NPM: Postpartum Visit – Increase the incidence of women attending a postpartum checkup within 12 weeks after giving birth and receiving the recommended postpartum care components.

 

The Office on Women's Health (OWH) is responsible for reviewing all cases of maternal mortality in Missouri. A team of professionals participates in the Pregnancy Associated Mortality Review Board (PAMR). The PAMR board provides recommendations for each case reviewed. However, the recommendations can only be as detailed as the data received on the case. An OWH abstractor does an incredibly thorough job reviewing all records available. Unfortunately, part of the story is still missing. As a part of OWH efforts to improve the depth of information received, informant interviews will be conducted by OWH in 2025. These interviews will allow OWH to connect with the next of kin of all moms who have died in Missouri. OWH will offer grief and support services and hope to learn more about each family’s story. Part of the information collected will include prenatal care initiation and postpartum support. With the combination of qualitative and quantitative data, OWH will identify and implement strategies to reduce the barriers to care in Missouri.

 

OWH also leverages Title V funding to support staff time needed to implement strategies funded by other revenue streams. By combining MCH resources with these other revenue streams, OWH can implement strategies to improve postpartum care. First, the team leverages funds from the Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM) Program to contract with the Missouri Hospital Association (MHA) and as well as local hospitals directly. OWH is also working with MCH leadership and the MHA to implement the “Care for Pregnant and Postpartum People with Substance Use Disorder” (CPPSUD) Patient Safety bundle. In addition to this bundle, the team also uses Title V funds to leverage Opioid Settlement Funds to support hospitals in engaging women who have opioid use disorder (OUD) or are at risk of developing OUD because of substance use disorder (SUD) before, during, and after pregnancy. These funds will support a wide spectrum of care, including addiction and recovery services, maternal health care, mental health care, and addressing social determinants of health. Finally, OWH leverages state general revenue funding for programs to improve postpartum support. These include providing free group prenatal care through a program in Kansas City and a doula training project that increases the number of doulas available in Missouri to increase moms access to prenatal and postpartum care. (Full discussion of quality initiatives through the Perinatal Quality Collaborative in NPM: Well Women Care below.)

 

The MCH Services Program will continue to support a leadership role for Local Public Health Agencies (LPHAs) at the local level to build community-based systems and expand the resources those systems can use to respond to priority maternal child health issues and promote the health of mothers and infants by assuring prenatal, delivery, and postpartum care. The program has increased partnership from 111 to 112 local public health agencies for FFY 2025.

 

In assessing a baseline of current postpartum services provided, all LPHA partners provided supplemental data in FFY 2024 to identify maternal health services currently provided by the agency and other community partners, as well as existing gaps in services. The MCH Services Program will continue to support local public health efforts to support postpartum women.

• 57 LPHAs and 71 other community partners provide postpartum depression screening and referral.
• 36 LPHAs and 63 other community partners provide postpartum follow-up within the first 4-6 weeks after delivery.
• 50 LPHAs and 65 other community partners provide postpartum education within the first 4-6 weeks after delivery. The LPHAs leverage other services to provide postpartum screenings and education, such as collaborating with local Women, Infants and Children (WIC) clinics, Nurse-Family Partnership, and other home visiting programs.

• 75 LPHAs and 61 other community partners screen for Insurance/MoHealthNet coverage. 50 LPHAs and 62 other community partners directly assist with enrollment in MO HealthNet (Missouri Medicaid) for Pregnant Women.
• 36 LPHA and 65 other community partners provide prenatal case management and/or referral.

 

Statewide Parent Advisory Network (SPAN) funding will be leveraged to offer 90 hours of International Board Certified Lactation Consultant (IBCLC) trainings, with the goal to increase the number of IBCLCs in Missouri. Trainings teach IBCLCs to refer a client when something is out of their scope of practice. An IBCLC may meet with a postpartum woman due to delayed onset of breastmilk as a result of an underlying postpartum condition or concern. In these cases, the IBCLC refers the client to the Obstetric/Gynecologist for care of conditions or medical concerns that may have otherwise gone undetected. IBCLCs will be encouraged to promote appropriate whole-person postpartum follow-up care.

