Women/Maternal Health Domain - Annual Report
Illinois’ Title V has two priorities for the Women and Maternal Health Domain:
- Assure accessibility, availability, and quality of preventive and primary care for all women, particularly for women of reproductive age (Priority #1).
- Promote a comprehensive, cohesive, and informed system of care for all women to have a healthy pregnancy, labor and delivery, and first year postpartum (Priority #2).
The Title V team will continue to analyze more detailed data on maternal mortality through the work of the two Illinois maternal mortality review committees and will publish an updated report on data and recommendations in fall 2023.
While not worsening, multiple maternal health indicators in Illinois have remained stagnant over the last 4-5 years. Most Illinois women have continued to access health care services; about 3 in 4 women of reproductive age received at least one preventative visit in the last 4 years (NPM #1). In 2021 nearly 80% of pregnant women started receiving prenatal care in the first trimester (NOM #1). However, there are opportunities to improve the receipt of these needed primary and preventative health services, particularly for women with lower educational attainment, lower income, those on Medicaid, or who are uninsured. New grantees within the IDPH Well Woman Program are aimed at jumpstarting a positive trend in years to come.
Reduction in the teen birth rate in Illinois continued to fall to an all-time low in 2021 (NOM #23), representing a nearly 50% decrease since 2015. However the rate of chlamydia infections for women age 15-24 remains one of the indicators with the highest racial/ethnic disparities in Illinois. The chlamydia infection rate in 2021 was nearly six times as high among Black women as it is among White women (SOM #1). Illinois will continue to improve reproductive health services through school-based health centers, the state’s family planning program, and coordination with the state STI program.
Trends for the health of Illinois’ women during pregnancy and the postpartum period have shown mixed progress. In Illinois, non-Hispanic Black mothers are about twice as likely to experience a severe maternal morbidity and more than four times as likely to die during pregnancy or the first 42 days postpartum as non-Hispanic White mothers (NOM #2, NOM #3). In recent years, the maternal mortality rate has improved slightly overall yet continue to show widening racial disparities. Decrease in the rate of severe maternal morbidity has been inconsistent in the past, but most recently has shown notable improvement in comparison to other states’ progress (up 15 spots in ranking of all states since the baseline year). We will continue to analyze more detailed data on maternal mortality through the work of the two Illinois maternal mortality review committees and will publish an updated report on data and recommendations in 2023.
Similarly, the percent of low-risk cesarean sections (NPM #2) has remained consistent around 25% in the last 5 years. While not worsening, Illinois must begin to make progress on this indicator to achieve the HealthyPeople 2030 objective of a rate no higher than 23.6%.
The Illinois Perinatal Quality Collaborative has continued the important statewide initiative around Birth Equity which will hopefully reduce the disparities in outcomes during the maternal health period. Several ILPQC initiatives are ongoing simultaneously and have been highly engaging - in 2020 and 2021, 100% of Illinois’ birthing hospitals participated in at least one obstetric quality improvement initiative (ESM #2.1).
In FY22, Title V utilized the following strategies to address Women’s and Maternal Health:
- Priority #1- Assure accessibility, availability, and quality of preventive and primary care for all women, particularly for women of reproductive age.
1-A. Support the implementation, dissemination, evaluation, and improvement of the Illinois Healthy Choices, Healthy Future Perinatal Education Toolkit, which includes information and resources for consumers of women during preconception, prenatal, postpartum, and interconception care.
In collaboration with EverThrive Illinois (EverThrive), Title V continues to support the ongoing enhancement, dissemination, evaluation, and improvement of the Healthy Choices, Healthy Futures Toolkit. The perinatal education toolkit serves as an informational resources to a wide range of providers of women during preconception, prenatal, postpartum, and interconception care. This online resource features an educational matrix of resources, social marketing materials, post-partum transition strategies, brochures, and other tools. The targeted audience is providers that supported people of reproductive age in addition to people themselves seeking to find easy to understand, reputable resources to help support them with the information they needed as they navigated the various reproductive phases.
During FY22, EverThrive continued to update and to promote the Healthy Choices, Healthy Futures Toolkit. The toolkit remains accessible via a website maintained by EverThrive (https://www.healthychoiceshealthyfutures.org/). Information was broken down into specific timeframes along the reproductive journey. It included fact sheets, ovulation calendars, informational videos, and many links to resources, such as the Better Birth Outcomes, ConnectTeen, and Family Case Management. The toolkit has reached over 400 individuals through presentations and 4,946 through digital outreach. EverThrive also partnered with I PROMOTE-IL to evaluate the toolkit. This evaluation plan will include surveys and focus groups and is expected to be completed by FY23.
EverThrive Illinois continued engagement in another key activity that was not originally captured in the State Action Plan. This activity focused on the COVID-19 public health emergency. In FY22, EverThrive ensured that Illinois families had up-to-date information about COVID-19 through its quarterly Town Hall Series and updated webpage. Topics covered in the Town Halls included housing, COVID-19 vaccinations for pregnant and lactating people, substance use prevention and treatment in pregnant people, and how Medicaid health plans are supporting pregnant and postpartum people. The Town Hall series provided timely, relevant information on COVID-19 and maternal and child health. During FY22, EverThrive Illinois continued to provide information and resources about COVID-19 for pregnant/postpartum people, families, and their communities and providers, focused on the unique needs and interests of this population. EverThrive accomplished this through maintenance of a COVID-19 information page on their website and promotion, including on social media. EverThrive IL’s COVID-19 webpage provided information regarding testing, vaccinations, breast/chest feeding and accessing clinical care during the COVID-19 pandemic and included resources addressing social determinants of health needs during the pandemic. The webpage was developed with feedback from low-income Illinoisians of color in mind and responding to their needs during the pandemic. Throughout FY22, EverThrive IL promoted the COVID-19 webpage on social media and via email, reaching 1,061 page views
1-B. Partner with the Illinois Department of Corrections (DOC) and two state women’s correctional centers to support ongoing health promotion activities for incarcerated women and staff training, and to ensure women and infants receive Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) services while residing in DOC facilities.
