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 maternal and infant mortality rate in Delaware and we understand the importance of preconception care, quality prenatal and postpartum 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 community risk factors, leveraging talents and resources, and striving to find new ways to provide services.

 

Over the last year, the Delaware DPH team work through the DHMIC committee infrastructure to develop one year action plans, to assist with implementation of the Five Year Delaware Healthy Mothers and Infants Consortium’s (DHMIC) strategic plan.  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.  The DHMIC Five Year Strategic Plan is available on Dethrives.com and is driving our DHMIC Chair and Vice Chair who are two years into their leadership roles, and have a considerable task of onboarding and membership engagement activities.  With the newly elected Governor Matt Meyer in January 2025, coordination and DHMIC governance and membership are at the center of discussions as well as elevating our strategic priorities.   The DHMIC appointed members remain focused on the following aspirational goals:

1. The elimination of disparities between White, Black, and Hispanic infant and maternal mortality.
2. The reduction of pre-term birthrate from 11% to less than 7% to be the lowest
   in the country. 
3. The development of an innovative model of care that addresses both the health disparities and the reduction in pre-term births. 

 

The DHMIC leadership is still settling into their roles, responsibilities, with continued planning, preparation and reviewing historical documents to guide the new vision and direction.  Dr. Priscilla Mpasi completed her second year as Chair of the DHMIC along with Tiffany Chalk, who served as Vice Chair.  To help re engage members and revisit strategic priorities, the DHMIC had a retreat on December 16, 2024, whereby 11 out of 16 DHMIC appointed members gathered for an in-person meeting held at the Hilton Garden Inn in Dover, DE. A virtual session took place on February 21st via Zoom for the members who were unavailable to attend the in-person meeting. The meeting was facilitated by Liddy Garcia-Bunnel, Principal of Health Management Associates (HMA), several members from the Division of Public Health (DPH) were present for support, and the Vice-Chair of the Well Woman/Black Maternal Health (WW/BMH) Committee, Mona Liza Hamlin, was invited to the meeting space as well. The purpose of the meeting was for the members to review a list of DHMIC related items which included going through the DHMIC By Laws, mission, vision, strategic plan, an overview of the budget and state investment appropriated to DPH to support DHMIC and the DHMIC committee infrastructure was reviewed as well. The last 45 minutes of the retreat concluded with a private meeting strictly reserved for all DHMIC members to go over membership accountability and opened the floor for members to discuss the establishment of the DHMIC Executive Committee. 

 

Staff in the Division of Public Health’s Family Health Systems Section largely provide staff support to the committees, in addition to contractual staff support and help carry out and execute strategies to support the DHMIC’s strategic plan.  The current Committees and workgroups 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 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.  The purpose of the BMHW is to address the disproportionately high and unacceptable disparity rates of maternal mortality and morbidity in Delaware.  Partners continue to be engaged around the theme 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.

 

The Committee has been working on a blueprint to develop Her Story 2.0.  The original vision of the Her Story initiative was to elevate women's voices and develop women-centered messaging in different stages of life. The people initially involved were strategically selected to represent a group of women at various stages of their lives.

 

We now have an opportunity to reimagine Her Story with a stronger, dual call to action:

• Empowering women through the sharing of their stories
• Encouraging providers to gain a better and more accurate understanding of women's experiences.

 

By pursuing the goal of motivating women to talk about their stories, the initiative will create a platform for providers to hear directly from the women they treat.  The target audience for Her Story 2.0 will be

• Primary: Women of reproductive age, focused on Black women and women with behavioral health challenges (SUD and mental health), across the life course (includes either prenatal or postpartum in Delaware)
• Secondary: Health care providers, including OBGYN’s, primary care providers, and nurse practitioners who treat the primary audience

 

The goal is to support women and give them additional capacity to navigate the perinatal system of care. Another focused aspect is reaching clinicians and supportive staff with messaging, and increase awareness of resources provided on DE Thrives to treat patients with dignity and respect and provide quality care to all. Some topics and themes discussed include:

• Raise awareness of perinatal discrimination that occurs for populations disproportionately impacted by maternal and infant mortality
• Educate target populations on the importance of the fourth trimester and postpartum visit within 12 weeks after giving birth
• Empower/educate women to be advocates for their own health; educate them on what they need to know and ask
• Behavioral Health (SUD/Mental Health/Depression/Anxiety); Trauma-informed care,
• Maternal Health Warning Signs (i.e. complications such as infection and bleeding, pain and discomfort, high blood pressure, etc.)
• Acknowledging men’s role in health outcomes for moms and babies
• Access and barriers to reproductive health care, perinatal and postpartum care (i.e. low socioeconomic status, racial discrimination, lack of social support, lack of adequate health insurance, etc.

