In the domain of Maternal/Women’s Health, we continue to focus on increasing the number of women who have a preventive visit to optimize the health of women before, between and beyond pregnancies.  As in the past, our key priority is to find ways to reduce the infant mortality rate in Delaware and we understand the importance of preconception care and quality prenatal care for our mothers.  In order to continue making progress in providing “whole health” care to our women and mothers, we continue to bolster and nurture our community partnerships by working together focused on addressing the social determinants of health, leveraging talents and resources, and striving to find new ways to provide services.

 

Over the last year, we continue to monitor the Delaware Healthy Mothers and Infants Consortium’s (DHMIC) strategic plan which covers a 3-5-year timeframe.  The MCH Director was involved in the strategic planning process, as well as several other MCH stakeholders that were involved in the Title V MCH Needs Assessment process and selection of priorities, which helped with alignment of goals and strategies.  Beginning in the 1990s, Delaware’s infant mortality rate was increasing while the national trend was decreasing.  Prompted by a list of 20 recommendations, developed by an Infant Mortality Task Force in 2005, the plan called for the creation of the Delaware Healthy Mother & Infant Consortium (DHMIC), a Governor appointed body, to help ensure that the recommendations were put into effect.  The DHMIC is currently undergoing a review of its current infrastructure and revisiting its bylaws and committee structure to monitor implementation of the Infant Mortality Task Force recommendations.  Staff in the Division of Public Health’s Family Health Systems Section largely provide staff support to the committees and help carry out and execute strategies to support the DHMIC’s strategic plan.  The new framework and structure of the DHMIC is designed to focus more intensively on the strategic goals and priorities.  The Committees include:

1. Well Woman/Black Maternal Health Committee - The focus of this committee is on a comprehensive, evidence-based approach to reproductive health and the health of women before, during, and after pregnancy - one that is woman-centered and clinician-engaged.  The group functions to meet the diverse and often complex needs of reproductive-age women, particularly from more vulnerable populations, and works to foster leadership and information sharing, solicit voices of the consumer, encourage innovation, build awareness, and promote reproductive life planning. 
   1. The Black Maternal Health Workgroup (BMHW) sits under and reports to the Well Woman Committee.  The purpose of the BMHW is to address the disproportionately high and unacceptable rates of maternal mortality and morbidity in Black and Indigenous People of Color (BIPOC) communities in Delaware.  The BMHWG will work to ensure all women of reproductive age in Delaware will be healthy and have access to safe, respectful, culturally appropriate maternal care before, during and beyond pregnancy.

 

2. The Social Determinant of Health Committee which seeks to understand where people live, work, play and pray can help create actionable engagement strategies to improve health outcomes by addressing barriers rooted in structural racism.  This group works to collaborate with the community, offer space for shared learning with providers, review policies and programs to identify opportunities for change, evaluate best practices, identify health needs, and engage the faith-based community.  The SDOH Committee decided to focus on housing for pregnant and parenting women as a priority.  In reviewing literature and recent studies, SDOH Committee Co-chairs Rita Landgraf and Rep. Minor Brown proposed exploring the feasibility of a pilot in Delaware similar to the Healthy Beginnings at Home pilot in Columbus, Ohio.

 

1.  The Housing and Guaranteed Basic Income Implementation Workgroup.  This group was recently established over the last year to report directly to the SDOH Committee.  While we don’t yet know the full extent, the unique health and social vulnerabilities faced by pregnant women who experience homelessness or are housing insecure have no doubt increased during the COVID-19 pandemic.  To respond to this crisis, the workgroup is exploring a case management and wrap around support intervention to provide these women with housing stability and prevent homelessness and wrap around social supports, such as financial literacy coaching, home visiting, and connectivity to the Delaware Housing Assistance Program (i.e. pays for utilities, monthly rent, security deposits, and offers case management support).  In addition the group along with the Division of Public Health maternal and child health team, are implemented a second demonstration pilot, which is a guaranteed basic income model.  In doing so, programs such as the Healthy Beginnings at Home Pilot in Columbus, Ohio, and other guaranteed basic income pilots in other municipalities across the country are under review, which have led to a decrease in emergency hospital stays and negative birth outcomes, like the number of pre-term births, infant mortality, and decrease the number of days baby is in the NICU.  

 

The guaranteed basic income demonstration project, called Healthy Women Healthy Babies (HWHBs) Opportunity.  HWHBs Opportunity is for pregnant women who live within certain high-risk community zip codes, and are under 185% FPL. Approximately 15 women will be enrolled in this initial phase of the project, with potential for expansion. The women will receive $1,000 per month for 24 months, getting a debit card with disbursements the 1st and 15th of each month. 

 

To support this work, Family Health Systems is working on a MOU Agreement to work with the Federal Reserve Bank of Atlanta (“Atlanta Fed”) to update and make available a free interactive tool called the Guaranteed Income (GI) Dashboard to Delawareans.  The Federal Reserve Bank of Atlanta is leading an initiative to conduct research on benefits cliff and develop tools to support community and state efforts to improve economic security for families. Through this work, the Atlanta Fed developed an interactive tool called the CLIFF Guaranteed Income (GI) Dashboard to assist policymakers, program leaders, funders, individual families, and other stakeholders understand the interactions between GI and public assistance support. The GI Dashboard does not store any information that is input into the tool.

 

The CLIFF GI Dashboard shows the effect that receiving guaranteed income through the Healthy Women Healthy Babies Opportunity has on the receipt of public assistance. The dashboard is being used to inform prospective participants in guaranteed-income (GI) pilot programs about the possible implications of a guaranteed income on their eligibility for social safety net programs so they can make an informed decision about whether to enroll in the GI demonstration project. 

 

DPH is supporting the GBI demonstration project, Healthy Women Healthy Babies Opportunity, with State Infant Mortality funds as well as ARPA funds to expand and support this demonstration project, which was approved by the Office of the Governor. 

