Title V Strategies to Ensure a Continuum of Women's Health Services

Maternal and Child Health professionals who work within Title V-funded agencies and programs are well positioned to address women's health needs across the lifespan. Title V directors and their staff work on issues such as health status before, during, after, and between pregnancies; healthy lifestyle practices, such as healthy nutrition and physical activity; and prevention of chronic disease, such as obesity, diabetes, and heart disease. This paper provides an overview of state Title V women's heath activities. Information is presented about some current state efforts, as well as opportunities for ongoing Title V work to influence women's health.

Since its inception in 1935, the Maternal and Child Health Services Block Grant (Title V of the Social Security Act), of the largest Federal block grant programs, has provided a foundation for the health of the Nation's mothers and children (). The funds are used to help promote and improve the health of mothers and women of childbearing age, infants, children, adolescents, and children with special health care needs. This is done in a variety of ways, including direct services, such as prenatal care, pregnancy planning and spacing, well child care, immunizations, and specialty services for children and youth with special health care needs.

The HRSA's MCHB oversees the Maternal and Child Health Services Block Grant, which is also known as Title V. Block grant funds are provided to all 50 states, the 8 US territories, and the District of Columbia. These grants are directed toward addressing 10 priority challenges identified by MCHB, two of which are directly associated with preconception and interconception care: 1) to significantly reduce infant mortality and 2) to provide care for women before, during, and after pregnancy and childbirth.

To receive Title V Block Grant funds, each state and jurisdiction must submit an annual application to MCHB outlining plans to address national and state priorities. An assessment of state MCH needs is required every 5 years to identify the priority challenges facing women and children in a state. States and jurisdictions then develop a plan to address these challenges. Each year of the 5-year cycle, states are required to submit an annual report and application for continued funding. The annual Title V Block Grant application and reporting process requires states to address 18 National Performance Measures, several of which are devoted to maternal and infant health, such as adequacy of prenatal care, reduction in tobacco use during pregnancy, and reduction in infant mortality. Additionally, each state is required to address seven to ten state-specific Performance Measures that are derived from the state's 10 priority areas identified as a result of the 5-year needs assessment. Title V agencies make decisions about how funding will be used to address the federal and state performance measures. Funded activities cover a broad range of health issues and priorities, including preventive health services, healthy environment, healthy weight, respiratory health, oral health, mental health, nutrition and physical activity, and planning and spacing of pregnancies. Title V agencies monitor their accomplishment of these performance measures and report each year on progress. Annually this information is entered into the Title V Information System (TVIS), which provides easy access to state plans and accomplishments.

State Title V agencies are engaged in many activities through their programs to improve the health of women throughout their life. The following section briefly discusses factors affecting women's health that are addressed by Title V programs.

Title V agencies are working to implement the recommendations on Improving Preconception Health and Health Care published in 2006 by the US Centers for Disease Control and Prevention (CDC). Although prenatal care has long been a focus and continues to remain essential to healthy pregnancies, the value of long-term health and preconception care for women is recognized as vital in making further improvements in infant and women's health. Not only does this approach promise improved health for infants, but also for women, regardless of whether or not they choose to become parents. More and more states are identifying preconception (including interconception) health and health care as one of their priority needs ().

Several national organizations have supported the importance of preconception health and health care to their members, including state health officials and state Title V officials (, ). State Title V agencies have developed plans to address the importance of preconception and interconception health and care as evidenced in their MCH Block Grant applications and report. State public health and maternal and child health leaders support preventive measures to reduce maternal and infant morbidity and mortality as evidenced by state priorities related to healthy pregnancy and healthy newborns.

A 2006 review of Title V data through TVIS identified a total of 23 states reporting a state priority need relevant to preconception health and health care. A total of 42 states and jurisdictions reported State Performance Measure related to preconception, such as preconception health care, prevention of neural tube defects, encouraging healthy birth spacing, planning of families, reduction in unintended pregnancy, and healthy weight promotion and obesity prevention ().

For preparation of this paper, a search was conducted in 2008 on the narratives of all 59 Title V MCH Block Grants through the TVIS using the keywords “preconception” and “interconception” (, ). The search identified 39 states and 2 jurisdictions that discussed these topics in the narrative sections of their Title V Block Grant FY 2006 Annual Report and FY 2008 Application. More than 30 grants discussed specific efforts developed in this area of women's health and 9 grants briefly addressed the subject.

