis, evaluation, and research services. Their staff launched several research studies during the reporting period to gather more information on maternal health, focusing on the experiences of pregnant people and providers within the health system.

MOMS Postpartum Care and Contraception Study was administered for the following purposes: to improve postpartum access to contraception; provider familiarity and expertise with postpartum contraception provision; and to understand behavioral health screenings provided during postpartum visits. Half of the providers reported working in a hospital setting, with the other half reporting a primary practice setting in a rural health clinic or federally qualified health center. Results suggested a need for: provider education on insurance coverage for contraception; training in intrauterine device (IUD) and implant insertion and removal; and improved consistency of substance use screening. Survey results also pointed toward more training in the provision of contraception to individuals with disabilities.

Nine providers who completed the survey completed an interview to provide further contextualization of findings from the survey. The interview coding is underway. UMRIIC will create summary reports and submit manuscripts on these topics to a contraception-focused journal: 1) barriers and facilitators to contraception from a provider perspective; 2) long-acting reversable contraception for persons with disabilities; 3) provider attitudes toward IUDs and implants and how often they provide them; 4) reported provider adherence to contraceptive guidelines and contraceptive counseling; and 5) contraceptive care in a rural state.

The Provider Survey: Understanding and Improving Barriers to Treatment and Care of Substance Use Disorder was conducted to identify provider bias related to treatment and care of pregnant women with substance use disorder. The survey addressed provider knowledge, attitudes, and practice regarding substance use during pregnancy and the care of women who utilize substances during pregnancy to better understand implicit bias among obstetric care providers. Ninety-seven providers participated in the survey. The participants included multiple providers/professionals including OB/GYNs, RNs, APRNs, PAs, LCSWs, SW, therapists, and pharmacists providing maternal care within Montana. The provider survey data has been analyzed and is being formatted for submission to the Nursing for Women’s Health journal.

Facilitators and Barriers to Seeking Treatment and Care of Postpartum Depression was studied to identify risk and protective factors associated with seeking care for postpartum depression symptoms among Montana women who use substances or those with mental health concerns. In partnership with Empaths, a MOMS perinatal substance use and mental health treatment system housed with the Billngs Clinic, pregnant women who qualified for services due to substance use or opt-in to the program due to mental health concerns, were invited to participate in a qualitative interview. Participants were interviewed using a qualitative descriptive approach informed by the Behavior Model of Health Services for Vulnerable Populations. These interviews provided an understanding regarding knowledge of and barriers to receiving care for postpartum depression. Four main themes arose from the interview process regarding barriers and facilitators to receiving care for postpartum depression: Family history of mental health concerns and/or substance use, stigmatization around mental health or substance use, lack of awareness surrounding postpartum depression, and isolation.

Maternal Health Care Experiences Survey – Wellness Visit Survey Module was conducted to gather information on patient access to, and experiences with, the women’s wellness visit to contribute to the Title V MCHBG Needs Assessment. UMRIIC developed a series of questions on the wellness visit to include in the maternal health care experiences survey. The wellness visit survey module gathered information on: health care utilization (annual wellness visit, and having a wellness visit the year before pregnancy); services included (physical exam, health history, health screening(s), reproductive life planning); health screenings (cervical cancer, depression and/or anxiety, sexually transmitted infections, substance use, breast cancer, and other screenings); patient satisfaction; and an open-ended question on areas for improvement.

Partners at DPHHS contributed to the development of this survey module.The survey had 427 respondents. Most (65.7%) of participants reported having a wellness visit the year before pregnancy. Fewer (54.1%) reported having an annual wellness visit every year. Of those that reported having a wellness visit every year, about half (54.1%) stated this visit included a conversation on reproductive life planning. UMRIIC will complete additional analyses for the upcoming Title V MCHBG Needs Assessment and present the findings at the American Public Health Association Conference in November 2023.

In FFY 24, MOMS will work with Billngs Clinic to ensure that their Year 5 activities are completed and that UMRIIC receives the necessary data to complete their analysis. BC will continue to offer ECHO clinics; the Empaths Perinatal Substance Treatment System, which streamlined a pregnant/postpartum women’s access to substance use disorder (SUD) and mental health treatment; and, Cuddling Cubs, a virtual postpartum support group facilitated by the Rocky Mountain College’s Occupational Therapy Doctorate program.  UMRIIC, MOMS staff, and BC have collaborated on data collection tools for the purpose of determining these programs’ impact and potential for other states to replicate.  The MOMS PS will serve as a resource for the two CPHDs that have indicated maternal health as an area of focus by selecting NPM 1 or by reaching out for technical assistance from MCHBG staff.