 

Health Management Associates (HMA) was hired contractually by the Division of Public Health to analyze conditions in Delaware that would inform these two demonstration pilots, such as housing stability, enrollment size and criteria, funding availability, and evaluation needs.  As part of this, HMA also engaged childbearing women who are or who have been housing insecure to help in the design of the pilot.  The findings should help the DHMIC’s implementation workgroup and the SDOH Committee make recommendations to the broader DHMIC on how to design and monitor these demonstration pilots.

 

The Housing and GBI Implementation Workgroup established through the Delaware Healthy Mother and Infant Consortium, continues to meet to design and implement both demonstration projects. 

As of July, the first guaranteed basic income cohort is full, serving 15 women. Thirteen women started April 1st and 2 women started on May 15th.  Four more women started in Cohort two as of July 1, 2022.  Rosehill Community Center, one of the Healthy Women Healthy Babies mini grantees, is screening for eligibility and administers enrollment and manages the program.  Each recipient receives a debit card and gets $500 1st and 15th of each month, for 24 months.  DPH is supporting this effort with both State Infant mortality funds as well as ARPA funds.  The backbone entity is Health Management Associates, and contracts with DPH to support and monitor and report on this work.  Some basic program model components are described below:

• GBI Eligibility

• Pregnant women in 1st or 2nd trimester
• Eligibility based on current income;​ under 185% FPL
• Eligibility based on $1,000 extra earnings per month​
• Live in a HWHB High risk Zones

 

• Minimum requirements:
  • Program recipients must be a part of the evaluation (survey and interview) every 2-3 months
  • Work with a Case worker/Community Health Worker, preferred weekly to 2x per month; required every quarter
  • Work with a Financial Coach and Career Team (if applicable); preferred weekly tot 2x per months; required every quarter

 

• Some preliminary data (as July 2022):
  • All 15 cards are active
  • Average Purchase Amount: $43.63
  • 25% spent on food
  • When fast food and restaurants are combined, these account for 13% of expenditures
  • 12% of the funds were spent at grocery stores
  • About 12% were third party transfers – we will explore these in our interviews in late June/July
  • 8% on gas
  • 4% at discount stores
  • 4% on utilities
  • Everything else – 3% or less
  • Planning to add a new Cohort of 25 women in July 2022 (4 women enrolled as of this writing).

 

3) Maternal and Infant Morbidity/Mortality workgroup, which examines the data and evidence of the health status of women in Delaware, particularly those in the 14- to 44-year-old age range and those with poor birth outcomes (e.g., premature birth, low birth weight).  This group works to foster leadership, identify gaps in data, cultivate relationships, enhance provider knowledge, review findings, reframe postpartum/interconception care, enhance capacity for statewide quality improvement, and explore best practices to address risks. 

 

Education and prevention are a cornerstone of the DHMIC work, utilizing the latest social media platforms. In partnership with a social marketing firm, Aloysius Butler and Clark (AB&C), the Division of Public Health and several Maternal and Child Health partners we continued to develop, update and launch messaging through the use of social media, whereby we continue to post messages via blogs, Twitter, Facebook, YouTube, and most recently added Instagram, in which all MCH programs and initiatives participate.  The branding tagline, Delaware Thrives, evolves around the theme that “Health Begins Where You Live, Learn, Work & Play”.  This year we continued to focus on updating existing content and adding new content on the website (www.DEThrives.com) that is easy to grow, easy to maintain, and easy to navigate, and one that is search relevant.  A small core workgroup continues to meet to look at the content and develop messaging for blogs, tweets and posts on preconception health topics for men and women.  It is hard to believe that the DEthrives social media and website was launched in 2013, and now is due for a refresh and update.  DEThrives is currently undergoing a comprehensive update.

 

Due to the ongoing challenges with the pandemic and the comfort level and ease of partners to meet in person, we held our 2022 Annual DHMIC Maternal and Child Health Summit virtually on the platform Socio, on April 26, 2022.  For 16 remarkable years, DHMIC has been making good on its promise to provide statewide leadership coordination of efforts to prevent infant mortality and improve the health of women of childbearing age and infants throughout Delaware.  The Delaware Healthy Mothers and Infants Consortium (DHMIC) and the Department of Health and Social Services (DHSS), Division of Public Health (DPH) organize this event.  The summit brings together leaders in the area of family health to discuss new approaches to enhance the health of women, children and families of all ages.  Developed around the theme “Listening. Connecting. Inspiring Change,” the DHMIC summit integrates a full agenda of educational, advocacy, networking, and story-sharing opportunities to mobilize participants to better understand the reasons why - and the ways how - they can leverage their professional, personal, and community service resources to decrease racial disparities in maternal and infant health. 

 

The Summit reached another historic reach this year, with over 450 attendees this year, including health care professionals, community influencers, policymakers, faith community leaders, and concerned citizens to be empowered on critical topics by leadership from DHMIC, Delaware Thrives, and the Delaware Division of Public Health (DPH), along with local and national experts from various fields who are committed to ending racial and ethnic health disparities.  A summary of the agenda follows:

Keynote presentations

• Understanding and Effectively Addressing Inequities in Health — David R. Williams PhD, MPH, Florence and Laura Norman Professor of Public Health, Chair, Department of Social and Behavioral Sciences; and Professor of African and African American Studies and of Sociology, Harvard University Transforming and Empowering Women in Birth — Jennie Joseph, LM, CPM, Founder and President of Commonsense Childbirth Inc. and Creator of The JJ Way®
• Black Maternal Awareness Resolution — Delaware Representative Melissa (Mimi) Minor-Brown
• Panel Discussion: Addressing Black Maternal Health in Delaware from a Community and Provider Lens
• Postpartum Revolution — Angelina Spicer, Stand-Up Comedian and Activist

 

Special Remarks and Presentations

• Lt. Governor Bethany Hall-Long, State of Delaware
• Karyl Rattay, MD, MS. FAAP, Director, Delaware Division of Public Health
• Dr. David Paul, Chair, DHMIC
• DHMIC Health Equity Awards presentation
• Health Equity Awards presentation