 

Additionally, the workgroup members discussed potential outreach methods, metrics, community partners, potential challenges, and how to leverage Her Story 1.0 in our work moving forward.

 

2) One of the DHMIC Committees which seeks to understand where people live, work, play and pray can help create actionable engagement strategies to improve health outcomes by addressing social context factors.  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 Committee is focused focus on housing stability for pregnant and parenting women.   The Delaware Healthy Maternal Infant Consortium, experienced a change in leadership and Representative Minor-Brown stepped into the role of Speaker of the House, thus, relinquishing her role as Co-Chair. Ray Fitzgerald, Executive Director of the Wilmington Housing Authority serves as Co-Chair, with newly designated Dr. Julius Mullen, with extensive background and expertise in non profit leadership, trauma informed care, brain science, mental health and youth development. 

 

3) Data Committee – Over the last year, this committee has been redefined its purpose and re energized membership and has a new Chair, Dr. Alethea Miller and Vice Chair, Dr. Linsey Ashkenase.  The mission of the Data Committee of the Delaware Healthy Mothers and Infants Consortium is to leverage timely and relevant data to effectively communicate and enhance maternal and infant health outcomes across Delaware.  The vision is to be a leading force in maternal and infant health, where data-driven insights lead to innovative solutions, equitable healthcare, and improved outcomes.   

 

Education and prevention are a cornerstone of the DHMIC work, utilizing the latest social media platforms, particularly when it comes to increasing awareness of the importance of well woman care. In partnership with a social marketing firm, Aloysius Butler and Clark (AB&C), the Division of Public Health and several Maternal and Child Health (MCH) partners we continued to develop, update and launch messaging through the use of social media. We continue to post messages via short videos or reels, short animated posts to showcase interviews about our MCH work, blogs, Twitter, Facebook, YouTube, Instagram, and in the near future planning to maximize our reach by using LinkedIn, in which all MCH programs and initiatives and professionals participate and are showcased as a post and/or story so our messaging can be shown broadly on different social media platforms to reach different audiences , demographic, or general interests based on our user's life's stage. The branding tagline, Delaware Thrives, evolves around the theme that “Health Begins Where You Live, Learn, Work & Play to help encourage all to make healthier choices and to take action in their community.”

On April 14th, the DHMIC held its 19th annual summit to discuss ways to prevent infant and maternal mortality and to improve the health of women of childbearing age and infants throughout Delaware. The DHMIC focuses on understanding and addressing the racial, ethnic and geographical disparities that are present in high-risk zip zones to reduce poor health outcomes in mothers and their infants. This year’s theme was Our Vision. Our Voices. Elevating Community Voices to Transform Maternal and Child Health.

 

The summit sold out with 419 Eventbrite registrations, with nearly 380 in-person attendees (the venue’s maximum capacity is 360), which included about 17 walk-ins. The event drew in many healthcare professionals, policymakers, community influencers, community partners, stakeholders, and citizens such as nursing students who were interested in learning ways on how to provide access to proper care for all Delaware mothers, before, during, and after pregnancy, their babies, and families no matter their socioeconomic, racial, or ethnic status.

 

DHMIC Chair, Priscilla Mpasi, MD, Lt. Governor Kyle Evans Gay, and DHMIC Vice-Chair, Tiffany Chalk, CMP, who was the emcee for the event, provided opening remarks on the importance of why we should continue the work to address maternal and infant mortality and morbidity in Delaware. State dignitaries including Speaker of the House and State Representative Melissa Minor-Brown (a former DHMIC appointed member) and Senator Marie Pinkney, a DHMIC appointed member, presented the Black Maternal Health Awareness Resolution in the morning. U.S. Senator Lisa Blunt Rochester also made an appearance in the afternoon sharing inspirational words on how she plans to continue providing services for the MCH population.

