Low-risk Cesarean Delivery (FY 2023 Application)
Percent of cesarean deliveries among low-risk births (NPM 2) was selected as a measure for the Women/Maternal Health domain to address the state priority need of developing a proactive and responsive health system that equitably meets the needs of all populations and eliminating barriers.
For some medical indications, cesarean births can be a life-saving measure. However, for some low-risk pregnancies, a cesarean delivery can lead to preventable risks of maternal mortality and morbidity outcomes. Such outcomes include mortality due to hemorrhage or morbidities, such as infection, uterine rupture, cardiac arrest, and anesthesia complications. In Michigan from 2014-2018, 14.8% of pregnancy-related deaths were due to hemorrhage and 13.1% were due to infection or sepsis. Overall, 62.3% of pregnancy-related deaths in Michigan from 2014-2018 were deemed preventable1. In 2020, 28.7% of all live births[1] in Michigan were low-risk cesarean deliveries. The 2020 percentage of low-risk cesarean deliveries (28.7%) is above both the Healthy People 2030 goal of 23.6% and the 2020 average for the United States (US) which was 25.9%[2].
As with other birth outcomes, racial disparities are evident in low-risk cesarean births. In 2020, of all live births, 30.9% of black pregnant people had low-risk cesarean deliveries, as did 32.1% of American Indian pregnant people and 31.3% Asian/Pacific Islander women, compared to 28.0% of white pregnant people1,[3]. In addition to the data portraying disparities in low-risk cesarean deliveries, anecdotal qualitative data suggest that black and brown pregnant people may feel coerced into delivering via cesarean section. Research has documented the negative feelings and self-perception that can be experienced when birth plans go awry. This can further contribute to experiences of post-traumatic stress disorder, postpartum depression, and anxiety. The Michigan Maternal Mortality Surveillance Review Committee recognized the common themes across maternal deaths and drafted recommendations which included increasing education for providers related to culturally competent care; reducing stigma, bias, and barriers; and integrating a health equity framework to address systemic inequities. The ESM and additional strategies for this NPM will continue to focus on reducing the number of low-risk cesarean deliveries, as well as the racial disparity that exists in this delivery method.
Each of Michigan’s 10 prosperity regions are represented by a Regional Perinatal Quality Collaborative (RPQC) making up the Michigan Statewide Perinatal Quality Collaborative. The RPQCs are focused on improving perinatal outcomes for moms, babies, and families. They are tasked with leading implementation of data-driven quality improvement efforts, authentic engagement with families and community members, convening regular meetings with diverse, cross-sector stakeholders, conducting systems change work and implementing evidence-based interventions. This work is also inclusive of addressing disparities in birth outcomes. The RPQCs are well-respected and comprised of clinical and community leaders, community-based organizations, families, and community members. To help create culturally appropriate and community-informed services, authentically engaging families is a priority of the RPQCs and will apply to efforts directed at reducing low-risk cesarean births. Title V funding has directly supported the RPQCs and/or corresponding MCH initiatives.
The COVID-19 pandemic has impacted hospitals across Michigan, including birthing hospitals. Increasing alignment between the RPQCs and the Michigan chapter of the Alliance for Innovation on Maternal Health (AIM) not only encourages birthing hospital participation and accountability with the AIM safety bundles, but also addresses the disparate outcomes in low-risk cesarean births by bringing awareness of the issue to Collaborative members, as well as offering a platform for garnering feedback, lived experiences and other anecdotal qualitative data.
Objective A: By 2025, reduce the number of cesarean deliveries among all Michigan low-risk births to 27%.
Michigan Vital Records data will be used to track the number of low-risk cesarean deliveries and three strategies will be used to address this objective. The first strategy is to provide information and data related to this NPM with the RPQCs. Increasing the knowledge of the RPQCs related to rates of low-risk cesarean delivery and associated poor outcomes will create broad, baseline understanding across many different agencies, organizations, and health systems. Voices of families, especially those with lived experience, will enrich the understanding and stimulate discussion on efforts and interventions, including nonpharmacological, that can be implemented to address the growing trend of utilizing cesarean delivery for low-risk births.
The second strategy includes continual updates to RPQC membership by regional representatives related to the Obstetrics Initiative (OBI) and the Alliance for Innovation on Maternal Health (AIM) bundle. These national initiatives are evidence-based and recognized as best practices for safely reducing low-risk, primary cesarean births. RPQC members are well-versed in these initiatives and will be an asset in providing education, related to data and implementation, and technical assistance. In addition to assistance with implementation, RPQCs can provide bias training opportunities for providers that are tailored to their region. Michigan’s disparities in low-risk cesarean delivery rates can be attributed to biases and systemic racism. The intent is that as more providers are routinely trained in bias topics, they will become more aware of their personal biases and work toward preventing biases from affecting clinical judgement, especially when faced with decisions related to low-risk cesarean deliveries. Thus, it is expected that this strategy will help drive down the disparity observed with this measure.
