Ongoing Needs Assessment Activities

The Office of Assessment and Evaluation (OAE) leads the collection, analysis, and interpretation of public health maternal child health data at the Arizona Department of Health Services. OAE’s mission is to serve as a resource to all stakeholders so that programs and partners make data-driven decisions that provide equitable opportunities for achieving optimal health for all children, women, and families in Arizona. OAE provides technical assistance and expertise on: data analytics, data management, epidemiology, program evaluation, public health assessment, and surveillance. Recently, OAE led or played a major role in two large statewide needs assessments: the Title V Maternal and Child Health (MCH) Needs Assessment and the Arizona Home Visiting Needs Assessment.

In addition, ongoing assessments help identify emerging and continuing needs for Arizona’s MCH populations:

• Maternal Mortality Review: The Maternal Mortality Review Committee (MMRC) in Arizona reviews and reports on all deaths occurring within 365 days of a pregnancy in the state, regardless of manner of death, in an effort to identify and prevent other risks women may face before, during or after pregnancy.  The program’s latest report can be found here.
• Child Fatality Review: The Arizona Child Fatality Review (CFR) Program reviews all possible factors surrounding a child’s death and identifies ways of reducing preventable fatalities, and currently supports 10 local teams in conducting initial reviews, with oversight from the State team and its two committees. The program’s latest report can be found here.
• PRAMS: The Arizona Pregnancy Risk Assessment Monitoring System (AZ PRAMS) is a collaborative research project between ADHS and the CDC.  PRAMS surveys women who have recently given birth and provides longitudinal data, across Arizona’s diverse maternal population, on factors such as low birth weight, preterm birth, ante/postpartum obesity, mental health, COVID-19, COVID-19 vaccination, breastfeeding, amongst others. More information on PRAMS can be found in the Women’s Health domain.
• Neonatal Abstinence Syndrome (NAS): OAE performs data analysis and produces a monthly report based on available NAS data and the latest case definition provided by the Council of State and Territorial Epidemiologists (CSTE). OAE has used administrative datasets to research infant substance exposure and NAS since 2018, and the findings consistently support the need for improved surveillance and interventions in this area. OAE is part of an internal agency workgroup to implement the CSTE NAS Standardized Case Definition more broadly and build our capacity to address the suspected cases and the non-opioid cases.
• Home Visiting Data: OAE supports and maintains the Home Visiting Efforts-to-Outcome (ETO) Data System, which is used by all ADHS’s home visiting programs except Parents as Teachers to collect information on screening and service delivery. A statewide report is scheduled for publication in fall 2021.
• Prenatal and postnatal care assessment: ADHS's latest Maternal Mortality and Severe Maternal Morbidity Report shows that Severe Maternal Morbidity (SMM) rates were worse among Arizonan women who received late, inadequate or no prenatal care. SMM rates were also worse among women living in rural counties, with longer driving distances and times to care, and living in areas where more women are uninsured. OAE will conduct a more focused needs assessment related to access and utility of prenatal and postpartum care in Arizona. This needs assessment is also written into the Maternal Mortality Action Plan as a priority from SFY2020.
• Maternal Health Literature Reviews: The purpose of this project is to conduct literature reviews on two key mechanisms that other states are using to address needs in maternal healthcare: Medicaid expansion and telehealth services. This project included a brief needs assessment of current trends in prenatal and postpartum care in Arizona using existing secondary data sources. One intern conducted a literature review on the effect of Medicaid expansion on access to care and maternal health outcomes, including data from states that have implemented early presumptive eligibility and/or postpartum coverage up to one year. A second intern conducted a literature review on whether increased availability of telehealth and mobile health services led to improved outcomes during the perinatal period, particularly in rural communities.
• Healthy Bodies Healthy Smiles Oral Health Study: The Office of Oral Health led and OAE supported the implementation of an oral health study to assess the current oral health status of Arizona’s elementary school children, through a statewide oral health survey of kindergarten and third grade children in Arizona’s public schools. The study was paused in 2020 due to COVID-19, but will be re-initiated in fall 2021. Information will be shared with the CDCs National Oral Health Surveillance System and used to develop recommendations and policy direction for the improvement of children’s oral health.

Changes in the health status and needs of the state’s MCH population

The following sections focus on changes to the health status of MCH populations in Arizona and present data from two recent morbidity and mortality reports (referenced above). Morbidity and mortality data provide critical health status information, highlights noticeable disparities, and provides direction for public health programming. Form 10 includes other indicators of health status, which are discussed throughout each of the population domain narratives.