 

There was a total of 24 speakers throughout the day, which was made up dignitaries, DHMIC leadership, two keynote speakers, and four different breakout sessions. The presentations presented throughout the day ranged from topics on adverse childhood experiences (ACEs), patient centered care, how men could impact maternal health outcomes, an interactive session for a maternal and child health (MCH) hub blueprint, guaranteed basic income (GBI), and more.

 

Many information sharing strategies were available during the Summit such as a surprise poetry ready by the Poet Laureate of Delaware to kick off the Summit inspired by the voices and experiences of women during the postpartum period, a passport themed activity was offered to attendees to encourage group discussions and education with the innovation stations, also known as vendor tables, attendees were encouraged to submit family photos to be shared at the beginning of the summit to show Delaware families thriving, an interactive photobooth was offered, and attendees were given the opportunity to submit inspirational words shared on a projector screen during the event to go along with the Our Vision. Our Voices theme.

 

For the first time, DEThrives offered community organizations to submit a rate of proposal form to share what work they are doing in the community, which ultimately led most organizations an invitation to be one of the eighteen innovation stations at the event. The innovation stations were placed in a separate room which allowed attendees to learn about community services available throughout the state. A resource table was placed in the hallway where attendees had to pass to arrive in the main ballroom and in the separate breakout room where the innovation stations were for supplemental hardcopy materials relating to the materials that were presented throughout the day.

Bridget Buckaloo, a DHMIC appointed member, presented the annual Kitty Esterly, MD, Champion Award which recognizes a person and an organization who puts in the extra effort to address and change the root causes of infant mortality by improving the overall health and well-being of mothers and the community. The Delaware Healthy Mother and Infant Consortium (DHMIC) established the Champion award to recognize exemplary individuals or groups and organizations in the community that have made a significant impact in moving their communities along the process of increase positive health outcomes and promoting culturally competent healthcare workforce and environment.  The award is named for the beloved Dr. Katherine L Esterly, a member of the DHMIC from its inception until her death. Dr. Esterly who was the first neonatologist in the state of Delaware worked tirelessly for the cause of infants, particularly the disadvantaged.  Shawnisha Thomas, LPCMH, Thomas Clinical Consultation Services, received the outstanding individual award. The organization award was awarded to the Delaware Adolescent Program, Inc. (DAPI). The announcement of these awards on social media was a top post earning 299 engagements on DEThrives’ social media accounts in April which earned almost 1K impressions for that post alone.

 

News of the 19th DHMIC annual Summit and its purpose were shared on six local and regional news media placements which was secured on three media outlets such as NBC10 (news of the summit was shared 3x from  this outlet on April 14th), 6ABC (news of the summit was played 2x from this outlet on April 14th), and Delaware Public Media (the interview was published on May 2nd), where the DHMIC Chair, Priscilla Mpasi, MD, was interviewed. This resulted in an estimated of 460K+ impressions (number of times a post has been displayed).

 

During the 19th annual Delaware Healthy Mother & Infant Consortium (DHMIC) Summit, Delaware State Representative Melissa Minor-Brown and State Senator Marie Pinkney, who are also DHMIC members, presented the Black Maternal Health Awareness Week Resolution. The DPH/Family Health Systems team drafted the resolution to elevate this important week. The resolution states evidence-based data of Delaware’s 5-year (2018-2022) infant mortality rate which is 6.1 deaths per 1,000 live births, which is above the 5-year national average of 5.5. For reference, Delaware ranks 34th in the nation for the highest prevalence of infant morality. Based on infant mortality data for the state of Delaware, there are 11.3 infant deaths per 1,000 live births, the 5-year Delaware Black (non-Hispanic) infant mortality rate is 3.3 times the 5-year White (non-Hispanic) infant mortality rate of 3.4 infant deaths per 1,000 live births. Statistics such as the above were shared throughout the week of BMHAW and the resolution was also read during the DHMIC Annual Summit.

 

In celebration of the Black Maternal Health Awareness Week (BMHAW) observance (April 11th – 17th), community voices and leaders read the BMHAW Concurrent Resolution on April 8th at Delaware’s Legislative Hall. Community voices such as the DHMIC Chair Dr. Priscilla Mpasi, Vice-Chair Tiffany Chalk, Speaker of the House and State Representative Melissa Minor-Brown (a former DHMIC appointed member), Senator Marie Pinkney (a DHMIC appointed member), April Lyons-Alls the Director of MPA Program with Delaware State University, Mona Liza Hamlin Vice-Chair of the WW/BMH Committee, LaToya Brathwaite who is the Founder and Lead Practitioner of her business Mother, Baby, & Beyond LLC, and others were present to read and share the BMHAW Resolution. This resolution brings awareness to the unfortunate disparities that are present in Black (non-Hispanic) mothers compared to White (non-Hispanic) mothers.

