Women/Maternal Health - Annual Report
Illinois’ Title V priority for the Women and Maternal Health Domain is:
- Assure accessibility, availability, and quality of preventive and primary care for all women, particularly for women of reproductive age (Priority #1)
There are some concerning trends for the health of Illinois’ women and mothers. In recent years, the maternal mortality and severe maternal morbidity rates have improved slightly overall, yet continue to show increasing racial disparities. In Illinois, non-Hispanic Black mothers are about twice as likely to experience a severe maternal morbidity and more than four times as likely to die as non-Hispanic White mothers (NOM #2, NOM #3). Building on improvements over the last several years, the teen birth rate in Illinois continued to fall to an all-time low in 2019 (NOM #23), representing more than a 50% decrease since 2010.
Most Illinois women are accessing important health care services; about 3 in 4 women of reproductive age received at least one preventative visit in the last year (NPM #1) and 3 in 4 pregnant women received prenatal care beginning in the first trimester (NOM #1). However, there are still opportunities to improve the receipt of these needed health services, particularly for women with lower educational attainment, lower income, those on Medicaid, or who are uninsured. There are also particular types of services, such as dental care and mental health care, that are more challenging for women to receive. For example, the proportion of pregnant women having their teeth cleaned during pregnancy has remained in the 40-50% range and has not substantially improved since monitoring for this indicator began in 2012.
The rate of chlamydia infections among women ages 15-24 is one of the indicators with the highest racial/ethnic disparities in Illinois – with the infection rate being nearly six times as high among Black young women as it is among White young women. For this reason, Illinois will continue to monitor this indicator as SOM #1 and seek to improve reproductive health services through school-based health centers, the state’s family planning program, and coordination with the state STI program.
The IL Title V utilized the following strategies to address the Women and Maternal Health Domain priority:
- Support dissemination of the Illinois Healthy Choices, Healthy Futures Perinatal Education Toolkit, which includes resources about pre-/inter-conception health and the transition to postpartum care.
In collaboration with EverThrive Illinois, IL Title V supported the ongoing enhancement, dissemination, and tracking of the Illinois Healthy Choices, Healthy Futures Perinatal Education Toolkit. The toolkit was initially created by the Child Health Insurance Program Re-Authorization Act (CHIPRA) Quality Demonstration Grant workgroup to provide patient-focused information on preconception, prenatal, postpartum, and inter-conception health topics, provider-focused information on postpartum care transition strategies, a prenatal care quality assurance tool, and a high-risk referral crosswalk, developed by the American Congress of Obstetricians and Gynecologists (ACOG) and the Illinois Academy of Family Physicians (IAFP). The toolkit was accessible via a website maintained by EverThrive Illinois: http://healthychoiceshealthyfutures.org/. The toolkit’s target audience is social service providers that support people of reproductive age in addition to people themselves seeking to find easy to understand, reputable resources to help support them with the information they need as they navigate the various reproductive phases.
During FY20, EverThrive Illinois updated and promoted the Healthy Choices, Healthy Lifestyles Perinatal Education Toolkit. EverThrive Illinois engaged social service providers in focus groups to provide feedback on the tool, created a new format for the toolkit, and developed additional contextual content to help viewers navigate the site. According to EverThrive Illinois’ data, the toolkit received more than 203 views in the first half of FY20.
With the onset of the COVID-19 pandemic, EverThrive Illinois used its platform to launch a COVID-19 webinar series in the second half of FY20. It utilized its existing networks, tables, and communication platforms to understand how families, particularly moms and children, were navigating and adjusting through the pandemic. The webinar series targeted social service providers and covered the following topics:
- COVID-19 and Public Benefit Changes. This webinar covered changes made to public health benefits programs in response to COVID-19, and discussed Medicaid, Supplemental Nutrition Assistance Program (SNAP), WIC, and Temporary Assistance for Needy Families (TANF).
- COVID-19 and Mental Health. This webinar featured a panel discussion with Erikson Institute and Chicago Children's Advocacy Center and focused on how social service providers can support young children and their families’ mental health needs during the challenges of the pandemic.
- Selfcare for Social Service Providers. This webinar addressed the importance of self-care practices for social service providers, with an emphasis on the role of vicarious trauma and navigating current pandemic stressors.
During COVID-19, EverThrive Illinois partnered closely with the MCH Family Councils to assess and to respond to the needs of pregnant/postpartum people and parents during the pandemic and launched a COVID-19 response media campaign. The full campaign achieved 1.25 million impressions and reach 988,000 individuals. Posts touched on being pregnant during COVID-19, anxiety and depression during the pandemic, domestic violence, included information regarding women expecting during COVID-19, support for pregnant women to reduce anxiety regarding COVID-19, and support for families where children typically receive meals through the free and reduced meals program in school.