 

As in the past, we put out a call for the Summit looking for bold ideas, bold new programs, or a bold new approach to improving the health of women, men, infants, and families, calling them Delaware Thrives!  Community Voices Breakout Sessions.  Participants were encouraged to submit a short description of their organization and/or program and a facilitator was assigned to each room to ask questions and engage the participants in a dialogue. The following topics were covered virtually in breakout rooms on the conference platform:

• Room 1: Women’s Emotional Wellness – Focus on the Needs and Barriers for Hispanic and Latina Women in Delaware
• Room 2: Be Empowered: Resources, Programs and Tools for Women
• Room 3: Urgent Maternal Warning Signs Hope
• Room 4: Healthy Women Healthy Baby Zones

 

Not only are the organizations/programs featured during the DHMIC 2022 Summit rich with content, featuring the breakouts also establish the foundation for consistent dialogue around these organizations/programs as DHMIC partners and ultimately result in greater awareness of and support for the DHMIC mission. 

 

The DHMIC also awarded its Health Champions awards during its Annual Summit.  Representative Melissa Minor Brown, and DHMIC member, received the individual Champion in Health award for championing maternal health policy to address health disparities.  Westside Family Health Care, a federally qualified health center in Delaware, received the group Champion in Health award.  Westside Family Health Care, a federally qualified health center in Delaware, received the group Champion in Health award. 

 

All speaker presentations have been repurposed on https://dethrives.com/summit-2022and social media channels, including Facebook and Twitter.

 

As a continued effort on addressing maternal mortality and morbidity and to make a concerted effort to reduce our racial disparity in infant mortality, Delaware has identified Infant Mortality as a State Performance Measure.  Our work to address infant mortality is spearheaded by the Center for Family Health Research and Epidemiology, which is housed within the Family Health Systems Section, led by our Title V/MCH Director.  These efforts are very much a part of our Title V federal state partnership and continue to be supported by $4.2M in state funding allocated to DPH for prevention of infant mortality.  The DHMIC has undertaken an aggressive initiative to examine the social determinants of health by taking a Life Course approach to both understanding and addressing the disparities that have led to the rise in black maternal and infant mortality in Delaware.  DHMIC and its partners continue to engage the community at large, health care providers, policymakers, faith-based organizations, and African American influencers in understanding the impact of race-related constructs such as perceived discrimination and structural racism on black women and their families.

 

All eyes are on the accomplishments resulting from implementing 8 Healthy Women Healthy Baby (HWHB) Zones community-informed strategies that aim to increase awareness, educate, better serve women of reproductive age and amplify the voice of black maternal health grass roots organizations.  The primary focus is innovation and to spread evidence-based programs and place-based strategies to improve the social determinants of health and equity in maternal and infant health outcomes, as a complement to our medical intervention, HWHBs 2.0.  The first-ever mini grants support the shared initiative to narrow the wide variance in birth outcomes between black women and white women by building state and local capacity and testing small-scale innovative strategies.  DPH worked with Health Management Associates (HMA), as the lead backbone entity, to develop a mini-grant process to fund local communities/organizations to implement interventions to address social determinants of health in priority communities throughout Delaware.  The eight mini grantees awarded include Delaware Adolescent Program, Inc. (DAPI), Delaware Coalition Against Domestic Violence (DCADV), Delaware Multicultural and Civic Organization (DEMCO), Hispanic American Association of Delaware (HAAD), Kingswood Community Center (cycle 1 only), Black Mothers in Power, Parent Information Center (PIC), Delaware Breastfeeding Coalition and Rosehill Community Center.  A short description of the awarded community-based interventions are described below.

 

• Delaware Adolescent Program, Inc.: serves teen mothers and their partners providing mentoring services and Support for social and emotional well-being and support in navigating the health and social services system.
• Delaware Coalition Against Domestic Violence: This organization provides support to victims of domestic violence and administers flexible Health Access Funds to support the safety and health of the participants.  DCADV also trains health care providers on best practices for domestic violence assessment and response.
• Delaware Multicultural and Civic Organization (DEMCO): Provides life skills supports and job training education to young women of childbearing age, including those who are pregnant and parenting
• Hispanic American Association of Delaware: This organization provides pregnancy and postpartum support in Spanish to women ages 15-44 who live in ZIP code 19720 in New Castle County.
• Rose Hill Community Center: Provides fitness, nutrition counseling and self-improvement classes to women at no cost.

• Parent Information Center (PIC):  Train six doulas, who will provide nonclinical emotional, physical, and informational support before, during, and after labor and birth.  In partnership with community organizations, the program will also provide virtual training on childbirth education, breastfeeding initiation, prenatal nutrition, healthy family relationships, and community supports; empower women to be their own self-advocates; provide one-on-one coaching calls with pregnant women (prenatal and postpartum) starting six weeks before due date and continuing six weeks postpartum; offer postpartum support groups with other new parents as well as breakout sessions on breastfeeding, sexuality, mental health, and infant development; and create an awareness campaign focused on prenatal and postpartum support.
• Rosehill Community Center: This organization will use its new cycle of additional grant funding to address toxic stress - as they feel that stress during the pandemic has led to fear and anxiety, and has caused residents in their service area to be overwhelmed and have feelings of isolation and loneliness.  Rose Hill’s funded program will work to serve women ages 15 to 44 in New Castle (ZIP code 19720) and Wilmington (ZIP code 19801) by providing free mental health workshops with psychologists and psychiatrists twice a month, covering the following topics: feelings of isolation, depression, self-care, setting boundaries, stress, and knowing your triggers, etc.  Rose Hill will provide lessons on reducing stress, breathing sessions, mindfulness training, and journaling. They will also provide massage therapy and stretching techniques (three times per client), as well as yoga lessons once a week.
• Black Mothers in Power (BMIP), a grassroots organization focusing on Black mothers in the community and underserved populations.  The BMIP will provide and sponsor a doula program to train 10 black women to become certified doulas through the National Black Doula Association.  The organization will be training five doulas in New Castle County and Kent County, and will be focusing on engaging at-risk pregnant women who live in high-risk zones.  Each doula will help women during the critical times of pregnancy, birth and postpartum, and early parenting.
• Breastfeeding Coalition of Delaware will provide breastfeeding support groups to the HWHB high-risk zones of Wilmington, Claymont, and Seaford.  It will offer accessible support, engaging groups, text check-ins, access to variable levels of lactation support, and incentives for participation.  In addition, the Breastfeeding Coalition of Delaware will hire three diverse breastfeeding peer counselors (BPC) and one lactation consultant to provide breastfeeding support to women.  At the completion of the program, the Breastfeeding Coalition of Delaware will host a baby shower for participants, where they will provide needed baby supplies, education, and support to pregnant and postpartum women.