 

The Newborn Health Program will partner with a variety of community health providers to raise awareness and provide education for the MCH population on MCH resources for women of childbearing age and their families. Providers will receive free copies of the Pregnancy and Beyond book, along with a wide variety of educational materials containing information to improve pre-conception, prenatal and postpartum care and postpartum mood disorders. Pregnancy and Beyond includes content regarding the importance of postpartum follow-up care. 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 work with an informal internal MCH work group to prepare comprehensive, current and accurate outreach materials and maximize outreach opportunities at conference exhibits, webinars, virtual baby showers, and health fairs and by distributing various educational materials through the Home Visiting programs.

 

Home Visiting programs will continue to share information with all contracted local implementing agencies (LIA) to increase home visitor understanding of the changes and uncertainties in healthcare coverage. Home visiting staff will provide information during home visits to assist enrolled clients in accessing insurance for prenatal, postnatal, and well woman care. A standard agenda topic on the monthly subrecipient monitoring and support calls with each LIA supervisor will require Home Visiting Program Specialists to provide updated resources, including current guidelines for accessing and maintaining insurance coverage to assist enrolled clients in accessing a regular and ongoing equitable source of healthcare. 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 eight weeks of delivery. Demographic data will be analyzed for inequities and barriers to accessing and maintaining healthcare.

 

The Department of Health and Senior Services (DHSS) is committed to working with multi-sectored partners to improve perinatal outcomes. As part of the Maternal Mortality Prevention Plan, DHSS will continue to contract with the MHA to implement standardized maternal care provider trainings, using creative modalities, on: trauma--responsive and culturally and linguistically appropriate care; screening, referral, and treatment of mental health conditions during and after pregnancy; substance use during and after pregnancy; cardiovascular disorders associated with pregnancy; and gestational diabetes and other endocrinology disorders associated with pregnancy. The MHA will also develop a standardized Postpartum Plan of Care template to plan for and optimize comprehensive postpartum care. (Full discussion of Plan in NPM: Well Women Care below.)

 

MCH leadership will interface with processes such as the statewide Fetal Infant Mortality Review (FIMR) Network and the Missouri Child (0-17 years) Fatality Review Program (CFRP) to identify any trends in fetal and infant mortality related to postpartum health. The recommendation will be made to the FIMR Network to include the promotion of whole-person follow-up postpartum care as a protective strategy in response to all fetal and infant loss.

 

MCH leadership will collaborate with partners and stakeholders to promote postpartum checkups and whole person postpartum follow-up care across the full 12-month postpartum period. MCH leadership will continue to work with the MHA and the Missouri Maternal-Child Learning and Action Network (MC-LAN)/Perinatal Quality Collaborative (PQC) to provide guidance, education and programming to improve the health care experience and outcomes for pregnant and postpartum women and their babies. The MCH Director will work with MO HealthNet Maternal/Infant Health leadership to provide technical assistance and training for LPHAs, as needed, regarding MO HealthNet for Pregnant Women, prenatal case management, postpartum benefits, benefits available for substance use treatment and mental health services, etc. MCH leadership will partner across internal programs and with the University of Missouri, the LPHAs, the Missouri Maternal Health Action Network, home visiting programs, the full scope of women/maternal health care providers, pediatricians, family practitioners, provider organizations and other partners working and interfacing with women during the postpartum period. Partnerships with community-based organizations and providers, including community health workers, doulas, professional midwives, community paramedics, peer support specialists, and faith-based organizations, will be leveraged to promote postpartum follow-up care.

