Section III.E.2.c State Action Plan Narrative by Domain

MCH Population Domain: Women/Maternal Health

National Performance Priority Area: Well-woman Care, with an Emphasis on Minority and Low-income Women– 2023 Annual Plan Narrative (October 1, 2022– September 30, 2023):

During the 2020 Maternal Child Health (MCH) Needs Assessment, it was identified that women in North Dakota are lacking in preventive health visits. According to the 2017-2019 North Dakota Pregnancy Risk Assessment Monitoring System (PRAMS) data, 69.2% of women (43.8% of American Indian (AI) women, 75.5% of White women, and 47.8% of women of other races) reported having a “routine” check up in the 12 months prior to becoming pregnant. In 2020, this number decreased to 66.2% (36.7% of AI women, 73.9% of White women, and 39.3% women of other races). For women who completed the 2020 PRAMS survey for North Dakota, nearly 67.4% of AI respondents reported utilizing Medicaid as their primary insurance during the most recent pregnancy; in contrast, just under 14.3% of White respondents and 34.5% of “other races” respondents listed Medicaid as their health insurance.

In 2020 and 2021, Title V staff gathered a group of stakeholders (8 external partner organizations) to discuss strategies to increase the number of women, ages 18-44, who report having a preventive health visit within the past 12 months. Again in March 2022, Title V staff gathered stakeholders to review the strategic plan and discuss progress and potential revisions. Based on the needs and capacity of Title V staff, combined with the MCH Stakeholder meetings, seven strategies were identified to increase preventive visits for women in North Dakota.

Timely access to appropriate health care is vital to achieving better health outcomes for women; Medicaid coverage—especially during pregnancy and the postpartum periods—provide a unique opportunity to provide preventive care. Uninsured women are less likely to receive preventive services and are more likely to develop chronic health conditions. Nationally, the rate of uninsured females aged 19-64 in 2020, as reported by Kaiser Family Foundation (KFF) is 11% and in North Dakota the rate is 8%. Because pregnant women can qualify for Medicaid with a slightly higher income, Medicaid is one way to bridge the gap for those who may not otherwise be able to afford insurance and thus provide access to critical preventive care. According to KFF, 24% of births were financed by Medicaid in 2020, while according to KFF, the overall number of women covered by Medicaid is much lower with only 10% of women ages 15-49 on Medicaid.

As of March 2022, North Dakota has enrolled 120,566 individuals in Medicaid and CHIP — a net increase of 72.3% since the first Marketplace Open Enrollment Period and related Medicaid program changes in October 2013 (https://www.medicaid.gov/state-overviews/stateprofile.html?state=North-Dakota). Given the high number of women covered by Medicaid and engaging with the medical system during the pregnancy and post-partum period, there is a unique opportunity to provide preventive care by capitalizing on this time when women are more likely to have access to care.

Women covered by Medicaid, especially minority women, are at higher risk for adverse outcomes of pregnancy. In the six weeks after a mother gives birth, Medicaid-eligible women can obtain valuable services related to the acute concerns of pregnancy and birth. However, six weeks of Medicaid coverage is often not long enough for these conditions to resolve, potentially leaving women unable to access necessary care due to lapse in coverage. The American College of Obstetricians and Gynecologists (ACOG) describes that after the initial postpartum period, women slowly transition from postpartum-related medical care to well-woman care that has a broader focus. It is during this time that women can begin getting appropriate interconception care to assure a healthy subsequent pregnancy and to address health concerns that could affect her long-term health outcomes overall. By extending Medicaid one year postpartum, we increase the potential for these women to enter their next pregnancy in a healthier state.

Nationally, a major focus of many women's health campaigns is extending postpartum access to Medicaid. There is widespread understanding that extending Medicaid coverage is a strategic way to provide better access to preventive health care. One example is Illinois, which is advocating for an extension of Medicaid fueled in part by the absence of postpartum coverage. A recent study in Illinois demonstrated that 75% of maternal deaths were related to mental health and most deaths occurred within six months after giving birth. These findings highlight the need for continuity of care for women continuing for months, not mere weeks postpartum. The need for the extension of Medicaid may be particularly important for minority women: research shows that women of color and who have lower incomes are more likely to suffer from post-partum depression, which may require longer-term care and treatment.

Title V staff identified that extending Medicaid one year postpartum was a key strategy to improve preventive women’s care. In 2020, a taskforce was convened to discuss Medicaid extension. Resources from other states and national organizations were collated to outline the need for Medicaid extension of coverage to 1-year post-partum in North Dakota for the purpose of being shared with internal and external partners. Additional meetings were held to discuss these papers and determine viability of this project moving forward.