 

The second full year Evaluation report was released in June 2022.  Some of the preliminary findings from the participants demonstrate progress and a positive impact as it relates to the overall NPM1 Well Woman:

• Demographic data:  500 women and girls served; majority of participants from Zip codes 19702, 19720, 19801, 19804, 19805, 19901, 19904; 605 of participants were black, 35% were white, 6% identified as “multi-racial/other”; 105 participants said Spanish was their primary language; About ½ have a high school diploma or GED.
• Most common expressed needs by the women screened and engaged in the mini grantee interventions were referred to resources for stable housing, utility assistance, help reading health materials (health literacy), and access to food. Nearly half struggle with childcare, transportation, social support or access to medical care.
• 72% of participants have either been pregnant, are parenting, or is currently pregnant.
• Participants were screened for pregnancy intention and referrals were made as appropriate to local family planning provider sites and Healthy Women Healthy Babies providers.  The majority of participants are not intending to become pregnant in the next year.
• Of the DEMCO participants, on average 82% of participants felt that they had improved their professional skills and increased confidence to prepare for employment.
• Of the DCADV participants, 96% of flex fund recipients reported that the funds "Significantly" or "Completely" reduced their financial stress.
• Of the Rosehill participants, 59% of participants lost weight.  On average, participants lost 3lbs over the course of the program.
• Of those that participated in the DAPI intervention, they were asked “To what extent did the program increase resilience to relationship pressure and intention to apply refusal skills?”  75% of students reported confidence applying refusal skills (“I would feel comfortable saying no to my partner when I don't feel like having sex”). 
• Participants showing statistically significant improvements in depression, anxiety and stress.
• Adapted wrap around services and support during Covid-19 included “flex funds”, computers and internet needs.  Flex funds were most commonly used to meet basic needs such as food, diapers, winter coats, and feminine hygiene products, to support needs of children, to pay utility bills, to meet physical needs, and to buy essential furnishings.

 

One key component of the HWHB Zones initiative is the provision of coaching and technical assistance (TA) to the mini-grantees (and one unfunded organization) throughout the life of the initiative to build capacity and ensure sustainability of the interventions, as well as focus on continuous quality improvement.  In Grant Cycle 1, 2, and 3, the TA consisted of two learning collaborative meetings as well as individual coaching and TA.  Each mini grantee has a coach from HMA with whom they meet regularly.  The frequency and length of coaching and TA calls and meetings over the last year were developed by each coach and mini grantee in collaboration.

 

Coaches reported a variety of strengths and weaknesses across the HWHBs Zones mini-grantees prior to participating in the HWHBs Zones initiative and, therefore, the TA needs that were identified vary widely across the mini-grantees. Common needs included:

• programmatic challenges (i.e., unexpected challenges related to implementing the proposed program).
• fiscal challenges (i.e., challenges with submitting invoices or receipts).
• data challenges (such as challenges collecting data, recording data, or submitting data); and/or
• infrastructure challenges (i.e., not having enough staff).

 

The HMA coaches supported the mini grantees in their efforts to be responsive to the changing and emerging needs of the people they serve.  Mini grantee needs for technical assistance during these crises have included:

• how to transition services to virtual rather than in person.
• how to respond to changing and emergent needs of the people served by the mini-grantees, such as technological needs to be able to continue to participate in services, urgent needs for “flex funds” to pay for necessities in the face of sudden unemployment, needs for additional social support and behavioral health support;
• how to conduct consent for enrollment in the evaluation online.
• how to collect data online.
• how to support individuals and communities experiencing trauma; and

• how to collect information from participants about emerging needs, about how well virtual services are meeting their needs, and barriers to participation in virtual services.

 

The DHMIC embraced the focus and framework of a preconception health approach, to optimize the health of women before, between and beyond pregnancies.  Delaware developed the Women’s Wellness initiative, Every Woman Every Time Delaware:  Reimagining the Preventive Medical Visit, which at its core seeks to strengthen the dynamic interplay between a woman and her health care provider(s) by encouraging honest and open communication about her reproductive and general health care needs.  The initiative focuses on four broad areas including 1) Pregnancy intention screening; 2) Assessment of health risk behaviors, and prevention and education tools 3) management of chronic health conditions 4) identification of social determinants of health with linkage to services.  DHMIC, through DPH has a contractual support position, a Women’s, Infants, and Families Nurse Consultant that devotes time and expertise to lead the Women’s Wellness initiative.  This year, the WIF Nurse Consultant resigned, and DPH is finalizing the recruitment and hiring process to onboard a new individual to carry out this work.  Some of the core responsibilities include:

• Identify and develop life course perspective tools for health care providers and community outreach centers.
• Develop and carry out education programs.  Prepare educational materials and assist in planning and developing health and educational programs for health care providers, peer counselors, consumers and community.
• Act as a resource and support workgroup activities to advance preconception health as well as the Healthy Women Healthy Babies 2.0 as it relates to well women care.
• Promote at the grass roots level the programs and initiatives of the DHMIC, this may include conducting workshops, conferences, and seminars such as decreasing unintended pregnancy rates, improving well woman care/preconception care, postpartum rates, birth spacing, etc.; required to speak before special interest groups, community organizations, medical and health care groups, or the general public.
• Provide expert consultation in women's and fetal/infant health and recommend modifications to programming based on knowledge of best practices. 