 

DHSS will continue to convene key organizational leaders in the Interagency Maternal Health Consortium to explore and improve maternal healthcare access across Missouri through exploration of 12 priority areas of action, identified based on interagency meetings and discussions with additional health advocates, providers and provider organizations. The Consortium will explore initiatives to address the social drivers of health and promote postpartum care and outcomes, such as remote telehealth for maternal-fetal-medicine visits, postpartum home visits, a 24/7 MCH call center, and increased utilization of community-based maternal care providers, such as doulas and perinatal community health workers. Additional priorities to promote maternal health include partnerships between maternal health care providers and birthing facilities, rural hospital and obstetric payment reform, malpractice liability coverage, modernization of birth center regulation, integrated nurse midwifery with obstetric care, EMS obstetric readiness training, rural health workforce pipeline incentives, and graduate medical education for obstetric providers.

 

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

 

Maternal Mortality

OWH will continue abstracting and reviewing all pregnancy-associated mortalities in Missouri to ensure information on all maternal deaths occurring within one year of pregnancy is captured. These reviews will aid in identifying strategies to prevent maternal mortalities. DHSS will report findings from the PAMR and collaborate with other key stakeholders to implement PAMR recommendations. OWH will continue identifying 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 CDC-ERASE MM grant award. This funding directly supports agencies and organizations that coordinate and manage Maternal Mortality Review Committees to identify, review and characterize maternal deaths, and identify prevention opportunities. 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 occurring 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 five of the grant. In addition, a Patient Abstract System linkage was developed during year two of the grant to identify additional hospitalizations/emergency room visits to aid in case abstraction. OWH contracts with the MHA through the ERASE MM grant to implement patient safety bundles in Missouri birthing facilities, clinics, and critical access hospitals. The 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, including substance use disorder, 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. Starting in the fall of 2024, the partnership with MHA will directly work on addressing causes and solutions for the disparities evident in the work.

 

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) with funding from the Health Resources and Services Administration, Alliance for Innovation on Maternal Health - AIM. Through this effort, MHA leads the 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 implementing these initiatives, the MC-LAN has expanded to include the Perinatal Quality Collaborative (PQC). The PQC has since started implementing the AIM CPPSUD patient safety bundle. OWH will continue collaborating with MHA and other critical 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 healthcare community. The committee meets three times per 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 the burden on the facilities and leverage critical stakeholders to assist with implementing AIM bundles.

 

Maternal Mortality Prevention Plan

Discussions with key partners identified the need for a comprehensive plan for maternal mortality prevention, with targeted funding and initiatives. DHSS leveraged Title V funding to propose a new state-funded budget initiative to implement a Maternal Mortality Prevention Plan. The Governor’s final approved state fiscal year 2024 budget included $4.35 million to implement the Plan and effect simultaneous transformation through five domains of action affecting maternal health, with the social determinants of health interwoven throughout all five domains. Implementation of the Plan, including a robust evaluation plan to monitor progress, measure success, ensure accountability, and inform ongoing maternal mortality prevention efforts, was launched through partnerships with internal and external maternal health partners. Improved maternal health data collection, standardization, harmonization, transparency, and support will enhance data quality and access, identify poor outcomes during pregnancy and make improvements to support healthy pregnancy, delivery and postpartum outcomes. The Plan included development of a MCH Dashboard, published in June 2024, along with a new MCH Data Sources webpage. DHSS contracted with the University of Missouri to establish a collaborative hub and spoke model Maternal Health Access Project (MHAP), inclusive of perinatal mental health, with a single point-of-entry system for referrals to prenatal care providers and community-based agencies, resources, programs, and services for prenatal women. Through a contract with the MHA, DHSS initiated implementation of three of the domains: 1) standardized, evidence-based maternal quality care protocols; 2) standardized maternal care provider trainings, using creative modalities, on trauma--responsive and culturally and linguistically appropriate care and screening, referral, and treatment of mental health conditions during and after pregnancy; SUD during and after pregnancy; cardiovascular disorders associated with pregnancy; and gestational diabetes and other endocrinology disorders associated with pregnancy; and 3) a Postpartum Plan of Care to plan for and optimize comprehensive postpartum care.