Illinois is home to two women’s correctional facilities: Logan Correctional Center (LCC) and Decatur Correctional Center (DCC). OWHFS’s Division of Population Health Management (DPHM) collaborates with the Illinois Department of Corrections (DOC) to support pregnant women and new mothers housed within the women’s prisons. These facilities housed more than 2,500 women and supported eight Mom and Baby joint housing units. Specifically, DPHM provided pregnancy education, breastfeeding education, and lactation support and counseling. DPHM also provided the facilities with new breast pumps, pumping kits, milk storage bags, and breast pads to support those women who were able to pump and provide milk for their baby.
In the past, DPHM provided obstetrical and neonatal simulation training at the LCC and DCC for physicians, nurses, and other staff within the prisons. The goal of this training was to allow for staff to test their obstetrical and neonatal skills and prepare for any labor and/or delivery encounters at the facility. The training and education also afforded the staff the opportunity to debrief afterwards to identify other opportunities to improve the quality of care for pregnant women. The regional APC network administrator and the maternal-fetal medicine (MFM) physician APC co-director played a vital role in providing the education and answering the women and staff’s questions. The MFM also served as the lead for Southern Illinois University School of Medicine’s (SIUSOM) Correctional Medicine Pilot Program at LCC.
Due to the pandemic, DMPH experienced limitations in providing education and support to the women and health care staff at LCC and DCC in FY22. Limited courses were held online during FY22 and DMPH resumed in person services in FY23.
1-C. Implement well-woman care mini grants to assist local entities in assessing their community needs and barriers; and, to develop and implement a plan to increase well-woman visits among women ages 18-44 years based on the completed assessment.
IL Title launched its Increasing Well-Woman Visits program (well-woman care mini grants) in 2019. These planning grants were offered to initiate interest in expanding services and assisting local entities in assessing their community needs and barriers. The Implementation Phase: Increasing Well-Woman Visits – Community (IWWV-C) Grant program launched as a two-year grant commencing July 2021.The grantees funded focused on four main objectives 1) Assist women 18-44 with accessing quality, comprehensive preventative care (e.g., Mammogram, pap and pelvic exams, emotional well-being, tobacco and substance use, violence and injury prevention, sexual health and healthy relationships, and physical health and health promotion), 2) Support evidence-informed guidance, to address behavioral, social, and environmental determinants of health, 3) Assist communities with assessing the barriers to women scheduling preventative care visits, and 4) Increase awareness of the importance of well-woman visits for at least 75% of staff at grantee organization.
During FY22, the grantee of this program focused on expanding awareness of the programs within the communities served. Grantees worked on completing and improving relationships with providers, social media campaigns, and podcasts to reach patients. The COVID-19 pandemic was identified as still being an issue for efforts during this timeframe. Some unique highlights of various grantees include program staff receiving training to assist patients signing up for insurance, program staff trained in Adult Mental Health first aid and included other staff that worked at the local health department as well and lastly, increased HPV vaccinations by 66% within a grantee’s population served.
A planning phase of this grant was created in January 2022 to increase the reach of the program. Grantees who successfully complete the planning phase are eligible to continue the program with the Implementation phase and expanded scope when it begins in FY24.
1-D. Partner with UIC Center for Research on Women and Gender to implement a program at two clinic sites to expand the capacity of health care providers to screen, to assess, to refer, and to treat pregnant and postpartum women for depression and related behavioral health disorders.
The University of Illinois at Chicago's Center for Research on Women and Gender (UIC-CRWG) received Title V funding in FY20-22 to implement a pilot project to expand the capacity of perinatal health care providers in Illinois. The focus of this project was to screen, to assess, to refer, and to treat pregnant and postpartum women for depression and related behavioral health disorders. The scope of the project also included increasing awareness of, and access to, affordable and culturally appropriate services to pregnant and postpartum women and their infants. The project targeted obstetricians, gynecologists, nurse midwives, pediatricians, psychiatric providers, mental health care providers, social workers, and primary care providers in geographical areas serving disadvantaged women, including Cook County/Chicago and Peoria County/Peoria.
The main objectives of the program were to: 1) provide in-person workshop training and resources on screening, diagnosis, and referral for maternal depression and related behavioral disorders to perinatal providers; 2) provide real-time psychiatric consultation and care coordination for providers; 3) screen women for depression, anxiety, suicide risk, and substance use during the perinatal period using Computerized Adaptive Testing (CAT); 4) increase access to depression prevention and treatment for medically underserved women using a telehealth intervention; 5) increase access to substance use treatment for pregnant women; and 6) plan for scale-up and sustainability to implement the project components statewide.
In FY22, screenings continued at University Village with all providers. A total of 229 screens with the computerized adaptive testing for mental health (CAT-MH) were conducted during routine prenatal care at the clinics during FY22. Eleven screens were positive for major depressive disorder (4.8%), 13 positive screens for generalized anxiety disorder (5.68%), and four were at intermediate or high risk of substance use disorder (1.75%).
This project was concluded in FY22.
1-E. Support the Chicago Department of Public Health (CDPH) efforts to foster, partner, and collaborate with organizations and agencies providing male and partner involvement programs.
The CDPH’s Maternal, Infant, Child and Adolescent Health Bureau serves thousands of infants, children, adolescents, pregnant people, and parents each year through a variety of programming supported, in part, by Title V funding. Family Connects Chicago (FCC) assesses and addresses the needs of post-partum birthing persons who are Chicago residents and their newborns, with the goals of providing connections to needed services and care and improving health outcomes. FCC is an evidence-based, universal post-partum home visiting program for birthing persons, their newborns, and families. Family Connects has served over 10,000 families since launching in March of 2020. The services of Family Connects focus on mom and newborn care through both in-home and office screenings and teachings. The visits occur between three to 12 weeks after birth during which nurses assess the health of the birthing person and newborn, and provide education and resource referrals (e.g., referrals to healthcare providers or community-based ancillary services and supports) to address the individual needs of each family. FCC also features Community Alignment Boards (CABs) which coordinate community-based organizations and resources across all six city regions to strengthen the connections, quality, and viability of referrals. FCC promotes health equity through its universal approach. Services were offered to all persons who gave birth in participating pilot hospitals. Research has shown that when services are focused on the specific needs of each family rather than targeted to certain socioeconomic groups, participation is more robust. FCC’s community alignment aspect identifies gaps in resources in communities with the most need. The six citywide CABs help CDPH and hospital providers to tailor services referrals and resources to meet the individual needs of each family to ensure equity in support.