 

Summit speaker presentations and photos and reels are repurposed on https://dethrives.com/summit and social media channels, including Facebook and Twitter.

 

Delaware has made a significant investment of resources to focus on addressing maternal mortality and morbidity and specifically, implemented many programs and interventions to reduce our racial disparity in infant mortality.  According to the March of Dimes, women in Delaware are overall at moderate vulnerability to adverse outcomes based on their availability of reproductive health services with a clear increase in vulnerability across the southern parts of the state. Access to prenatal care varies based on race/ethnicity and poverty with almost half of Hispanic women living in higher poverty areas experiencing inadequate prenatal care (43%). Black non-Hispanic women in Delaware experience higher rates of preterm birth compared to other groups, thus putting their infants at risk for complications and death.  Our work to address maternal and infant mortality and morbidity 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 health of women 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 on black women and their families.

 

The Title V MCH team works very closely with the Maternal and Child Health Review Commission, which currently sits in the Administrative Courts, and the data supports our prevention and education work to improve the health of women before, during and between pregnancies.  By continuing to study the circumstances surrounding maternal and child deaths, we can strengthen support systems, address unfair and uneven conditions that can complicate pregnancies and births, and ensure that every child and family gets a strong, healthy start. Review teams that carefully consider each death are made up of dedicated partners in medicine, nursing, behavioral health, public health, insurers, social work, education, child welfare, forensics, law enforcement, and community advocacy. The Commission’s Community Action Team (CAT) was also established over the last year and engages more public and community partners to interpret and act on recommendations from the review teams. The Delaware Healthy Mother and Infant Consortium (DHMIC) and the Delaware Perinatal Quality Collaborative (DPQC) do important work and collaborate to improve community-based and clinical care for women and infants.  DPH works in partnership with the Maternal and Child Death Review Commission and co-leads two federal grants to support high-quality reviews of sudden child deaths, which includes funding from the Centers for Disease Control and Prevention (CDC) to participate in the Sudden Unexplained Infant Death (SUID) and Sudden Death in the Young (SDY) case registry. CDC support through the Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE-MM) grant funds dedicated staff to review maternal deaths and funds all initiatives and activities of the CAT to implement recommendations for improving maternal and infant health.  Based on our current Delaware data, women who experience stillbirths and infant deaths, particularly when prematurity is present, often have multiple pregnancy-related, behavioral health and social issues that impact their overall health.  Many women (40%) have a history of mental health conditions going into their pregnancy, and about one-third have symptoms of postpartum mental health issues after the loss. In addition, multiple life stressors, history of abuse—including domestic violence—social chaos and financial concerns are not uncommon, adding to the mother’s overall stress and ability to cope.

 

The Maternal Mortality Review (MMR) Committee sits under the Maternal and Child Death Review Commission and reviewed 9 maternal deaths, also known as pregnancy associated deaths.in 2024. Noteworthy findings from these reviews include:

• Overdose continues to be the most common cause of death reviewed by the MMR team. Many women who were struggling with substance use disorder (SUD) also had a serious mental illness and social risk factors such as unstable housing, domestic violence or traumatic experiences.
• Most maternal deaths could be prevented. The Delaware MMR team votes on whether or not they think the death could have been prevented, and in the majority of cases they said yes.
• The late postpartum period, months after delivery, is when deaths are occurring. In the group of cases reviewed, all of the deaths occurred in the late postpartum period. This is contrary to what people may think is the riskiest period: it is not on the day of delivery but months later. Especially for women dealing with SUD and social stressors, the postpartum period can be a time when it is harder for them to get the support they need.

 

The MMR Committee members identified the following recommendations based on the 2024 cases:

1. To address the multiple kinds of stressors affecting women at risk, it is recommended that healthcare providers make more referrals to offer them the services of a care coordinator who can help women navigate the system to get the care they want.