 

One of the WIF Nurse Consultant’s projects is to focus on educating young women of reproductive health age on reproductive life planning, working with the Warehouse.  The Warehouse concept arose from the need for quality afterschool programs for youth in one of Wilmington’s higher crime areas.  Unlike a traditional community center, the Warehouse employs a collaborative teen engagement structure involving a network of youth-serving nonprofits that will operate within the Warehouse framework and deliver programs under a shared roof.  The mission of the Warehouse is to create a collaborative culture to revolutionize teen engagement in Wilmington with the vision of supporting confident, competent and courageous young adults ready to take the next step in their lives. The Warehouse also creates a physical safe space and network of support for Wilmington teens while nurturing a culture of opportunity that stands in opposition to a culture of poverty and violence.  To support the REACH Riverside community revitalization effort, The Warehouse became part of the holistic Community Health and Wellness effort underway in Riverside.  To create alignment with the REACH model, The Warehouse is also guided by five pillars of success: Recreation, Education, Arts, Career, & Health.  The WIF Nurse Consultant will remain engaged in the Health pillar and offer maternal and child health education on the DHMIC reproductive life planning.

 

The WIF Nurse Consultant is also promotes the Preconception Peer Education Program and encouraging new colleges and universities to adopt and operationalize the program.  The PPE program was implemented in May 2007 by the Office of Minority Health (OMH) of the Department of Health and Human Services, supported by DPH and the DHMIC for replication.  This national program was launched as part of its initiatives to eliminate health disparities among racial and ethnic minorities in the U.S.  The Preconception Peer Educators (PPE) Program was developed to raise awareness among college students about being well before, during, and beyond pregnancy.  The overarching goals of the PPE program are to reach college-aged populations with targeted messages stressing the importance of preconception health and health care, train college students, particularly minority students as peer educators, and provide them with the tools necessary to educate other students of reproductive age (15-44) on their respective campus about the importance of receiving preventive care, education, and counseling before deciding to create a baby.  While the program initially was going strong at the University of Delaware, there are some changes in leadership that are making its sustainability a little rocky.  Over the next year, plans include providing technical assistance and support to the University of Delaware to ensure sustainability and engaging Delaware State University as a partner to establish a new PPE chapter. 

 

DPH and the Division of Medicaid and Medical Assistance (DMMA) under the auspices of the DHMIC have begun having conversations with community stakeholders (including birthing hospitals) about the support doulas can provide to women prenatally, during labor and delivery and postpartum and what would be needed to move towards credentialing and Medicaid reimbursement.  The DHMIC established a Doula Adhoc Committee, which is led by DHMIC member and legislator, Representative Mimi Minor Brown, to continue to address doula policy and reimbursement opportunities.  While many of the services provided by doulas are nonmedical, there is evidence of the benefits of doulas to address health disparities and improve maternal and infant outcomes.  There are barriers to designing a reimbursement structure and process for seeking Medicaid reimbursement. Some of these barriers include establishing minimum requirements for certification & training, reasonable reimbursement rates for both Doulas and Medicaid, and billing coverage if doulas enroll as independent providers.  Also, ​because many doulas see themselves as rooted in their communities and not necessarily the formal healthcare system, there is currently no single national doula network or credentialing association and we do not know how many doulas there are in the state/people interested in offering doula services.  DMMA, per a law passed this year by the Delaware General Assembly, is required to submit a plan to the Governor outlining a plan, timeline and proposed budget to cover Doulas services under Medicaid.  The process of developing the plan is frequently shared with the Doula Adhoc Committee for input, as well as a stakeholder engagement process to inform the plan and implementation of state infrastructure to support a reimbursement pathway under Medicaid.  There are two organizations now, including Black Mothers in Power (serving Wilmington) and Parent Information Center (serving Sussex), who have received a DPH/DHMIC Healthy Women Healthy Babies mini grant to work on a small scale pilot to develop a network of doulas, provide training and increase capacity in the state, which will be monitored closely for lessons learned.  

 

Healthy Women Healthy Babies (HWHB) program 2.0, rolled out operations based on the new vision and framework focused on performance-based outcomes.  DPH contracts with seven health providers to deliver the HWHB services at 20 locations across the state.  The Healthy Women Healthy Babies program provides preconception, nutrition, prenatal and psychosocial care for women at the highest risk of poor birth outcomes.  DPH worked tirelessly in collaboration with the DHMIC and several MCH partners to review a recent release of a comprehensive evaluation of the program and specific birth outcomes to help inform plans for improving program quality (2011-2015).  Overall, results for the program were more mixed - not as clear as the results were for African American participants, making the case that it was time to revisit the program model to further enhance outcomes. 

 

The HWHBs 2.0 program uses an outcomes-orientation and learning collaborative approach throughout the contracting process and ongoing service delivery relationship.  By focusing on outcomes, the program takes an equity-driven approach that deepens funder-provider-participant mutual accountability in designing and delivering services focused on reaching a core set and minimum of 6 benchmark indicators (i.e. screening for pregnancy intention; increase women who have a well woman visit; screen for substance misuse; increase the proportion of HWHB participants that abstain from tobacco use; depression screening and referral; social determinants of health screening, etc.).  

 

Data collection and analysis is central to this new HWHBS 2.0 model as well as continuous quality improvement (CQI) for ongoing learning and improvement.  This means that tracking, assessing, and improving outcomes for the HWHB program require a deliberate CQI plan and effort by providers which emphasizes quality improvement.  Another important component to the program, providers are required to coordinate and collaborate with a Community Health Worker (CHW), Health Ambassador, Lay Health Advisor (LHA), or Promotora, defined as an individual who is indigenous to his or her community and consents to be a link between community members and the service delivery system, to further enhance outcomes for women and babies.  Resources supporting community health workers are limited, and to demonstrate the value added, Delaware DPH invested in a small Community Health Worker pilot this year focused on engaging women of reproductive age and connecting women to the Healthy Women Healthy Babies providers and other community services and supports in high risk areas in the City of Wilmington.  This year, we are leveraged  additional funding streams to support expansion into high risk zones in Kent/Sussex Counties.

