SummaryTune into our third episode in the Avalere Health Essential Voice podcast series focused on social determinants of health (SDOH). In this segment, our expert from Avalere’s Center for Healthcare Transformation is joined by officials from the Washington State Department of Health to discuss public health programs focused on maternal and child health, and how these programs relate to healthcare access and health outcomes.
Christina: Hello and welcome to another episode of Avalere Health Essential Voice in the series focused on understanding the social determinants of health. My name is Christina Badaracco, and I’m a research scientist and a registered dietitian in the Center for Healthcare Transformation at Avalere. I’m joined today by Lacy Fehrenbach, Deputy Secretary for COVID-19 response, and until recently, the Assistant Secretary of Prevention and Community Health, and Paul Throne, Director of the Office of Nutrition Services, both in the Washington State Department of Health.
Today’s episode will focus on maternal and child health as it relates to public health programs, and their correlation with healthcare access and health outcomes.
Maternal and child health has received increasing attention in both healthcare and public health programs as we learn more about the importance of promoting health across the lifespan, and even across generations. In the US, we’re also witnessing growing problems related to maternal mortality, poor mental health, obesity, and diabetes, particularly as disparities among ethnic and socioeconomic groups are expanding.
Lacy, what are the current areas of interest and research related to maternal and child health in your department and Washington State?
Lacy: One of our top priorities is to center equity in our maternal and child health programs. On many population health measures, Washington appears to be doing well, but when you dig deeper into our data, we have unacceptable disparities. Infant mortality is one example of this. Black and American Indian families have disproportionate rates of preterm birth, low birth weight, and infant mortality. We also see disparities in kindergarten readiness among communities of color, which suggests that not all communities have equal opportunities for children to thrive.
Another area of growing interest is mental health. In 2019, we released the findings of a review of maternal deaths over a 3-year period. According to this report, behavioral health conditions, including suicide and overdose, were the leading cause of pregnancy-related deaths. They accounted for 30% of these deaths between 2014 and 2016. The typical medical conditions, hemorrhage and hypertension, caused 20% and 10% of deaths, respectively.
One contributing factor to theses death rates was the difference in how providers treated their patients based on race, income, or mental health conditions. Recommendations from that report specify the need to address the social determinants of health like structural racism and social inequities to increase access to postpartum care in the year after a pregnancy ends, and to reduce barriers to mental health services and community support structures for these women. Ultimately, we must focus on whole person, whole family, whole community health if we want children and families to thrive in our state.
Christina: Absolutely, thank you very much. In the US, we have multiple federal programs that are administered through the states and aimed to improve maternal and child health. One of these is the Special Supplemental Nutrition Program for Women, Infants, and Children, also known as WIC. Paul, can you tell us more about this program and why it’s important for promoting participants’ health?
Paul: I’d love to. WIC is one of several nutrition programs that are administered by the USDA Food and Nutrition Service. It’s not primarily a food security program, although it has that impact. It is fundamentally a medical intervention for optimal child development. It started when healthcare providers in the 1960s and 70s saw that poor child development in the US was often linked with poor nutrition. They came up with the wonderful idea to prescribe food as a prevention and treatment for poor child development.
Today, almost half of all infants born in the US get support from WIC. Families qualify for WIC by income, and in Washington State, that’s 185% of the federal poverty level or below. They can also qualify by enrollment in another federal program, like Medicare. They also must qualify by nutritional risk and by either being pregnant or being a child aged birth to five years.
We consider all families who qualify by income to be at some nutritional risk. Families can join WIC at any time, but ideally, we like to get a mom involved when she’s pregnant to support her nutritionally. Kids are more likely to stay on the program for the full five years if mom started while she was pregnant.
We begin working with the families by assessing their nutritional risk. We use more than 100 different risk variables. Some of them are predictable, such as, is the mom smoking or drinking, or does she have low or high maternal weight gain? For a baby, some predictable risks are inadequate prenatal care, or being small or large for their gestational age, but we also assess some unusual risks like pica, which is a compulsion to eat things that aren’t actually food, or a lack of sanitation while preparing infant formula. We can address all those things with WIC.
After we do the risk assessment, a family is issued a food package that’s especially tailored to their needs. A major focus is to increase a pregnant woman’s consumption of key nutrients like iron, protein, calcium, vitamin A, and vitamin C. But WIC is about a lot more than food. We make referrals to address other health and welfare needs. We provide nutritional counseling. We monitor the child’s growth over time, and we offer emotional support for families because it can really be overwhelming to be raising children under difficult economic circumstances, especially during COVID.
