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

 

Over the last year, we continue to monitor the Delaware Healthy Mothers and Infants Consortium’s (DHMIC) strategic plan which covers a 3-5-year timeframe.  The MCH Director was involved in the strategic planning process, as well as several other MCH stakeholders that were involved in the Title V MCH Needs Assessment process and selection of priorities, which helped with alignment of goals and strategies.  Beginning in the 1990s, Delaware’s infant mortality rate was increasing while the national trend was decreasing. Prompted by a list of 20 recommendations, developed by an Infant Mortality Task Force in 2005, the plan called for the creation of the Delaware Healthy Mother & Infant Consortium (DHMIC), a Governor appointed body, to help ensure that the recommendations were put into effect. The DHMIC is structured into five subcommittees to monitor implementation of the Infant Mortality Task Force recommendations for the following critical areas: data and science, education and prevention, health equity, standards of care, and systems of care.  Staff in the Division of Public Health’s Family Health Systems Section largely provide staff support to the committees and help carry out and execute strategies to support the DHMIC’s strategic plan.  The five subcommittees are on hold, and in lieu of these groups meeting, three Workgroups were established by the Chairs of the DHMIC as an interim structure designed to focus more intensively on the strategic goals and priorities.  The workgroups include:

1) Well Woman/Black Maternal Health Workgroup – The focus of this workgroup is on a comprehensive, evidence-based approach to reproductive health and the health of women before, during, and after pregnancy — one that is woman-centered and clinician-engaged. The group functions to meet the diverse and often complex needs of reproductive-age women, particularly from more vulnerable populations, and works to foster leadership and information sharing, solicit voices of the consumer, encourage innovation, build awareness, and promote reproductive life planning. 

 2) The Social Determinant of Health Work Group which seeks to understand where people live, work, play and pray can help create actionable engagement strategies to improve health outcomes by addressing barriers rooted in structural racism. This group works to collaborate with the community, offer space for shared learning with providers, review policies and programs to identify opportunities for change, evaluate best practices, identify health needs, and engage the faith-based community.

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

 

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

 

Unfortunately, due to the COVID-19 pandemic, we had to cancel our 2020 Annual DHMIC Maternal and Child Health Summit, previously scheduled in April.  The Delaware Healthy Mothers and Infants Consortium (DHMIC) and the Department of Health and Social Services (DHSS), Division of Public Health (DPH) organize this event. The summit brings together leaders in the area of family health to discuss new approaches to enhance the health of women, children and families of all ages. In lieu of the Summit this year, we convened the DHMIC for a virtual public forum in June on the impact of COVID-19 on maternal and child health populations. The audience was comprised of primarily health care providers and community representatives interested in promoting maternal and child health, the pursuit of health equity, and the expansion of community engagement in addressing the social determinants of health.

 

As a continued effort on addressing maternal mortality and morbidity and to make a concerted effort to reduce our racial disparity in infant mortality, Delaware has identified Infant Mortality as a State Performance Measure. Our work to address infant mortality is spearheaded by the Center for Family Health Research and Epidemiology, which is housed within the Family Health Systems Section, led by our Title V/Maternal Child Health 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 Delaware Healthy Mother and Infant Consortium has undertaken an aggressive initiative to examine the social determinants of health by taking a Life Course approach to both understanding and addressing the disparities that have led to the rise in black maternal and infant mortality in Delaware.  DHMIC and its partners continue to engage the community at large, health care providers, policymakers, faith-based organizations, and African American influencers in understanding the impact of race-related constructs such as perceived discrimination and structural racism on black women and their families.