Maternal Health

Maternal Mortality

The MMRC identified 134 maternal deaths between January 1, 2016, and December 31, 2017, of which they determined that 23.1% (n = 31) were Pregnancy-Related Deaths, with the remainder being either Pregnancy-Associated but not Related (70.9%, n = 95) or Unable to Determine Relatedness to Pregnancy (6.0%, n = 8).

The 2016-2017 Pregnancy-Associated Mortality Ratio was 79.1 and the Pregnancy-Related Mortality Ratio was 18.3 deaths per 100,000 live births in Arizona for women ages 15-49. American Indian or Alaska Native women had the highest Pregnancy-Associated Mortality Ratio (PAMR) at 128.3 deaths per 100,000 live births (based on fewer than 20 cases; interpret with caution). The PAMR was 90.3 for White, non-Hispanic women, 77.5 for Black or African American (based on fewer than 20 cases; interpret with caution), and 63.4 for Hispanic or Latina women.

Among Pregnancy-Related Deaths, the majority of deaths (64.5%) occurred within 42 days of the end of pregnancy. The majority of Pregnancy-Associated Deaths (50.0%) occurred between 43 to 365 days after the end of the woman’s pregnancy, almost a third (31.3%) occurred within 42 days of the end of pregnancy, and nearly 1 in 6 (16.4%) occurred while the woman was still pregnant.

The MMRC determined that 83.6% (112/134) of Pregnancy-Associated and 80.6% (25/31) of Pregnancy-Related Deaths were preventable. Among all Pregnancy-Associated Deaths, Substance Use Disorder contributed to the death in 38.1% of cases, followed by Mental Health Conditions (28.4%) and Obesity (15.7%). Suicides or probable suicides accounted for 9.7% of Pregnancy-Associated and 19.4% of Pregnancy-Related Deaths.

The two most common underlying cause categories among Pregnancy-Related deaths were Cardiovascular, Coronary, or Cerebrovascular Conditions (25.8%) and Conditions of Pregnancy (22.6%), which includes amniotic fluid embolism, preeclampsia, and eclampsia. While a variety of contributing factors were identified across reviewed deaths, there were four main areas of contributing factors identified in over half of all reviewed deaths: continuity of care, communication, assessment, and clinical skill or quality. In addition, obesity was a contributing factor in nearly a third of deaths (32.3%) and mental health was a contributing factor in over a quarter of deaths (25.8%).

Severe Maternal Morbidity

Severe Maternal Morbidity (SMM) includes unexpected outcomes of labor and delivery that lead to significant short- or long-term consequences to a woman’s health and wellbeing. Beginning in 2019, ADHS conducted a study to identify and review SMM events using Hospital Discharge Database (HDD) and birth certificate data, based on an enhanced version of an algorithm developed by the American College of Gynecologists and Obstetricians (ACOG) Alliance for Innovation in Maternal Health Initiative (AIM).

Among Arizona resident births in reporting hospitals from 2016 through 2019, there were 3,547 incidents of SMM during delivery (809-995 events per year). Arizona’s overall SMM rate for this period was 119.4 per 10,000 delivery hospitalizations, with annual rates ranging from 109.9 to 128.1. The most common SMM diagnoses were: adult respiratory distress syndrome (299; 8.4%), acute renal failure (272; 7.7%), and sepsis (270; 7.6%). The most common SMM procedures were blood transfusion (2397; 67.6%), hysterectomy (275; 7.8%), and ventilation (161; 4.5%).

At 303.0 SMM events per 10,000 delivery hospitalizations, the SMM rate for American Indian or Alaska Native women was over 3.5 times greater than the SMM rate for non-Hispanic White women (83.3). Black or African American women (163.8) had an SMM rate nearly twice the rate among non-Hispanic White women and Hispanic/Latina women (133.0) and Asian or Pacific Islander women (132.3) experienced rates over 1.5x that of non-Hispanic White women. Differences in SMM rates were also observed by maternal age, parity, pregnancy interval, maternal health status prior to and during pregnancy, prenatal care, method of delivery, geographic location, and the facility’s level of care and indicators of socioeconomic status such as primary care area of residence, maternal education, and payer type.

Infant and Child Health

Infant Mortality

The Arizona infant mortality rate has remained relatively stable from 2010 to 2019. According to the Child Fatality Program, Arizona’s infant mortality rate (5.2 deaths per 1,000 live births; 2019) has been consistently lower than or equal to the US infant mortality rate (5.6), Black/African American (12.3) and American Indian/Alaska Native (6.1) infants have consistently higher infant mortality rates as compared to White infants (3.6). Arizona infants were most likely to die of natural (69%) or undetermined causes (73%). Moreover, infants accounted for 32% of all accidental injury deaths and 31% of all homicides.

