Women/Maternal Health Overview
The health of women and mothers is a key focus of the Division of Maternal and Infant Health, which oversees the Reproductive Health Unit and Michigan’s Title X program. Title V funds directly support several programs and services designed to improve women’s pre- and inter-conception health, particularly family planning. Title V funds are also used to understand and address women’s health issues more broadly as they relate to maternal mortality and factors such as race, class, and gender inequity that drive disparities. For example, Title V funding supports Michigan’s Maternal Mortality Surveillance activities and PRAMS. To address additional health needs of women, Michigan leverages other federal funds, such as the Preventive Health and Health Services Block Grant (CDC), and partners with the chronic disease, cancer prevention, substance abuse prevention, and injury and violence prevention programs within MDHHS. Additional partnerships that impact women’s health include local health departments (LHDs), the Michigan Council for Maternal and Child Health, Family Planning service providers, and the Michigan Primary Care Association.
At the local level, in FY 2020 LHDs expended Title V funds on activities to support well-woman visit (NPM 1), oral health for women (NPM 13) and former SPM 3 (depression across the life course). Six LHDs worked on NPM 1 by providing gap-filling direct services for reproductive services, cancer screening, STD testing and reproductive education. LHDs also completed outreach, media campaigns and surveys to community partners related to postpartum visits prior to the COVID-19 pandemic. LHDs expended LMCH funds on oral health services for women by educating clients on oral health benefits and referring for services. Three LHDs expended funds on mental health initiatives including staff development and gap-filling depression screening for women.
Michigan’s approach to women’s health emphasizes improving access to health services for this population, including reproductive and oral health services, based on the concept that access to care can be preventative across a variety of health needs. In 2019, Black mothers in Michigan experienced twice the risk of severe maternal morbidity (321.1 per 10,000 delivery hospitalizations) as White mothers (158.1 per 10,000) (MDHHS, 2019). Similarly, pregnancy-related mortality (11.3 per 100,000 live births, MDHHS, 2017) is lower in Michigan than the national average (17.3 per 100,000, CDC, 2017) but the risk among Black women (21.3 per 100,000) is much higher than among White women (8.9 per 100,000). The disparity in the rate that Black and White Michigan mothers undergo low-risk cesarean births has moved from parity (in 2013) to 11% higher in Black mothers (MDHHS, 2018). Black mothers were also 1.8 times as likely as White mother to report their most recent pregnancy was mistimed or unwanted (PRAMS, 2018). These disparities have led Michigan to place greater focus on understanding and addressing the conditions that place non-Hispanic Black women at greater risk for adverse health outcomes, including disease and death before and after childbirth.
Although surveillance data tends to focus on indicators of a healthy pregnancy and healthy infant, wellness in pregnancy and at birth reflect women’s health status prior to conception. While 8.3% of US infants (NVSS) and 8.8% of Michigan infants born in 2019 were born with a low birth weight, 14.5% of babies born to non-Hispanic Black mothers in Michigan had a low birth weight (MDHHS, 2019). Similarly, while 10.2% of US infants (NVSS) reported in 2019 were born preterm, the percentage was much higher among Michigan’s non-Hispanic Black mothers (14.4%) (MDHHS). These data suggest that Michigan is far from achieving equity in health among women; improving women’s health status must focus on addressing the conditions that lead to disparate outcomes for Black women and their infants. Another trend in Michigan is the dramatic rise in rates of infants born with neonatal abstinence syndrome, which increased from 2.0 per 1,000 in 2008 to 7.6 per 1,000 in 2016 (which represents a slight decline from the 2015 peak of 8.5 per 1,000) (MDHHS). Partners at the state and local level have been designing and implementing strategies to understand and address this crisis.