- Partner with the Illinois Department of Corrections and two state women’s correctional centers to support ongoing health promotion activities for incarcerated women (including health education programs and lactation support) and prison staff training.
Illinois is home to three women’s correctional facilities that house more than 2,500 women and support eight Mom and Baby joint housing units. During FY20, the Division of Population Health Management (DPHM), which is a division of OWHFS, continued its collaboration with the Illinois Department of Corrections (IDOC) to support pregnant women and new mothers and infants housed within two of the women’s prisons, Logan Correctional Center (LCC) and Decatur Correctional Center (DCC). Specifically, DPHM provided pregnancy education, breastfeeding education, and lactation support and counseling. In addition to the incarcerated women receiving this information, the health care staff received prenatal and delivery education as well.
DPHM also partnered with outside agencies to provide support the women’s needs once a baby is delivered as well as increased the awareness of other key programs to that would promote health education to incarcerated women and IDOC staff. A partnership with the Illinois Department of Children and Family Services (DCFS) assisted in identifying appropriate parenting education curriculum. DPHM sought to increase the women and staff’s awareness of the WIC program and work with the IDOC staff and the women to ensure that the women and babies received the needed care while residing in an IDOC facility. DPHM also provided the facilities with new breast pumps, pumping kits, milk storage bags, and breast pads, and strengthened its partnership with the Baby Talk Program to provide enhanced educational services for new mothers and babies up to 3 years old who resided at DCC.
OWHFS and Title V leveraged the expertise of the regional administrative perinatal center (APC) to provide additional trainings at both facilities. Specifically, four health care trainings were conducted between both facilities with approximately fifty staff being trained. The health care training team of the regional APC as well as a maternal and fetal medicine (MFM) physician have participated in the trainings. Establishing this relationship is important because it allows the MFM to meet with the women in their home setting prior to any office visits and address questions as well as identify anyone who may be experiencing a high-risk pregnancy. These interactions occur during the health care trainings and is part of a Q&A with the pregnant women present.
OWHFS’ work with IDOC was also supported by Title V’s downstate perinatal nurse. During FY19, she attended hospital meetings discussing the care of women from the correctional centers and how perinatal regionalized care transports improve maternal and neonatal outcomes. The Title V perinatal nurse collaborated with the Title V perinatal nurse and other OWHFS staff and proposed the educational plan for health programming to the administration of the LCC.
Obstetrical and neonatal simulation training was provided at the LCC for nurses, mid-level providers, nursing administration, and a physician. This simulation allowed staff to test their obstetrical and neonatal skills and prepare for any labor and/or delivery encounters at the facility. It also allowed them the opportunity to debrief afterwards to identify other opportunities to improve the quality of care for pregnant women. The regional APC network administrator and the maternal-fetal medicine (MFM) physician APC co-director played a vital role in providing the education and answering the women and staff’s questions. The MFM also served as the lead for Southern Illinois University School of Medicine’s (SIUSOM) Correctional Medicine Pilot Program at LCC.
Due to the pandemic, DMPH experienced limitations in providing education and support to the women and health care staff at LCC and DCC. DMPH looks forward to resuming its services in the near future.
- Identify pregnancy-associated deaths and facilitate two state Maternal Mortality Review Committees (one focused on pregnancy-related deaths and one focused on violent deaths)
Since 2002, Illinois has followed the CDC recommendation to identify all pregnancy-associated deaths. Illinois uses multiple methods simultaneously to ensure pregnancy-associated deaths are accurately identified and counted each year. First, the state database of death certificates is used to identify deaths that may be pregnancy associated. There is a checkbox on the death certificate that indicates whether a woman was pregnant at the time of death or pregnant within the last year.
Some cause of death codes indicate that a death may have been related to pregnancy. Death certificates for any woman age 15 to 50 years are also checked against the databases of birth certificates and fetal death certificates to look for matching information. If there is a birth or fetal death record in the 12 months prior to a woman’s death, her death is flagged as a pregnancy-associated death. In addition to the state data systems, there are other ways that maternal deaths are identified in Illinois. All Illinois hospitals are required by the state to report any known pregnancy-associated deaths to IDPH within 24 hours. Second, IDPH completes regular searches of major newspapers throughout Illinois to identify articles or obituaries that indicate the death of a woman while pregnant or within one year of pregnancy. For example, if an obituary mentions that a deceased woman has a surviving child who is less than 1 year old, the woman’s case is flagged as a potential pregnancy-associated death.
