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

Women’s Health

The Section for Women’s Health (SWH) 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 the continuation of the Women’s Health Network listserv. The WOMEN: Take Charge of Your Health publication includes information on topics such as preventative health, preconception health, obesity prevention, breastfeeding, postpartum depression, and disease prevention. This resource is also available on the Department of Health and Senior Services (DHSS) website at www.health.mo.gov/womenshealth. The My Health Tracking Card provides a means to track blood pressure, cholesterol, and weight, and is available on the DHSS website at https://health.mo.gov/living/families/womenshealth/pdf/my-health-tracking-card.pdf. Resources are provided to the general public, Local Public Health Agencies (LPHAs), and others who contact the SWH 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 in services for women, changing technology in women’s health, available resources, training opportunities, events and funding opportunities.

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 reflects the geographic diversity of Missouri. The Council is charged with informing and advising the 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, as well as, multiple directors of critical social services foundations serving women throughout Missouri.

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. This includes the promotion of dental visits during pregnancy. As quantities allow, ODH will supply infant toothbrushes and Healthy Smiles from the Start booklets to the St. Louis Safe Kids Coordinator for use during their training in baby safety classes. The baby safety classes cover safe sleep habits, car seat safety, breast and bottle-feeding and oral care. The training reaches pregnant moms, new parents and grandparents and is done in both English and Spanish.

The ODH will also continue to provide education to women about the importance of oral health for the mother’s overall health, during pregnancy and throughout her lifespan. 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 GHC Home Visiting Program. Materials are also distributed via local public health agencies, dental offices, and at community outreach events. The importance of dental visits among pregnant women is reinforced in literature distributed by the ODH via its collaboration with WIC, the Home Visiting Program, and Federally Qualified Health Centers.

Community Health

The Maternal Child Health (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 pregnant women:

• Ten 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 of the LPHAs, Jackson County Health Department, is planning to coordinate community conversations with women of childbearing age in previously identified high risk zip codes to create a health equity agenda and priority listing for each zip code area.
• Nine LPHAs have selected to prevent and reduce obesity among women of childbearing age as their PHI.
• Ten LPHAs have selected to prevent and reduce smoking among women of childbearing age and pregnant women as their PHI. These LPHAs will continue increased efforts to assess smoking in women of childbearing age and offer smoking cessation resources and programs. Outreach efforts will continue to engage community partners and providers to increase collaborative educational efforts and resource sharing, and strengthen referral networks. 
• Two LPHAs have 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 MCH Services Program will also support LPHA efforts to provide education on the importance of adequate dental care and overall oral health; collaborate with partners to provide screening, referral and direct provision of preventive dental services for oral health needs; 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 maternal and child health 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 is able to provide referrals to 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 maternal and child health resources for women of childbearing age and their families which includes preconception, prenatal, and postpartum care, as well as smoking cessation, postpartum mood disorders, and the importance of taking folic acid. The program accomplishes 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 maternal and child health internal work group and maximize outreach opportunities at conference exhibits, health fairs, and through the Home Visiting Programs by distributing various educational materials.

Home Visiting

The Genetics and Healthy Childhood (GHC) Home Visiting Program will continue to share information with all contracted local implementing agencies to help home visitors better understand Affordable Care Act (ACA) marketplace changes and uncertainties in order to assist enrolled clients to access insurance for prenatal, postnatal, and well woman care through email; postings on the Missouri Home Visiting Gateway Website (https://health.mo.gov/living/families/hvcqigateway/) under resources and weekly updates; and through the continuous quality improvement quarterly home visiting newsletter, Quality Outlook (https://health.mo.gov/living/families/homevisiting/cqinewsletters.php). The program will continue to collaborate with the Missouri Department of Social Services (DSS) Family Support Division (FSD) User Assistance Team to update a Question and Answer Document for the Missouri Eligibility Determination and Enrollment System (MEDES). This document will be shared with contracted home visitors to provide current information they can use when assisting women in applying for and accessing MO HealthNet (Missouri’s Medicaid) coverage for pregnant women, unborn children, and newborns, to assure their ability to attain appropriate prenatal care. The Home Visiting Program 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 GHC Home Visiting Program Services include:

• Promoting smoking cessation for all primary caregivers who answer yes to smoking at enrollment and at subsequent 6 month time points during enrollment. Annual performance measure data will be collected on the percentage of primary caregivers who report smoking, using tobacco, or other forms of nicotine delivery, including e-cigarettes, at enrollment and are referred to tobacco cessation counseling or services within three months of enrollment. In addition, home visitors will be provided with information and resources to share with enrolled participants for tobacco cessation such as the DHSS Missouri Tobacco Quitline and TEL-LINK,
• Providing information and resources that promote the benefits of pregnancy to the full 40 weeks to all contracted home visitors to share with clients. Sources for these resources will include DHSS and the March of Dimes. GHC Home Visiting Program Managers will assess the receipt and use of these resources during monthly subrecipient monitoring calls with contracted local implementing agencies,
• Screening all prenatally enrolled clients within three months of delivery. Primary caregivers not enrolled prenatally will be screened within the first three months since enrollment. Home visitors will utilize the Public Health Questionnaire 9 (PHQ-9) depression screening tool at these prescribed time points and additionally anytime home visitors recognize potential symptoms of depression. Individuals who screen positive will be referred to the appropriate services. Annual performance measure data will be collected for depression screening as described above. Additionally, annual performance measure data will be collected on the percentage of completed referrals to services for a positive depression screening, 
• Promoting the powerful and informative film, Dark Side of the Full Moon. This can be offered as a free community resource since the program purchased indefinite streaming rights to the platform, and
• Providing contracted home visitors with ordering information for oral health resources from the ODH and the Missouri Primary Care Association to share with enrolled primary caregivers to promote the importance of receiving preventive dental care during pregnancy.

Environmental Health

Many persons are not aware that lead exposure can be a problem for women of childbearing age as well as for their developing fetus and nursing infant. The most serious effect of high levels of lead during pregnancy can cause 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 they are known to be pregnant with elevated blood lead levels (EBL) of 5 mcg/dL or higher (tracked by the ABLES 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 and ongoing basis. 

The Prenatal Substance Use Prevention Program will promote the importance of prenatal substance use prevention to promote healthy pregnancy and birth. The program utilizes statewide community placement sites, which 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. Missouri Tobacco Quitline tip cards and MO HealthNet resources will be utilized.

Maternal Mortality

DHSS Section for Women’s Health (SWH) 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 termination 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.

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. During year one of ERASE MM implementation, the SWH improved internal processes to expedite maternal mortality case identification, abstraction and review. For example, rather than waiting on death files to be finalized, the SWH coordinated with the Bureau of Vital Records to use provisional death files. This process improvement greatly improved the timely identification of potential maternal mortality cases. These process improvements will continue to be refined during year two of the grant. In addition, a Patient Abstract System (PAS) linkage will be created to identify additional hospitalizations/emergency room visits that will aid in case abstraction. Through the ERASE MM grant, the SWH is able to contract with the Missouri Hospital Association (MHA) to implement patient safety bundles in Missouri birthing facilities, clinics and critical access hospitals. This work will continue and includes plans to implement “Obstetric Care for Women with Opioid Use Disorder” bundle. Maternal overdoses were identified as a leading cause of death for PAMR in a report published in June 2020 titled, “Missouri Pregnancy-Associated Mortality Review: 2017 Annual Report”. The SWH Maternal/Infant Mortality Coordinator will work closely with the PAMR Board and Title V Program to implement the initiatives in this grant.

Missouri became an Alliance for Innovation on Maternal Health (AIM) state in 2019. Through this effort, the Missouri Hospital Association (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. SWH will continue collaborating with MHA and other key stakeholders through the Maternal and Child Learning and Action Network (MC LAN) to assist with implementation efforts of the AIM bundles in MO birthing facilities. Hospitals enrolled in AIM will be required to report data metrics into the AIM data portal. DHSS and MHA will assist hospitals with data submission to minimize burden on the facilities. DHSS will then work with MHA to leverage key stakeholders to assist with the process of implementing AIM bundles in interested facilities.