For 2023, the priorities for women’s health are to reduce and eliminate barriers to ensure equitable and optimal health for women and to reduce disparities in infant and maternal morbidity and mortality. The strategies described below are linked to NPM 1: Well-Women Visits and NPM 13.2 Preventive Dental Visits - Pregnancy.

In 2023, $2,017,415.00 in Title V funds will be allocated across 14 (out of 15) of Arizona’s county health departments via the Maternal and Child Health Healthy Arizona Families Intergovernmental Agreement (MCH HAF IGA) to implement strategies specific to self-selected MCH National Performance Measures (NPMs). The counties will implement strategies focused on NPMs related to improving the health of women and mothers at the community level. BWCH will also promote and provide webinars on topics related to achieving health equity and selecting evidence-based strategies to the county programs.

Title V Family Planning Program: Within the MCH HAF IGA, nine (9) counties (Apache, Cochise, Gila, Graham, Greenlee, La Paz, Mohave, Navajo, Yuma) will implement family planning and reproductive health services to low-income and other higher need women, including those living in rural and underserved areas or without a reliable form of health insurance, and their partners. The overall goal of this program is to improve the health of women of childbearing age before, during, and after birth to promote optimal health, outcomes, and wellness for all Arizonans; in alignment with our priority to reduce and eliminate barriers to ensure equitable and optimal health for women and NPM 1: Well-Women Visits. Services provided will include family planning and reproductive health education; counseling on birth control methods and provision of birth control; screening for pregnancy, sexually transmitted infections, and cervical cancer; and referrals to other clinical or social services. Separately, the Arizona Title V Program also provides $250,158 to a network of federally qualified health centers (Valleywise Health) to provide these services in Maricopa County.

BWCH will continue to coordinate the annual summit for Title V Family Planning nurses that meets their clinical and educational needs. BWCH will work with the Arizona County Directors of Nursing Association (ACDONA) and county family planning nurses to identify training topics and anticipated outcomes.

BWCH will also continue to improve access to care for women by collaborating with the Healthy Arizona Workforce Program, WIC, home visitors, and community health workers to encourage and promote well-woman visits and sliding fee scale clinics; leverage partnerships to increase awareness and address barriers to accessing well woman visits; and encourage technical assistance to safety net providers to establish patient reminder protocols.

BWCH will continue to coordinate with the STD Control and the HIV Prevention Programs within the Office of Disease Integration & Services to ensure that we are aligning program activities and leveraging funding to reduce incidence of sexually transmitted infections before, during, and between pregnancies and eliminate vertical transmission of syphilis and HIV. Likewise, efforts will be coordinated with the Sexual and Domestic Violence Programs in the Bureau of Chronic Disease and Health Promotion to align strategies.

Arizona identified the continued need to improve the health of women before and between pregnancies as a priority. BWCH will continue to support the Preconception Health Alliance in partnership with the Arizona Family Health Partnership and the Arizona Chapter of the March of Dimes. The Alliance meets quarterly and will continue to increase its partnering agencies and will continue to implement strategies outlined in the strategic plan.

In 2023, Arizona’s Title V Program will continue to work on reducing severe maternal morbidity (SMM) and maternal mortality (MM) through a multi-pronged approach that includes coordination between the federally funded Maternal Health Innovation Program (MHIP), Maternal Mortality Review Program (MMRP), and Alliance for Innovation on Maternal Health (AIM) and through the state lottery–funded Health Start Program.

The Arizona Health Start Program is an evidence-informed, promising approach home visiting program for at-risk pregnant and/or postpartum women with children under the age of 2 that is funded through the state lottery (as part of the Title V match) and the Maternal Health Innovation Program. In 2023 the Health Start Program will continue to implement the Triple P evidence-based parenting program in two sites, which will enhance parenting education and build family strengths with the most at-risk clients.  Health Start will continue to integrate the Community Health Worker American Public Health Association Core Competencies into training for new staff that will emphasize the core skills of communication, advocacy, capacity and relationship building and care coordination and focus on promoting health equity. Through the continued use of the All Babies Cry application and education in Health Start, families will be offered safer alternatives to addressing the needs of infants and toddlers. The Health Start Program will continue to address maternal health needs by continuing the extensive screening and assessment of prenatal and postpartum women for perinatal mood and anxiety disorders, substance use, intimate partner violence and observing parent-child interactions. Maternal morbidity and mortality prevention education will continue to be integrated through the use of the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) education and resources, including sharing the Post-Birth Warning Signs magnets and flyers with clients and families.

The Health Start Program will collaborate with Prevent Child Abuse Arizona, the Arizona Department of Child Safety, Maricopa County Department of Public Health, the Arizona Substance Exposed Newborn Prevention Statewide Task Force and the Arizona Chapter of Postpartum Support International to ensure that linkages are strengthened and resources are shared to address the needs of all families and ensure positive health outcomes for mothers and babies. Health Start will assist with the planning and implementation of the Safe, Healthy Infants and Families Thrive Summit which will address the care coordination and unique needs of mothers experiencing a substance use disorder and infants who may have been exposed prenatally.