 

There is strong evidence that home visiting supports good maternal and women’s health outcomes.  Since 2010, Delaware has competitively applied for and has been awarded the Maternal Infant Early Childhood Home Visiting Grant (MIECHV) funding through the Affordable Care Act.  Funding is used to support evidence-based home visiting programs through increased enrollment and retention of families served in high risk communities.  Delaware grant funds are also used to sustain and build upon the existing home visiting continuum within Delaware, which includes three programs including Healthy Families America (known programmatically as Smart Start) Nurse Family Partnership, and Parents as Teachers.  This year, additional funding (approximately $345K and a second round of funding) was awarded through the American Rescue Plan to support MIECHV.   We will be working with our current MIECHV training and TA vendor to provide related trainings on emergency preparedness and response planning for families as well as any other topics identified by LIAs related to the pandemic.  For example, conducting virtual home visits, conducing intimate partner violence and depression screenings virtually.  We will also work with our health ambassadors to provide an emergency preparedness workshop for families.

 

Delaware Division of Medicaid and Medical Assistance (DMMA) continues to explore Medicaid reimbursement for evidence-based home visiting programs and recently released language supporting evidence based home visiting in the Managed Care Organization (MCO) Request for Proposal.  While we have learned that there are a variety of approaches and mechanisms for reimbursement through Medicaid, movement on solidifying reimbursement for home visiting services is finally getting some traction.  DMMA has secured TA support from Mercer to work with DPH to explore financing models.

 

In Delaware, there are two different Health Ambassador programs, each striving to make a difference in the lives of Delaware’s women and their families and serves as a compliment to home visiting services.  This past year, new contracts were negotiated for delivering Health Ambassador Services, in response to an RFP released in June 2017.  Studies have shown that the use of community health workers has been documented as a method to enhance health education and promotion with high-risk, hard- to-engage, and underserved populations.  As a complementary strategy to home visitation, promotors serve as Health Ambassadors in the largely rural and Hispanic areas of southern Delaware while cultural brokers serve as Health Ambassadors in the urban communities in the City of Wilmington.  Health Ambassadors use innovative, creative and culturally sensitive strategies to engage women and families.  Health Ambassadors promote health education messaging on a range of maternal and child health topics:  before, during and after pregnancy, birth spacing, reproductive life planning, as well as make a direct connection to Delaware 2-1-1 to link with a variety community based services including home visiting services as well as federally qualified health centers that can provide well women care.  Health Ambassadors have been critically vital during the pandemic, to keeping families engaged in home visiting and helping families access critical support needs and emergency supplies.  The promotors were able to perform contactless drop-off to home visiting families when local stores ran out of essential items such as food, diapers, and wipes.  In addition, health ambassador programs quickly transitioned to “Virtual” chat-n-chews and baby showers to create a safe space for women in the community to share their concerns around pregnancy.

 

School Based Health Centers (SBHCs) provide prevention-oriented, multi-disciplinary health care to adolescents in their public school setting, and also contribute to better outcomes related to NPM 1 Well Woman Care.  There is a growing interest for expansion to elementary, middle and additional high schools.  School Based Health Centers are going through a paradigm shift, and there is a lot of stakeholder interest and commitment to understand national and in state innovations in practices and policies, and explore options moving forward to enhance SBHCs in Delaware within the local healthcare, education, and community landscape.  Delaware currently defines SBHCs as health centers, located in or near a school, which use a holistic approach to address a broad range of health and health-related needs of students.  Services may also include preventative care, behavioral healthcare, sexual and reproductive healthcare, nutritional health services, screenings and referrals, health promotion and education, and supportive services.  SBHCs are operated by multi-disciplinary health professionals, which includes a nurse practitioner overseen by a primary care physician, licensed behavioral health provider, licensed nutritionist, and or dental hygienist.  SBHCs are separate from, but interact with, other school health professionals, including school nurses and school psychologists and counselors.  SBHCs also operate alongside and interact with outside health care professionals and systems. 

 

The Delaware Division of Public Health (DPH), in collaboration with several key stakeholders, completed a year long process to create a Delaware School-Based Health Center (SBHC) Strategic Plan, released in 2021.  The planning helped DE develop a model for expansion of SBHCs that is both financially sustainable and anchored in best practices.  The goal is to ensure that SBHCs are responsive to the individual needs of Delaware’s children - who, for a variety of reasons, may not otherwise have access to the health care system for critical health and wellness services.  The final plan was released in June 2021 and is available for viewing at DEthrives.com/sbhc.  This year and ongoing, the DPH Adolescent and Reproductive Health Bureau team is working on aligning staff to support implementation of the strategic plan, provide technical assistance to our medical sponsors and support expansion.

 

For the past 30 years, Delaware School Based Health Centers, located in 33 public high schools, have contributed to the health of the state’s high school adolescents and have been an essential strategy to support women’s overall physical and mental health.   Eventually, these young women and men will be our health consumers, so it is essential to support health and wellness during this critical period and coming of age.  SBHCs provide at-risk assessment, diagnosis and treatment of minor illness/injury, mental health counseling, nutrition/ health counseling and diagnosis and treatment of STDs, HIV testing and counseling and reproductive health services (27/33 sites) with school district approval as well as health education.  Given the level of sexual activity among high school students, persistent high rates of sexually transmitted infections (STIs) and the numbers of unintended pregnancies, reproductive health planning services are very important. In addition, the Adolescent and Reproductive Health Bureau assembled a team to work with a social marketing vendor on a STI prevention and awareness campaign, called ERASE the STIGMA.

