In May 2005, the Infant Mortality Task Force at the time issued a report that included 20 recommendations to reduce the number of Delaware babies who die before their first birthday (rate of infant mortality) and to eliminate the racial disparity in the rate at which these babies die.  The infant mortality rate is generally regarded as proxy for the overall health of a community.  The infant mortality rate (IMR) for black babies is 2.7 times that of white babies in Delaware.  Maternal age, chronic illness (asthma, hypertension, diabetes), nutrition, infection (STI, HIV), stress, unwanted pregnancy, smoking, and other drug use and lack of prenatal care are all factors that increase the risk of adverse pregnancy outcomes and maternal complications.  Therefore, as a result of the IMTF in Delaware and the research that they put into their report, along with their 20 recommendations, one of their recommendations was to create the Delaware Healthy Mother Infant Consortium (DHMIC), a governor appointed consortium comprised of 15 citizens in Delaware who would oversee the IMTF recommendations. 

In turn, the DHMIC established the Healthy Women Healthy Babies (HWHBs) program in July 2009.  A significant amount of state funds, approximately $4.2M, is invested in several infant mortality reduction initiatives as well as improved health outcomes for women and babies.  The primary focus of the IMTF/HWHB funding has been to reduce the number of Delaware babies who die before their first birthday.  The strategy has been to identify women at the highest risk of poor birth outcomes and to address any underlying medical conditions that predispose them for poor outcomes before they get pregnant or if they are already pregnant, to work with them to mitigate their risk.  The success of this effort lies in the fact that since its inception, our infant mortality rate had dropped by 25% over the last decade of intense efforts and evidence-based program interventions.  Even so, the current infant mortality rate of 7.3 deaths per 1000 live births, which is driven almost entirely by the racial disparity in infant death rates, is still significantly higher than the national average of 5.9. In the past few years, substantial funding has been directed at addressing the social determinants of health which are the major drivers behind the racial disparity.  In FY 21, $1.5 million has been budgeted to this SDOH effort and will remain a priority. 

The HWHBs program aims to reduce the occurrence of adverse birth outcomes, infant mortality and low birth weight babies by providing support and services to high risk women during preconception and prenatal care for women who are at risk for poor outcomes.  The goal is to provide assistive services to encourage the woman to maintain a healthy weight, nutritious diet, receive appropriate amounts of folic acid, manage chronic disease, address environmental risk factors such as smoking, substance abuse or other stress-inducing circumstances, as well as the development of a personalized reproductive life plan (for all women and men).  The HWHB program has been nationally recognized by the National Association of Maternal and Child Health Programs for providing evidence-based preventive services beyond the scope of routine prenatal care.

The HWHB program is housed under the Division of Public Health in the Family Health Systems Section and has completed the first year of the new refreshed model to improve preconception, prenatal, and birth outcomes of Delaware women, particularly those at increased risk.  The new model is a value/performance-based approach focused on meeting or exceeding 6 benchmark indicators, with an emphasis on addressing the social determinants of health and incorporates the role of community health workers to further support outcomes.  The Division of Medicaid and Medical Assistance (DMMA) was an essential partner in the transformation of the HWHBs 2.0 model and continues to play a role in the program’s enhanced model and performance-based redesign.  In the next year, we plan to review benchmark data indicators as well as explore data linkages of HWHBs 2.0 patient data with Medicaid claims data to monitor benchmarks and outcomes.  Last year, Medicaid hired a MCH Quality Assurance Administrator, and DPH convenes reoccurring monthly meetings with this individual along with the DMMA Medical Director to align quality improvement efforts with Title V MCH priorities to improve health outcomes for women and babies. 

The HWHB Program was developed using a life course framework to explain health and disease patterns, particularly health disparities, across populations and over time.  Health is interconnected or a series of inter-dependent stages over the course of one’s life.  The life course framework recognizes the interaction of behavioral, biological, environmental, psychological and social factors that contribute to the health and well-being throughout an individual’s life.  The available research is clear that the path to more significant and sustained improvement in the statewide maternal and infant mortality rate and in eliminating the persistent racial disparity lies in addressing the social determinants of health - the social context factors that compromise the health of families which then makes them susceptible poor outcomes.  