During FY22, CDPH leveraged the FCC Regional Community Alignment Boards to survey community-based programs and initiatives that promote partner and male engagement. Regional CABs regularly local early childhood providers that offer Head Start and Early Head Start programs that specifically strive to include partner and male engagement as part of their service models. This includes strengthening proficiency to engage with families around such areas as health care connections for male/partner and health co-parenting skills. CDPH also leveraged its active participation in the IL-ECCS initiative as it continues to develop a unified approach to integration, alignment, and financing of programs within and across all state prenatal-to-3 systems while increasing the capacity of the health system to interface and collaborate with early childhood and maternal, child, and health (MCH) systems.
The FCC model relies heavily on community alignment to function optimally. Community alignment is the process whereby local knowledge and expertise feeds into the universal referral system and increased coordination of resources is achieved. The community alignment functions include enhancing access to services for needs identified during home visits, improving family connections with providers, identifying system-level issues, and elevating policy issues. Chicago has adapted the model to address the city’s scale and diversity of communities by organizing the city into 6 regions, each of which have a unique community alignment board. These boards consist of health and social service providers, early childhood providers, individual community members, advocates, and other maternal child health stakeholders. Their role is to interpret the data from the home visits about the needs of families in their communities, identify community resources and services to meet those needs, inform the program about ways to improve reach of the service, and advocate for resources to address gaps
- Priority #2- Promote a comprehensive, cohesive, and informed system of care for all women to have a healthy pregnancy, labor and delivery, and first year postpartum.
2-A. Convene and facilitate state Maternal Mortality Review Committees (MMRC and MMRC-V) to review pregnancy-associated deaths and develop recommendations to improve quality of maternal care as well as reduce disparities and address social determinants of health.
Since 2002, Illinois has followed the CDC recommendation to identify all pregnancy-associated deaths. Illinois used multiple methods simultaneously to ensure pregnancy-associated deaths are accurately identified and counted each year. The state database of death certificates is used to identify deaths that may be pregnancy-associated. A checkbox on the death certificate indicates whether a woman was pregnant at the time of death or pregnant within the last year. Additionally, some cause of death codes indicate that a death may have been related to pregnancy. Finally, death certificates for any woman aged 15 to 60 years are also checked against the databases of birth certificates and fetal death certificates to look for matching information. If there was a birth or fetal death record in the 12 months prior to a woman’s death, her death is flagged as a pregnancy-associated death.
In addition to the state data systems, there are other ways that maternal deaths are identified in Illinois. All Illinois hospitals are required by the state to report any known pregnancy-associated deaths to IDPH within 24 hours. IDPH completed regular searches of major newspapers to identify articles or obituaries that indicate the death of a woman while pregnant or within one year of pregnancy. For example, if an obituary mentions that a deceased woman has a surviving child who is less than 1 year old, the woman’s case is flagged as a potential pregnancy-associated death.
Though information from death certificates and other public health records may help identify counts of maternal deaths, these records cannot determine the preventability of deaths, or the factors involved in the death. Once the maternal deaths are identified, IDPH contacts the hospitals and health centers where the women received care to request records from the time of her most recent pregnancy to her death. These medical records provide details about the woman’s death and her medical history. For instance, records are routinely requested from the hospital where the woman died, the hospital where she gave birth, and the physician’s office or health center where she received prenatal care. When relevant, records are also requested from police departments, sheriff’s offices, and medical examiner or coroner’s offices. IDPH is constantly reviewing records to identify additional records that provide information on the case. Hospitals and medical providers are required to provide copies of all medical records related to maternal deaths within 30 days of IDPH’s request. IDPH compiles this information to confirm and accurately track the number of pregnancy-associated deaths in Illinois each year.
The CDC recommends review of maternal deaths by a multidisciplinary committee as a means of gathering additional information about if the death was related to pregnancy, what the underlying cause of death was, whether the death was preventable, and opportunities for preventing future maternal deaths. During 2017, IDPH implemented a new review process to align with best practices promoted by the CDC. The goal was to improve several key components of the review process, including standardizing case abstraction, increasing review efficiency through structured meeting facilitation, and shifting to a population-health focus (instead of a purely clinical emphasis) to also consider how social and non-medical factors that may have contributed to a death. Overall, IDPH saw a need for more structured administrative and technical support to the committees, especially in terms of chart abstraction and data analysis. As a result, IDPH committed to taking a more active role in supporting the committee meetings, participating in reviews, and collecting and analyzing data. To align with national work, Illinois adopted the use of standard CDC data collection forms and resources. This ensured that the data collected by the Illinois MMRC and MMRC-V would be consistent with each other and with other review committees across the country.
During FY22, Illinois continued to implement the Maternal Mortality Review process for deaths potentially related to pregnancy. From October 2021 to September 2022, the MMRC held five meetings and reviewed 29 cases, and the MMRC-V held six meetings and reviewed 54 cases.
In addition to regular review meetings, IDPH identified the need for implicit bias training within the committees to meet national guidelines and processes. In the fall 2021, Illinois facilitated Implicit Bias Training for all members of the MMRC and MMRC-V, as well as many IDPH staff. Objectives of the training included: increase awareness of participants’ own cultural identities, establish common terminology, understand sources of unconscious bias and how bias can influence interactions with others, and develop strategies to combat bias to improve intercultural effectiveness.
In FY22, IDPH continued to enhance its efforts to improve maternal health and to reduce maternal mortality. Following the first statewide Maternal Health Summit in 2021, the Maternal Health Leaders Group was created. This group met quarterly to share ongoing initiatives and work to coordinate efforts to improve maternal health outcomes across Illinois. The group was composed of 1-2 stakeholders from maternal health initiatives around the state and facilitated to enhance IDPH’s understanding of ongoing work.
