Women/Maternal Health

Annual Report Year 2021

Overview: The District continues to prioritize increasing access and utilization of preventive health care services for women of reproductive age. According to the 2020 Behavioral Risk Factor Surveillance System (BRFSS), 77.2% of women in the District had a routine checkup within the past 12 months. There are clear visit gaps for women who are Medicaid beneficiaries. Women with an annual income of less than $20,000 (14.3%) are less likely to visit the doctor regularly than those with an annual income between $20,000 - $50,000 (26.4%) or those above or equal to $50,000 (59.3%). Women who are low-income experience health inequities that increase their risk of unintended pregnancy. This risk can be influenced by factors such as: personal, cultural, economic, and social circumstances; and may be linked to unmet reproductive health needs that increases the likelihood of infant and maternal mortality rates in the District. From 2019-2020, 48.5% of District women who gave birth to a live infant were of a healthy weight prior to pregnancy, 46.8% were either overweight or obese before their pregnancy, and 3.3% were underweight. Black and Latina mothers in the District were more likely to be overweight or obese prior to pregnancy (60.8% and 54.9%, respectively) than non-Hispanic White mothers (27.2%). Pre-pregnancy hypertension and pre-pregnancy diabetes have been shown to increase the chance of a mother giving birth to a low birthweight baby.

Although District women are engaging in some preventative care services, rates of women accessing prenatal care are significantly lower. From 2019-2020 most live births (68.4%) were to women who initiated prenatal care during the first trimester of pregnancy; 1.8% of live births received no prenatal care. Eighty-five percent of non-Hispanic white mothers, 81% of non-Hispanic Asian/Pacific Islanders mothers, nearly 70% of Hispanic mothers (67.8%), but only a little more than half of non-Hispanic black mothers (55.2%) initiated prenatal care during their first trimester. To increase the percentage of women aged 18-44 who have had a preventative health visit within a one-year period, from 58% to 63%, programmatic efforts must reflect this intention, especially among non-Hispanic Black women. Increased access to healthcare also requires a person-centered environment that empowers women to take ownership of their health. Thus, we strive to build a wraparound informed system that includes equitable service delivery addressing social determinants of health (SDOH) such as housing, hunger, transportation, and technology.

Priority: Improving women’s reproductive health and promoting equitable access to care

Objective 1: Increase use of preventive care services among reproductive age women (modified for FY23)

Strategies: First, actively implement patient reminders and create outreach initiatives for women in the District to increase knowledge, awareness, and build self-efficacy to attend their well women visits. Secondly, assess the quality of care received by women who are Medicaid beneficiaries and identify and address barriers to increase the use preventative services among reproductive aged women in the District.

Performance Measures:

• National Performance Measure 1: Percent of women, ages 18 through 44, with a preventative medical visit in the past year
• Evidence-Based-or-Informed-Strategy 1.1: Number of women who responded and in participated in PRAMS was developed to document these experiences of the Districts residents.
• Evidence-Based-or-Informed Measure 1.2: Number of women referred for an annual well women visit by a perinatal program

Activities:

In FY 2021, Title V continued to fund La Clínica de Pueblo’s, Mujeres Saludables (Healthy Women) Program. As a Federally Qualified Health Center (FQHC) and NCQA- recognized Level III Patient Centered Medical Home (PCMH), La Clínica del Pueblo (La Clínica) continues to employ a family practice model of care that is rooted in a holistic approach aimed at eliminating barriers to care. The PCMH model is La Clínica’s overarching evidence-based approach to increase the utilization of preventative services among female patients of reproductive age and decrease no-shows for well-women and prenatal appointments. La Clínica engaged in capacity building activities to enhance their use of population level monitoring and follow-up for gender specific services (inclusive of well-women visits and pre-natal care). Their FY21 primary goal was to increase the percentage of women in their target population (Low-income, immigrant, Latina women of reproductive age (18-44), including women in prenatal stage, residing in DC) that attend a preventative medical visit (or well-woman visit). To achieve their goal, they focused on the following four objectives and evidence-based strategies:

• Improving La Clínica’s use of patient reminders to schedule annual preventative medical visits
• Addressing the SDOH that may influence MCH target population health and access and use of health care
• Enhancing La Clínica’s capacity to provide prenatal care through quality improvement activities
• Increase awareness among the Latino community, including members of the focus population regarding reproductive health and preventative care

La Clinica’s goals, objectives, and evidence-based strategies are aligned with DC’s priority and goals to increase the use of preventative care services among reproductive age women to ultimately achieve the following  performance measures: National Performance Measure 1: Percent of women, ages 18 through 44, with a preventative medical visit in the past year, and Evidence-Based-or-Informed Measure 1.2: Number of women referred for an annual well women visit by a perinatal program.