Title V programs have, in a few short years, expanded their efforts to incorporate preconception and interconception health and health care along with women's health care.

The following description of state activities was obtained during a 2008 review of state Title V MCH Block Grant narratives (via TVIS), which show that many states are addressing preconception and interconception health in a number of different ways. Many Title V Programs have embraced the CDC's Recommendations to Improve Preconception Health and Health Care (). Title V resources are used to provide and coordinate services to improve women's health, train health care providers, educate women, and build infrastructure to support the delivery of such services. The following examples provide a brief description of a number of state activities underway to integrate preconception and interconception care as described in their MCH Title V Block Grant submissions. The list is not inclusive of all states' efforts in this area of women's health; it is a snapshot of what some states are doing to address preconception and interconception health and health care as described in their MCHB grant application.

A number of states have identified preconception and women's health as state priorities and/or developed state performance measures.

Collaborating with partners to integrate preconception care is addressed by many of the states. Title V resources assist in the development of specific programs and implementation of policy changes that address the need for preconception and interconception care. An example might be a state Title V program coordinating efforts with the state Title XIX (Medicaid) agency.

Illinois Title V has implemented an intensive Interconception Care Pilot Project that focuses on reducing unintended pregnancy via programs that address family planning services and pregnancy prevention projects, such as education on unintended pregnancy and the importance of birth planning and spacing. Illinois Healthy Women has resulted in several Medicaid service improvements and expansions intended to improve women's health, including coverage for adult preventive care and risk assessments (e.g., piloting preconception), recommended content of annual preventive (preconception care) visits, and outreach to locate high-risk pregnant women. The interconceptional care strategy includes the following 3 components: 1) identification of risk/chronic condition, 2) provision of a medical home, and 3) care management. Within Medicaid, DHFS also has implemented a primary care case management model to provide a primary care “medical home,” pay a monthly care management fee to providers, and use a pay-for-performance strategy. The program permits ongoing monitoring, tracking, and provider feedback, and allows direct access to certain services, such as obstetrics/gynecology and behavioral health. An innovative interconception care model in two communities is currently being piloted to identify women who previously had a poor birth outcome and provide interventions to help them address issues related to the poor birth outcome before becoming pregnant again. Changes in Medicaid billing permit and encourage maternal depression screening during pediatric visits.

Indiana is working with various partners, including the Office of Medicaid Policy and Planning, Office Of Women's Health, Indiana Perinatal Network, Indiana Minority Health Coalition, Governor's Office of Faith Based Initiatives, state legislators, local county coalitions, and others, to develop a preconception and interconception health program. Indiana also is working with the state chapter of the American College of Obstetrics and Gynecology to encourage providers to offer preconception and interconception care messages.

The Rhode Island Department of Health's Task Force on Prematurity is addressing the 10 state developed recommendations for improvement, one of which is to expand preconception care opportunities before and between pregnancies for all women.

Several states have either added new or are expanding current programs to include preconception and interconception services. Nebraska is expanding an existing preconception program for women and is focusing particular attention to disparities in outcomes experienced by African-American women. Arizona is developing a preconception health initiative and has funded four projects to reduce infant mortality with an emphasis on improving preconception health and awareness among women. Delaware has a preconception care program associated with the Comprehensive Family Practice Team's prenatal program. Maryland has expanded the Women Enjoying Life Longer Program, a pilot project that expands family planning services to include preventive health services including preconception care for women of childbearing age. Michigan has an Infant Mortality Coalition Initiative that implements Preconception/Interconception Care projects in 11 communities. The programs offer preconceptional counseling through the Maternal Infant Health Program, Nurse Family Partnership Programs, and the Kalamazoo Pilot Preconception Program. Michigan is in the early stages of crafting a preconception and interconception plan to promote readiness for pregnancy. One of the primary messages will be for all women contemplating pregnancy to cease smoking before becoming pregnant, and if pregnant to cease early.