2. To connect women at the time of delivery so they are set up for postpartum follow up, embed care coordinators, including nurse navigators, in delivery hospitals.

3. To reduce the occurrence of overdose deaths, it was recognized that it is important that providers have discussions with women about harm reduction approaches to mitigate their risk of death—such as through the use of naloxone—even in the midst of living with SUD.

 

Due to the collaborative efforts from the Department of Health, the Delaware Maternal and Child Death Review Commission (MCDRC), the Delaware Perinatal Quality Collaborative (DPQC), and the Delaware Healthy Mother & Infant Consortium (DHMIC), a new toolkit was created for Providers to share patient materials to promote and educate women and their families on the Urgent Maternal Health Warnings Signs. The toolkit includes flyers, posters, double-sided tear off prescription pads, and a Provider Letter. These items can be ordered and delivered for free or can be downloaded here from the DEThrives.com site in English, Spanish, or Haitian Creole.

 

DPH is proud to share accomplishments resulting from implementing 11 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.  Since early 2020, 11 community-based organizations (CBOs) throughout Delaware have been funded and supported by this initiative to provide services, support, and community resources to women of color (and their partners and children).  The CBOs want to help them live healthier, happier lives – with a long-term goal of reducing disparities in maternal and infant health outcomes. The primary focus over a five year cycle was innovation and to spread evidence-based programs and place-based strategies to improve the social factors of health, as a complement to our medical intervention, HWHBs 2.0.  The first-ever mini grants supported 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 factorsstr of health in priority high risk communities throughout Delaware. While the specific services and activities provided by the CBOs vary greatly, each CBO’s work taps into a strategy or set of strategies that has been shown to be supportive of this long-term goal.  The CBOs that were funded through the four funding cycles (between 2019 and 2024) of the HWHB Initiative included:

1. Black Mothers in Power
2. Breastfeeding Coalition of Delaware
3. Christina Cultural Arts Center
4. Delaware Adolescent Program, Inc.
5. Delaware Coalition Against Domestic Violence
6. Delaware Multicultural and Civic Organization
7. Hispanic American Association of Delaware
8. Impact Life
9. Parent Information Center
10. REACH Riverside (Kingswood)
11. Rose Hill Community Center.

Over the five years of the initiative, mini-grantees provided services to 4,129 individuals[1], primarily to women of color.  Services provided by organizations were designed to meet the needs of pregnant and parenting women, many of whom were experiencing challenges with physical and mental health in addition to food and/or housing insecurity, social isolation, lack of childcare, and having significant challenges accessing medical care.  Services provided include:

• Breastfeeding education and support.
• Career and professional development training.
• Case management and referrals to other services.
• Doula training and certification; education to providers about doulas.
• Education and social support to build healthy relationships and life skills.
• Fitness classes, self-improvement classes, wellness classes.
• Health access funds to help meet basic needs.
• Nutrition counseling, meal planning and recipes.
• Parenting education and support.
• Pop-up cashless grocery stores.
• Training to other providers.

 

Table 1. Healthy Women, Healthy Babies Mini-Grantees, Areas of Impact and Details about Impacts, Delaware, 2019-2024

Mini-Grantee	Key Areas of Impact	Details about Impacts
Black Mothers in Power	Increase the number of Black doulas in Delaware.	29 new doulas trained.
Breastfeeding Coalition of Delaware	Increase the rate and duration of breastfeeding.	79% of participants reported they were still breastfeeding at the end of seven months.
Christina Cultural Arts Center	Increase skills in self-care and parenting, sense of support and community, knowledge of child’s development, and confidence in parenting and parents’ well-being.	83% of parents report strong protective beliefs and behaviors.
Delaware Adolescent Program, Inc.	Increase healthy relationships among youth; empower youth to make decisions about the reproductive health and their future.	85% of participants completed a life plan and of those, 99% said they intend to use it; increases in beliefs of control over when they become pregnant, in using contraception or abstaining, and in setting and achieving goals.
Delaware Coalition Against Domestic Violence	Reduce financial stress and increase hopefulness of participants; provide counseling and referrals to needed health and economic supports; increase health care provider support; screening and referral of survivors for domestic violence services.	96% of participants reported feeling more hopeful. 82% of participants reported that receiving the flex funds reduced their financial stress.
Delaware Multicultural and Civic Organization	Increase healthy life skills and improved economic status; improve professional skills and job readiness.	100% of participants applied for at least one job after using the career counselor, and two-thirds discovered new career paths, developed new skills, and became more committed to their continued education.
Hispanic American Association of Delaware	Reduce participant stress, anxiety, and depression.	Participants had statistically significant reductions in stress.
Impact Life	Reduce food insecurity and improve access to healthy food options and nutritional education; improve physical health.	Participants highly value the program; receiving food has made a significant positive difference in their lives.
Parent Information Center	Increase the number of doulas, particularly women of color, in Delaware; increase awareness about doulas.	118 doulas trained and 109 women served by doulas, with high rates of satisfaction. There were statistically significant gains in knowledge.
REACH Riverside	Improve fatherhood engagement and skills; improve access to basic need items.	Increased skills and knowledge about being a good father.
Rose Hill Community Center	Increase participation in physical activities; knowledge, attitudes, intentions towards nutritional food options; and physical and mental wellness. Reduced stress.	Reduced stress, reduced weight, and improved health among participants.