In 2019, prematurity was the most common cause of death among infants with 170 deaths due to prematurity. Black/African American infants were disproportionately affected by death due to prematurity; comprising 6% of births in Arizona but 14% of deaths due to prematurity in 2019. Some risk factors for death due to prematurity include preterm labor, premature rupture of membranes, lack of prenatal care, chorioamnionitis, hypertension, sexually transmitted diseases, diabetes and substance abuse. Congenital anomalies and suffocation were the second and third most common causes of infant deaths.

Sudden Unexpected Infant Death (SUID) is the death of an infant less than 1 year of age where the cause of death was not apparent prior to a death investigation. In 2019, there were 75 SUIDs; a 26% increase from 2018. Cause of death can be difficult to determine with SUIDs, but suffocation was the most prevalent cause and 99% of SUIDs were deemed preventable. Black/African American and American Indian/Alaska Native infants each account for 6% of total birth in Arizona but make up 21% and 11% of SUIDs, respectively. Risk factors for SUIDs were unsafe sleep environment, unsafe sleep location, objects in sleep environment, and bed sharing. One fourth of SUIDs involved substance use.

Child Mortality

The child mortality rate in 2019 was 24.1 and 10.8 deaths per 100,000 children for children between the ages of 1 to 4 and 5 to 9, respectively. The child mortality rate among children ages 1 to 4 has decreased by 20% since 2018, but the child mortality rate for children ages 5 to 9 has remained relatively consistent since 2011. Black/African American children (46.5 deaths per 100,000 children; 2019) and American Indian/Alaska Native children (37.2; 2019) have experienced higher child mortality rates when compared to other races in Arizona since 2011. In Arizona, children (aged 1-17) accounted for 25% of all accidental injury deaths, 26% of all homicides and 15% of all natural deaths. Moreover, children between the ages of 8 and 14 accounted for 42% of suicides.

Adolescent Mortality

The adolescent mortality rate in 2019 was 19.5 and 44.8 deaths per 100,000 for children between the ages of 10 to 14 and 15 to 17, respectively. The adolescent mortality rate among children ages 10 to 14 has increased steadily since 2015. Similarly, the adolescent mortality rate among children ages 15 to 17 has also increased by 40% since 2014. In Arizona, adolescents accounted for 43% of accidental injury deaths due to motor vehicle crashes. Furthermore, adolescents accounted for 44% of all homicide deaths in Arizona in 2019 and 16% of natural deaths.

In 2019, the suicide mortality rate was 5.0 deaths per 100,000 for children ages 10-17 years; a 41% decrease from 2018. American Indian/Alaska Native children were disproportionately affected by suicides; with American Indian/Alaska Native children comprising 5% of the total population but 18% of adolescent suicides. The leading causes of suicide deaths among children ages 10 to 17 were strangulation, firearm injury and poisoning. Some identified risk factors to the 2019 suicides were family discord, mental health discord, abuse/neglect history and bullying.

Substance use related deaths are where a child or any individual involved in the death of the child used or abused substances, such as alcohol, illegal drugs, and/or prescription drugs, and this substance was a direct or contributing factor in the child’s death. In 2019, of the 777 deaths captured through the child fatality review, 119 were substance use related. Poisoning, firearm injury and motor vehicle crash were the three leading causes of substance use related deaths. American Indian/Alaska Native and Black/African American children were disproportionately affected by substance use deaths with American Indian/Alaska Native and Black/African American children accounting for 13% and 11% of substance use related deaths but only compromising 5% and 6% of the total population, respectively. Among substance use related deaths with a decedent child user, marijuana and opiates were the most common substances. Among substance use related deaths with another child or adult user, marijuana and methamphetamine were the most common substances followed by alcohol.

Title V Program Capacity and Systems of Care

Arizona Revised Statute (A.R.S. Title 36-691) designates ADHS, one of the executive agencies that report to the Governor, as Arizona's Title V MCH Block Grant administrator. Most of the programs funded through Title V are housed in the Division of Prevention’s Bureau of Women’s and Children’s Health (BWCH). Where the funded programs are not a part of BWCH, there is a clear coordination of efforts. More information on the Arizona Title V Program’s organization and capacity can be found in the Title V Program Purpose and Design section of this application.