Once the list of potential cases is complete, IDPH contacts the hospitals and health centers where the women received care to request records from the time of her most recent pregnancy to her death. These medical records provide details about the woman’s death and her medical history. For instance, records are routinely requested from the hospital where the woman died, the hospital where she gave birth, and the physician office or health center where she received prenatal care. When relevant, records are also requested from police departments, sheriff’s offices, and medical examiner or coroner’s offices. IDPH is constantly reviewing records to identify additional hospitals or health care providers that may be able to send more records that provide information on the case. Hospitals and medical providers are required to provide copies of all medical records related to maternal deaths within 30 days of IDPH’s request. IDPH compiles this information to confirm and accurately track the number of pregnancy-associated deaths in Illinois each year.
Though information from death certificates and other public health records may help identify counts of maternal deaths, these records cannot determine the preventability of cases or the factors involved in the case. The CDC recommends review of maternal deaths by a multidisciplinary committee as a means of gathering additional information about how the woman died, whether the death was preventable, and opportunities for preventing future maternal deaths.
During 2017, IDPH implemented a new review process to align with best practices promoted by the CDC. The goal was to improve several key components of the review process, including standardizing case abstraction, increasing review efficiency through structured meeting facilitation, and shifting to a population-health focus (instead of a purely clinical emphasis) to also consider how social and non-medical factors that may have contributed to a death. Overall, IDPH saw a need for more structured administrative and technical support to the committees, especially in terms of chart abstraction and data analysis. As a result, IDPH committed to taking a more active role in supporting the committee meetings, participating in reviews, and collecting and analyzing data. To align with national work, Illinois adopted the use of standard CDC data collection forms and resources. This ensured that the data collected by the Illinois MMRC and MMRC-V would be consistent with each other and with other review committees across the country.
During 2020, Illinois continued to implement the maternal mortality review process for deaths potentially related to pregnancy. From October 2019 to September 2020, the MMRC held four meetings and reviewed 23 cases, and the MMRC-V held five meetings and reviewed 35 cases. IDPH was prepared to release its second maternal morbidity and mortality, which covered cases reviewed during FY19. Unfortunately, due to the COVID-19 pandemic, the report was delayed. It was decided that the second maternal morbidity and mortality report would be revised to consist of two years of cases reviews, FY19 and FY20, and scheduled for release in early FY21.
In FY2020, IDPH continued to enhance its efforts to improve maternal health and to reduce maternal mortality. IDPH hired a Maternal Morbidity and Mortality analyst and a Maternal Mortality Review operations manager who are funded by the CDC Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE-MM) Grant. These positions support IDPH’s efforts to support and manage the MMRCs. In addition, IDPH continued its partnership with the UIC CoE-MCH on its HRSA Maternal Health Innovation Grant. IDPH is serving as a co-lead and the Title V director is co-chairing the Illinois Maternal Health Task Force. Finally, IDPH has a key role on the Merck for Mothers Grant with EverThrive Illinois and the Alliance (a network of FQHCs). This grant seeks to improve prenatal care provided at federally qualified health care centers (FQHCs).
- Conduct reviews of severe maternal morbidities (SMM) through the regional administrative perinatal centers and convene statewide SMM review sub-committee to develop recommendations for improving local reviews of SMM.
According to CDC, severe maternal morbidity (SMM) has increased more than 200% between 1993 and 2014. In collaboration with the 10 administrative perinatal centers and the UIC Center for Research on Women and Gender (UIC-CRWG), Illinois began the Severe Maternal Morbidity (SMM) Surveillance and Review Project during 2017. In this project, all Illinois obstetrical hospitals identified and reported on SMM cases, defined as a pregnant or postpartum (up to 42 days) woman who was admitted to an intensive care unit (ICU) and/or transfused with four or more units of packed red blood cells. UIC-CRWG developed a standardized SMM review form in partnership with the APCs. The form was used by APCs and their network hospitals to collect more information on the circumstances surrounding SMM events, preventability, and opportunities for intervention. APCs used the SMM review forms to report into the ePeriNet database, which allows for population-based analysis of SMM over time.
UIC-CRWG provided technical assistance to the hospitals and APCs as they conducted reviews and evaluated the quality of the data reported into ePeriNet. The statewide SMM review sub-committee meetings provide an opportunity for dialogue and collaboration between UIC-CRWG, the APC administrators, and the subcommittee members to discuss lessons learned and to identify ways to strengthen hospital level reviews.