 

In addition, Delaware’s SBHCs provide important access to mental health services and help eliminate barriers to accessing mental health care among adolescents (i.e. women).  Over the last couple of years, school district school boards voted and approved to add Nexplanon as a birth control method and offered at the school-based health center sites and as of this writing total 14 sites).  This is a major accomplishment being that each school district’s elected school board members vote on and approve what services can be offered at each SBHC site.  Offering the most effective birth control methods as an option, gives more young women informed choices so that they can decide when/if to get pregnant and ultimately reduce unplanned pregnancies. 

 

Unplanned pregnancies are expensive and cost women, families, government, and society.  Extensive data show that unplanned pregnancies have been linked to increased health problems in women and their infants, lower educational attainment, higher poverty rates, and increased health care and societal costs.  And, unplanned pregnancies significantly increase Medicaid expenses.  By reducing unintended pregnancy, we can reduce costs for pregnancy related services, particularly high risk pregnancies and low birth weight babies, improve overall outcomes for Delaware women and children, decrease the number of kids growing up in poverty, and even potentially reduce the number of substance exposed infants.

 

Launched in 2016, Delaware Contraception Access Now (DE CAN) (www.upstream.org/delawarecan/) improves access for all women to the full range of contraceptive methods, including the most effective, IUDs and implants.  By implementing Upstream USA’s whole healthcare practice transformation approach, DE CAN created a long-term system change for contraceptive access across Delaware.  It includes three critical components to help break down barriers for all women accessing contraceptive care.  First, it enables health centers to make reproductive care a routine part of primary care by implementing a Pregnancy Intention Screening Question (PISQ) – a variation of the question, “do you want to become pregnant in the next year?” – at every healthcare appointment.  Second, if they do not want to become pregnant, DE CAN trains health centers to counsel patients on the full range of contraceptives available to them.  DE CAN enables health centers to be able to provide patients with their choice of contraception at that visit – the same day – by training administrative staff on business processes such as billing, coding and stocking devices.  Third, DE CAN created consumer demand for contraception by developing consumer-marketing campaigns to educate women about their options for care.

 

Delaware CAN includes health centers that serve nearly 80% of women of reproductive age in the state.  Nearly 2,000 women in Delaware have taken advantage of the "All Methods Free" program during the intensive intervention.  Upstream hosted 130 trainings, trained nearly 3000 clinicians and staff from 41 partners representing 185 sites across DE.  A key component of the model is quality improvement and implementation coaching that follows each training.  During the quality improvement phase of the initiative, Upstream and health centers work together to remove barriers, implement patient centered contraceptive counseling, integrate pregnancy intention screening into the EHR and set up data collection to assess impact.  The 41 partners serve nearly 125,000 women of Delaware’s approximately 190,000 women of reproductive age.  The Division of Public Health’s team, along with Upstream, USA worked closely with Medicaid and several MCH stakeholders to ensure that there are no policy barriers to all women getting same-day access to all methods of birth control, at low or no cost.  The Delaware Division of Medicaid and Medical Assistance (DMMA) revised its reimbursement policy for hospitals providing labor and delivery services, so that they can offer their patients placement of IUDs and implants immediately post-delivery if patients request them.  This change in policy promotes optimal birth spacing and increases access to this birth control method.

 

DPH has successfully integrated the nationally recognized Delaware Contraceptive Access Now (DECAN) initiative into the Family Planning Program, which sits in the Family Health Systems Section in DPH, where Title V MCH also resides organizationally.  Since FY20, the program receives a consistent state GF investment in the amount of $1.5M and furthers the DPH’s priority to sustain providing low cost access of all methods of birth control, including the most effective LARCS to low income women across the state.  This initiative continues to improve public health by empowering women to become pregnant only if and when they want to by training staff on best practices in patient-centered care and shared decision-making, that will increases their knowledge of all contraceptive methods including mechanism of action, efficacy, risks, side effects and benefits.   Developments in the last year, include a bill passed into law that would extend and authorize Pharmacists to dispense and administer hormonal birth control.  The Adolescent and Reproductive Health Bureau team is drafting regulations for review and consideration to support implementation.

 

The Division of Public Health’s team, is working with five of the six Delaware birthing hospitals to ensure that all patients can receive the contraceptive method of their choice immediately after giving birth, including immediate post-partum LARCS.  This change in policy will promote healthy birth spacing and give women more access to all methods of birth control.  Currently the largest hospital system in the state, Christiana Health Systems offers these services, as well as Nanticoke Health Systems and Bayhealth Medical Centers.  Beebe Medical Center has trained their providers and have implemented this service in the past year.  The Division of Public Health continues to work with all hospitals statewide on training and technical assistance with these new processes and procedures.  Furthermore, Delaware’s Division of Medicaid and Medical Assistance also implemented a reimbursement policy change approved by the Centers for Medicare and Medicaid Services (CMS) allowing the cost of long acting reversible contraception (LARC) to be carved out of the federally qualified health center (FQHC) prospective payment system (PPS) rate.

 

The Pregnancy Intention Screening Questions (PISQ) is an important door opener to discuss preconception health with a woman’s health provider and was implemented into the Division of Public Health’s Electronic Medical Records System.  This was no small feat, especially for a state agency such as DPH, as other DE CAN providers have been struggling with enhancing their EMRs to add a PISQ in their system.  DPH Family Health Systems considers this a huge win, which will continue to be a source of data to monitor.  The Pregnancy Intension Screening Question has the potential to reduce disparities in care and outcomes, especially for groups with higher rates of unintended pregnancy and adverse birth outcomes.  DPH requires that all Healthy Women Healthy Babies providers also include a PISQ benchmark measure for consistency and alignment with the DE CAN program.

 

DPH has developed a Contraceptive Counseling training based on Upstream, USA’s team approach patient-centered contraceptive counseling model and continues to provide support to Sub-Recipient Sites on sustainability of this initiative.  This training is offered to all Title X Family Planning sites as well as Delaware Social Service Organizations to provide patient-centered contraceptive counseling for their clients experiencing challenges including substance use disorder, mental health issues, homelessness and domestic violence.  A partner resource page has been developed by Upstream, USA so that tool kits and documentation are available to providers to support and sustain the project.  