WIC is a wonderful program. It has proven outcomes, including a greater chance that the mom will deliver a full-term, healthy-birth-weight infant, a greater chance that the pregnancy will be healthy for mom, and a greater likelihood that the child will be on track to reach developmental milestones. Moms who get WIC are 30% less likely to experience the death of their newborn in the first year. We estimate that WIC in Washington State has saved the lives of almost 900 infants in the last 10 years.
One of the things I love the most about WIC is that it provides breastfeeding support. We know that for families that can breastfeed, breast is best, but breastfeeding, while completely natural, doesn’t always come naturally to everybody. We employ peer counselors who have been WIC participants themselves and have breastfed their own infants. They can support moms who need a little extra encouragement or some teaching. I often think about how our peer counsellors helped a woman who was a refugee from the wars in Afghanistan. She had been badly wounded and lost one of her breasts. When she sought refuge here in the US and became pregnant with twins, our WIC breastfeeding peer counselors gave her the support to successfully breastfeed both of her twins from her remaining breast, which is an incredible testament to the commitment of this mom, and to how effective this support can be.
Christina: Thank you, Paul, for sharing that wonderful story and for those statistics that show the importance of this program. I will also add that WIC is our second largest federal nutrition assistance program in the US, closely following the Supplemental Nutrition Assistance Program, also known as SNAP. It’s funded through the annual appropriations process since it’s not an entitlement program.
A few years ago, I spent several months counseling women and children in two different WIC clinics at Massachusetts General Hospital in Boston, so I know firsthand the importance of this counseling and helping this population access and consume nutritious food, thereby keeping them healthy. The appointments are important opportunities to screen patients for certain health conditions and social issues, enabling counselors to connect them to necessary social services and keep them connected to other healthcare providers.
So, Paul, we’ve also seen that participation, even among those who are eligible, is declining on a national level. This is concerning for stakeholders across the healthcare system. Why is this happening? What are you seeing in Washington State specifically?
Paul: Yes, WIC participation in Washington peaked after the 2008 recession at about 200,000 people per month. Since then, our enrollment and participation has slowly declined. In the last few years, it’s been going down about 6 to 7% per year. We think most of this decline is the result of three factors.
First, the economy had been steadily improving until this year, which meant that more people were working and probably making enough money to rise above our income qualification level.
We also know that birth rates are at historic lows and people are waiting longer to have children, and they’re having fewer children. So, there are fewer families within our demographic.
Finally, although we try to make it as easy as possible for families to engage with WIC, this program still requires a certain amount of commitment. It requires annual appointments, and sometimes more frequently than that. Sometimes it requires blood work for the mom or the children, and the family has to bring all the kids in. That can be a burden, especially for moms who use public transportation, or don’t get paid time off.
We try hard to reach all eligible people, but about half of the people on Medicaid in Washington State qualified to be in WIC are not currently in the program. We’re especially worried that we’re not reaching qualified Black or African American and American Indian Alaskan Native families. As we know from looking at the social determinants of health, these communities are at higher risk of poor pregnancy outcomes, higher maternal and infant mortality, and many other health disparities. We need to do a better job of making WIC a place that people want to go for support.
Christina: Right. So how is the current COVID-19 pandemic affecting your administration of the program as well as participation rates?
Paul: It’s had a huge impact on us. When COVID became a national emergency, USDA responded by making it possible for us to provide our services without in-person contact. We use video, telephone, and even see people through their car windows in the WIC parking lot. Whatever it takes to get WIC to our families without putting them or our WIC staff at risk of exposure. Unfortunately, the federal waivers that allow us to do this end on September 30, and Congress has not authorized them to continue at this point.
We were prepared for an increase in demand for WIC, and we’ve seen about a 3% growth in our caseload here in Washington from the beginning of March to the end of June. That’s in contrast to the half a percent decline we were seeing every month. It’s a slightly greater increase than those numbers might appear to show, but it’s still less than we were expecting. We think that the generous unemployment benefit and some increases in SNAP benefits have had an effect on how many families feel that they need WIC as a backup. Those benefits changed, though. With the additional $600 weekly unemployment benefit running out at the end of July, and rental protections ending at some point, we think more families will be seeking every benefit that they qualify for, including WIC.
Christina: So, a question for either of you. What types of innovations would you like to see to address these threats to food security and maternal and child health? What lessons do you think these would offer to public health professionals and other stakeholders throughout the healthcare system going forward?