By the end of FY21, the program:

• Was unable to reach women in the appropriate age range with patient reminders due to technical issues;
• Served a total of 92 women who received preventative well-woman’s appointment surpassing their goal by 184%;
• Hosted a training titled, Creating a Culture of Patient-Centered Care, for its Clinical providers and other interested staff. The training was attended by 67 participants (447% of our goal of 15) and focused on how providers can set aside their internal biases to better center the patient regarding women’s sexual and reproductive health;

La Clínica faced a few challenges due to the shortened implementation period of FY21, which was only 4 months long. Due to COVID-19, La Clínica had to deal with increased infection control protocols in addition to testing, triage, navigation, and care for patients testing positive for the virus. Additionally, La Clínica has also partnered with federal, local, and state governments to facilitate the administration of COVID-19 vaccines. Along with the additional demands of COVID-19 pandemic on clinical staff resulting in a workforce shortage, it was difficult for La Clinic to achieve their target indicators, but they continued to institute efforts to address these challenges.

In FY21 Title V provided funding for Unity Health Care’s, Well Woman Project. The overall purpose of Unity’s well woman project is to improve access to preventative health services for women ages 18 to 44. Their purpose is also completely aligned with the District’s National Performance Measure 1: Percent of women, ages 18 through 44, with a preventative medical visit in the past year, and Evidence-Based-or-Informed Measure 1.2: Number of women referred for an annual well women visit by a perinatal program. They plan to reach this goal by providing a comprehensive program to increase annual visits through targeted outreach planning. They focused on the following objectives and evidence-based strategies:

• Develop and initiate an outreach plan to women of reproductive age (that have not had a One Key Question screening/annual physical) to initiate scheduling preventive women’s health visits
• Schedule 10% of women that were outreached to for preventive health visits

Unity Health Care’s, Well Woman Project intended to increase the number of women of reproductive age (18-44) getting a One Key Question (screening/annual physical) from. A project team was created specifically to address this objective. They devised an outreach plan to be implemented by their Population Health Specialist. The Population Health Specialist position is tasked with reviewing the patients due for their annual visit, contact the patients, and then schedule their visits. During annual visits, women are screened for pregnancy intention, then referred to services based on their answer. In the event patients are not engaged, their Community Health Worker provides follow-up to patients who are no-shows for well woman visits.

Due to the short nature of the project year, they were unable to report any data, findings, and conclusions as it relates to their evaluation results. Staffing shortages and hiring challenges greatly impacted their ability to fulfill their indicated activities and intended workplan. However, a key success during FY21 was the hiring and onboarding of their program manager. This allowed Unity Health Care to progress and begin to implement their proposed activities to best serve their community.

The District’s Title V grantees are fully devoted to meet the needs of their target populations and implement strategies to increase the use of preventative services among reproductive age women. In order to assess population level data Title V funds, the DC Pregnancy Risk Assessment Monitoring System (PRAMS). PRAMS is state-specific population based-surveillance system with the mission to improve maternal health and reduce infant morbidity by producing actionable data on attitudes and experiences before, during, and shortly after pregnancy. The PRAMS data informs maternal and child health program and policy development. DC PRAMS targets DC-resident women who give birth to a live newborn in the District of Columbia (DC) within 2-6 months of the time of the survey. A portion of the information collected from DC PRAMS ascertains barriers women experience to engaging in early and continuous prenatal care, as well as other experiences that influence respondents’ overall health. Identifying these barriers will help DC Title V to develop strategies to increase the use of preventive care services, improving preconception, and ultimately the health of infants. DC PRAMS major goals are to identify groups of women and infants at high risk for health problems, monitor changes in health status, and measure progress towards the health of mothers and infants. The Districts Evidence-Based-or-Informed-Strategy 1.1: Number of women who responded and in participated in PRAMS was developed to document these experiences of the District’s residents. The average weighted response overall in the DC PRAMS data collection was 58% in 2020. The topics included in DC PRAMS are breastfeeding, childhood stressors, contraception, discrimination, insurance, mental health, oral health, preconception care, prenatal care, postpartum care, safe sleep, substance use, vaccination, and violence plus two covid supplement questions regarding the COVID-19 experience and the COVID-19 vaccine.

Objective 2: Improve prenatal care for pregnant women (modified for FY23)

Strategies: Enhance capacity to provide a safe space for woman to engage in early and continuous prenatal care to prevent maternal complications.