Patricia Tarango, Chief, BWCH, currently serves as the Title V Administrator and MCH Director, and Laura Luna Bellucci, Chief, Office of Children’s Health, serves as Title V Children with Special Health Care Needs (CSHCN) Director.  More information on Arizona’s MCH workforce can be found in the MCH Workforce Development and MCH Epidemiology Workforce sections of this application.

The majority of Title V-funded activities focus on “enabling” or “public health services and systems” and serve primarily as preventive or safety net services in communities with limited resources.  Appendix A lists Title V-funded programs (with a brief description) implemented by BWCH by population domain and Office. Several programs serve more than one population, but for the purposes of the summary table, programs are listed under the population domain they primarily serve. A more comprehensive list of BWCH programs is in Appendix C.

In 2020, ADHS merged the Office of Children’s Health and the Office for Children and Youth with Special Healthcare Needs. Between these two offices there is crossover in partnerships, intervention strategies, and funding, so an integrated approach will strengthen BWCH efforts to carry out the essential Title V components of an effective system of services for CYSHCN including: access to coordinated, ongoing, comprehensive care within a medical home; family-professional partnership at all levels of decision-making; access to adequate financing and private and/or public insurance to pay for needed services; early and continuous screening for special health needs; organized community services for easy use; and transition from youth to adult health care, work and independence.

The CYSHCN Program will maintain its unique mission and contracted service components within the Office of Children’s Health.  The CYSHCN Program focuses on family and health professional partnerships at all levels of decision-making and this work will be maintained and further integrated into all aspects of the OCH. Existing OCH prevention/intervention programs, including the High Risk Perinatal, MIECHV, and Sensory Screening, will be leveraged to support the mission of the CYSHCN Program: to continuously improve comprehensive systems of care that enhance the health, future and quality of life for children and youth with special health care needs and their families.

Title V Partnerships, Collaborations, and Coordination

BWCH works with internal and external partners in every aspect of our work to maximize the capacity and reach of Arizona’s Title V Program and better serve Arizona’s women and children. Below are a few examples of the partnerships, collaboration, and coordination that occurs within Arizona’s Title V Program; other examples abound in this application.

BWCH holds many federal grants that serve the maternal child health population, including Title V Abstinence Education; Personal Responsibility Education Program (PREP); Maternal, Infant, Early Childhood Home Visiting (MIECHV); Sudden Unexpected Infant Death Registry; Maternal Health Innovation Program; Enhancing Reviews and Surveillance to Eliminate Maternal Mortality; the Pregnancy Risk Assessment Monitoring System (PRAMS); Primary Care Cooperative Agreement; State Loan Repayment Program and the Oral Health Cooperative Agreement. The State Systems Development Initiative (SSDI) is managed through the Bureau of Public Health Statistics.

BWCH has multiple partnerships in place with the three public universities that provide education for the health professions—Northern Arizona University in Flagstaff; Arizona State University in Phoenix; and University of Arizona in Tucson.

Collaboration with other state agencies occurs on a regular basis. For example, the Strong Families AZ Interagency Leadership Team (IALT) brings together leadership from each of the state and tribal agencies providing home visiting services to coordinate home visiting planning in Arizona (e.g., guidelines, professional development, funding opportunities) and includes representatives from ADHS, DES, ADE, AzEIP, First Things First (FTF), Native Health, Healthy Start, DCS, Head Start and AHCCCS. Additionally, Arizona’s Title V Program partners with FTF on the development and implementation of early childhood education and childcare programs and the MCH Director serves as the ADHS representative on the First Things First Board.

Tribal nations and other tribal entities: Title V collaborates with the Navajo Department of Health on the Navajo PRAMS Workgroup to increase response rates of Navajo women in the PRAMS survey and with Diné College on the Navajo MCH Committee to address maternal and child health needs and priorities identified through the Navajo Nation MCH Needs Assessment. The Maternal Health Innovation Program has established relationships with the Inter Tribal Council of Arizona and the Navajo Nation to expand maternal and child health services in tribal lands, including training of community doulas. ADHS also has in place a tribal consultation policy that includes the completion of an annual report to the Governor’s Office.

Arizona’s Title V Program provides funding and technical assistance to county health departments for maternal and child health activities through the MCH Healthy Arizona Families IGA.  County health departments are key partners in statewide MCH program planning and initiatives.

BWCH will continue to build on the established partnerships with the various agencies, networks, coalitions, families and consumers described above in addition to reaching out to new partners. The Bureau’s programs and initiatives are richer and more impactful as a result of the collective knowledge, resources, and skills that each of our partner agencies, family members, and consumers contribute to improving the health of women and children in Arizona.