It is important to note that the COVID-19 pandemic affected SMM reviews during CY20. APC administrators reported that many morbidity and mortality reviews (M&Ms) were cancelled, and staff furloughs decreased some APC’s capacity to upload reviewed cases to ePeriNet.
- Participate in ASTHO Long-Acting Reversible Contraceptives (LARC) State Learning Collaborative and advise state family planning program and contraceptive initiatives.
Although the ASTHO Long-Acting Reversible Contraceptives LARC Learning Collaborative ended in FY18, Illinois continues to work to increase education and support of health care providers and patients around the use of LARC. This includes working with the IDOC to incorporate family planning into the two women’s prisons to offer family planning services to women prior to release, collaborating to expand the efforts of ILPQC’s immediate postpartum LARC initiative, and integrating the Title X Family Planning Program with school-based health centers.
- Collaborate with IDPH Division of Oral Health to convene stakeholders and to develop a statewide strategic plan and resource manual for oral health during pregnancy and early childhood (same as strategy #3-C).
IL Title V and the Division of Oral Health recognize that oral health is an essential component to improving the overall health for women, children, and families. Anticipatory guidance, education, and risk-based care is routinely provided within the prenatal and primary care provider health care system. The primary purpose of the Illinois Oral Health During Pregnancy and Early Childhood Project was the development of the Oral Health During Pregnancy and Early Childhood in Illinois resource manual. The resource manual presents actionable activities that encourage adoption of an oral health focus within the health care environment. This focus supports prenatal and primary care providers to educate, to assess, and to refer patients for oral health issues.
With a patient-focused and systems-oriented approach, prenatal and primary care providers can easily implement the field- tested oral health integration concepts provided in the resource manual. Oral Health During Pregnancy and Early Childhood in Illinois is divided into three main sections addressing educational information. The sections are: General Information, Oral Health Practice Guidelines for Pre- and Perinatal Women, and Early Childhood and Families with Young Children.
Further subsections detail strategies to implement for in-office system change. The appendices, inserts, and resources provide additional information aimed at improving health literacy, encouraging routine self-care practices, promoting prevention activities, and addressing access to treatment services.
To promote a change within inter-disciplinary systems, the Oral Health During Pregnancy and Early Childhood in Illinois resource manual establishes a care coordination protocol to close the communication loop between providers. The protocol includes a referral form for use by health care/support services providers to initiate a referral to an oral health care provider. To close the communication loop, the oral health provider completes the oral health section of the referral form and returns it to the referring provider. By using these forms, the communications between providers are standardized and coordinated.
In addition, the DOH developed a white paper entitled Next Steps in Oral Health: Case for Fluoride Varnish Reimbursement for Children and Pregnant Women. The paper presented information to Illinois’s managed care organizations (MCOs) and Bureau of Managed Care to encourage policy change to expand fluoride varnish coverage for children ages 3–6 and pregnant people to be provided by both medical and oral health professionals.
- Lead CoIIN - Social Determinants of Health workgroup to assess, quantify, and describe the impact that child care has on prenatal, intrapartum, and postpartum care in Illinois and develop optional strategies and approaches that could be implemented in clinic and hospital settings to address child care.
The CoIIN-Social Determinants of Health began in Fall 2017. The Illinois CoIIN team was a cross-disciplinary group that focused on reducing infant mortality by addressing social determinants of health. Through focus groups and informal discussion with health care providers, the team identified child care, or lack thereof, during pregnancy, childbirth, and postpartum as a non-traditional social determinant of health that may negatively impact health outcomes for the mother and her baby. In informal discussions with Illinois’ birthing hospitals, it was learned that the lack of child care during pregnancy, at childbirth, and in the postpartum period is not only a barrier to timely access to health care, but has resulted in poor outcomes, including the death of a mother who, while very ill, refused to go to the emergency department because she had no one to watch her new baby and another mother who miscarried because she left the hospital, against medical advice, to get home to other children who were unsupervised.
The lack of child care has never been quantified. To begin tackling this issue and making the case for changes in policy/procedures at the local, community, and state levels, the Illinois CoIIN team developed a three-pronged approach to collect data that consisted of surveying birthing hospitals and FQHCs, and interviewing Healthy Start clients.
In FY2019, the workgroup successfully partnered with hospitals and local community health centers. The survey was disseminated to 98 hospitals and 44 FQHCs. In addition, the team developed seven questions to survey among postpartum Healthy Start participants to gain insight on child care-related issues among postpartum women. Based on the results of the pilot project, approximately one-third of postpartum women surveyed had a health care visit delayed or missed due to a lack of child care.