Performance Measures:

• National Performance Measure 1: Percent of women, ages 18 through 44, with a preventative medical visit in the past year

Activities:

La Clínica de Pueblo’s, Mujeres Saludables (Healthy Women) Program instituted activities in FY21 to ensure that their target population is receiving timely and quality prenatal care. La Clínica’s objective by the end of FY21 was to improve women’s health by enhancing capacity to provide prenatal care through quality improvement activities led by La Clínica’s Clinical Champions program, ensuing at least 65% of pregnant women enter care in their first trimester. During FY21 La Clínica saw 11 prenatal patients. All of the patients (100%) entered care in the first trimester.  The shortened 4-month grant period delayed work on this objective.

Unity Health Care’s, Well Woman Project created a space to improve coordination of care to support access to prenatal services and resources during the 1st trimester of pregnancy and postpartum follow up care. Their goal was to increase the number of women receiving prenatal care in the 1st trimester by 1% annually. The initial in-person prenatal intake visit is to be conducted by an RN and OB Coordinator to help ensure that there is continued engagement for the patient’s prenatal care. This visit also allows the co-coordinator to complete family/social/previous pregnancy history and identify any risk and schedule any additional visits needed based on risk. When issues arise, Unity Health Care’s providers can diagnose and treat earlier, including reducing the risk of preterm birth. In the event patients are not engaged, their Community Health Worker provides follow-up to patients who are no-shows for prenatal care during pregnancy.

Unity Health Care experienced challenges fully implementing their planned annual activities due to a shortened grant period as well as staffing and hiring barriers.

Objective 3: Reduce Implicit Bias/Discrimination (modified for FY23)

Strategies: The District has created opportunities for implicit bias and racial equity trainings for providers. The strategy to improve the perceived treatment of women in the District while receiving medical services is to train those providing services, to provide an environment where their patients feel heard, appreciated, and empowered.

Performance Measures:

• State Performance Measure 1: Reduce Implicit Bias/Discrimination – percentage of pregnant women and new mothers who felt they were treated unfairly while getting services.

Activities:

In 2021, the DC Primary Care Office collaborated with The DC Center for Rational Prescribing (DCRx) and Innovation Horizons, LLC in the development of Implicit Bias: A Practical Guide for Healthcare Settings,[1] DCRx’s second module on implicit bias. Broadly targeting all employees in a healthcare setting, including all medical providers and staff, the module’s objectives are to help participants 1) understand how implicit bias can negatively impact health outcomes; 2) identify examples of implicit bias in healthcare settings and their root causes; and 3) reflect on one’s own biases and develop strategies to overcome biased decision-making. The module provides an overview of the concept of implicit bias, expands on the overview through five scenarios depicting realistic situations that may take place in healthcare settings at any point during a patient’s care, and reviews the reasons certain interactions display bias. The module was released on September 15, 2021 and offers 1.00 continuing medical education (CME) credit (AMA PRA Category 1 Credit), 1.00 ACPE (Accreditation Council for Pharmacy Education) Pharmacist credit, or 1.00 ACPE Pharmacy technician credit through the George Washington University School of Medicine and Health Sciences.

The District of Columbia Hospital Association (DCHA) administers the District of Columbia Perinatal Quality Collaborative (DCPQC) in collaboration and funded by DC Health. The DCPQC serves as the Healthy Start Community Action Network (CAN) for the District of Columbia and the District’s champion for reducing maternal mortality, improving maternal and infant health outcomes and narrowing racial and place-based disparities in maternal health. During FY21 the DCPQC developed a strategic plan address systemic racism and implicit bias in a health care setting. The DCPQC explored options for a respectful care education and engagement series to be implemented. The three-part series is offered to each hospital team as a group to encourage group collaboration and action in follow up to each session and on an ongoing basis. Content includes the following: A foundational session lead by national experts exploring individual and implicit bias including tools to disrupt patterns of bias and engage at an individual level; a follow up session in partnership with the DC Primary Care Association and lead by DC mothers on respectful care and local context with a series of checklist tools designed to assist hospitals in assessing their current practices and environments; a session on shifting to focus on how to facilitate action in a broader context with tools to foster change at an organizational, institutional, and community level.

DC PRAMS provides a space to better understand the maternal attitudes and experiences before, during and shortly after pregnancy. The survey consists of 77 core and standard questions. One of the covered topics is Discrimination and includes Question 65. During the 12 months before your new baby was born, how often did you experience discrimination, or harassment, or were made to feel inferior because of your race, ethnicity, or culture?  Four percent of women responded always/often, 8.2 responded sometimes, and 87.9% responded rarely/never. This PRAMS question can help the District in gauging experience regarding implicit bias and discrimination. Changes in the rates can hopefully in part be attributed to the two efforts mentioned above.