 

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, 3, and 4 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.

 

In January 2021, as an expansion of the HWHB Babies Mini-Grant Initiative, the State of Delaware began implementing a Guaranteed Basic Income (GBI) Demonstration for pregnant women.  The GBI Demonstration was created with input and support from DHSS, the DHMIC.  Community partners included Rose Hill Community Center, the Delaware Coalition Against Domestic Violence, and Stand by Me, all of which provided services and support to the participants.

 

The GBI Demonstration provided $1,000 a month in the form of a debit card for two years to women who enrolled during their first or second trimester of pregnancy.  Women had to have incomes below 185% of the federal poverty line to enrolled.  Forty women enrolled in the Demonstration.  Participants also received linkages to and guidance on prenatal care and post-partum care, financial coaching, and referrals for primary health care, mental health, and personal health and wellness.  GBI was part of Delaware’s HWHB Mini-Grant Initiative, which provided free services to pregnant women at risk of poor maternal and infant health outcomes.

 

The GBI Demonstration was designed to reduce stress, improve the physical and mental health of participants and their children, and improve maternal and infant birth outcomes.  Additionally, the Demonstration was designed to reduce utilization of emergency departments and decrease hospitalizations, and to increase financial stability, housing stability, and employment stability.

 

As the HWHB Initiative ended its fifth and final year of implementation, evaluation data demonstrate that the program achieved its intended goals.  Over the course of the GBI Demonstration, participants spent their stipend on basic necessities:  food, household items, transportation, rent, Internet and phone, clothing, utilities, insurance, childcare, and personal hygiene.  Across the 40 enrollees, nearly one-third of the stipends (between 27% and 30%) were used for food.  Participants’ physical and mental health improved throughout their participation in the Demonstration. Participants could make ends meet and felt they were a better provider for all their children.  Participants appreciated the close relationships they built with their case managers and were closer to meeting their personal and financial goals.  Some women found new jobs, bought homes, paid off debts, and improved their credit scores.  The GBI program in Delaware was a smart investment with a very sizeable, positive return for participants, the state, and the local economy.  This program, which combined monthly cash grants of $1,000 plus a cluster of important wrap-around services, improved the health of pregnant women, new mothers, and their babies.  It also connected the women to important social and economic benefits including employment, food security, and safe and affordable housing.  GBI also helped participants achieve financial self-sufficiency and reduce stress and anxiety.  The ROI study of the GBI Demonstration showed that the investment in that part of the program paid for itself more than three times over and provided both immediate and lasting benefits to participants and their families.

 

Recognizing the potential of doulas to improve outcomes for our most vulnerable women and babies, the State of Delaware is exploring ways to improve access to doula care for this population, including Medicaid reimbursement.  DPH and the Division of Medicaid and Medical Assistance (DMMA) under the auspices of the DHMIC have facilitated 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 was led by DHMIC member and legislator, Representative Mimi Minor Brown, addressed 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.  This past year, the committee released a short issue brief summarizing its accomplishments and will likely sunset, as the DHMIC explores broader maternal health workforce challenges.