 

Women’s Health Initiatives

OWH will implement a strategic plan to improve women’s health across the lifespan. This includes work at all levels of the social-ecological model, individuals, relationships, communities, and society. To enhance individual knowledge, OWH will continue to provide education and resources to promote well-woman care, including distribution of the WOMEN: Take Charge of Your Health publication and the My Health Tracking Card and continuation of the Women’s Health Network listserv. The publication includes information on preventive health, preconception health, obesity prevention, breastfeeding, postpartum depression, and disease prevention. It will be updated to include evidence-based information, resources, and recommendations from experts and leaders in women’s health, including hotlines like 988, the tobacco Quitline, and the domestic violence hotline. This resource is available on the DHSS website at www.health.mo.gov/womenshealth. The publication is available in English and Spanish and can be accessed online and in print. The current printing of the book includes a QR code linking to a survey. This survey will collect data on what participants learned and how they used the resource. The My Health Tracking Card helps track blood pressure, cholesterol, and weight. Resources are provided to the general public, LPHAs and others who contact OWH or visit the website. The Women’s Health Network listserv comprises organizations and individuals concerned with women’s health and provides 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 is distributed at least twice a month.

 

OWH will also improve women’s health using relationship-level strategies. This includes improving how women and moms communicate with healthcare providers and how providers communicate with patients. The team used data from the PAMR to collaborate with Bucket Media and create campaign materials to address the leading causes of maternal mortality. The maternal mortality rate is significantly higher for Black women and women using Medicaid. However, there is no statistical difference in the various causes of death for women based on these factors. Through a data-to-action approach, the team used funding from the CDC ERASE MM Program to engage with mothers on how to raise medical concerns during pregnancy and postpartum. The initiative encourages medical and non-medical providers to take the concerns of pregnant and postpartum women seriously. These skills are essential throughout a woman’s life and will help improve their ability to self-advocate and reduce maternal death.

 

OWH will also address women’s health at the community and societal levels. OWH supports the newly renamed Missouri Women’s Health Advisory Committee, which consists of internal and external stakeholders, representing diverse communities across the state. This committee will help improve the coordination of service delivery by increasing DHSS’ awareness of community needs and helping identify policy changes needed to improve access and quality of care. An example of work to be accomplished with help from the committee includes establishing the doula registration process necessary to reimburse for doula services, beginning in early 2025.

 

Community Health

The MCH Services Program will continue to support LPHA efforts to provide education on the importance of adequate dental care and overall oral health. To increase the number of women receiving preventive dental visits during pregnancy, LPHAs will offer preventive dental services and collaborate with their partners to provide screening and referral. The MCH Services Program will also support LPHA and 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.

 