In 2021, the team planned to continue facilitating discussions with the task force and to develop a strategic plan for how to pursue the extension of Medicaid postpartum. However, unexpectedly, the American Rescue Plan Act allowed North Dakota to pursue the option of extending Medicaid. North Dakota made the decision to extend Medicaid one year postpartum starting on January 1, 2023. 

Therefore, in the 2022-23 plan, Title V staff will work closely with the Department of Human Services to develop a strategy for implementing the extension of Medicaid.  The team will be particularly involved in determining annual reporting indices, by identifying key data elements that could serve as markers of success. 

The second strategy the Title V staff will use in 2022-23 is to continue to reach women of lower incomes and/or from a minority demographic through contracting with at least six local organizations using participatory grant making.

In 2020-21, the Title V staff piloted the use of participatory grant making with local grantees. Potential partners met (virtually) to discuss ideas for increasing well-woman visits in their community and consider ways to collaborate. Participatory grant making was used to allocate funding. In this novel approach, shared decision making allows partners to distribute the funding among themselves. Grantees had varying degrees of success in reaching women in their communities in 2020-2021, with some being highly successful and others less so. However, the transparency and equitability of participatory grant making was well-received among grantees and the Title V team used the strategy again in 2021-22, with improved orientation for grantees, more guidance on reporting guidelines, and more stringent criterion for appropriate grant outcomes. Grantees in 2021-22 are required to report on number of women receiving well woman care.

In the 2022 strategic planning meeting, the Title V team was advised to continue using this strategy in the 2022-23 year. To amplify the well-woman work, the current six grantees will use lessons learned in 2021-22 to expand and build upon their projects in the next grant cycle. Examples include reaching more women than in 2021-22, expanding their projects to reach women of different race/ethnicities, increasing the number of women who follow up with well woman care in their programs. Regular technical assistance will be provided by the Title V staff to aid partners in reaching their goals. For example, the Title V program staff can connect grantees with local and state partners that can increase the efficacy of their grant activities. To see more about this innovative approach to disseminating MCH grant funding to local partners, please see Section III.A.3. MCH Success Story.

The ESM will be enhanced to capture number of women who followed up with well woman care, to measure impact of this strategy.

The third strategy that MCH staff will use is developing a combined preventive health flyer/brochure to be disseminated through five pilot sites in North Dakota. While many NDDoH resources have moved to online formats, stakeholders from organizations serving low income and minority women have identified that a paper-based brochure is still the ideal for many of the women they serve. The first step in implementing this strategy will be to convene a task force comprised of agencies focused on women’s health, especially community-based organizations (CBOs) that serve low-income and minority women in North Dakota. According to the Community Tool Box resource from the Center for Community Health and Development at University of Kansas, multisector task forces serve many purposes, such as helping the parent organization hone in on the areas that need most attention and allow concentration on specific areas of focus. Ten key stakeholders will be identified in 2022-23 and the task force will be convened four times over the 2023 calendar year. NDDoH will collaborate with the task force to develop the preventive health brochure. Then, through the task force, five pilot sites will be identified to disseminate the brochure to women across North Dakota. Pilot sites will be chosen that reach the community and those providing services that impact the social determinants of health. According to the Journal of American Board of Family Medicine (2021), intentional partnership with CBOs is necessary to make progress in improving health for more vulnerable groups.

As mentioned above, women of color and lower income are more likely to suffer from postpartum depression. In fact, the Centers for Disease Control (CDC) 2020 data reports that the overall age adjusted suicide rate for the North Dakota is 18.09 per 100,000 (135 total deaths) as compared to the national rate of 13.48 per 100,000 (45,979 total deaths). By sex, the age adjusted suicide rate in North Dakota is 28.15 per 100,000 (109 total deaths) for males and 7.49 per 100,000 (26 total deaths) for females with an increase in suicide rate in females as compared to males when compared to data from 2019: males 28.90 per 100,000(113 total deaths), females 6.17 per 100,000 (23 total deaths). Nationally, the rate for males is 21.90 per 100,000 (36,551 total deaths) and in females the rate is 5.52 per 100,000 (9,428 total deaths) with an increase in suicide rate for males as compared to females. Moreover, the suicide rate for the non-Hispanic AI population in North Dakota is at a rate of 40.29 per 100,000 (19 total deaths) compared with the US rates of 23.85 per 100,000 (663 total deaths). However, in North Dakota, there has been a decline in suicide rates between 2019-2020 in non-Hispanic White: 2019- 19.38 per 100,000 (122 total deaths) and in 2020 -17.30 per 100,000 (108 total deaths). Nationally, age adjusted suicide rates for non-Hispanic White has seen a decline between 2019-2020: 2019-17.52 per 100,000 (37,672) and in 2020-16.75 per 100,000 (35,716 total deaths). 