Arizona continued to experience a rise in opioid-related overdoses and deaths, particularly those related to fentanyl use and exacerbated by the stress due to the COVID-19 pandemic. As part of the ongoing response to the opioid epidemic, particularly as it impacts Title V populations, in collaboration with and with funding from the Bureau of Chronic Disease and Health Promotion, the Health Start Program will continue the media placement of the Stigma Reduction Media Campaign for Women with Opioid Use or Substance Use Disorder. This campaign will continue to be directed toward women who are of reproductive age to promote behaviors that prevent/reduce prenatal exposure and to reduce the stigma that pregnant and parenting substance use disorder (SUD)/opioid use disorder (OUD) women feel when interacting with healthcare providers and support services. In response to the increased use of recreational cannabis by women during pregnancy and in the postpartum period, the Health Start Program will continue work on a Cannabis Awareness Project that will involve the development of a cannabis/marijuana warning sign poster and supportive education and materials that will be placed on the Arizona Department of Health Services Marijuana Program (under the Public Health Licensing) webpage. This effort will increase awareness of the detrimental effects that cannabis use during pregnancy has on the developing fetus and infant and the safety concerns of use with children in the home.

Arizona is one of nine states that was awarded HRSA’s Maternal Health Innovation Program (MHIP) grant in 2019.  With the continuation of the MHIP grant, Arizona will continue to support and address the five main goals listed in the Governor’s Goal Council: 1. Knowledge and Education for Pregnant and Postpartum Women; 2. Improving Knowledge and Education for Pregnant and Postpartum Women; 3. Improve Access to Care; 4. Support Workforce and Workforce Capacity; and 5. Improve Surveillance and Support Systems of Care. MHIP funding will be leveraged to meet the needs of the Governor’s Goal Council through a work plan developed by the multidisciplinary Maternal Health Task Force that engages stakeholders from across the state to identify pressing issues and potential opportunities related to maternal health. The Maternal Health task force and its sub-task force groups: Maternal Health Steering Committee, Maternal Mental Health, Tribal Maternal Health, and AIM Steering Committee will continue to meet and provide guidance on the maternal health efforts being implemented by MHIP. 

In 2022, the MHIP will continue to fund the Arizona Maternal and Infant Mortality Summit to bring together statewide stakeholders to share leading causes and risk factors for maternal and infant mortality, identify opportunities to reduce preventable maternal and infant mortality, and brainstorm how Arizona can improve health equity for populations experiencing disparities in maternal and infant mortality and morbidity. The Summit is organized and hosted jointly by the MHIP and Maternal Mortality Review Program (MMRP).  MHIP and the MMRP collaborate on a number of initiatives to implement state-specific actions that address disparities in maternal health and improve maternal health outcomes, including the prevention and reduction of maternal mortality and severe maternal morbidity, in order to optimize resources by sharing access to maternal health data and experts. 

Given that the leading causes of death and severe maternal morbidity (SMM) in Arizona are related to cardiac conditions, hypertensive disorders of pregnancy, sepsis, and mental health conditions, it was evident that education around urgent maternal warning signs was needed in Arizona. In 2022, MHIP leveraged the CDC’s Hear Her campaign to increase awareness of maternal warning signs and share critical information with Arizona maternal health stakeholders and birthing people. In 2023, MHIP will expand those efforts, developing and launching a campaign with an increased focus on perinatal mood and anxiety disorders.

Through MHIP and AIM funding, ADHS will continue to support workforce capacity and support systems of care through implementation of the Alliance for Innovation in Maternal Health (AIM). Since the AIM launch in April 2021, 33 of the 44 birthing hospitals in Arizona (accounting for over 90% of all births statewide) have been implementing the Severe Hypertension in Pregnancy patient safety bundle. The implementation will continue through 2023 with ADHS funding the Arizona Hospital and Healthcare Association to provide technical assistance and ongoing support to the participating birthing hospitals through monthly calls, webinars/training, and interpersonal education to share lessons learned and challenges experienced to improve implementation efforts and health outcomes. MHIP will also be working with community partners to develop a Continuing Medical Education (CME) course for emergency department staff to better equip them in providing care and identifying early warning signs of pregnant and postpartum people.

With funding from the MHIP, BWCH will continue the Count the Kicks campaign and training in Arizona.  Establishing a partnership with Count the Kicks will help build awareness among women in their third trimester of the importance of counting their baby’s movements and telling their provider right away if they detect any change, with the aim of decreasing stillbirths in Arizona. Webinars targeted to specialized groups such as OBGYNs, home visitors, etc. will be provided to continue to create awareness and promote the materials available for ordering. Additionally, targeted email campaigns and social media ads will be used to further create awareness of Arizona’s campaign. According to Count the Kicks’ Arizona profile, Arizona loses, on average, 489 babies a year due to stillbirth and, on average, 158 babies could be saved every year. Participating states have shown a significant decrease in stillbirth rates after a five-year investment. 

In 2020, a contract was established with a rural health center in Cochise County, Chiricahua Community Health Center (partnering with Tucson Medical Center), to provide prenatal telemedicine services in the community. This work will continue to be supported in 2023 through MHIP funding.