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 selected to improve pre-conception, prenatal, and postpartum health care services for women of childbearing age as their Priority Health Issue (PHI).
  • One LPHA elected to decrease the number of women with a recent live birth who experience frequent postpartum depressive symptoms as their PHI and will continue to work to increase community awareness of postpartum depression, increase educational opportunities for 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 referrals and resources to mental health services. 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 is successful. The health department is planning to expand to offer screenings to postpartum women with a child under the age of one presenting to the health department for other services, such as state or court-ordered DNA paternity testing. In addition, the health department plans to encourage the use of the screening tool with at least five community-based organizations that provide services for women of childbearing age.
  • Ten LPHAs elected to ensure women of childbearing age receive an annual preventative well visit. Some will be changing organizational practices to include well-woman care, including assistance with the Medicaid application and enrollment process as part of the services offered at their health departments. Others will foster coalitions and networks to increase the number of state and community-based organizations collaborating to increase access to services for women of childbearing age.
    • The Atchison County Health Department plans to facilitate and host two women’s wellness events annually for women of childbearing age, including screening for sexually transmitted infections, cholesterol, blood sugar, and blood pressure. Referrals will be made to a local practitioner for those who have abnormal test results. The health department will collaborate with local organizations such as the Mobile Food Pantry and the Head Start Program to promote these events.
    • The Howell County Health Department plans to increase the number of community organizations working together to increase annual preventative medical visits for women of childbearing age. Staff will work with the Prevention Team at the Missouri Department of Social Services (DSS)-Children’s Division. The Primary Prevention team works to support and engage with families and provide and connect them to community resources. In addition, they plan to collaborate with child care providers to provide education and resources regarding annual preventative visits to mothers and families and assist them with scheduling a visit to the health department.
    • The Springfield-Greene County Health Department plans to create a community system to promote community alignment of MCH services. The NEST Partnership is transitioning to Family Connects. Family Connects is a universal home visiting program for families and newborns in Greene County and includes a Community Advisory Board (CAB) component. The goal of the CAB is to guide and support the full implementation of Family Connects in the community and help identify and address gaps and deficiencies in resources, systems, processes, and policies to help ensure equitable outcomes for the MCH population.
    • The Madison County Health Department plans to continue working to increase the number of women of childbearing age with insurance coverage for women’s health services. They will ensure staff have the skills and knowledge to screen for coverage, provide education on available services, and assist with the Medicaid application and enrollment process. In addition, a follow-up measure will be implemented to ensure women who received assistance from the health department are actively covered and obtaining recommended services.
  • Two LPHAs have elected 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.
    • The St. Louis County Department of Public Health plans to continue adopting a policy to ensure equitable and just birth practices, including screening pregnant women to determine the need for doula and home visiting nursing care, and build trust in the healthcare system. A Lived Experience Advisory Board has been created with plans to continue developing a mission and vision statement in FFY 2025. The board will support community leadership and will provide feedback on the proposed policy.
    • The City of St. Louis Department of Health plans to continue training MCH partners, including Affinia Healthcare, Integrated Health Network, and Nurses for Newborns, on fair and impartial care, cultural competence and delivery of culturally congruent care. A second session will include training on group prenatal care models and other maternal health best practices.

 

The TEL-LINK Program will help improve women and maternal health by providing health care service referrals to increase access to care for any childbearing woman or mother needing assistance. The program promotes this service through search engine campaigns to reach the underserved population. TEL-LINK will partner with tobacco control programs, WIC clinics, and dental care providers to provide referrals to 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 various community health providers to raise awareness and educate the MCH population on available 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 free distribution of the Pregnancy and Beyond book and other educational materials. 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 HBB Unit will continue utilizing and promoting an informal MCH internal work group and maximize outreach opportunities at conference exhibits, webinars, virtual baby showers, health fairs, and home visiting programs.

 

The Missouri WIC Program will promote the importance of depression screening by utilizing the Patient Health Questionnaire-2 (PHQ-2) for prenatal, breastfeeding, and non-breastfeeding women. 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. The WIC Program will continue the referral system to home visiting programs, TEL-LINK, the Missouri Primary Care Association, and other support programs. The WIC Program will continue outreach efforts to enroll women in the WIC Program during their first trimester.

 

The Prenatal Substance Use Prevention (PSUP) 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. The PSUP Program maintains 32 sets of substance-exposed infant manikins and reallocates the sets based on requests by community partners. In addition, awareness campaigns will promote healthy pregnancy and abstaining from all substances before, during, and after pregnancy.

 

The MCH Director will continue collaborating with the Division of Cannabis Regulation, Harm Reduction and Cannabis Grant programs, Office of Public Information, and other programs in the Bureau of Community Health and Wellness and across DHSS to provide educational information and resources regarding the dangers of using marijuana during pregnancy and while breastfeeding.

 

Home Visiting

Home Visiting programs will continue to share information with all contracted local implementing agencies (LIA) to help home visitors better understand the changes and uncertainties in healthcare coverage. Home visiting staff will assist enrolled clients in accessing insurance for prenatal, postnatal, and well-woman care through information provided during home visits. Through a standard agenda topic on the monthly sub-recipient monitoring and support calls with each LIA supervisor, Home Visiting Program Specialists will continue to address the need 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 eight weeks of delivery.

