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).
Overall, most Illinois women are accessing health care services; about 3 in 4 women of reproductive age received at least one preventative visit in the last year (NPM #1) and 3 in 4 pregnant women received prenatal care beginning 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. The rate of chlamydia infections among women aged 15-24 is one of the indicators with the highest racial/ethnic disparities in Illinois – with the infection rate being nearly six times as high among Black women as it is among White women (SOM #1).
Building on improvements over the last several years, the teen birth rate in Illinois continued to fall to an all-time low in 2020 (NOM #23), representing more than a 60% decrease since 2010. 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.
There are some concerning trends for the health of Illinois’ women during pregnancy and the postpartum period. In recent years, the maternal mortality and severe maternal morbidity rates have improved slightly overall yet continue to show widening racial disparities. 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). 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 spring 2023.
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 began the “Promoting Vaginal Births” statewide initiative in 2020, which will hopefully decrease the cesarean rate in future years. 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 FY21, 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 resource for health care 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 social service 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 FY21, 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 292 individuals through presentations and 4,134 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.
Another activity that contributed to this strategy in FY21 was EverThrive’s engagement in reproductive justice. Reproductive justice is the right to determine what happens with your body (bodily autonomy), whether to have children or not, and how to parent in safe and sustainable communities. EverThrive strived to achieve reproductive justice for all people and families—especially those in Black, Brown, Indigenous, and LGBTQIA communities. They ensured that members of these populations had the access, resources, and health care necessary to create and sustain healthy families on their own terms. Support from Illinois’ Title V program amplified EverThrive’s ability to do this critical work in partnership with people most impacted by inequity.
EverThrive Illinois also engaged 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 FY21, 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 COVID-19 vaccination, rights of individuals giving birth during the pandemic, and messaging for health care providers on COVID-19 recommendations for pregnant people and infants. EverThrive also focused on social determinants of health exacerbated by the pandemic, such as housing access and the intersection of mental health and maternal mortality and morbidity. The webpage contained resources for families and included the COVID-19 vaccination campaign aimed at parents and caregivers. The web page entitled, “Caring for Your Family During the COVID-19 Pandemic” contained information about prevention, such as vaccination, masking, and hand washing, and special considerations for pregnant and lactating people. EverThrive used the MCH Family Council members to provide feedback on the messaging and assess whether it resonated with the community.
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 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 FY21. DMPH looks forward to resuming its services in FY22.
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. It was expected that in FY20, grantees would receive additional support to implement the plans developed in FY19. Unfortunately, due to grantees’ competing priorities to address the COVID-19 pandemic, IL Title did not launch the implementation phase of the grant until FY21.
The Implementation Phase: Increasing Well-Woman Visits – Community (IWWV-C) Grant program launched as a two-year grant commencing July 2021. Funds were distributed to support evidence-informed guidance; address behavioral, social, and environmental determinants of health; assist communities with assessing the barriers to women scheduling preventative care visits; and increase awareness of the importance of well-woman visits for at least 75% of staff at grantee organization.
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 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 FY21, two clinics (Heartland Health Services Olt Clinic and University of Illinois Health University Village clinic) participated in the project. A total of 266 screens with the computerized adaptive testing for mental health (CAT-MH) were conducted during routine prenatal care at both clinics during FY21. Thirty-three screens were positive for major depressive disorder (12.4%), 35 positive screens for perinatal anxiety (13.2%), and 11 were at intermediate or high risk of substance use disorder (4.1%). Additionally, six screens showed possible or likely post-traumatic stress disorder (PTSD) (2.1%). In addition, 11 providers from University Village (6 physicians and 5 nurse midwives) were trained via webinar on use of CAT-MH and available mental health resources.
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.
During FY21, CDPH initiated planning efforts to address collaborative needs with organizations to provide male and partner involvement programs despite a hardship created by administration turnover. This collaboration was a new action item for FY21 and CDPH worked on the assessment of areas for integration into existing CDPH efforts. The Family Connects Program was identified as a potential existing program to integrate male and partner involvement.
Family Connects has served 1,602 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. CDPH developed new activities and identified potential intersections of care for male and partner involvement strategies, such as health care connections for male/partner and health co-parenting skills.
- 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 FY21, Illinois continued to implement the Maternal Mortality Review process for deaths potentially related to pregnancy. From October 2020 to September 2021, the MMRC held five meetings and reviewed 31 cases, and the MMRC-V held five meetings and reviewed 28 cases. IDPH released its second maternal morbidity and mortality report in April 2021, which covered cases reviewed during FY19 and FY20. This report is the most extensive report Illinois has released on maternal health. It includes analyses of chronic disease during pregnancy, severe maternal morbidity, pregnancy-associated deaths, pregnancy-related deaths, and violent pregnancy-associated deaths, in addition to a detailed list of critical factors and recommendations prioritized by actor.
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 FY21, IDPH continued to enhance its efforts to improve maternal health and to reduce maternal mortality. Illinois held the first statewide Maternal Health Summit on September 29-30, 2021. The summit created a shared space to learn about factors contributing to maternal mortality, discussed recommendations generated by the MMRCs, and developed specific action steps to implement programs and policies to improve outcomes for women and families. For more information on the summit, see the MCH Success Story section of this application.