More information on our partnerships, collaborations, and coordination can be found in III.E.2.b.v.a. Public and Private Partnerships, Appendix D Title V Program Partnership List and Appendix B List of MCH Group Affiliations.

Operationalization of 5-Year Needs Assessment

The 2020 Title V MCH Needs Assessment yielded seven priority statements that had statewide stakeholder approval and buy-in. The Title V Needs Assessment Steering Committee provided direction to the Title V Program on priority areas and operationalization of the five-year needs assessment. Following the community health assessment framework, the committee will continue to support Arizona’s Title V Program as we implement steps 7-9 of Community Engagement Cycle from the Community Health Assessment Toolkit (below).

BWCH conducts annual ‘visioning meetings’ with agency stakeholders to ensure that the state’s action plan is reviewed, updated and reflects action driven implementation of strategies. Each strategy and metric for a population domain is discussed in detail and strategies are created or revised. Epidemiologists provide updates on emerging issues pertaining to that population domain to spark conversations and innovative thinking.

In addition, as part of our continuous improvement and measurement process, BWCH conducts an annual review of its selected NPMs, State Performance Measures (SPMs), and associated Evidence-based or -informed Strategy Measures (ESMs), using Arizona-specific information from the Strengthen the Evidence Base for MCH Programs initiative. Program managers, office chiefs, and agency stakeholders participated in the annual review along with the Title V MCH Director. OAE provides an annual dashboard to monitor and track the state’s performance measures. This dashboard is used with internal and external partners during strategic planning processes to ensure that any program or project is linked to a NPM or SPM. 

Organizational Structure and Leadership

Since the last Title V application submission in September 2020, BWCH’s organizational structure and leadership has remained largely the same.

In November 2020, Ms. Ana Lyn Roscetti, Chief, Primary Care Office, resigned from ADHS. At this point, the Primary Care Office became an office within the Office of Oral Health.  Ms. Edith Di Santo was hired as Chief for the Office of Primary Care in March 2021; she reports to Ms. Julia Wacloff, Chief, Office of Oral Health.

In February 2021, Ms. Laura Luna Bellucci was named Title V CSHCN Director, since her Office oversees the CYSHCN Program.  Ms. Patricia Tarango, Bureau Chief, BWCH, had temporarily served in this role after the retirement of the previous Title V CSHCN Director.  Ms. Tarango continues to serve as the Title V MCH Director.

The VI. Organizational Chart included in this application shows BWCH organizational structure and leadership as of July 2021.

The table below summarizes other personnel requirements and changes by BWCH Office:

Emerging Public Health Issues

Many of the priority areas identified by the 2019-2020 needs assessment process remain relevant in our communities. Across all population domains, there is a need for increased access to and coverage of culturally-appropriate, quality health care, including oral and mental health services. Barriers to access include lack of affordable health insurance, transportation, and childcare. There is also a need for parent and family education and children’s health services, especially for children and youth with special health care needs (CYSHCN), along with food and nutrition programs and substance use services. Care coordination, navigation, and collaboration among institutions remain important.

In addition, the following indicators were identified as being poorer in Arizona than the national counterparts, and present ongoing targets for intervention to improve health outcomes:

Adolescent mortality

Adolescent suicide

Adolescent well visit

Bullying (victimization)

Child vaccination

Early prenatal care

Early term birth

Flu vaccination

Health insurance coverage

Mental health treatment

Overall health status

Post-neonatal mortality

Received needed health care

Tdap vaccination

Tooth decay / cavities

Well women visit

Lastly, perhaps the most relevant and pressing issue affecting health and services is the ongoing COVID-19 pandemic. In Arizona, as we have seen across the nation, the COVID-19 pandemic has laid bare long-standing inequities in health outcomes and provision and shown us the true cost of our indifference to these disparities. A more thorough look at how the COVID-19 pandemic has affected Arizona’s MCH populations can be found in the Overview of the State section of this application.

References

US Centers for Disease Control and Prevention. Severe Maternal Morbidity in the United States | Pregnancy | Reproductive Health | CDC. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/severematernalmorbidity.html.  Published 2017. Accessed February 15, 2019.

AIM Program – Alliance for Innovation on Maternal Health | Council on Patient Safety in Women’s Health Care. https://safehealthcareforeverywoman.org/aim-program. Accessed December 4, 2018.

Arizona State Department of Health Services. Arizona Child Fatality Review Team. https://azdhs.gov/prevention/womens-childrens-health/reports-fact-sheets/index.php#child-fatality-review-annual-reports. Published 2019. Accessed February 13, 2021