 

In 2023, DPH engaged doulas across the State of Delaware to gather their insights on issues related to training and certification to inform the development of a statewide infrastructure to increase access to high quality doula are for women most at risk of poor birth outcomes in the state. The stakeholder engagement study aimed to gain an in-depth understanding of community-based doulas’ knowledge, attitudes, feelings, beliefs and experiences in relation to training and certification, as well as other perceived needs in the state. Our specific research questions included the following: How do doulas perceive training and certification requirements for their practice? Assuming certification is required for Medicaid reimbursement, what core competencies do doulas believe should be included in approved training programs in order to meet the needs of low-income women and women of color? What supports do doulas believe are needed to better serve the Medicaid population in Delaware?  Three focus groups were conducted in September and November 2022 for a total of 11 participants.  A brief summary of findings:

• Training and Core Competencies – Any training required for Medicaid reimbursement should include full spectrum of care, from prenatal to postpartum.  Cultural competency training is essential component.  Need-based financial assistance for training should be provided to support access to doula care.
• Certification – Provide flexibility in training requirements and include a pathway for experienced doulas to waive training requirements.
• Education of Health Care Providers – positive working relationships between licensed providers and doulas is critical for the delivery of high quality, integrated care.  Raise awareness about doulas’ scope of services and the value they offer to birthing people.
• Doula Representation – Representation of doulas in policy making, from planning to implementation is essential.
• Professional Development & Networking/Mentorship Opportunities -  the State or health care organizations should develop training, TA and support systems for navigating the Medicaid reimbursement process.

 

DMMA, per HB 343, passed in 2022 by the Delaware General Assembly, finalized a doula care services benefits package under Medicaid.  Additionally, building off of HB 80, which required coverage of doula services under the State’s Medicaid plan beginning in 2024, HB 362 broadened access to doula services and improve maternal healthcare outcomes for more individuals by extending similar coverage to private health insurance plans.  As this evolves, it will be important to monitor access and maternal health outcomes, as there has been a very slow uptake.  Additionally, DMMA explored Medicaid doula benefit designs in other states, including meeting with Medicaid leaders in California and Virginia on their benefit design and development. Building on lessons learned from Virginia, DMMA connected with their Certification Board to learn more about certifying doulas for Medicaid reimbursement. The selected Certification Board has worked with Virginia and Rhode Island to develop their approach to their Medicaid Doula certification process.  In January 2024, Medicaid designed and launched the benefits package and reimbursement structure and process for Doulas seeking Medicaid reimbursement. There are minimum requirements for certification & training, reasonable reimbursement rates for both Doulas and Medicaid, and billing coverage if doulas enroll as independent providers.  As of this writing, there are 14 Doulas enrolled in Medicaid as a provider.  Our first birth with a doula certified by Medicaid took place in April 2024. This past year, Delaware amended our State Plan Amendment to allow for Medicaid doulas to receive 5 additional postpartum visits with the recommendation from a licensed clinician. 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 standard of practice and we do not know how many doulas there are in the state/people interested in offering doula services, other than the data compiled from our two HWHBs mini grantees that trained Doulas in the State of Delaware. 

 

Healthy Women Healthy Babies (HWHB) program 3.0, was implemented over the last year and will be monitored in the coming year using a 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.  There was an important focus on incorporating a strong behavioral health component and emphasis on the postpartum period in the 3.0 model.   

 

The HWHBs 3.0 program will continue to use an outcomes-orientation and learning collaborative approach throughout the contracting process and ongoing service delivery relationship.  By focusing on outcomes, the program takes an 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; postpartum visit, etc.).   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. 

 

This year, we continued to support braiding funding streams to support community health worker expansion into high risk zones.  The HWHB community health workers conduct community outreach in the high risk zones via a systematic approach in partnership with community based organizations to address well woman care aspects of health and social factors such as housing, transportation, food insecurity, and access to mental health services.  In order to measure the impact of hiring, training and deploying community health workers to engage women of reproductive age and provide linkages to services and resources in the community, DPH developed a dashboard for the client referrals and goals documented by the community health workers (CHW) from from October 2020 to March 2025. In this time frame, 304 unduplicated clients were documented as having referrals and goals set with CHWs. In turn, 1,102 referrals and goals were reported among these 304 clients, which represents between three and four referrals (and goals) on average per client. We also monitor the number of clients by referral category as well as the number of times the clients were referred to the respective categories. For example, Food-related referrals were the most reported referral category by count of referrals (n = 241; 21.9 percent) followed by Baby Supplies-related referrals (n = 147; 13.3 percent), and Housing-related referrals (n = 137; 12.4 percent). These three categories represented almost half (47.6 percent) of all referrals reported.