 

Additional Home Visiting services include:

• Promoting smoking cessation to all primary caregivers who report smoking at enrollment 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 equipped with tobacco cessation information and resources, such as the Baby and Me Tobacco-Free Program™ (BMTF), 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. Home Visiting Program Specialists will assess the distribution and use of these resources during monthly sub-recipient 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. Individuals who screen positive will be referred to appropriate services, including counseling, physician referral, Mommy and Me curriculum, etc. Annual performance measure data will be collected for depression screening, including data on the percentage of completed referrals. Current resources on mental health are shared with contracting LIAs through weekly updates and monthly subrecipient calls.
• Providing contracted home visitors with information promoting the importance of receiving preventive dental care during pregnancy and at all stages of life for both primary caregivers and their children.

 

Oral Health Promotion

The Office of Dental Health (ODH) is committed to educating childbearing women and mothers about the importance of oral health for overall health and well-being during pregnancy and throughout their lifespan. This includes promoting dental visits during pregnancy. Information is shared through various materials developed by ODH and the Missouri Dental Association. The “palm card” provides quick information about the importance of dental health during pregnancy, baby teeth, and fluoride varnish. Resources are distributed to women through the ODH Pregnancy webpage and via ongoing collaborations with the Missouri WIC Program and the Home Visiting programs. Resources are distributed via LPHAs, Federally Qualified Health Centers (FQHCs), dental offices, and community outreach events. As funding allows, supplies for “Brushing for Two” dental kits will be distributed to WIC clinics, FQHCs, rural hospitals, and clinics targeting underserved populations. These kits include toothbrushes for mom and baby, dental floss and toothpaste for mom, a timer, and literature on various topics, such as dental health, tobacco cessation and lead poisoning and prevention.

 

ODH is piloting a program that provides funding through three LPHA WIC offices to offer oral health education, supplies, fluoride varnish, and a warm handoff to a dental provider. LPHA staff encourages the mother to keep the appointment by emphasizing the importance of oral care during pregnancy. The LPHA then tracks the referral outcomes to determine the initiative's impact. As funding allows and if more LPHAs are interested, ODH aims to expand this initiative.

 

ODH is contracting with Uzazi Village in Kansas City and Jamaa Birth Village in St. Louis to provide dental care to pregnant and postpartum women. Uzazi Village is a non-profit organization that offers perinatal health care to racially diverse, underserved pregnant women who are served by Medicaid. A Medicaid-credentialled dental provider provides dental services on-site twice a month, serving an average of eight women each day. To further promote oral health education for mothers and children, ODH is also collaborating with Raising St. Louis, an affiliate of Children Hospital of St. Louis/Barnes Jewish, which connects mothers, fathers, and other family members to help build and sustain the family unit, reduce the high infant mortality rate, promote literacy, and increase access to health care. All educators are certified Parents as Teachers educators and make home visits to families in the St. Louis area.

 

Environmental Health

Many persons are not aware lead exposure can be a problem for women of childbearing age as well as the developing fetus and nursing infant. The most severe 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 book and other pamphlets and brochures for distribution to expectant and new parents.
• Contact women and their health care providers when pregnant women have elevated blood lead (EBL) levels of 5 mcg/dL or higher (tracked by the Adult Blood Lead Epidemiology and Surveillance staff).
• Provide lead education and resource materials to health care providers, LPHA and health plan lead case managers, and 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 regularly.

 

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

 

Other Activities to Promote Women and Maternal Health

 

The MCH Director will actively engage in statewide collaborative efforts to promote the health of women of childbearing age, including but not limited to leading the State Health Improvement Plan (SHIP) Infant and Maternal Health priority area and continued engagement in PAMR, the MC-LAN, the Women's Health Committee, the Maternal Health Action Network, 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 the sharing of information and resources, shared learning, and identification of opportunities for alignment and collective impact.