 

All eyes are on the first year and accomplishments resulting from implementing 6 Healthy Women Healthy Baby (HWHB) Zones community-informed strategies that aim to increase awareness, educate, better serve women of reproductive age and amplify the voice of black maternal health grass roots organizations.  The primary focus is innovation and to spread evidence-based programs and place-based strategies to improve the social determinants of health and equity in maternal and infant health outcomes, as a complement to our medical intervention, HWHBs 2.0.   The first-ever mini grants support the shared initiative to narrow the wide variance in birth outcomes between black women and white women by building state and local capacity and testing small-scale innovative strategies.  DPH worked with Health Management Associates (HMA) to develop a mini-grant process to fund local communities/organizations to implement interventions to address social determinants of health in priority communities throughout Delaware.  The six mini grantees awarded included Delaware Adolescent Program, Inc. (DAPI), Delaware Coalition Against Domestic Violence (DCADV), Delaware Multicultural and Civic Organization (DEMCO), Hispanic American Association of Delaware (HAAD), Kingswood Community Center, and Rosehill Community Center.  A short description of the awarded community-based interventions are described below.

 

• Delaware Adolescent Program, Inc.: serves teen mothers and their partners providing mentoring services and Support for social and emotional well-being and support in navigating the health and social services system.
• Delaware Coalition Against Domestic Violence: This organization provides support to victims of domestic violence and administers flexible Health Access Funds to support the safety and health of the participants. DCADV also trains health care providers on best practices for domestic violence assessment and response.
• Delaware Multicultural and Civic Organization (DEMCO): Provides life skills supports and job training education to young women of childbearing age, including those who are pregnant and parenting
• Hispanic American Association of Delaware: This organization provides pregnancy and postpartum support in Spanish to women ages 15-44 who live in ZIP code 19720 in New Castle County.
• Kingswood Community Center: Convened workshops for dads to increase fatherhood/partner engagement. Following the workshops, held a virtual town hall for men. Worked with the Wilmington Urban League to assist with identifying women for approved flex funds, which was particularly helpful to the community during COVID-19 with financial assistance for essential needs (i.e. groceries, etc.). 
• Rose Hill Community Center: Provides fitness, nutrition counseling and self-improvement classes to women at no cost.

 

Figure1.  HWHBs Zones Mini-Grantees Demographic Data.

Some of the preliminary findings from the participants demonstrate progress and a positive impact as it relates to the overall NPM1 Well Woman:

• Most common expressed needs by the women screened and engaged in the mini grantee interventions were referred to resources for stable housing, utility assistance, help reading health materials (health literacy), and access to food.
• 72% of participants have either been pregnant, are parenting, or is currently pregnant.
• Participants were screened for pregnancy intention and referrals were made as appropriate to local family planning provider sites and Healthy Women Healthy Babies providers.  The majority of participants are not intending to become pregnant in the next year.
• Of the DEMCO participants, on average 82% of participants felt that they had improved their professional skills and increased confidence to prepare for employment.
• Of the DCADV participants, 96% of flex fund recipients reported that the funds "Significantly" or "Completely" reduced their financial stress.
• Of the Rosehill participants, 59% of participants lost weight. On average, participants lost 3lbs over the course of the program.
• Of those that participated in the DAPI intervention, they were asked “To what extent did the program increase resilience to relationship pressure and intention to apply refusal skills?”  75% of students reported confidence applying refusal skills (“I would feel comfortable saying no to my partner when I don't feel like having sex”). 

 

 

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, the TA consisted of two learning collaborative meetings (one in person in December and one virtual in May), as well as individual coaching and TA.  Each mini grantee has a coach from HMA with whom they meet regularly. The frequency and length of coaching and TA calls and meetings over the last year were developed by each coach and mini grantee in collaboration.

 

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

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

 

Importantly, the emergence and impacts of COVID-19 and the killing of George Floyd followed by growing national attention to racial inequities have had a significant impact on mini-grantees and the communities they serve. The HMA coaches supported the mini grantees in their efforts to be responsive to the changing and emerging needs of the people they serve. Mini grantee needs for technical assistance during these crises have included:

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

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

Capacity building grants were also awarded to the HWHBs Zones mini grantees toward the end of year one as a result of performance indicators, gaps identified and technical assistance provided, which will ensure progress continues in Cycle 2. 