 

In 2021 the Delaware Family Planning program completed four full in-person training sessions on March 30, 2021, June 28, 2021, August 25, 2021 and November 17, 2021 and as of today we have completed two training sessions in 2022 on February 23, 2022 and May 26, 2022.  These trainings included interactive conversations and games that cover topics such as the DECAN initiative, all methods of contraception, bias and coercion, patient-centered/shared decision making, patient centered contraceptive counseling, and hands-on clinical Nexplanon and IUD training for clinicians.  On April 6, 2022 we had a non-clinical training virtual training for DOC.  The DECAN program will have two additional trainings in 2022 on August 24, 2022 and October 27, 2022.  

 

The DPH Family Planning team has been working with the Department of Corrections (DOC) since the beginning of the initiative to be able to provide access to all methods of birth control to incarcerated women that are transitioning back into the general population and are seeking such methods.  Starting November 1, 2020, a policy and procedure was finally approved and these services are available to all incarcerated women in Delaware.  All birth control methods provided through this formal relationship with DOC are provided by DE CAN state funds and are managed through the State Pharmacy.  The Family Planning Trainer Educator provides training to all women’s corrections staff on all methods of contraception, techniques for patient-centered /shared decision making along with training on bias and coercion.  This is to ensure that services are offered in a voluntary manner.  In addition, a law was passed this year in the Delaware Momnibus that includes offering Doula support services to women in DOC, and the maternal and child health team will monitor the developments of implementing this law to support these women to improve birth outcomes.

 

Since June 2021, 34 staff members have been trained on the DECAN initiative, all methods of contraception, bias and coercion, patient-centered/shared decision making, patient centered contraceptive counseling, and newly added cultural competency.  There have been 12 clinicians trained in Nexplanon insertions/removals and 8 clinicians trained on IUD insertion/removals.  A total of 10 provider sites have taken part in the DECAN trainings including staff and providers from Westside Family Healthcare, Brandywine, Beebe Healthcare, Tidal Health, Department of Corrections, LaRed Health Center, Planned Parenthood, UD NMPCC, Sussex Tech High School and Rosa Health Center.  

 

The early evidence of Delaware CAN’s outcomes among Delaware healthcare providers is very promising, as Child Trends released a research brief estimating that following Upstream’s partnership with the state of Delaware.  Child Trends issued a report using available contraceptive data from 2014 to 2017 in Delaware among Delaware Title X family planning clients ages 20–39.  The observed movement from moderately effective contraception to highly effective Long Acting Reversible Contraception (LARCs), paired with a small decrease in no method, was linked to a substantial simulated decrease (24.2 percent) in the unintended pregnancy rate among this population.  The complete report, including methodology and limitations, was commissioned by Upstream and can be found at ChildTrends.org.

 

To assess DE CAN’s long-term impact, the University of Maryland in partnership with the University of Delaware, is conducting a rigorous and independent evaluation of the intervention.  The evaluation includes both a process and impact study and assesses outcomes such as contraceptive use, LARC utilization, Medicaid costs, and unplanned pregnancies resulting in unplanned births.  The evaluation is also exploring implementation and identifying key lessons learned to document, contextualize and deepen understanding of the impact of DE CAN.  The evaluation involves eight distinct data collection activities and runs from 2016-2022.  Data collection activities include: Title X patient survey, Delaware Primary Care Physician survey, interviews with women, male partner interviews, sustainability survey and stakeholder interviews and surveys.  Some very preliminary findings were shared:

• We find increases in LARC use for Title X adult patients
• We find increases in postpartum LARC use for Medicaid and non-Medicaid women
• We find increases in LARC insertion for teens enrolled in Medicaid, age 15-18.We do not find statistically significant results for LARC insertion for adult non-postpartum women in Medicaid, age 19-44.

 

Oral Health for Pregnant Mothers

 

At the onset of this grant cycle, we set specific objectives for this health priority and we sought to increase the percentage of women who have a dental visit during pregnancy from a reported rate of 40.5% to 43%.  We have achieved our goal of increasing the rate to 43%, but we intend to continue our efforts so that we move closer to achieving the national average of 53%.  According to PRAMS, the percentage of Delaware women who reported visiting a dentist or dental clinic during their most recent pregnancy rose between 2007 (36.0%) and 2015 (44.4%).  While this information shows a positive trend for women in Delaware, we continue to lag behind the national average of 53% in 2015.

 

According to findings from our 2020 Stakeholder Survey, there is a high desire to address this health priority, but partners feel there is little progress being made thanks, in part, to inadequate resources.  The respondents believe there are evidence-based strategies available to help move the needle in this area, but not enough “boots on the ground” to make it happen.  The findings tell us that the oral health for pregnant woman and oral health for children is our weakest area of success and respondents advised us to stay the course with seeking to improve oral health rates for both domains.  However, during the Needs Assessment process oral health in the Women/Maternal Health Domain did not rank in the top 10 overall.

 

So, although not selected as a priority, we will continue to work with the Bureau of Oral Health and Dental services on ensuring our partners serving women have resources to educate women on the importance oral health and making referrals to dental services when needed.  Our Healthy Women, Healthy Babies program provides support dental services for Healthy Women, Healthy Babies patients through two Federally Qualified Health Centers FQHCs (including one in Sussex County) to help promote access to oral health.  In collaboration with the FQHCs and the DPH’s Bureau of Oral Health and Dental Services Program, more women of childbearing age will have access to dental care.  We are happy to report that our sister agency, Delaware Medicaid and Medicare Assistance (DMMA) recently negotiated with one of their Managed Care Organizations (MCO) to include Medicaid coverage for adults over the age of 21 for one preventive oral health visit and one set of laboratory dental x-rays per year.  This is exciting new progress for Medicaid and MCH will continue to work with DMMA to expand coverage in the future for problem and urgent dental care coverage.  We anticipate that the expansion of coverage for preventive oral health care will show trending successes in the coming years.