Well-Woman Visit (FY 2020 Annual Report)
In 2020, MDHHS focused on strategies to maintain access to reproductive health services and improve the quality of family planning counseling and access to long-acting reversible contraceptives (LARCs). Michigan’s Family Planning network used telehealth services to ensure access to contraception while limiting exposure to COVID-19 for staff and clients. Telehealth visits were delivered directly to clients by telephone, video, or messaging technologies. Telehealth by telephone was more widely used to support client access to reproductive health care because it removed the need for high-speed internet access and a smartphone. Following a telehealth visit, clients could receive their birth control by mail (i.e., pill, condoms), “curbside pick-up” (i.e., pills or shot), or at a local pharmacy. Offering telehealth allows in-person clinic visits to be prioritized for provider dependent methods such as LARCs and high-risk clients needing examination. COVID-19 has adversely impacted Michigan’s Family Planning Program by stalling provider recruitment efforts and delaying new sub-recipient implementation of Title X services. Similarly, MDHHS was unable to host its annual LARC clinical practicum due to COVID-19 health and safety guidelines. The Michigan Collaborative for Contraceptive Access (MICCA) demonstration project was able to improve LARC access with five of the eight hospital sites successfully launching immediate postpartum LARC services. MICCA emphasized the importance of patient-centeredness and equity in contraceptive quality improvement efforts.
The Family Planning Program engages consumers by soliciting their feedback through state and local client satisfaction surveys and participation on state and local Advisory Boards. Youth voice is incorporated into policies, programs, and practices by collaborating with Michigan Youth Voice, a statewide youth council coordinated by the Michigan Organization on Adolescent Sexual Health. The quality of contraceptive care is assessed by monitoring local agency quality assurance mechanisms (e.g., abnormal pap follow-up) and improvement efforts (e.g., PDSA cycles).
Objective A: Increase the percent of females aged 15 to 44 who use a most or moderately effective contraceptive method from 81% to 84% by 2020.
Having access to a broad range of effective contraceptive methods allows each person who can get pregnant the opportunity to choose the method that is right for them to successfully delay or prevent pregnancy. In 2020, 79.6% of female (i.e., assigned at birth) Family Planning clients aged 15 to 44 years old chose a most (i.e., sterilization, vasectomy, or LARC) or moderately effective (i.e., pills, patch, ring, cervical cap, or diaphragm) method, with 14.7% choosing LARC. MDHHS did not meet its ambitious target of 84%. The integration of approximately half of Family Planning and STD clinics has resulted in more comprehensive services for clients, while at the same time, has increased the number of females (i.e., assigned at birth) aged 15 to 44 who report external condoms as their primary method of contraception. In FY 2020, MDHHS worked to maintain access to a broad range of contraception, while balancing individuals’ contraceptive needs and preferences. Preserving access to a broad range of contraception, particularly for low-income and un/underinsured people who can get pregnant who often face multiple barriers (e.g., financial, transportation, paid leave, etc.) to contraceptive care (which was exacerbated by COVID-19) is critical to be able to make informed decisions about their reproductive health. In FY 2020, MDHHS’s Family Planning Program served 24,908 clients, 91% were female (i.e., assigned at birth), 61% were low-income (≤100% federal poverty level (FPL)), 86% were working poor (≤100% - 200% FPL, underinsured), and 35% were uninsured.
To promote Michigan’s Title X network, MDHHS implemented a statewide outreach/media campaign from January 2020 to March 2020. The statewide media campaign was designed to raise awareness of Family Planning clinics and to direct individuals to MDHHS’s Family Planning website to find a clinic location near them. The campaign was administered in high infant mortality communities (above the state rate) and prioritized low-income, uninsured, individuals aged 20-35 years old, with an emphasis on reaching Latinx and African American populations. Multiple modalities were used such as audio streaming (e.g., Spotify), Digital (e.g., mobile web/Hispanic mobile), social (i.e., Facebook, Instagram), and Google Adwords. Based on Google Analytics, MDHHS’s Family Planning website traffic increased significantly during the campaign period. Social media posts using the family graphic drove 53% of click traffic. The click-thru-rate for most of the modalities exceeded industry standards.
During FY 2020, Title V funds supported the Michigan Collaborative for Contraceptive Access (MICCA), a statewide learning collaborative formed in partnership with MDHHS, the University of Michigan and the Michigan State University’s Institute for Health Policy with an overarching goal to accelerate the integration of evidence-based peripartum contraceptive services into routine clinical practice in Michigan. This two-year demonstration project assisted eight Michigan hospitals to implement immediate postpartum LARC services. MICCA employed techniques from the field of implementation science to help hospitals select evidence-based implementation and evaluation strategies using an evidence-based implementation toolkit, technical assistance, and infrastructure for peer mentorship to support hospitals’ local efforts. Additionally, MICCA emphasized the importance of patient-centeredness and equity in contraceptive quality improvement efforts. Five of the eight sites successfully launched immediate postpartum LARC services and four sites were able to report utilization data with an average utilization of 8%. Common implementation barriers were non-reimbursement by commercial payers, difficulty engaging operations staff, and inadequate infrastructure. Facilitators of success were effective clinical champions and implementation planning and evaluation tools. The MICCA demonstration report and Implementation Toolkit are available at the Michigan Contraceptive Access Project MCAP website.