IDPH also continued other key activities, such as the IDPH and University of Illinois at Chicago (UIC) Center of Excellence in Maternal and Child Health (CoE-MCH) successfully applied for the HRSA Maternal Health Innovation Grant.
2-B. Partner with statewide Severe Maternal Morbidity (SMM) Review Subcommittee to develop recommendations for standardizing and improving hospital-level SMM case reviews across Illinois’ Regionalized Perinatal System.
According to the CDC, severe maternal morbidity (SMM) has increased more than 200% between 1993 and 2014. In 2017, Illinois began a collaboration with the 10 administrative perinatal centers and the UIC Center for Research on Women and Gender (CRWG). This SQC subcommittee became the Severe Maternal Morbidity (SMM) Surveillance and Review Project. In this project, all Illinois obstetrical hospitals identified and reported on SMM cases, defined as a pregnant or postpartum (up to 42 days) woman who was admitted to an intensive care unit (ICU) and/or transfused with four or more units of packed red blood cells.
CRWG developed a standardized SMM review form in partnership with the APCs. The form was used by APCs and their network hospitals to collect more information on the circumstances surrounding SMM events, preventability, and opportunities for intervention. APCs used the SMM review forms to report into the ePeriNet database, which allows for population-based analysis of SMM over time.
As the SMM Surveillance and Review Project continued, CRWG provided technical assistance to the hospitals and APCs as they conducted reviews and evaluated the quality of the data reported into ePeriNet. The statewide sub-committee meetings provided an opportunity for dialogue and collaboration between CRWG, the APC administrators, and the subcommittee members to discuss lessons learned and to identify ways to strengthen hospital level reviews. During FY21, the SMM Review Subcommittee was tasked with developing recommendations for standardizing and improving hospital-level SMM case reviews across Illinois’ Regionalized Perinatal System. Over the course of the year the committee identified key challenges and trends of preventability and what opportunities have been identified to barriers that exist. Much effort went into determining how to engage providers and to establish best practices for data collection.
The committee, after developing the above, had concluded their regular meetings in early 2022.
2-C. Participate in and collaborate with the Illinois Maternal Health Task Force established through the I PROMOTE-IL program (HRSA Maternal Health innovation Grant) to develop a statewide Illinois Maternal Health Strategic Plan to translate and build on findings and implement recommendations from the Illinois MMRC, MMRC-V, and SMM.
In FY19, the University of Illinois at Chicago (UIC) successfully applied for the HRSA Maternal Health Innovation Grant. The Innovations to ImPROve Maternal OuTcomEs in Illinois (I PROMOTE-IL) program will assist the state in collaborating with maternal health experts and optimizing resources to implement state-specific actions that address disparities in maternal health and improve maternal health outcomes. A key component of the grant is the Illinois Maternal Health Task Force.
During FY22, Illinois’ Title V director has served as a co-chair of the taskforce. Title V representation on the task force is important as Title V is a leader for all maternal health activities in the state, including Maternal Mortality and Severe Maternal Morbidity reviews. Thus, Title V’s ongoing participation and collaboration ensures that the task force is fully integrated into the existing maternal health infrastructure without duplication of efforts, assists in the tracking of maternal health legislation at the state and federal level to inform additional policy solutions, and addresses identified gaps outside of Title V’s efforts.
An ongoing key task of the Illinois Maternal Health Task Force is the creation of a Maternal Health Strategic Plan. The purpose of the plan is to guide, to support, and/or to strengthen the efforts of multiple organizations, groups, and individuals to reverse inequities that exist in maternal, infant, and family health outcomes across Illinois. After review of Illinois Maternal Mortality Report and MMRCs’ recommendations, the task force disseminated the first version of its strategic plan in February 2021. The strategic plan had five priority areas. The second iteration was published in FY22 and reflected the progress made.
2022 Strategic Plan AJ v2 (ipromoteil.org)
A key action step reported in the 2022 Strategic Action plan was to support the implementation of the Early Childhood Comprehensive Systems including the implementation of the Prenatal-to-Three Program (ECCS) grant work. Illinois Title V collaborated with DHS (HRSA awardee) to being the planning work needed to inform the development of a universal support system. A key challenge identified was that data systems across the state do not integrate with one another and this creates a barrier in access for providers and patients and subsequently the understanding of programs available for families. It was identified, that as of FY22, there was not a system in the state that involved all women perinatally.
During FY22, IL Title V continued to support the ECCS grant in representation on the Illinois Maternal Health Task Force Care Coordination and Case Management Committee (CCCMC). The CCCMC serves as the advisory committee for the implementation of ECCS by providing advice on the project and recommending strategic directions, policy, and financing changes. This committee will continue to provide advice on the project and recommend strategic directions, policy, and financing changes.
The collaboration continues through FY 23 with a focus on finding better pathway for providers/parents to understand referral process to programs.
2-D. Support and collaborate with the state-mandated Illinois Task Force on Infant and Maternal Mortality Among African Americans to assess the impact of overt and covert racism on pregnancy related outcomes, identify best practices and effective interventions, address social determinants of health, and develop an annual report with recommendations to improve outcome for African American women and infants.
IDPH released its first Illinois Maternal Morbidity and Mortality Report in October 2018. Influenced by the report, the Illinois General Assembly passed Public Act 101-0038, which created the Illinois Task Force on Infant and Maternal Mortality among African Americans (IMMT). This task force focused on identifying best practices to decrease infant and maternal mortality within African American residents of Illinois. Three subcommittees were formed in to address distinct activities within the scope of work needed by IMMT: Community Engagement Subcommittee, Systems Subcommittee, and Programs and Best Practices Subcommittee.
- The Programs and Best Practices Subcommittee (P&BP) was charged with reviewing research that substantiates the connections between a mother's health before, during, and between pregnancies, as well as that of her child across the life course; reviewing research to identify best practices and effective interventions for improving the quality and safety of maternity care; reviewing research to identify best practices and effective interventions, as well as health outcomes before and during pregnancy, in order to address pre-disease pathways of adverse maternal and infant health; reviewing research to identify effective interventions for addressing social determinants of health disparities in maternal and infant health outcomes; gathering data; and presenting recommendations to the IMMT based on findings.