Engaged in an aggressive, ongoing initiative to significantly decrease maternal mortality and morbidity – as well as infant mortality – in Delaware’s African-American population, DHMIC orchestrated a webinar on Birthing While Black, a webinar on Exposing the Crevices and Breakdowns in the System: The Implications of COVID-19 on Black and Brown Pregnant Women & Families in Delaware, and recognized Black Breastfeeding Week during August 23-29, 2020 sharing information on several local events and promoting the health benefits to both mom and baby.  For many black and brown women, the birthing experience is traumatic. The statistics for black and brown women are disproportionate and frightening both nationally and in Delaware.  Black women are 3-4 times more likely to die in childbirth than white women and are 2-3 times more likely to experience complications during childbirth.  It is important to call out the impact of structural racism and implicit bias in the birthing experience. The DHMIC and its partners are working hard to consciously share these experiences and bring awareness to this public health crisis.  And now there is COVID-19 to add to women’s anxiety.  Materials and webinar PowerPoints for all speakers are archived and available on DEThrives.com.

 

 

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

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

 

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

 

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

 

 

 

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

 

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

 

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

 

To compliment the work of the Healthy Women Healthy Babies program as well as strategic initiatives of the DHMIC, Delaware leveraged funding in 2018 through one of four cooperative agreements awarded by the U.S. Department of Health and Human Services’ Health Resources and Services Administration Maternal and Child Health Bureau (HRSA MCHB) to a national coalition supported by UNC Center for Maternal & Infant Health (UNC CMIH) and the National Preconception Health and Health Care Initiative (PCHHC). Funding is administered through UNC School of Social Work. DE is one of four states participating in this CoIIN grant (i.e. OK, NC, CA, DE).  This Preconception CoIIN focused on developing, implementing, and disseminating a woman-centered, clinician-engaged, community-involved approach to the well woman visit to improve the preconception health status of women of reproductive age, particularly low-income women and women of color.  Efforts aligned very well with our transformation of the Healthy Women Healthy Babies program, and specifically, one of the benchmark indicators included a measure on screening for pregnancy intention for all women participating in the program.

 

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 Child Death Review Commission formed a small home visiting workgroup in 2019 which continues to meet including the Delaware Division of Medicaid and Medical Assistance to explore Medicaid reimbursement for evidence-based home visiting programs.  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 has not progressed.  There has been a lot of interest this year from several advocates in establishing a formalized Doula network as a standardized approach to ending racial disparities, and we suspect more dialogue over the coming year.

 

In Delaware, there are two different Health Ambassador programs, each striving to make a difference in the lives of Delaware’s women and their families and serves as a compliment to home visiting services. This past year, new contracts were negotiated for delivering Health Ambassador Services, in response to an RFP released in June 2017.  Studies have shown that the use of community health workers has been documented as a method to enhance health education and promotion with high-risk, hard- to-engage, and underserved populations. As a complementary strategy to home visitation, promotoras serve as Health Ambassadors in the largely rural and Hispanic areas of southern Delaware while cultural brokers serve as Health Ambassadors in the urban communities in the City of Wilmington. Health Ambassadors use innovative, creative and culturally sensitive strategies to engage women and families. Health Ambassadors promote health education messaging on a range of maternal and child health topics:  before, during and after pregnancy, birth spacing, reproductive life planning, as well as make a direct connection to Delaware 2-1-1 to link with a variety community based services including home visiting services as well as federally qualified health centers that can provide well women care.  Health Ambassadors have been critically vital during this unprecedented year, to keeping families engaged in home visiting during the COVID-19 crisis. The promotoras were able to perform contactless drop-off to home visiting families when local stores ran out of essential items such as food, diapers, and wipes. In addition, health ambassador programs quickly transitioned to “Virtual” chat-n-chews and baby showers to create a safe space for women in the community to share their concerns around pregnancy.

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

The Delaware Division of Public Health (DPH), in collaboration with several key stakeholders, will be convening over the next year to create a Delaware School-Based Health Center (SBHC) Strategic Plan. A planning process will be used to develop a model for expansion of SBHCs that is both financially sustainable and anchored in best practices. The goal is to ensure that SBHCs are responsive to the individual needs of Delaware’s children — who, for a variety of reasons, may not otherwise have access to the health care system for critical health and wellness services.