IDPH also continued other key activities, such as the IDPH and UIC CoE-MCH partnership on the HRSA I PROMOTE-IL Grant. Another activity is IDPH’s participation on the Merck for Mothers Grant with EverThrive Illinois and the Alliance (a network of federally qualified health centers [FQHCs]). This grant seeks to improve prenatal care provided at FQHCs. Another noteworthy development in FY21, was Illinois becoming the first state to provide continuous coverage of full Medicaid benefits for mothers, regardless of any change in circumstances during the first year after delivery. This policy change was directly supported by a recommendation in the first Illinois Maternal Morbidity and Mortality Report released in 2018.
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.
With the focus on standardizing best practices across the state, the committee took into consideration internal and external review paths and developed updates to the SMM review form. Special consideration was given to the development of a best practice policy surrounding the selection of SMM cases for committee review. The committee explored expanding the perinatal network administrators (PNA) role in case selection. A noted success of the committee was the ability to help administrators complete the case review at the hospitals. Topics such as provider improved outcomes, definition updates on organ system function and disfunction, improved evaluation of specifically identified morbidities, and practices to capture near misses instead of just mortalities were addressed.
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. Illinois’ Title V director has served as a co-chair of the taskforce since its inception. Title V representation on the task force is important because 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 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.
A 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. A subsequent version was disseminated in FY22. To avoid confusion regarding the correct strategic plan, the most current figure and plan is noted.
In addition to the maternal health strategic plan, members of the task forced assisted in designing a best practices toolkit for SMM reviews. The toolkit included a slide deck, webinar, and resources for hospitals to use.
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.
To ensure support and collaboration from IDPH, the Title V director was appointed as the IDPH director assignee and other Title V staff provide key support to each subcommittee.
In FY21, IMMT issued its inaugural report with six recommendations:
- Provider Education: Health care systems should require standardized implicit bias, racial equity, and trauma-informed care education for all providers who work with pregnant and postpartum patients to enhance the level of competency across the state.
- Access and Equitable Care – Telehealth: (1) The state, through HFS, should expand and standardize the acceptability, accessibility, utilization, and best practices for telehealth, including phone visits for reproductive-age, pregnant and postpartum women, and their infants up to age 1; and (2) managed care organizations (MCOs) and third-party payors should establish standards of care utilizing telehealth as a vital modality of contact and ensure that all patients have access to equitable and quality preconception, prenatal, labor and delivery, and postpartum care.
- 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.
- 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.
- 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.
- IDPH Support: The state should enhance IDPH’s capacity to support the activities of the task force and its affiliated subcommittees and workgroups by supporting 1-2 dedicated FTEs within OWHFS for the duration of the task force. The Task Force also strongly encourages the state to provide financial investment to support collaborations with key stakeholders to develop and to implement 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.
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 with the extension of coverage from 60 days to 12 months postpartum, allowing managed care reinstatement within 90 days, and waving hospital presumptive eligibility.
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. The extended coverage authorized under the waiver will not go into effect until the continuous eligibility under the public health emergency ends.
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.
IDPH 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.
2-H. Assess, quantify, and describe the impact of child care 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 child care, 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. IDPH intended to offer small grants to clinics to develop and to implement family friendly strategies to address child care needs but, unfortunately, these grants were not offered in FY21 due to the ongoing COVID-19 pandemic. Title V hopes to launch the grant program in FY23.
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 FY21, IDPH continued to support ILPQC as they worked to support hospital teams to achieve MNO-OB initiative aims by December 2020 and to transition into sustainability. Sustainability includes completion of a Sustainability Plan to submit to ILPQC and the perinatal network administrators. ILPQC held three quarterly MNO-OB sustainability webinars in FY2021 with high-level collaborative attendance (~100 attendees per call) 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.
ILPQC also offered two collaborative learning webinars (November and December 2020) that averaged 80 participants per call. These webinars focused on hospitals implementing sustainability plans including: (1) completion of the plan and submission to ILPQC and their perinatal network administrator; (2) compliance monitoring of key MNO-OB aims including MAT, Recovery Treatment Services, Narcan Counseling, and prenatal/labor and delivery screening for OUD with a universal validated screening tool; (3) new hire and continuing education plans for hospital teams on optimal OUD care and reduction in stigma and bias; and (4) systems changes, including OUD clinical algorithms, MNO Folders, and up-to-date mapping of resources for MAT and Recovery Treatment Services. Forty-nine (49) MNO-OB teams submitted sustainability plans, accounting for more than 50% of MNO-OB teams.
It is important to note that through improved screening protocols and linkage to treatment, hospital teams have made sizeable improvements across the course of the MNO-OB initiative. The chart below shows the increase of universal screening for OUD on labor and delivery, percentage of patients linked with OUD to Medication Assisted Treatment, and percentage of patients linked to recovery treatment services.