- The Community Engagement Subcommittee (CE) was charged with reviewing research that substantiates the connections between a mother's health before, during, and between pregnancies, as well as that of her child across the life course; gathering research regarding women’s health before, during, and between pregnancies; reviewing data on social and environmental risk factors for Black/African American women and infants; and determining better assessments and analysis on the impact of overt and covert racism on toxic stress and pregnancy-related outcomes for Black/African American women and infants. In addition, the CE was charged with engaging the community to collect the voices of Black/African American women and families regarding maternal and infant health and presenting recommendations to the IMMT based on findings.
- The Systems Subcommittee was charged with reviewing data on social and environmental risk factors for Black/African American women and infants; studying nationwide/international data on maternal and infant deaths and complications, including data by race, geography, and socioeconomic status; identifying partners or key stakeholders in which the state should engage to address Black/African American maternal and infant mortality in a systematic way; and presenting recommendations to the IMMT based on findings.
In FY22 and late FY21 several recommendations that stemmed from the FY 21 IMMT inaugural report have received legislative backing and are now a component of law. Four of the six recommendations have been adopted and are at various states of implementation.
FY22 Update-During late 2021 the Illinois legislation body adopted 20 ILCS 2105/2105-15.7) Sec. 2105-15.7. Implicit bias awareness training which states, “For license or registration renewals occurring on or after January 1, 2023, a health care professional who has continuing education requirements must complete at least a one-hour course in training on implicit bias awareness per renewal period”. https://www.ilga.gov/legislation/ilcs/ilcs5.asp?ActID=325
- Access and Equitable Care - Birthing Centers: (1) The state should complete its evaluation of the demonstration program authorized by the Alternative Health Care Delivery Act [210 ILCS 3] and enhance its support of free-standing birthing centers to address maternity deserts in Black/African American communities; and (2) community organizations should explore opportunities to establish free-standing birthing centers to address maternity deserts in Black/African American communities. Effective August 20, 2021 the P.A. 102-0518 – Birth Center Licensing Act creates a process by which an independent birth center can be licensed by IDPH. Title V staff are currently completing the rules for this in collaboration with Illinois Health Care Regulation. https://www.ilga.gov/legislation/publicacts/fulltext.asp?Name=102-0518
- Postpartum Medicaid Reimbursement: The state through HFS should reimagine the current framework of bundled Medicaid reimbursement for obstetric care by unbundling the postpartum visit from prenatal care and labor and delivery services. Specifically, the state should support the implementation of a universal early postpartum visit within the first three weeks and a comprehensive visit within 4-12 weeks postpartum. This will improve postpartum access to care and positively impact the incidence of maternal morbidity and mortality in the postpartum period.
FY22 Update-Public Act 102-0665, effective 10/8/21 includes the following. “HFS reimbursement of universal postpartum visit within the first three weeks of childbirth and a comprehensive visit within four to twelve weeks postpartum. Postpartum care provided by perinatal doulas, certified lactation counselors, international board-certified lactation consultants, public health nurses, certified nurse midwives, community health workers, and medical caseworkers are to be covered under this program.
- Doula Certification and Coverage: (1) The state should support the increased utilization and reimbursement of doula services for prenatal and postpartum care, which includes supporting the development of an educational infrastructure for the certification of community-based doulas across the state; and (2) academic institutions and community-based organizations should establish community-based doula certification programs that develop a workforce able to provide prenatal and postpartum care in Black/African American communities and, subsequently, improving infant and maternal health.
FY22 Update- In April 2021 the Governor signed amendment to the Illinois Public Aid Code to ensure coverage of doula by HFS. https://ilga.gov/legislation/102/HB/10200HB0158enr.htm
To ensure support and collaboration from IDPH, the Title V director remained as the appointed IDPH director assignee and other Title V staff provide key support to each subcommittee. In alignment with the IMMT reports recommendation IDPH has continued to support the committee through Title V staff involvement and is developing a collaboration with state sister agencies to foster 100% implementation of the report’s recommendations.
In addition to developing its own recommendations and report, members of the IMMT and its subcommittees are actively involved in I PROMOTE-IL’s Illinois Maternal Health Task Force and subcommittees. This engagement ensures that the activities of the two task forces is aligned and complements each other.
The next report from IMMT for calendar year 2022 was in development by the end of Title V grant year 2022 and will contain new recommendations for legislators to consider.
2-E. Facilitate the collaborative effort between the Illinois Maternal Health Task Force and the Illinois Task Force on Infant and Maternal Mortality Among African Americans to align their strategies and activities towards improving maternal health in Illinois.
The I PROMOTE-IL Illinois Maternal Health Task Force and the Task Force on Infant and Maternal Mortality Among African Americans (IMMT) were established in FY20. With similar goals and the Title V director holding a key role in both task forces, it was important to have the two task forces collaborate on strategies and align activities needed for improving maternal health in Illinois. In addition, the task forces share multiple members that facilitates constant communication between the two groups. This communication is especially important as both task forces have recommendations/strategies to address community based perinatal support (e.g., doulas, community health workers, lactation consultants), telehealth utilization especially in light of the changing health landscape due to the COVID-19 pandemic, postpartum care reimbursement, and obstetric care deserts in Illinois.
2-F. Participate in state inter-agency committee efforts to improve Medicaid coverage and care coordination for pregnancy and postpartum women.
In April 2021, Illinois became the first state to receive federal Centers for Medicare & Medicaid Services (CMS) approval of its Continuity of Care & Administrative Simplification 1115 waiver application. The 1115 waiver extends Medicaid postpartum coverage from 60 days to 12 months. Specifically, the waiver allows Illinois to continue to receive federal match for postpartum Medicaid claims up to one year postpartum, including allowing women to enroll at any time during the first year postpartum if they become eligible at that time. Babies may be covered for the first year of their lives provided the mother was covered when the baby was born. Moms and Babies enrollees have no co-payments or premiums and must live in Illinois. However, it is worth nothing that the COVID-19 public health emergency allowed for continuous eligibility of all enrollees so the provisions of this waiver did not go into effect.