Over the next year, DPH in collaboration with DHMIC partners plan to further track and analyze benchmark data and the performance based approach to the to the Healthy Women Healthy Babies program, a medical intervention, by simultaneously supporting the 8 community based interventions in high risk zones implemented across the state that address some of the underlying environmental, economic and social structures that impact resources needed for health, such as poverty, lack of stable housing, access to healthy foods, access to early childhood education, medical legal partnership, financial literacy, etc.  The plan for the coming year, is to discuss the findings from the Housing Pilot Feasibility Analysis and prepare recommendations that take into account the ROI, costs and sustainability, and explore alternative evidence based models, such as universal base income models (i.e. Abundance birth project in San Francisco, CA).  In the coming year, Health Management Associates (HMA) will continue working closely with DPH and DHMIC to serve as a backbone agency as part of the maternal and infant mortality reduction work to build state and local capacity, and test the 8 small scale innovative strategies to shift the impact of social determinants of health tied to root causes related to infant mortality.  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.  HMA will work with DPH and DHMIC to staff and facilitate the SDOH Workgroup, staff and facilitate a Doula Adhoc Committee, provide coaching and technical assistance to the 8 local community based interventions, schedule quarterly learning collaboratives for partners, provide extensive coaching and technical assistance to existing and new mini-grant awardees, and create shared metrics and tools for quality improvement and overall evaluation. 

The Delaware Perinatal Quality Collaborative (DPQC) was established in February 2011 as an action arm of the DHMIC.  DPH federally funds a Perinatal Project Nurse Coordinator, which is dedicated to promoting the success of the Cooperative.  In response to the opioid epidemic, a large part of the last few years has involved monitoring the increases of Neonatal Abstinence Syndrome (NAS) voluntarily reported by hospitals.  The Cooperative also implemented a standard definition of NAS in September 2016 so that all hospitals were identifying babies that met this criterion.  In addition, Dr. Khaleel S. Hussaini, Delaware’s CDC MCH epidemiologist is beginning to compile, and present data related to Perinatal Quality Indicators (PQI’s) using birth certificate data, looking at Delaware resident births by hospital.  The data hopes to explore opportunities and examine the challenges for monitoring, preventing, and reducing complications during pregnancy, improve care and improve accuracy and timeliness of birth certificate data; and provide individual hospital reports on select PQI’s.  Other states use this data to drive public health initiatives and Delaware is excited to be on this data driven path as well.  In September of 2017, Delaware successfully leveraged a CDC Perinatal Cooperative grant.  As a condition of the grant, the Perinatal Cooperative identified OB Hemorrhage Protocol as their priority quality improvement project.  Delaware reports 20 OB Hemorrhages in the state; to decrease that number by 25%, which may be aggressive and quite challenging hemorrhaging is a national problem due to the increase in occurrences in this country, and in Delaware, in part due to previous c-sections, advanced maternal age, co-morbid conditions, multiple gestations, diabetes and hypertension.  A full-time master’s Prepared Nurse position will continue to support the program by going to birthing institutions and coordinate to get the necessary data from the birthing facilities.  A data system will also be developed, and the data needs will be inputted into the system so that it can be extracted for reporting purposes. 

This year, the DPQC was formally established in Delaware Code and signed by the Governor during a virtual press conference in July 2020.  Data collection and analysis is crucial to the DPQC’s efforts to improve the care and outcomes of DE’s women and their babies.  The foundation of the collaborative is to share current data to use for benchmarking and QA/QI, identify best standards of care/protocols, realignment of service providers and service systems, continuing education of professionals and increasing public awareness of the importance of perinatal care.  Establishing the Collaborative in Code will allow them the ability to:

1. Enter binding memoranda of understanding among member institutions to hold each other accountable for sharing quality improvement data and for following the protocols for securely handling the shared data.
2. Enter into agreements with data storage and or transmission companies to provide their services to the Collaborative to enable it to do its work.
3. Apply for funding to support the work of the quality collaborative.
4. The confidence that the quality improvement data that members share will not be released to the public.  The quality improvement focus of the Collaborative requires that member-birthing institutions be able to share their quality data freely without concern that unauthorized persons may have access to information.  The legislation would enable the collaborative to close some of its meetings to the public.  Placing the DPQC in statute will allow for sharing of more confidential data and cases that could potentially be a violation of state data laws but are important for continuous quality improvement and learning among providers/ birthing institutions.  (i.e. patient data protection including HIPPA).  For example, even a medical chart review of 10 patients should not be shared publicly, but this is how the birthing hospitals/institutions learn from each other.  The same applies to case reviews.
5. Continue to function in cooperation with the DHMIC.

Preconception peer educators (PPE) will continue to provide community outreach to increase infant mortality awareness with an emphasis on preconception and interconception health targeting the 18+ population.  They primarily engage minority serving colleges and universities and develop public/private partnerships.  PPE is a state-wide initiative originally created by the Office of Minority Health but brought to fruition in Delaware by the DHMIC.  PPE consists of college students becoming trained peer educators via statewide training.  Once trained, these students are expected to raise awareness and educate their campus and community about Delaware’s problematic infant mortality rate and its effect on families in the area.  This involves discussing issues with young women and men to ultimately understand that their personal decisions have a major effect on their future family.  The main messages that PPE aims to present are:

1) Delaware’s trend of high infant mortality and how this relates to unintended pregnancy

2) the glaring health disparities that exist among black and other minority groups and how this translates within the state’s infant and maternal mortality rates

3) the importance of always having a plan to become (or not become) pregnant and how physical, mental, and emotional health contribute to one’s preparation for pregnancy.

Currently, the PPE’s most prominent chapter exists at the University of Delaware.  PPE at the U of D’s educational outreach has included presentations in high school classrooms, informative kiosks on campus, educational presentations to Greek life organizations, and even occasional abroad experiences in Jamaican villages.  Over the years, this chapter has evolved in many ways, but currently its students as well as the DHMIC are less focused on community and abroad outreach and more focused on the internal organization of each chapter as well as their presence on campus.  There is a current need over the next year to create standardized operations and procedures within this chapter to keep the organization afloat when faced with turnover of leadership and participants.  PPE at the U of D plans to operationalize each of their on-campus outreach initiatives to measure its effectiveness in educated the community.  The plan is to quantify the direct impact that the education and awareness will have on the community by adapting data-recording methods that have been successful in similar outreach organizations such as Planned Parenthood of Newark Delaware and Healthy Hens at the U of D. Simultaneously, PPE at the U of D will establish a “blueprint” of their developed procedures for those who may be interested in instituting a chapter of PPE at other Delaware universities and colleges (i.e. Wesley College, Delaware State University, etc.).  This “blueprint” will include descriptive information regarding PPE at U of D’s typical events hosted on campus, the roles and duties of each executive board member, and the methods used to train effective PPEs.  In the coming year, efforts will focus on sustaining the UD PPE Chapter, as they identify a new faculty advisor as well as engaging in conversations with the Delaware State University to start a new chapter.

Overall, this current PPE initiative aims to expand preconception health messaging throughout the state to improve the health and well-being of Delaware men, women, and families.  By intervening at the high school and college level, PPE brings the topic of family planning to the forefront; through peer-to-peer interactions, the target population of young adults can engage in legitimate and educational conversation about a subject matter that can initially feel intimidating.  An annual training will be held in the 2021 for PPEs on several maternal and child health content-based workshops with a second training focused on core competencies and skills training for new recruits based on the peer educator curriculum from NASPA.org. 