 

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.  The Maternal and Child Death Review Commission was very focused in their annual report and recommends that evidence based home visiting program referrals are essential to support pregnant women and supports the Delaware Division of Medicaid and Medical Assistance’s (DMMA) efforts to reimburse for evidence-based home visiting services such as Nurse Family Partnership, Healthy Families Delaware and Parents as Teachers.

 

Delaware Division of Medicaid and Medical Assistance (DMMA) launched Medicaid reimbursement for evidence-based home visiting programs, and over the last year, while it has been painfully slow, the MCOs are finally making progress on negotiating a rate with the lead community based organization and partner, Children and Families First, which operates and delivers home visiting services (i.e. Nurse Family Partnership and Healthy Families Delaware) to women and families.  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. 

 

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 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.  A key strategy is to work closely with the Delaware School Based Health Center Alliance to assist with implementation, policy and best practices for delivering physical and behavioral health services to students.

 

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 five 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.  DPH Title V MCH was awarded the three year Pediatric Mental Health Care Access grant in the amount of approximately $850,000 annually, and plans to include exploring collaborative strategies with schools and School-based Health Centers to expand and increase access to pediatric mental health care services, as well as build provider capacity and support.

 

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, 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 enabled 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 the patient did not desire to become pregnant, DE CAN trained health centers to counsel patients on the full range of contraceptives available to them from most to moderate effective.  DE CAN enabled 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 and local provider clinics.

 

Delaware CAN included health centers that serve nearly 80% of women of reproductive age in the state.  Nearly 2,000 women in Delaware took advantage of an "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 included quality improvement and implementation coaching that followed each training.  During the quality improvement phase of the initiative, Upstream and health centers worked 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 served 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 were 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.  

 

In February 2024, DPH in collaboration with many partners and stakeholders were successful in promulgating regulations authorizing Pharmacists to dispense and administer contraceptives. With the regulations finalized, DPH is working on the implementation phase including facilitated small and large group discussions that result in clear action steps needed for the various components of this program, including training, resources, and payment for pharmacists as well as consumer support and awareness methods. The Adolescent and Reproductive Health Bureau team will support facilitation of the small group discussions as well as 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 promotes 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.

 

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 on a quarterly basis 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 2024 the Delaware Family Planning program completed four full in-person DECAN training sessions across the state on February 21, 2024, May 21, 2024, September 24, 2024, and November 21, 2024. On July 10, 2024 a requested on-site DECAN training was given at Beebe Health the need of Beebe specific providers needing to be trained and certified in Nexplanon insertions and removals. 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.  As of today, for 2025, we have completed one DECAN training session which was held on March 12, 2025. The DECAN program will have three additional trainings in 2025 on June 17, 2024, September 24, 2025 and November 20, 2025.  

 

There was a total of 23 staff members in 2024 whom were trained on the DECAN initiative, all methods of contraception, bias and coercion, patient-centered/shared decision making, patient centered contraceptive counseling, and cultural competency.  There was 23 clinicians trained in Nexplanon insertions/removals and 20 clinicians trained on IUD insertion/removals.  A total of 7 provider sites took part in the 2024 DECAN trainings including support staff and providers from Delaware Division of Public Health, Westside Family Healthcare, Beebe Healthcare, Tidal Health, LaRed Health Center, Coras, and The Rosa Health Center.  So far in 2025 there has been 5 staff trained in the non-clinical portion of the DECAN training as well as 3 clinicians trained in Nexplanon insertion/removals and 3 clinicians trained in IUD insertion/removals. 

 

To assess DE CAN’s long-term impact, the University of Maryland in partnership with the University of Delaware, conducted 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 explored 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.  In September 2023, a final evaluation presentation was shared with key stakeholders.  Data collection activities included: Title X patient survey, Delaware Primary Care Physician survey, interviews with women, male partner interviews, sustainability survey and stakeholder interviews and surveys.  Some 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.

 

[1] Total counts of individuals served by cycle of the initiative are higher because some individuals were served in one program in one cycle and then returned again later for different programming. In this report, unique individuals are counted only once. Additionally, one mini-grantee (Impact Life) could not count unduplicated clients served, so their number (1,333) likely is a duplicated count.