As a provision of the American Recovery and Prevention Act, states were allowed to file for a state plan amendment (SPA) for Medicaid extension to 12 months postpartum. This mechanism would allow state Medicaid agencies to receive approval for the extension of coverage and receipt of federal match funds for the coverage, but has fewer ongoing administrative requirements than an 1115 waiver. Illinois applied for a SPA that went into effect April 2022, effectively replacing the 1115 waiver. However, the COVID-19 public health emergency continued past this time, maintaining continuous eligibility for all enrollees, rendering the SPA unnecessary until the end of the public health emergency. With the end of the emergency in May 2023, the postpartum Medicaid SPA will be the authority that allows postpartum women to maintain continuous eligibility for Medicaid for 12 months after pregnancy.
Through the work initiated by the National Academy of State Health Policy (NASHP) Maternal and Child Health Policy Innovation Program (MCH PIP) [see strategy 2K], MCH staff from IDPH and HFS have begun to collaborate regularly on issues related to Medicaid policy, reimbursement, and innovations. The team meets bi-monthly to discuss various issues and to mutually inform the work of each agency. During FY22, HFS worked with IDPH to convene meetings with external partners to inform the new doula reimbursement policy. Legislation in 2021 required HFS to begin reimbursing for new non-clinical support services, such as doulas, lactation consultants, home visitors, and care coordinators (a recommendation from the maternal mortality review committees). HFS began by working on developing rules for implementing the doula reimbursement benefit and convened partners to better understand doula services and fair payment rates. HFS worked with IDPH advisory groups to identify relevant partners to invite to these listening sessions. HFS hopes to complete the proposal for the doula benefit in FY23.
2-G. Convene and partner with key stakeholders to identify gaps in mental health and substance abuse services for women that include difficulties encountered in balancing multiple roles, self-care, and parenting after childbirth; and leverage expertise to develop recommendations for system level improvements for Title V consideration and implementation.
Title V staff supported ILPQC’s continued efforts to identify strategies to support universal substance use disorder/opioid use disorder (SUD/OUD) screening prenatally, and obstetricians’ ability to counsel for Narcan and offer a prescription. ILPQC worked with I PROMOTE-IL’s Maternal Health Task Force to recommend required prenatal screening of SUD/OUD and developed a partnership with DHS Substance Use Prevention and Recovery (SUPR) to support hospitals’ ability to access point of care Narcan.
In FY23, Title V staff joined a multi-agency workgroup on Illinois’ implementation of plans of safe care for infants prenatally exposed to substances. This workgroup is being led by the Illinois Department of Child and Family Services (DCFS) to meet federal child welfare policy requirements.
2-H. Assess, quantify, and describe the impact of childcare on prenatal, intrapartum, and postpartum care in Illinois, and develop optional strategies and approaches that can be implemented in clinic and hospital settings.
Illinois participated in a three-year Collaborative, Improvement, and Innovation Network (CoIIN) that concluded in 2020. The CoIIN focused primarily on social determinants of health associated with infant mortality. Using surveys, focus groups, and informal discussions with health care providers and birthing persons, the CoIIN team identified childcare, or lack thereof, during pregnancy, childbirth and postpartum, as a barrier to care that has the potential of negatively impacting children and family health outcomes. In July 2022, we submitted a ”notes from the field” manuscript to the Maternal and Child Health Journal that discussed our data collection processes and findings from the CoIIN project.
Programs to this barrier of care addressing chilcare support have not been launched largely due to the COVID-19 pandemic. OWHFS will be evaluating the need for this activity during the upcoming needs assessment.
2-I. Support the Illinois Perinatal Quality Collaborative (ILPQC) in its implementation of obstetric and neonatal quality improvement initiatives in birthing hospitals.
The support of Illinois’s Title V program enables the Illinois Perinatal Quality Collaborative (ILPQC) to develop, to implement, to support, and to sustain statewide quality improvement initiatives with nearly all of the birthing hospitals in the state in collaboration with IDPH, the State Quality Council, the Regionalized Perinatal System, and other state and national stakeholders. ILPQC provides collaborative learning opportunities, rapid-response data, and quality improvement (QI) support to build hospitals’ QI capacity to implement evidenced based practices and improve outcomes for mothers and newborns in Illinois related to its most pressing maternal and infant morbidity and mortality issues across hospitals.
Mothers and Newborns Affected by Opioids Initiative
In 2018, ILPQC developed and launched the Mothers and Newborns affected by Opioids (MNO) Initiative with both an obstetric and neonatal component. ILPQC worked with hospital teams to implement system changes, such as implementation of screening, treatment algorithms, checklists, and local resource mapping, as well as clinical culture change using OB provider education, debriefs of Opioid Use Disorder (OUD) cases to identify missed opportunities to improve care, and regular data review to reduce risk and improve outcomes for every pregnant or postpartum woman with OUD. Objectives of the program were: (1) screen every pregnant patient for OUD with a validated screening tool; (2) assess readiness for and starting Medication-Assisted Treatment (MAT) and linking to Recovery Treatment Programs; (3) complete an OUD Clinical Care Checklist, which includes providing Naloxone (Narcan) counseling and prescription; (4) reduce stigma and bias across the clinical team; and (5) empower mothers through education to use non-pharmacologic care for their newborns exposed to opioids.
In FY22, the Title V team continued to collaborate with ILPQC as they worked to support hospital teams in sustainability of the MNO-OB initiative. Sustainability includes completion of a Sustainability Plan to submit to ILPQC and the perinatal network administrators. ILPQC held a MNO-OB sustainability webinar in FY2022 with high-level collaborative attendance (~100 attendees) to review progress towards achieving initiative aims and preparing for sustainability. MNO-OB sustainability work was funded by IDPH through December 2020. CDC funding was secured for sustainability work and commenced in January 2021.
Birth Equity Initiative
An initiative supported by Title V funding is ILPQC’s Birth Equity (BE) initiative, which began in FY21 and is ongoing in FY22.
The OB birth equity initiative (BE) launched in August 2021 with 86 hospital teams across the state with the aim of 75% or more teams implementing all key BE strategies by December 2023. The birth equity strategies include: (1) optimize race and ethnicity data collection and review stratified data; (2) screen all patients for social determinants of health and link to needed services; (3) standardize postpartum safety education and schedule early postpartum visits; (4) engage patients and community members for input in QI initiatives; (5) implement implicit bias and respectful care training for the healthcare team; and (6) share respectful care practices and survey patients on their care experience.