To increase Title X provider professional development, MDHHS’s Family Planning Program typically offers at least one clinical practicum on LARC in conjunction with its annual conference, the Family Planning Update. In accordance with federal and state COVID-19 health and safety guidelines, MDHHS moved the 2020 Family Planning Update from an in-person to a virtual event on September 16-17, 2020. As such, implementing the hands-on component of the clinical practicum was not feasible. The Conference Planning Committee cancelled the LARC clinical practicum and moved to assessing its provider network’s training needs for Calendar Year (CY) 2021. MDHHS surveyed its 33 local agencies for an 85% response rate. Approximately half (50%) of respondents reported an interest in a virtual LARC clinical practicum in CY 2021, equating to at least 30 providers in need. Respondents reported training needs for all LARC devices in particular Paragard, Liletta, and Nexplanon. MDHHS is working to develop a CY 2021 LARC clinical practicum training schedule that is responsive to the needs of its network and adheres to current health and safety guidelines. MDHHS intends to promote its LARC training schedule with providers outside the Title X network such as community health centers, school-linked health centers, private offices, and hospital-based systems to encourage utilization of contraceptive access best practices across the state.
Objective B: Increase the percent of women who report ever having discussed reproductive life planning during a visit with a doctor, nurse, or other health professional from 64% to 65% by 2020.
This objective is also Michigan’s ESM for the well-woman visit performance measure. Based on data from the Behavioral Risk Factor Surveillance System (BRFSS), Michigan’s FY 2020 reporting data indicates 59.9% of females (i.e., assigned at birth) discussed reproductive life planning during a visit with a doctor, nurse, or other health professional. This was a slight increase from the previous reporting year, which was 58.4%; however, MDHHS did not meet its ambitious target of 65%. To support progress toward this objective, MDHHS’s Family Planning Program discussed reproductive life planning with 22,614 females (i.e., assigned at birth), falling short of its service delivery estimate of 60,000 due to the Governor’s ‘Shelter in Place’ Executive Order (late March thru June 2020), COVID-19 implementation delays for new Title X agencies, and losing Michigan’s largest Title X sub-recipient (42,000 Title X users), Planned Parenthood of Michigan, in 2019.
During FY 2020, MDHHS continued to promote its Contraceptive Counseling modules to providers from Maternal and Infant Health, Home Visiting, and Adolescent Health programs. During FY 2020, 61 users viewed and 52 completed the Contraceptive Counseling modules, with a total of 17 continuing education credits requested. Of those that completed the modules during FY 2020, 43 completed the course evaluation and provided the following feedback: 90% felt the course was well-organized, 84% thought the course was helpful, and 76% found the course relevant to their job. MDHHS’s Family Planning Program partnered with Medicaid to assist with pay-for-performance client-centered contraceptive counseling for Health Plans, which focused on incentivizing Medicaid Health Plan contracted providers to enhance their contraceptive knowledge and skills using Family Planning’s Contraceptive Counseling Modules. During FY 2020, six providers received pay-for-performance credits from Medicaid Managed Care by completing this course.
During FY 2020, the Family Planning Program expanded the use of client-centered reproductive life planning and contraceptive counseling among programs that serve birth persons. MDHHS Family Planning staff facilitated a recorded breakout session on July 29 during the Home Visiting Conference’s Maternal Infant Health Program’s Model Day, on assessing pregnancy intention and client-centered contraceptive counseling using the Parenthood/Pregnancy Attitude, Timing, and How important is pregnancy prevention approach (PATH). PATH can be used with clients of any gender, sexual orientation, or age. PATH is designed to facilitate listening and efficient client-centered conversations about preconception care, contraception, and fertility, as appropriate. This breakout session allowed reproductive health counseling best practices to be shared with MIHP home visitors who routinely discuss pregnancy intention and contraception with program beneficiaries. The breakout was viewed by 157 or 95% of MIHP Model Day participants. MDHHS Family Planning staff also facilitated a recorded PATH breakout session on September 22 at the virtual Maternal Infant Health Summit. This breakout session allowed reproductive health counseling best practices to be shared with provider groups that do not specialize in women’s health, such as primary care providers, emergency room physicians, and family practice providers. The breakout session evaluation was completed by 17 conference participants. Session evaluations indicated the presenters were knowledgeable (90%), their teaching methods were effective (86%), and the presentation was performed without bias (82%).