 

Missouri is participating in the National Governors Association (NGA) Center for Best Practices Improving Maternal and Child Health in Rural America: State and Territory Policy Learning Collaborative to address the priority area, “Build Infrastructure for Sustained Success: State-level strategic planning, reporting, supportive platforms, collaboratives and centers contribute to improved, sustained outcomes for mothers, infants and their families, and increased accountability”. The Core Team, comprised of the MCH Director, DHSS Chief Medical Officer, Senior Policy Advisor from the Governor’s Office, Director of MO HealthNet, MHA Senior Vice President of Quality, Safety and Research, and Interim Director of the MHAP at the University of Missouri – Columbia, selected the following four policy actions to address the identified priority area:

1. Develop a statewide maternal health strategic plan.
2. Develop a proposal for a state Maternal Health Innovation Program through HRSA.
3. Expand home visiting programs.
4. Strengthen the community health worker workforce through certification and increased access to training.

 

State Health Improvement Plan

Improving Infant and Maternal Health is one of the priorities identified by the State Health Assessment and addressed by the SHIP. The goals and objectives outlined under the Infant and Maternal Health priority area are set on a five-year project scale, with work ongoing through 2027. DHSS recognizes infant and maternal health are intrinsically linked and must be addressed within the framework of the mother-infant dyad to achieve the goal of advancing equitable health during the childbearing continuum and improve health outcomes for childbearing women and their infants. MCH leadership will collaborate with a diverse group of partners to implement activities to achieve three targeted objectives.

• Increasing the percent of women of childbearing age who have received selected women/maternal preventive health services will be accomplished by:
  • Engagement of Community Health Workers, Doulas and other community based maternal health care providers.
  • Partnering with community-based organizations to provide prenatal care. Implement community-based health promotion efforts.
  • Raising awareness of the importance of reproductive life planning.
  • Educating women on the importance of immunizations.
  • Promoting comprehensive health care for pregnant women, postpartum women and women of childbearing age.
  • Supporting activities and facilitate partnerships to create environments that support healthy eating and active living.
  • Partnering with tobacco control programs and community-based partners to assure delivery of effective tobacco cessation services.
  • Participating in maternal and women’s health partnerships by convening public health and advocacy partners for strategic thinking and action, engaging clinicians as partners and engaging collaboratives to improve maternal health and health care equity.
  • Addressing underlying social drivers of health.
• Increasing the percent of women of childbearing age who self-report having received “respectful care” will be accomplished by:
  • Providing education to providers on the 12 domains of respectful care: being free from harm and mistreatment; maintaining privacy and confidentiality; preserving women’s dignity; prospective provision of information and seeking of informed consent; ensuring continuous access to family and community support; enhancing quality of physical environment and resources; providing equitable maternity care; engaging with effective communication; respecting women’s choices that strengthen their capabilities to give birth; availability of competent and motivated human resources; provision of efficient and effective care; and continuity of care. (NIH)
  • Partner with academic institutions to include respectful care into the education curriculum for all health care professionals (physicians, nurses, social workers, APRNs, nutritionists, health care administrators, etc., including facility related issues such as women’s perception of incompetence or disrespect of professionals attending delivery, unhygienic facilities and unavailability of basic supplies.
  • Qualitative phenomenological study with focus group discussions (FGDs) with primipara and multipara women using a semi-structured discussion guide to elicit discussion and audio recording and transcribing interviews verbatim.
  • Analyze data using thematic analysis approach to describe the prevalence of various categories of mistreatment during admission, labor and delivery and postpartum care (losing self-control, being overlooked, being informed of bad news without proper preparation, repeated examination without being properly communicated/informed, disallow companions and left unattended during labor).
• Reducing the percent of preventable maternal deaths with underlying mental health issues including SUD will be accomplished by:
  • Establishing a Perinatal Health Access Project.
  • Promote the use of validated screenings of mental health conditions and substance use disorder to be conducted at multiple intervals during pregnancy and the postpartum period;
  • Increasing provider knowledge of how to treat mental health conditions during pregnancy.
  • Promoting changes in systems, policies and environments; fostering positive public dialogue; countering shame, prejudice and silence; and building public support for suicide prevention.
  • Addressing the needs of vulnerable groups, tailoring strategies to match the cultural and situational contexts in which they are offered and seeking to eliminate disparities.
  • Collaborating with behavioral health agencies and partners to implement the Strengthening Families Protective Factors Framework.
  • Promoting efforts to reduce access to lethal means among individuals with identified suicide risks.
  • Implementing and spreading evidence-based suicide and self-harm prevention strategies and programs.
  • Strengthening collaboration across agencies, developing new tools and capacity, and implementing evidence-based change in suicide and self-harm prevention strategies.