There remain 86 birthing /children’s hospitals participating in the Birth Equity initiative in FY 22, holding monthly webinars focused on the key aims and drivers of the initiative. Most notably, with funding from Title V, ILPQC was able to provide additional supports for hospital implementation of key strategies of the birth equity initiative including a partnership with EverThrive as a community engagement consultant to help facilitate regional community meetings with the 10 perinatal regions to connect Illinois hospital teams with local community leaders to support achievement of the engaging patient/community in QI structure measure to more effectively implement Social Determinants of Health (SDoH) screening and linkage to resources. Title V funding also supported hospital access to NowPow, an online portal to support hospital efforts to identify local community resources to link patients to services.
ILPQC partnered with Everthrive IL to host 10 Regional Community Engagement meetings – 1 for each of the networks of the regionalized perinatal system to connect Birth Equity QI teams and local community members. Teams learned best practices for engaging with community members/patients for feedback on QI work and hear from community leaders within their perinatal network’s region for input on Birth Equity strategies. Also, the meetings provided a space for teams to develop community connections to help move forward patient and community engagement opportunities for their team. We partnered with the Perianal Network Administrators to host these meetings in coordination with their regional network meetings at their request. Patient/community members and hospital team participants reported the meetings were impactful, helpful, and insightful. Everthrive facilitated a survey to get feedback and ILPQC meets monthly with the Perinatal Network Administrators to discuss and make plans to implement their input. Some feedback we received: “This is such a great discussion! Hearing from the community panelists is powerful and very much needed. I appreciate all of the input.” – Provider, Stroger Network. “The meeting went very well. The 3 community partners articulated their positive experiences related to the 4 key drivers of the BE initiative.” – Administrator, Northwestern Network
ILPQC conducted focus groups with patients in Winter / Spring 2022 and facilitated the Regional Community Engagement meetings with Everthrive in Spring / Summer 2022 to obtain patient and community input on resources and processes for hospital team implementation of Birth Equity Key Strategies. This patient and community input impacted program development and implementation at the collaborative and hospital level.
ILPQC rolled out access to the NowPow system at the ILPQC 9th Annual Conference in October 2021. Teams had access to search NOWPOW for SDoH resources to link patients to needs resources that was screen positive on the SDoH screening tool through June 2022 via link on the ILPQC Birth Equity webpage. On average, about 350 people clicked on the link to access the data system/webpage per the month with about, 2-7 referrals on average per month. To optimize resources with limited funds, ILPQC transitioned in July 2022 to provide a link to free access to Find Help via ilpqc.org and provided guidance for hospital teams to access NowPow with their own funds.
ILPQC Engagement
ILPQC held three virtual events (9th Annual Conference in October 2021 and OB and Neonatal Face-to-Face Meetings in May 2022 where hospital teams from across the state attended all-day meetings virtually to learn and share quality improvement strategies with each other. More than 500 providers, nurses, and public health stakeholders attended the Annual Conference and more than 500 attended one or both of the Virtual 2022 Face-to-Face Meetings. Attendance of the Annual conference was up by 16% and increased over 65% for the Virtual 2022 Face-to-Face Meetings.
ILPQC hosted key players meetings (KPM) starting in December 2021 with 16 completed – the most completed for any initiative to date. One team’s feedback was “As one of the project team leaders, I thought the Key Players Meeting was informative, very engaging and a rewarding experience for us all. This structured experience helped us to work on our 30/60/90-day plan with much guidance from ILPQC” and another “We feel that the KPM meeting was so beneficial and left us feeling well supported in our journey for the birth equity initiative. We would rate this meeting a 10/10 of the initiative.” ILPQC continues to offer 1:1 QI support to all Birth Equity hospital teams to help achieve initiative aims.
ILPQC BE teams consistently showed show strong engagement through (1) attendance (100+ attendees) on monthly collaborative learning teams calls; (2) entering data into the ILPQC data system (65% of teams per month); and (3) participating in QI support (65 hospital teams reached out to). In addition, hospital teams have demonstrated progress towards the initiative aim with over 51 hospital teams about half of the structure measures in place or working on it.
Equity Work
ILPQC hosted 3 PQI SpeakUp Trainings here in Illinois with about 74 teams with 1 or more person attending (total 165) to build hospital team capacity to facilitate discussion on implicit bias. The SPEAK UP Champions™ Implicit and Explicit Racial Bias education was a total of 8 live virtual hours over two days and participants had access to supporting e-modules for three months after the training.
COVID-19
A final initiative of ILPQC worth mentioning was ILPQC’s COVID-19 Strategies webinars. To support hospitals in providing optimal perinatal care during COVID-19, ILPQC partnered with IDPH to offer COVID-19 strategies for OB and neonatal unit webinars. ILPQC increased the statewide calls with hospitals sharing their strategies for caring for mother-newborn dyads during COVID-19 to 34 in FY 22 from the 21 held in FY 21. It has also created a COVID-19 website as a repository for resources from national partners (CDC, ACOG, AAP) and local resources from IDPH and hospital teams (https://ilpqc.org/covid-19-information/).
2-J. Support the Perinatal Mental Health Program that includes a 24-hour telephone consultation for crisis intervention for women suffering from perinatal depression.
Postpartum depression is an important public health issue and ongoing priority in Illinois. Almost 1 in 5 women who deliver a live birth in the state will experience postpartum depression. Roughly two thirds of those women will be diagnosed, but only 22% will receive some form of treatment. Perinatal women in Chicago who experience signs and symptoms of postpartum depression can access the hotline and speak to trained professionals in times of crisis.
In FY22, Title V continued to support the Perinatal Depression Program that is administered by the Northshore University HealthSystem (Northshore). Northshore’s program includes mental health screening services and trainings along with the 24-hour hotline (MOMs Line). The hotline staff fielded approximately 1,086 calls originating from or pertaining to pregnant and postpartum persons. Callers were advised on appropriate resources and education and received a psychosocial assessment by a mental health professional, psychoeducation about perinatal mood disorders, and resources and referrals if desired.