Birth Equity Initiative
A second initiative supported by Title V, ILPQC’s Birth Equity (BE) initiative, began in FY21. Planning for this initiative included: (1) connecting with other state PQCs to learn about their Birth Equity QI initiatives, data collection strategies, and lessons learned; (2) developing data collection forms and reports for BE, including a Patient Reported Experience Measure (PREM) survey; (3) reviewing evidence based strategies and resources for the development of the Birth Equity QI toolkit; and (4) obtaining feedback on “Wave 1” data form and collection strategies from 15 Illinois hospitals prior to statewide launch of Birth Equity.
ILPQC recruited 86 birthing /children’s hospitals to participate in the Birth Equity initiative, 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: (1) 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 and (2) hospital access to NowPow, an online portal to support hospital efforts to identify local community resources to link patients to services.
ILPQC Conferences
ILPQC held three virtual events (8th Annual Conference in October 2020 and OB and Neonatal Face-to-Face Meetings in May 2021) where hospital teams from across the state attended all-day meetings virtually to learn and share quality improvement strategies with each other. More than 430 providers, nurses, and public health stakeholders attended the Annual Conference and more than 300 attended one or both of the Virtual 2021 Face-to-Face Meetings. ILPQC was able to successfully adapt our in-person meetings to a fully virtual format, including innovative strategies for hospital teams to share their QI work via online poster and storyboard sessions, and interactive breakout sessions to generate smaller group discussions.
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 held 21 statewide calls with hospitals sharing their strategies for caring for mother-newborn dyads during COVID-19. 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 FY21, Title V continued to support the Perinatal Depression Program that is administered by the Northshore University HealthSystem (Northshore). Northshore expanded the program to include mental health screening services and trainings along with the 24-hour hotline (MOMs Line). The hotline staff fielded approximately 1,105 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.
Below are a few examples that highlight the impact of the MOMs Line.
- Story #1 - Husband calling on behalf of wife who was experiencing thoughts of harming the baby; referred for free psychotherapy and psychiatric services.
The MOMs Line received a call from a husband to discuss concerns about wife's mood since birth of baby. Husband reported wife had been experiencing anxiety and had scary thoughts about harming baby. Husband requested that someone call wife to assess/provide support. The hotline staff called the patient and spoke to her for approximately one hour. The staff member assessed the patient’s mood and safety and provided psychoeducation regarding intrusive thoughts. The patient was offered psychoeducational materials and therapy referrals via email. Patient agreed to follow up with OB and request medication. She also indicated that she was open to further outreach from the hotline to facilitate referrals.
The hotline staff member made a follow up call to the patient a few days later and the patient expressed appreciation for the call the previous night. She felt relieved with the support received and felt there was a solution and a plan to feel better and hoped her feelings were temporary. Patient planned to increase self-care as discussed and try to get out and walk every day, exercise, and drink tea. Staff member praised patient and distinguished that self-care was a part of treatment but that engagement in formal treatment was recommended. Patient agreed and was eager to do so.
- Story #2 - Pregnant caller with anxiety; already linked with therapist, provided with additional resources
Patient presented as tearful in the beginning of the call. She expressed feeling anxious and indifferent towards pregnancy. She called MOMS Line after arguing with her partner. She experienced stressors from her partner and felt incredible pressure to take care of her current pregnancy. Patient voiced not feeling attached to this pregnancy. Patient felt extremely anxious that something was wrong with baby. When expressing her feelings to her partner, he yelled at her. The hotline staff member explained perinatal anxiety and how partner may also be feeling anxious. The staff member offered to send resources for both perinatal group and for partners.
By the end of the call, patient expressed feeling relief, and the staffer noted she sounded much more regulated.
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.
Northshore also partnered with I PROMOTE-IL to conduct a survey and increase the awareness of the MOMs Line across the state. The survey launched in December 2020 and the results were presented at the 2021 Annual AMCHP Meeting.
2-K. Partner with Department of Healthcare and Family Services (HFS) (Medicaid agency) in the National Academy for State Health Policy (NASHP) Maternal and Child Health Policy Innovation Program (MCH PIP).
In FY21, IDPH and HFS partnered to apply for the Maternal and Child Health Policy Innovation Program (MCH PIP) through the National Academy of State Health Policy (NASHP). The Illinois team’s proposed project centers on improving access to care for Medicaid-eligible pregnant and parenting women with or at risk of substance use disorders and/or mental health conditions through health care system transformation. Specifically, the group seeks to improve Medicaid managed care coordination processes for pregnant and postpartum Medicaid enrollees. They specifically want to address key drivers of adverse maternal morbidity and mortality outcomes, implement new prenatal and postpartum quality metrics to monitor and to drive improvement in health outcomes for prenatal and postpartum Medicaid managed care enrollees, and enhance their data sharing capacity which will inform interventions and improvements in maternal health outcomes. Activities to accomplish these goals include educating MCOs about the need to improve care coordination, identifying opportunities to improve the care provided, working with newly established provider types and MCOs to ensure providers are onboarded with billing technical assistance and MCOs understand their respective scopes of practice, developing quality measures, evaluating data, sharing data with MCOs, and encouraging MCOs to do root cause analyses and develop a quality improvement plan.
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