Pregnancy intention and preconception health messages were disseminated on MDHHS’s Facebook and Twitter accounts in FY 2020. Messaging during national health observances such as Minority Health Month, Maternal Health Awareness Week, and Women’s Health Week were promoted on MDHHS’s Facebook (114,900 followers) and Twitter (26,900 followers) accounts. National health observance and other program-specific messaging has at times been halted or greatly reduced given that the general public is turning to state/local health department social media platforms to stay abreast of COVID-19 health and safety guidelines, community testing sites, and other pertinent pandemic resources.
Objective C: Increase the percent of women with a past year preventive medical visit from 68% to 85% by 2020.
This objective is Michigan’s National Performance Measure for the Women/Maternal Health domain. Based on the Behavioral Risk Factor Surveillance System (BRFSS), Michigan’s FY 2020 reporting data indicates that 77.2% of females (i.e., assigned at birth) aged 18-44 years old had a preventive visit in the past year. This was an increase from the previous reporting year, which was 69.1%; however, it did not meet MDHHS’s ambitious target of 85%.
In FY 2020, MDHHS utilized multiple state-level surveillance data sources (e.g., BRFSS, PRAMS) and reports, like Michigan Health Equity Status Update Report, to assess racial/ethnic health care access disparities in Michigan. Timely reports such as MDHHS’s COVID-19 Response & Mitigation Strategies for Racial & Ethnic Populations & Marginalized Communities were used to glean short- and long-term strategies for improving health care access to Michigan’s Black, Indigenous, and people of color. As a result, MDHHS’s Family Planning Program will develop an encounter-level data analyses plan to assess and monitor client health disparities and inequities in quality of care once its provider network has transitioned from aggregated- to encounter-level data collection and reporting in CY 2022. Additionally, MDHHS plans to conduct multiple listening sessions across the state in FY 2021 to gather the lived experiences of Michiganders navigating their sexual and reproductive health needs to inform health education, clinical, and case management services. Achieving equitable health outcomes for Michiganders begins with incorporating their knowledge and expertise into the programs designed to support them.
Annually, local Family Planning agencies are reviewed and monitored on the development of medical and social service referral agreements and collaboration at the local level, as well as their assessment of client needs for primary care or other services. Agencies are required to assess client access to a primary care provider and make appropriate referrals, as needed. COVID-19 has impacted the number of local Family Planning agencies reviewed and monitored in FY 2020; however, MDHHS plans to resume monitoring and oversight activities in FY 2021.
During FY 2020, MDHHS used several avenues to educate local Family Planning providers on routine and emergent Medicaid and Medicaid Health Plan policy issues. Policy education efforts focused on receiving regular Medicaid updates, including COVID-19 policy updates; providing input on Medicaid’s common formulary; and providing 340B prices on medications (i.e., antibiotics and contraceptives) to set reimbursements. In FY 2020, regular Medicaid updates were received during Family Planning’s state-level Advisory Council and annual coordinator meetings. Local Family Planning agencies had the opportunity to provide input on applicable COVID-19 policy changes (e.g., telehealth) as issued, the common formulary on a quarterly basis, and 340B medications prices were provided to Medicaid on a quarterly basis. A Family Planning Program Consultant participates on the Telehealth Access Work Group, part of Michigan’s Coronavirus Task Force on Racial Disparities, where the future of telehealth services and Medicaid policy are routinely discussed.
Oral Health – Women/Maternal Health (FY 2020 Annual Report)
The MDHHS Oral Health Program (OHP) provides population-based oral health prevention efforts and effective utilization of the dental workforce in implementing and improving oral health access. Despite significant COVID-19 related challenges—which included a preventative dental care shutdown, cancelled workshops and educational opportunities, and the reallocation of staffing and resources—the OHP has continued to increase its collaborations with community partners to improve oral health through prevention activities and direct access programs. This remains evident in the activities of NPM 13 in FY 2020.