Objective 4: Increase the percentage of women in attending a well-woman’s visit screened for SDOH (modified for FY23)

Strategies: The major factors of poverty and race, along with food insecurity, concerns about safety and violence, and housing all affect the ability to reach one’s full potential. These factors and other social and economic needs of a women affect access to quality health care. The District has made it a priority to support programs and initiatives that address the social determinants of health and in turn will positively have an effect on our priority to improve women’s reproductive health.

Performance Measures:

• National Performance Measure 1: Percent of women, ages 18 through 44, with a preventative medical visit in the past year. 

Activities:

La Clínica de Pueblo’s, Mujeres Saludables (Healthy Women) Program instituted activities in FY21 to improve the target population’s health care by addressing the SDOH that may influence their health, access, and use of health care, ensuring that 80% of patients in need of support are referred to peer-led navigation. In order to meet this objective, La Clínica instituted the use of a SDOH tool, titled the PREPARE Tool Kit. PREPARE is an acronym for the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences. PRAPARE is both a standardized patient risk assessment tool as well as a process and collection of resources to identify and act on the SDOH. The PRAPARE Implementation and Action Toolkit is designed to provide interested users with the resources, best practices, and lessons learned to guide implementation, data collection, and responses to social determinant needs. Of the 92 patients who came in for a Well Women Visit during the reporting period, La Clínica’s staff successfully conducted 67 PREPARE Screens (73%). Patients with identifiable barriers to care per the PRAPARE screening were often recommended services over the phone by their Patient Care Coordinators during or after the assessment. For transportation insecurity to medical appointments, staff recommended using insurance companies’ transportation services. For food insecurity, they made referrals to WIC, DC Hunger Solutions, or food banks near the patient’s home.

In FY21 DC Health provided funding for Mahmee in DC. Mahmee is a scalable, HIPAA-secure maternity and infant care management platform that provides the missing digital infrastructure needed for patients to receive comprehensive prenatal and postpartum healthcare. The implementation of Mahmee’s perinatal connectivity software and Clinical care coordination services across the District of Columbia (DC) addresses longstanding challenges related to: (1) the collection and sharing of SDOH data and (2) the lack of connectivity between prenatal care and labor and delivery options for families residing in Wards 5, 7 and 8.

Challenges and obstacles in FY21 delayed progress to reach identified activities including a shortened implementation period. Initial onboarding meetings with prenatal care delivery sites and labor and delivery facilities revealed an increased need for clinical support at pilot sites. Additional care coordination and nurse triage beyond the originally contemplated scope is required based on feedback and data from patients and providers in Wards 5, 7, and 8.

In FY21 DC Health also continued to improve health equity at the intersection of housing insecurity and pregnancy by supporting the DC Calling All Sectors Initiative (CASI). CASI is a multi-sector collaboration supported from October 2019 through May 2022 by the Health Impact Project, a partnership between Pew Charitable Trusts and Robert Wood Johnson Foundation, with an aim to promote healthy pregnancies and births for people experiencing homelessness in the District of Columbia through ensuring equitable and responsive health and social supports. The grant was part of a ten-state cohort initiative to promote collaboration within state governments and with community organizations pursing maternal and infant health improvement. DC CASI is a health in all policies (HiAP) approach to improving perinatal health outcomes. DC Health has played a key role in leading and coordinating the multi-sector team driving CASI’s collaborative efforts, comprised of key District agencies and a community-based organizational partner, Community of Hope. Known as the Core Team, these collaborative partners work at the intersection of perinatal health and housing to create system-level changes that enhance government-funded services and supports and improve equitable outcomes for residents experiencing concurrent homelessness and pregnancy.

The Core Team has leveraged the Health Impact Project grant to define system assets, gaps, and opportunities for improvement that may enhance the experiences and health and housing outcomes of pregnant residents interacting with the homelessness assistance system. This process included meaningful engagement with community members with lived experience and homeless services providers in the District. Through ongoing dialogue, coordinated by DC Health, on how to measure and ensure that pregnant individuals and infants are connected to, and stay engaged with, services and supports that promote health, District agencies in partnership with community-based organizations have initiated increased data collection about pregnancy status of residents seeking housing support, expanded access to supportive services to include those in the first and second trimester of pregnancy, learned from system providers and residents with lived experience through surveys, focus groups, and interviews, and developed recommendations to advance perinatal health and health equity among the population of focus - pregnant individuals at-risk of or experiencing homelessness. DC CASI has been successful in maintaining long-term engagement from collaborating partners, who are committed to promoting the initiative recommendations and advancing shared goals.