Paul: Well, WIC certainly needs to modernize. The rules that we operate under are not really keeping pace with changing technology or the way today’s families like to access services. The remote services we’ve been doing these last few months have been really popular and have reduced the no-show rate at our agencies from about 15% to almost nothing.
One of the surprises has been that moms are taking the extra time they have from not coming into the clinic to engage with our WIC staff in deeper ways, having deeper conversations, which helps us better understand and meet their needs. More time with WIC leads to a more effective program. It’s been a tremendous help for us to be able to have remote services, but as I said, unless we can find some way to continue to modernize this program, these services end on September 30.
We’re also really limited by a lack of shopping options like online ordering, curbside pickup, and home delivery. These would be incredibly helpful during this pandemic, and many of us are used to shopping this way nowadays. We are looking forward to the day when WIC families can shop this way, too.
Lacy: I want to build on something that Paul said around remote services. The flexibility that WIC has provided is an example of how we can easily offer family services during a stressful time. Similarly, our state along with many others have significantly increased access to telehealth and tele-mental health. In addition to protecting people from COVID, telehealth can be more accessible and family centered if we do it well. This is especially true for families with low incomes or who live in rural settings. It is important to make sure they have the technology to access this, but this is an example of how the pandemic has pushed us to be innovative and bring some of our health services into the 21st century. It gives us a window into what we can do to serve families better in the future.
Christina: Absolutely, that’s such a great point. So Lacy, how is COVID-19 affecting the maternal and child population in other ways, and what initiatives is your department undertaking to address these issues and protect these people’s health?
Lacy: Great question. The pandemic has clearly made the drivers of inequity more visible. For example, racism and public health, healthcare, social services, access to care, the impacts of lost income, housing instability, and food insecurity are now more visible than ever. When we look at COVID cases in Washington State, Native Hawaiian and other Pacific Islanders, as well as Hispanic people, have age adjusted rates of COVID approximately 8 times higher than white people. Black and American Indian or Alaskan Native case counts are 3 times higher than those of whites.
This is not a factor of the virus itself; it’s a factor of the systems and structures in our society. People of color are more likely to be essential workers, and they’re less likely to have health insurance. They receive disparate healthcare, if they can access it at all. They’re helping society function and yet they have far worse outcomes.
There’s also the stress and isolation of the pandemic itself, as well as the effects of the depressed economy, like food insecurity. This is harmful to the emotional wellbeing of anyone, but especially pregnant and parenting people, and especially in low-income communities and communities of color. So, we’ve been really focused on thinking about holistic, culturally appropriate support and care for all pregnant and parenting people in Washington State.
We developed guidance to help anyone who is pregnant or parenting practice self-care and know what to expect during pregnancy, childbirth, and the early infant period during a pandemic. We also developed resources for people who have COVID to help them navigate childbirth, breastfeeding, and infant care and bonding, as they may need to take extra precautions to protect their baby. That includes the possibility of isolation or distancing between mother and baby, which is very, very challenging.
The pandemic is requiring us to be innovative in how we provide support for families. If we approach this with intentionality, we can adapt and build programs that consider whole person health and are responsive to the needs of families and communities. This will help us move toward our goal of improving health equity.
We are also investing in the community-based workforce to help people who have COVID isolate, and those who are in close contact to quarantine in their homes. These community health workers provide families basics like masks, cleaning supplies, groceries, and linkage to other community-based support so that they can stay home and stay safe.
Christina: Wonderful, thank you. So for the audience to learn more about these issues and what Avalere and leading stakeholders throughout healthcare are doing to address them, we recommend searching on Avalere.com for “social determinants of health” or “maternal health” to see previous articles we’ve written and podcasts we have posted about these topics. I’ll mention the recent insight titled “Declining WIC Participation May Lead to Poor Health Outcomes.” Lacy, do you have any resources to recommend to our audience?
Lacy: Yes, I have several. The Association of Maternal and Child Health Programs has a very large index of COVID-related resources for clinicians, public health professionals, policymakers, and families. The National WIC Association has excellent background information and policy initiatives for the future. The Center for Healthcare Strategies also has several resources to lessen the impact of COVID on vulnerable populations.
One final thought—a lot of the changes Paul and I talked about today came about because of COVID, but they can outlast the virus and help us address many other inequities we’re seeing in maternal child and family health.
Christina: Thank you for those resources and those excellent points. Thank you, Lacy and Paul, for joining us today. Your insights today are invaluable to our listeners. Thank you all for joining us and please stay tuned for more episodes focused on social determinants of health and maternal health. If you’d like to learn more, please visit us at Avalere.com.
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