In addition to the hotline services, Northshore created additional resources and training materials that were developed and disseminated during FY21. This additional material included 28 e-digests, three infographics, and three videos. This material consisted of best practices and testimonials and focused on the promotion of awareness on perinatal depression, perinatal anxiety, and postpartum psychosis. To access the infographics and video content developed, visit the Northshore website.
In FY21, IDPH and HFS were accepted as one of eight states in the National Academy of State Health Policy (NASHP) Maternal and Child Health Policy Innovation Program (MCH PIP). This 2-year project ran from April 2021 through March 2023. The Illinois team’s action plan centered on improving access to care for Medicaid-eligible pregnant and postpartum women through health care system transformation. Key accomplishments during this initiative included:
- Improving communication with Medicaid managed care organizations around maternal health and required each MCO to make maternal health the focus of one of their performance improvement plans. Discussed opportunities to improve care coordination processes for pregnant and postpartum enrollees.
- Identification of potential quality metrics focused on maternal health that could be added to pay-for-performance or pay-for-reporting metrics requires of MCOs.
- Holding partner meetings to inform implementation of requirements for Medicaid reimbursement of new provider types, including doulas, lactation consultants, home visitors, and care coordinators.
- Improving data sharing between two agencies and obtaining legal approval to work on building a data mart that would enable IDPH staff to directly access Medicaid claims data.
The most important result of the NASHP MCH PIP is that IDPH and HFS staff began meeting bi-weekly to coordinate activities across our agencies and to mutually inform each other’s work. We have strengthened our collaborative partnership and now regularly consult each other on questions where we would like input. Though the NASHP MCH PIP ended in March 2023, the ongoing partnership will ensure that our work in strategy 2F is stronger as we move ahead.
During FY22, the Title V utilized the following NEW activities:
During FY 22, Illinois continued to experience the closing of hospitals or the specific elimination of obstetrical services within hospitals. Title V is committed to ensuring timely access to appropriate levels of obstetrical care. In late FY22, Title V partnered with the University of Illinois at Chicago, School of Public Health, Division of Health Policy and Administration (UIC-HPA), to conduct an economic analysis exploring the influence of health care provider access and the casual effects of events or policies on this access. UIC-HPA will conduct this analysis by investigating the availability of maternal care (defined here as prenatal care, labor and delivery care, and postpartum care) and its effects on maternal and infant health related outcomes.
The analysis focus’ is on potential barriers or obstacles to accessing maternal care, including local geographic provider shortages and the configuration of Illinois’ regional perinatal network. Patients, patient-level associated information (e.g., residential ZIP code locations), and patient-level outcome measures will be defined based on available IDPH hospital discharge data and IDPH birth records data. The UIC-HPA research will bring its expertise in using large administrative health care claims datasets, developing models of individual and organizational behavior, and applying econometric and statistical methods.
Enhanced Maternity Care Access Measures
This component of the project will use a data-driven approach to define enhanced maternity care access definitions for smaller geographic areas (e.g., ZIP codes) and to consider access to OB providers across county borders. Measures of OB providers include birthing hospitals, Birth Centers, OB/GYNs, CNMs and a subset of family medicine physicians who provide OB services. This subproject could construct and compare additional definitions that consider access to OB providers with geodesic (“as the crow flies”) distance, approximate travel distance, and other travel cost/effort measures defined based on local population characteristics (e.g., estimated travel time, average vehicle access).
Effects of Hospital Closures and Staffing Changes in Obstetrics.
This component of the project will focus on the causal effects of hospital closures of birthing hospitals (i.e., hospitals with OB units), hospital OB unit closures, and potentially hospital OB-related staffing reductions on the provision of maternal care. More specifically, the UIC-HPA team will assess how hospital or hospital OB unit closures affect:
- Access to inpatient (labor and delivery) maternal care options;
- Labor and delivery, including in maternity care deserts and are the patients more likely to have Caesarean sections; and
- Maternal and infant health-related outcomes
The analysis for both components will be completed FY24.
2-M. Partner with the University of Illinois at Chicago (UIC) through the Center for Research on Women and Gender (UIC-CRWG) enhance all emergency departments (EDs) understanding and ability to recognize and provide care for pregnant and postpartum birthing person.
Emergency Department Toolkit
Stemming from MMRC recommendations of FY21, IDPH worked with the UIC Center for Research on Women and Gender (CRWG) to create and pilot a toolkit/ training to promote best practices in maternal healthcare among emergency department providers. Of the eighty-six (86) pregnancy-related deaths in Illinois in 2015-2017, more than seventy (70) percent had at least one (1) documented emergency department visit during pregnancy or postpartum and 43% presented to an emergency department two or more times. The Illinois Maternal Mortality Review Committees (MMRCs) documented the failure of multiple hospitals units, including emergency departments (EDs), to identify a woman’s pregnant or postpartum status and the lack of standardized policies for all providers who treat women of childbearing potential as factors that contributed to pregnancy-related deaths.
In Illinois’ first Maternal Mortality Review Report (2019), the MMRCs recommended that hospitals require obstetric consultations for all pregnant and postpartum women prior to discharge and provide clinicians and staff education on appropriate assessment of and treatment for postpartum women. The planned toolkit stemmed from MMRC recommendations and data showing most pregnancy-related deaths sought care in the emergency department during pregnancy or after pregnancy.
The main objectives of this project are to: (i) implement a toolkit for six (6) EDs (varied by geography and level of care) that provides education and resources for the timely identification of pregnant and postpartum women, potential warning signs of maternal complications, and appropriate treatment and referral; (ii) assess the feasibility, acceptability, and best practices for the toolkit among providers and staff at pilot EDs in multiple hospital settings in Illinois (e.g., urban and rural, birthing and non-birthing); (iii) update training materials based on findings from pilot study; and (iv) develop plan for disseminating and implementing the project components statewide. UIC-CRWG will coordinate with the Maternal Mortality Review Committees (MMRCs) and other key stakeholders to develop and implement the toolkit.
The toolkit will be piloted in 6 hospitals in the spring 2023.
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