New Mexico's Life Long Happiness is a family planning project that promotes the use of folic acid, avoidance of alcohol and drugs, and healthy diet and exercise for women of childbearing age to decrease birth defects. Ohio is implementing a Birth Outcomes Improvement Initiative, which will lead to the development and implementation of preconception and interconception service protocols for funded programs and other public health/private care providers. Ohio also plans to add preconception and interconception content to its care coordination and home visiting programs. Utah has developed a screening tool for women that will assist them in identifying preconception risks and provide appropriate referral resources. Utah is also developing a reference tool for women's health care providers that includes information on services and billing codes for preconception care, modeled after a California initiative. Wisconsin has enhanced the postpartum component of the Women's Health Now & beyond Pregnancy Pilot Project to address preconception care for future pregnancies. The state has developed preconception resources, such as tools, print materials, and position statements, as well as consumer and provider education promoting preconception care as a key strategy to improve birth outcomes.

States continue to address factors such as tobacco, alcohol and drug cessation during pregnancy, as well as increased efforts to address these issues before pregnancy. Efforts to promote folic acid consumption before pregnancy are underway across the country. An emerging area is helping women attain a healthy weight.

Nebraska will fully implement the Innovative Approaches to Promoting a Healthy Weight in Women Project that works to reduce overweight and obesity by increasing the number of women who adopt healthy, positive lifestyles. North Carolina is integrating concepts and supports for women to maintain a healthy weight before pregnancy into existing preconception efforts. Utah has a state performance measure to increase the percent of women who are at a healthy weight before pregnancy. They are developing strategies to increase awareness among women of childbearing ages and health care providers about the impact of weight on poor pregnancy outcomes.

Most states are engaged in training and professional development for health providers and women of childbearing age. The New England states are developing a regional effort to train stakeholders in a life course approach to women's health with an emphasis on preconception care. Colorado is expanding its Healthy Baby Website to address preconception care and healthy weight before pregnancy. New Jersey, Utah, and West Virginia have developed education materials for women addressing this topic.

States are also using data to guide program and service development. Many states operate PRAMS and use the data for program planning, development of recommendations, and evaluation. Tools are also being designed for use within public health practice. New Mexico has developed a Preconception Index, which includes intendedness of pregnancy; no frequent use of alcohol or binge drinking; no smoking before pregnancy; no physical abuse in 12 months before pregnancy by husband or partner; knowledge of folic acid's role in preventing birth defects; healthy weight; and health insurance before pregnancy. Oklahoma developed a PRAMS report with recommendations for reducing unintended pregnancy that included expanding preconception care. Vermont reviewed recent PRAMS data and identified 12 preconception and 7 interconception indicators that will be analyzed and discussed in a report on preconception health.

Overall, states are engaged in a wide variety of services, programs, and strategies to advance the case for a number of preconception and interconception health and care to improve overall health of women and their children.

The following summarizes some of the ways Title V programs impact women's health and how Title V leaders are influencing women's access to preconception care.

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  Coordination of state efforts. Title V programs continue to coordinate efforts between multiple government, nonprofit organizations, and other interested groups to improve the health of women and children with in their state.
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  Increasing access to health care. Title V leaders bring this issue to the attention of policy makers and participate in discussions related to financing and designing of state and national health care system reform. They are also designing public health preconception intervention by either expanding existing and/or creating new service options.
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  Promoting positive health habits. Title V and partner programs support the development of positive health behaviors, such as healthy eating and physical activity, while preventing the development of negative behaviors.
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  Engaging in workforce and consumer education. Many Title V agencies educate the public, as well as the health and public health workforce, about preconception care. Efforts range from individual counseling to web-based information for the public and training modules for health professionals.
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  Supporting surveillance and monitoring. Title V continues to engage in surveillance and analysis activities that monitor women's health, especially during pregnancy. The data are used in planning programs and strategies to address issues in women's health.
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  Integrating emerging issues into practice. Title V leaders continue to support the implementation of research-based strategies that improve perinatal outcomes. The renewed attention to preconception care is being embraced by MCH leaders and is being integrated into public health practice at the state and community levels. Title V leaders are engaged in national efforts to integrate preconception and interconception efforts into public health practice and serve on the CDC's Select Panel on Preconception Care.

Title V's proud tradition of making a difference in the lives of some our country's most vulnerable people continues. These effort has been made through development and implementation of needed interventions, often in conjunction with other service providers. Title V leaders continue to integrate research-based strategies such as preconception care, into their state efforts.