Preconception CoIIN.  DE was selected as a state CoIIN team for the National Preconception Health and Health Care Initiative’s application for the Collaborative Improvement and Innovation Network on Infant Mortality (IM CoIIN) HRSA-17-105 funding opportunity.  DE, along with CA, OK, and NC are working with the University of North Carolina, Chapel Hill, Center for Maternal & Infant Health, the parent agency of the grant.  The University of North Carolina requested a no cost extension for an additional year.  One of our main initiatives for the upcoming year is the development of patient education materials that incorporate what we have learned as a CoIIN over the past couple of years.  Delaware will help identify clinicians, largely representing our Healthy Women Healthy Babies program providers and other interested MCH partners to help create some initial materials this fall, as well as those who are willing to review materials and test them with patients.  National technical assistance webinars and newsletters on several preconception topics are also available to our state team partners. 

Over the next year, we will continue incorporating preconception health education into the clinic-based setting, mainly through our family planning sites as well as our Healthy Women Healthy Babies provider sites.  This is an excellent opportunity that will align and enhance Delaware’s efforts to transform the HWHBs 2.0 program.  Delaware will sustain the Preconception CoIIN work through HWHBS 2.0, and bring lessons learned to scale working with 7 health care providers in Delaware.  Milestones include working with providers on implementing small tests of change in asking the Pregnancy Intention Screening Question at the practice site level and gathering data to report on this benchmark indicator, implementing preconception health education in practice based setting, development of education materials and social marketing messaging via DEThrives Facebook, Twitter, and blogs for patients, practice workflow, and prioritizing preconception screening of patients.   

DE CAN Sustainability.  DE CAN has paved the way for improving access to all methods of contraception, including LARCs.  The statewide initiative has improved clinical counseling techniques based on best practices, increased same day access to birth control, increased number of patients screened for pregnancy intention, improved training of staff and clinicians, and increased patient awareness of family planning services.  Several outpatient private providers in addition to our Federally Qualified Health Centers serving our most at risk women, are DE CAN provider sites.  Many of these providers are already receiving funds (state and federal) through the Delaware Division of Public Health, as Title X/family planning providers or Healthy Women Healthy Babies providers.  Essentially, the DE CAN initiative is building on the fabric of our family planning and reproductive health service provider network.  DPH and Upstream USA are continuing to refine sustainability activities to fully integrate the key components of the initiative to DPH, and allow for Upstream USA to transition out of the state to replicate the initiative to other states (i.e. State of Washington, North Carolina, Massachusetts, and most recently Rhode Island). 

DPH is very pleased to share that the FY21 State General Funds in the amount of $1.5M were approved to support the sustainability and ongoing programmatic costs of Delaware Contraceptive Access Now (DE CAN).  DPH in-kind support will continue through DPH and DMMA, a contractual MCH Epidemiologist (.15 FTE) as well as the State Pharmacy as a mechanism to track, store and distribute LARC devices to participating Title X network providers to support the ongoing sustainability, infrastructure and ongoing operational costs.  In addition, DPH gained two (2) new state funded full-time FTEs to sustain limited program operations.  At a minimum, the next phase of DE CAN ensures that health care providers (through the Title X network) who serve low-income uninsured women, are equipped to provide the most effective long acting reversible contraceptive methods.  Furthermore, DPH plans to sustain limited training and technical assistance as designed by Upstream, in consultation with the Delaware DPH, to support the 39 community health centers[1] through attrition and staff turnover who serve the majority of low-income women.  The training plan for the upcoming year includes monthly WebEx hosted Contraceptive Counseling training sessions starting on September 23, 2020, offering a morning and afternoon session for staff convenience.  In-person clinical insertion and removal training will be offered on a quarterly basis, starting on October 21, 2020 and will also host a morning and afternoon session for providers.  The Family Planning team is offering tailored trainings based on specific provider’s needs, making sure that training and technical assistance is seamlessly integrated into their organizational processes and culture. 

In addition, DE CAN funding will also support a stock of LARCs for those birthing hospitals that provide LARCS immediate postpartum so that access continues for uninsured women.  These funds will ensure that a system is in place to sustain access to the most effective methods of contraception, LARCs (IUDs and implants), to Delaware’s uninsured and under-insured women of reproductive age.

[1] In CY2018, Title X had a total number of 39 provider sites, including SBHCs that provide reproductive health services.