 

Office on Women's Health

OWH supports several initiatives to assist women of childbearing age. In partnership with DSS, the Office supports the Uninsured Women’s Health Services Program and reimburses medical providers for women’s health services. Services include approved methods of contraception; sexually transmitted disease testing and treatment, including pap tests and pelvic exams; family planning, counseling and education on various methods of contraception; and drugs, supplies or devices related to the women’s health services described above when a physician or advanced practice nurse prescribes them. OWH continues to work with DSS and the Women’s Health Advisory Committee to identify areas for improvement in the program, such as application processes and eligibility. OWH maintains a public listing of pregnancy assistance information and ultrasound providers, and the list is indexed geographically and available online. OWH distributes an annual survey to develop a listing of private and public agencies in the state to help pregnant women. Typical services include food, clothing and supplies to support pregnancy, parenting skills, educational programs, and adoption assistance. OWH supports tobacco cessation for pregnant and postpartum women and their households through telehealth via the BMTF Program. OWH works with BMTF to publicize the program and offer it at no cost to participants across the state. OWH leads a doula training program to increase the number of doulas and doula training organizations across the state. OWH also represents DHSS on several statewide task forces and commissions, including the Missouri Sexual Assault Response Team and the Combatting Human Trafficking and Domestic Violence Commission. Finally, OWH supports the statewide Sexual Assault Nurse Examiner Telehealth Network. This network has completed the pilot stage and will expand access to forensic exams across the state. As a part of the network, women will be connected to primary care for follow-up after their exams. This connection point will not only improve their healing journey after trauma but will also improve lifelong health.

 

Missouri Maternal Health Action Network

DHSS will continue to contract with the University of Missouri Kansas City Institute for Human Development (UMKC-IHD) to facilitate the statewide, multi-sectored Missouri Maternal Health Action Network (the Network). The Network will continue efforts to connect stakeholders serving pregnant mothers and families impacted by substance use and mental health conditions with existing resources and toolkits and fostering partnerships among stakeholders and key partners. The Network supports pregnant women and mothers from the prenatal period through the full twelve-month postpartum period, as well as during the preconception and interconception phases. The Network engages mothers in the Moms’ Advocacy Network; provides capacity-building and leadership opportunities for interested mothers; creates a space for mothers to share their stories and drive system change; fosters peer support among the mothers; and facilitates connections to career opportunities for the mothers. The Network will continue the Moms’ Advocacy Network and host the leadership and self-advocacy academy with at least one cohort annually. The Network will seek additional opportunities to connect mothers with resources and opportunities for further education, licensing, and career development. The Network and its workgroups will work across partners and sectors to develop action plans to address gaps in the support system and other emerging issues. Using the Healthy People 2030 social determinants of health framework, the Network will advocate for equitable and upstream prevention strategies. The Network plans to utilize the six guiding principles of the trauma-informed approach developed by the CDC and the Substance Abuse and Mental Health Services Administration when hosting the Moms’ Leadership Academy, engaging the Moms’ Advocacy Network and facilitating Network meetings and activities.

 

A comprehensive evaluation plan will be implemented in FFY 2025, including a thorough process evaluation, a rigorous quality improvement process and an outcome evaluation to assess the short-, intermediate-, and long-term impact of the Network on professionals, families, and support systems. A five-year strategic plan is being developed, including planned strategies and activities and defined metrics to evaluate impact, demonstrating the Network’s commitment to accountability and transparency. The MCH Director will collaborate with the Network to develop the strategic plan, including planning for long-term sustainability.

 

NOTE: The Perinatal and Infant Health domain also contains content relevant to maternal health.