For postpartum depression specifically, there is also a large disparity between AI women and others: during the post-partum time, 21.5% of AI mothers and 25.9% of mothers of other races and 12.1% of White mothers reported depression symptoms.  High depression rates are seen prior to pregnancy as well: 2020 PRAMS data for North Dakota, 23.9% of AI mothers, 17.9% of White mothers, and 8.0% of mothers of other races reported they experienced depression during their pregnancy. According to the National Institute of Health, Systematic Review of Maternal and Infant Outcomes in 2019, untreated postpartum depression can have negative consequences for both the mother and baby. Implications for the mother can include obesity, alcohol/drug use, breastfeeding issues, and relationship disturbances. Implications for the babies can include lower cognitive functioning, violent behaviors, and psychiatric/medical disorders in adolescence.

According to the March of Dimes, studies suggest that increased access to doula care, especially in under-resourced communities, could improve a range of health outcomes for mothers and babies, lower health care costs, reduce c-sections (cesarean sections), decrease maternal anxiety and depression, and help improve communication between low-income, racially/ethnically diverse pregnant women and their health care providers. Therefore, Title V staff will also be identifying potential approaches to developing a doula pilot program that could be endorsed through the North and South Dakota Perinatal Quality Collaborative (NSDPQC). The goal of the NSDPQC is to achieve measurable improvements in statewide population-level maternal and infant health care and health by deepening and accelerating improvement efforts for maternal and infant health outcomes.

Depression is a significant issue both before and after pregnancy and highlights that mental health should be at the forefront of preventive care efforts. Early identification and treatment of depression in women of childbearing years is one key component to improving the over-all health and well-being of women (and their children) in the state. Title V staff will be working diligently on increasing depression screening, support, and referrals for women.

The American Academy of Pediatrics recommends routine screening of women in the post-partum period for depression at well-child visits. The Centers for Medicare and Medicaid Services (CMS) approved coverage of post-partum depression screening for women during their well-child visits in 2016. In year one of the plan, the team partnered with pediatricians to evaluate post-partum screening during well child visits. While many pediatricians were screening women in some way at well child visits, the process is not standardized, and data is not readily available to assess the efficacy of screening practices, number of referrals, or percentage of referrals resulting in follow-up mental health appointments. In year two, a pilot site began implementing screening, with support from the Title V team. All pediatricians at the pilot site were all able to implement postpartum depression screening in and found minimal negative impact on workflow. However, exact numbers of women screened, number of positive screens, and uptake of referrals could not be assessed by the pilot site. The IMPLICIT (Infants Using Continuous Quality-Improvement Techniques) Interconception Care Model is a cutting-edge model that embeds care for moms who might become pregnant again into well-child visits. It is a preventive care model that incorporates assessments and referrals. Although North Dakota does not have the infrastructure in place to implement all components of this model, Title V staff will continue to identify components of IMPLICIT that could potentially be integrated into current well-child visits. In addition, potential partnerships with neighboring states who are implementing this model (Minnesota) will continue to be explored as an option for technical assistance.

In the upcoming year, Title V staff will consider the following activities to continue to increase depression screening postpartum: 

1. Calling nurse managers, to ask about 2, 4, 6-month postpartum depression screening, including how the info is captured in the EHR and what happens after to ensure referral.

2. Consider an incentivized webinar/training on why postpartum screening is important at well child visit.  

Expanding Medicaid coverage until one-year post-partum is a critical step towards ensuring that if a woman would like to seek mental health, she has the insurance coverage to do so. In the coming years, the team will be looking at the combined efficacy of Medicaid extension and increased depression screening and referral. Medicaid extension to one year will increase the uptake of postpartum visits, where depression screening occurs. The extended and continuous Medicaid enrollment will allow those who screen positive for postpartum depression at these postpartum visits and at well child visits to act on referrals provided.

Key partners in 2022-23 include: 

• Altru Medical Facility
• Bismarck Global Neighbors
• Community churches
• East African Diaspora
• Head Start/Early Head Start
• Jamestown Regional Medical Facility
• Motherland Health
• New Hope for Immigrants
• New American Foreign-Born Immigrant, local stakeholder meetings
• North Dakota Women’s Network (NDWN)
• North and South Dakota Perinatal Quality Collaborative (NSDPQC)
• Sacred Pipe Resource Center
• Sanford Health Fargo
• South Sudanese
• Upper Missouri District Health Unit (UMDHU)
• Women Empowering Women
• Project Bee
• Women, Infants, and Children (WIC)
• Fargo Adult Learning Center
• Women’s Way (WW)
• North Dakota Family Planning Program (ND FFP)
• Spirit Lake Community Health Representatives
• Sontak Family Clinic
• New American Consortium for Wellness and Empowerment
• Full Life Assembly of God Church