For the past 30 years, Delaware School Based Health Centers, located in 32 public high schools, have contributed to the health of the state’s high school adolescents and have been an essential strategy to support women’s overall physical and mental health.  Eventually, these young women and men will be our health consumers, so it is essential to support health and wellness during this critical period and coming of age.  SBHCs provide at-risk assessment, diagnosis and treatment of minor illness/injury, mental health counseling, nutrition/ health counseling and diagnosis and treatment of STDs, HIV testing and counseling and reproductive health services (27/32 sites) with school district approval as well as health education. Given the level of sexual activity among high school students, persistent high rates of sexually transmitted infections (STIs) and the numbers of unintended pregnancies, reproductive health planning services are very important.

 

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

 

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

 

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

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

The Division of Public Health (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.  This initiative furthers the Division of Public Health’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.  

 

 

 

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

 

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

 

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

The Delaware Family Planning program completed two full in-person training sessions on September 18, 2019 and January 22, 2020 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.   The April 29, 2020 and July 22, 2020 trainings were cancelled due to COVID-19 pandemic. 

 

Over the last year, Upstream, USA transitioned several aspects of DE CAN out of the state to focus on the State of Washington, North Carolina, Massachusetts and most recently Rhode Island.  Ensuring the sustainability of Upstream’s intervention is an absolute priority and one that relies heavily on state-level policies, financial resources and regulations that remain supportive of widespread access to contraception. First, the FY20 state budget of $1.5M in June 2019 and level funding in FY21, ensures funding and resources to ensure a system is in place for uninsured women of reproductive age. Fortunately, Delaware also passed legislation to codify the Affordable Care Act's birth control benefit in state law by requiring insurance plans, including Medicaid, individual, group, and state employee health plans, to include coverage for contraceptives with no-cost sharing to the insured individual. It also expands on the ACA's coverage by requiring 12 months of birth control dispensed at one time and insurance coverage of emergency contraception without a prescription. Additionally, it requires private insurance coverage of immediate postpartum Long Acting Reversible Contraception (LARC), which makes Delaware the first state to do so. Delaware Governor Carney signed Senate Bill 151 into law on July 11, 2018.

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

To assess DE CAN’s long-term impact, the University of Maryland in partnership with the University of Delaware, is conducting a rigorous and independent evaluation of the intervention.  The evaluation includes both a process and impact study and assesses outcomes such as contraceptive use, LARC utilization, Medicaid costs, and unplanned pregnancies resulting in unplanned births.  The evaluation is also exploring implementation and identifying key lessons learned to document, contextualize and deepen understanding of the impact of DE CAN. The evaluation involves eight distinct data collection activities and runs from 2016-2021. Data collection activities include: Title X patient survey, Delaware Primary Care Physician survey, interviews with women, male partner interviews, sustainability survey and stakeholder interviews and surveys.  Some very preliminary findings were shared:

• We find increases in LARC use for Title X adult patients
• We find increases in postpartum LARC use for Medicaid and non-Medicaid women
• We find increases in LARC insertion for teens enrolled in Medicaid, age 15-18.

We do not find statistically significant results for LARC insertion for adult non-postpartum women in Medicaid, age 19-44.

Oral Health for Pregnant Moms – Annual Report

 

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

 

According to findings from our 2018 Stakeholder Survey, there is a high desire to address this health priority, but partners feel there is little progress being made thanks, in part, to inadequate resources.  The respondents believe there are evidence-based strategies available to help move the needle in this area, but not enough “boots on the ground” to make it happen.  The findings tell us that the oral health for pregnant woman and oral health for children is our weakest area of success and respondents advised us to stay the course with seeking to improve oral health rates for both domains.  However, during the Needs Assessment process oral health in the Women/Maternal Health Domain did not rank in the top 10 overall.

 

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