Addressing Maternal Health Disparities: Data from the Maternal Mortalities and Severe Maternal Morbidity in Arizona (Dec 2020) report shows that indigenous (American Indian/Alaska Native) communities and Black communities experience higher rates of maternal mortality and morbidity compared to other racial and ethnic groups in Arizona. 

To address the disparities observed and with American Indian/Alaskan Native stakeholder input, a specific Tribal Maternal Task Force was established to develop and implement a culturally relevant tribal maternal health strategic plan to improve maternal health outcomes and promote and execute innovation in tribal maternal health care delivery. The Tribal Maternal Task Force is staffed by a Tribal Maternal Health Innovation Program Manager who has over 10 years of direct service work experience and is a member of the Navajo Nation.

In response to recommendations put forth by the Tribal Maternal Health Task Force, MHIP established contracts with Diné College and with the Inter Tribal Council of Arizona to address the needs and improve health outcomes of indigenous women throughout Arizona. Through these two contracts, all 22 of Arizona’s Federally Recognized Tribal Nations are represented. In 2023, the work to improve maternal health among the Indigenous populations will continue to be funded through MHIP. Efforts include conducting training about Maternal Health and Family Wellness from an Indigenous Perspective, which are culturally centered and community driven and are provided by elders, Indigenous knowledge holders, and birth workers. An evaluator experienced in the native culture is collaborating with partners to enhance their programming efforts.

MHIP will also continue to fund the Maricopa County Department of Public Health Healthy Start Program to extend their services with high-risk Black/African American mothers. 

The Maternal Mortality Review Program (MMRP) is also aiming to address health disparities in Arizona through several data-related activities. First, the MMRP will continue to partner with Diné College and the University of Arizona to conduct an extension of the 2020 Title V Needs Assessment focused on access to prenatal, postpartum, mental, and oral healthcare in Arizona. While 2021 data collection efforts primarily included indigenous, African American, and rural populations, the continued needs assessment in 2022 will focus mostly on rural counties in Arizona that were not represented in 2021. Findings will be used to inform future programming for MMRP, MHIP, and Title V programming. The MMRP is also focused on development and dissemination of new data regarding maternal deaths related to mental health conditions and substance use disorder, and maternal health outcomes in rural Arizona. Dissemination of the new report is expected by September 2022 which will include recommendations to improve maternal health care, and will be shared with multidisciplinary partners across the state.

The MMRP will continue to disseminate findings from Maternal Mortality Reviews in Arizona by releasing a report regarding maternal mental health- and substance use-related deaths in Arizona. ADHS will continue to implement the Pregnancy Risk Assessment Monitoring System (PRAMS), a joint research project between the Arizona Department of Health Services and the Centers for Disease Control (CDC).  PRAMS conducts a survey about a woman's health and life experiences before, during, and after pregnancy and is the only surveillance system that provides data about pregnancy and the first few months after birth. Randomly selected mothers who delivered a live birth in Arizona may be eligible to participate in the mail and/or telephone questionnaires. AZ PRAMS aims to obtain data of high scientific quality on maternal behaviors before, during, and shortly after pregnancy that can be used to monitor health status as well as allow ADHS to more effectively tailor preconception, pregnancy, and postpartum services and programs to Arizona’s diverse population. AZ PRAMS provides longitudinal data on factors such as low birth weight, preterm birth, ante/postpartum obesity, mental health, COVID-19, and breastfeeding during and after pregnancy, across Arizona’s diverse maternal population. This knowledge across the state population of new mothers is necessary to monitor the progress of state and non-governmental program efforts to improve the quality of maternal and infant health services. AZ PRAMS is predominantly funded through the CDC, but receives supplemental funding through the Justice Reinvestment Fund (state), Council of State and Territorial Epidemiologists, and Title V to enhance program reach.

As part of the bureau's efforts to increase family involvement, the Office of Women’s Health will continue efforts to fulfill the goals as outlined in Phase 1 of the Engaging Families and Young Adult Program to establish family advisor positions in the women’s health domain.  Meetings began in 2022 and the Office of Women’s Health is working on developing drafts of scopes of work.  CYSHCN Program Director and Family Advisor, Dawn Bailey have been providing technical assistance and the Office of Women’s Health will continue to support bureau efforts to establish a family advisor position. The MHIP and the MMRP have also focused on engaging patients and families in our work and will continue to do so in 2023. The MMRP has onboarded three patient and family advisors to the Maternal Mortality Review Committee. These advisors not only serve as full MMRC members with voice and vote, but will also be engaged to inform how we disseminate MMRC findings to communities. 

MHIP has engaged a patient and family advisor for the AIM Steering Committee.  She is a fully participating and active member of the Committee as well as a speaker for the AIM Kick Off Event. The Maternal Mental Health Task Force has a patient advocate that actively participates in planning and programing efforts. MHIP is committed to continued engagement efforts for all committees and planning work. The team is also participating in a National Lived Experience Integration Community of Learning with Momma’s Voices. This was a Community of Learning that was in conjunction with several other states in which Momma’s Voices provided information and technical assistance in how to better engage and work with individuals with lived experience.