Objective A: Increase the number of medical and dental providers trained to treat, screen, and refer pregnant women and infants to oral health care services.
During FY 2020, the Perinatal Oral Health Action Plan continued to be implemented to support a better health status for women and girls. A main strategy continued to be the training and education of Michigan health professionals, particularly those who practice in and serve communities and women adversely impacted by health disparities. The number of medical and dental professionals who receive perinatal oral health education through MDHHS is the ESM for this NPM. Despite significant COVID-19 related challenges in FY 2020, the Perinatal Oral Health Program trained 423 health professionals in the medical and dental fields through lectures, webinars, conference calls and other training events. This number does not include the hundreds of additional professionals trained by partners, coalitions, and other Michigan entities. Many events and trainings were cancelled due to the pandemic which negatively impacted the number of providers trained, but virtual opportunities remained. A large Home Visiting virtual training session included a combined presentation with the Medicaid dental policy specialist to share information about the Medicaid pregnancy benefit with great success.
In addition, Michigan-specific Perinatal Oral Health Guidelines continue to be promoted, along with other educational materials. Efforts began to update this document in the reporting year. A partnership to teach a lecture on perinatal oral health to Nurse Midwifery and Nurse Practitioner students continued with the University of Michigan School of Nursing, with lectures occurring each semester as part of the curriculum. These lectures were moved to a virtual format due to COVID-19. This course had to be altered due to the inability to have a hands-on component but continued to include application in how to integrate oral health within your future practice. In addition, an interactive piece called “Why is Grace in the Emergency Room” helped initiate discussion on the social determinants of health and health equity. Positive student feedback continues to be measured at 99% with over 361 advanced practice nurses trained to date.
Objective B: Increase the number of socioeconomically disadvantaged pregnant women receiving oral health care services.
In FY2020, the OHP was able to enact perinatal oral health related PRAMS questions which will be critical in determining the long-term impact of programs and policies, specifically among different racial and ethnic groups. Development and analysis of recent PRAMS data was delayed due to COVID-19 but will be completed in the next fiscal year. A plan is in development for an in-depth and longitudinal look at data trends, with data briefs to be developed for public and stakeholder use.
In FY 2017, MDHHS awarded grant funds to the University of Detroit Mercy (UDM) School of Dentistry to implement a dynamic medical dental integration program. The project officially launched in FY 2018 and established itself with expansion in FY 2019 through funds from external partners. This partnership with the UDM School of Dentistry, the Michigan Primary Care Association (MPCA) and the OHP currently had 11 operating sites during FY 2020 but faced significant challenges. Due to a cessation of all preventative dental care for several months in the spring of 2020 due to COVID-19, many sites (6) were forced to close. This model of care, which places a dental hygienist directly within an OBGYN unit in an FQHC has provided 8,589 patient encounters during this reporting period. These services include 2,504 education visits by the hygienist and 813 cleanings for pregnant women. Although these numbers indicate a decrease from FY 2019, a significant number of women have received much needed care through this project. Evaluation began in 2019 with key informant interviews as well as interviews with participating patients and consumers. The evaluation continues into 2020 as significant delays occurred regarding the inability to conduct in-person interviews or have access to project sites since many closed during the preventive care shutdown. Additional efforts are underway to utilize electronic medical health records to track referrals and determine if the “referral loop” is being closed. Due to this project occurring within federally qualified health centers, a diverse population is being serviced in both rural and urban areas and includes women and children of all ethnicities and socioeconomic backgrounds.
In FY 2020, the wichealth.org module was continued to be utilized not only in Michigan but other states that participate with wichealth.org. Wichealth.org provides stage-based, client-centered, WIC nutrition education and an anticipatory guidance model in which WIC clients could complete educational lessons in English or Spanish to receive their WIC benefits. During the FY 2020 reporting period, 15,866 lessons were completed nationwide. WIC serves a diverse population and targets those within a lower social economic demographic. By developing education in partnership with WIC, the Oral Health Program has been able to reach populations that may have the most need and may experience the most health disparities. The module has also been developed in Spanish to better serve WIC clients and continues to be utilized by Spanish speaking clients.
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