In FY20, the workgroup explored the process for field testing questions it could potentially add to the state’s PRAMS project. Surveying postpartum women would add an individuals’ perspective to the need for emergency child care in the prenatal, labor/delivery and postpartum periods. Approaching this systematically would enhance the PRAMS surveillance system in Illinois and potentially other states. IDPH is hoping to have the questions regarding child care added in the Illinois PRAMS phase 9 revision process.
- Participate in Partnership for Integrating Oral Health Care into Primary Care project with IDPH Division of Oral Health and a local health department to integrate the interprofessional oral health core clinical competencies into primary care practice, particularly for pregnant women and adolescents.
IL Title V, the IDPH Division of Oral Health, the Partnership for Integrating Oral Health Care into Primary Care project and the Champaign-Urbana Public Health Department (C-UPHD) coordinated to integrate the HRSA interprofessional oral health core clinical competencies into primary care practice. This project will assist primary care health professionals and support staff at C-UPHD in conducting oral health risk assessments, screenings, preventive interventions, education, and interprofessional collaborative activities and care coordination services, as applicable. In the first half of FY20, the program screened 227 pregnant women, with approximately a 50% screening rate. For the second half of FY20, the goals were to increase the screening rate to 90%, add more dentists to the referral network. Unfortunately, due to COVID-19, many of the services were halted and the goals were not realized.
- Establish well-woman care mini-grant program to assist local entities in assessing their community for need and barriers and developing a plan to increase well-woman visits among women ages 18-44.
To assist in addressing NPM #11, the IL Title V launched the Planning Grant to Increase Well-Women Visits in Your Community Program. The overall goal of the program was to increase the percent of women ages 18-44 with a preventive medical visit (well-woman visits). To accomplish this goal, grant applicants developed a plan to positively influence the number of women seeking well-woman care within their respective communities. More specifically, applicants defined and described the community served, including barriers to accessing health care, identify locations ln the community where women are seen for Well-Woman visits, and develop a plan to describe the increased well-women care utilization in the community.
The University of Illinois at Chicago's Center for Research on Women and Gender received Title V funding in FY20 to continue to implement a pilot project to expand the capacity of perinatal health care providers in Illinois to screen, to assess, to refer, and to treat pregnant and postpartum women for depression and related behavioral health disorders, and to increase awareness of, and access to, affordable and culturally-appropriate services to pregnant and postpartum women and their infants. The project targets obstetricians, gynecologists, nurse midwives, pediatricians, psychiatric providers, mental health care providers, social workers, and primary care providers in geographical areas serving disadvantaged women, including Cook County/Chicago and Peoria County/Peoria. The main objectives of the program were: 1) providing in-person workshop training and resources on screening, diagnosis, and referral for maternal depression and related behavioral disorders to perinatal providers; 2) providing real-time psychiatric consultation and care coordination for providers; 3) screening women for depression, anxiety, suicide risk, and substance use during the perinatal period using Computerized Adaptive Testing (CAT); 4) increasing access to depression prevention and treatment for medically underserved women using a telehealth intervention; 5) increasing access to substance use treatment for pregnant women; and 6) planning for scale-up and sustainability to implement the project components statewide.
Specifically in FY20, the program was engaged in the following: hosting monthly perinatal mental health multidisciplinary meetings at UIC, with representatives from OB/GYN, midwifery, psychiatry, nursing, social work, Women’s Mental Health Research, and UIC-CRWG; training nurse midwives/providers at UIC and Heartland (Olt Street Clinic in Pekin) and screening with the CAT-MH; adopting DocAssist’s decision trees for all five screening conditions and distributing to providers; and working with Adaptive Technologies to develop a process to deliver a CAT-MH remotely during the COVID-19 pandemic to ensure women needing services were not missed. A total of 295 patients were enrolled in FY20.
Mask for MOMs Campaign. In April 2020, during the first wave of the COVID-19 public health emergency, UIC School of Public Health’s Center of Excellence in Maternal and Child Health (CoE-MCH), Black Girls Break Bread, EverThrive Illinois and IL Title V led a group of MCH partners in a Mask for MOM’s campaign. This campaign was developed to ensure pregnant persons and those in labor and delivery had access to face masks during their prenatal visits, when they arrived at hospitals for delivery, and when they were discharged postpartum. The group main priority was to help moms feel a little bit safer as they took care of themselves and their children in the prenatal and postpartum period. Through the support of many volunteers, the Masks for Moms campaign collected and distributed roughly 25,000 masks to pregnant people at community health centers, hospitals, and various community sites, focusing on pregnant people in some of the most vulnerable communities in Chicago and its surrounding areas.
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