Continued partnership with Michigan AIM (MI AIM) is the third strategy in reducing the number of primary low-risk cesarean deliveries. Partnering with stakeholders and professional organizations has allowed Michigan to work toward improved maternal morbidity and mortality outcomes, as well as reduction in disparities of adverse maternal outcomes. Several staff from the Michigan Department of Health and Human Services (MDHHS) are working directly with MI AIM, including the Michigan Title V Director who actively participates on the MI AIM Executive and Steering Teams. Currently, 62 birthing hospitals in Michigan have received a designation status award (i.e., bronze, silver, etc.), which corresponds to a certain level of participation in MI AIM. MDHHS will continue to work with AIM members to support and encourage all birthing hospitals to participate in MI AIM. The number of birthing hospitals participating in Michigan AIM is the ESM for this measure.
Objective B: By 2025, reduce the percentage of low-risk cesarean births in African American, American Indian, and Asian/Pacific Islander pregnant people to 28%, 29.3% and 28.4% respectively.
As discussed above, Michigan has disparities in the number of low-risk cesarean delivery by race. To achieve parity while reducing low-risk cesarean births across all racial/ethnic groups, Michigan’s goal is to achieve by 2025 a 10% relative decline in low-risk cesarean rates for African American, American Indian and Asian/Pacific Islander pregnant people, which equates to 28%, 29.3% and 28.4%, respectively. Four strategies will be used to address the disparities that exist in this birth outcome measure. The first strategy is to include bias and equity training as an annual criterion for MI AIM hospital designation. While each hospital is responsible for providing the training to their respective staff, the MDHHS Division of Maternal & Infant Health webpage houses numerous resources and trainings that hospitals can utilize. Every year Michigan birthing hospitals are assessed for their level of participation and commitment to implementing the AIM safety bundles and thus, improving maternal birth outcomes. Including bias and equity training in the criteria ensures it becomes and remains a priority area of focus for birthing hospital staff, eventually creating sustained change in policies and care for pregnant people of all races and ethnicities.
Encouraging and supporting ongoing bias and equity training of MI AIM Steering and Operational committee members is the second strategy. These two committees are comprised of practicing obstetric and gynecologic providers throughout Michigan who are leaders in the field and committed to improving maternal outcomes. The goal is to ensure these leaders are engaged and knowledgeable in the arena of health equity, including the root causes of disparate outcomes, to encourage growth of knowledge and policy and culture change within their respective health care organizations, as well as broadly throughout hospitals participating in MI AIM.
The third strategy is to support the efforts of the Mother Infant Health (MIH) Health Equity Action Committee, which is focused on developing action plans, deliverable outcomes and improvements in the priority areas highlighted in the Mother Infant Health and Equity Improvement Plan (MIHEIP). The Health Equity Action Committee is an opportunity for families and community members to participate in actively creating change. Current policy recommendations drafted by this Action Committee include: 1) extend Medicaid postpartum coverage and expand eligibility; 2) adopt and ensure culturally responsive practices in data and evaluation; and 3) create external accountability/ombudsman process and infrastructure. These recommendations have been shared with MDHHS leadership and the other Action Committees. The Health Equity Action Committee is expected to periodically meet throughout FY 2023 to revisit these recommendations, discuss any new concerns and draft any additional recommendations, as appropriate.
The fourth strategy focuses on providing ongoing education and training for Michigan Maternal Mortality Review Committee (MMRC) members. This committee is comprised of providers, epidemiologists, other content experts and most importantly family and community members, who review Michigan’s annual maternal deaths. The MMRC was recently restructured to assure diverse membership and equitable, regional member distribution. The team reviews the circumstances surrounding each death, categorizes the death as either ‘pregnancy-related’ or ‘pregnancy-associated, not related’, and determines if the death was preventable. The MMRC also releases recommendations specific to the broad categories of maternal deaths. The intention is that if these recommendations are followed, and changes are made by providers and health systems, more maternal deaths will be prevented. Recommendations are reviewed quarterly, with revisions and additions based on findings of each quarter’s case reviews. To ensure unconscious bias and health equity remain at the forefront of this committee when reviewing cases and creating recommendations, committee members are required to complete annual bias training for continued participation.
Oral Health – Women (FY 2023 Application)
The Title V needs assessment identified need among Michigan’s MCH population related to gaps in dental services for certain populations including young children and pregnant people. Focus group respondents identified a need for more standardized care practices for dental professionals to offer treatment options in an equitable manner as well as an overall shortage of dental providers that will accept Medicaid. As a result, a state priority need was established to “improve oral health awareness and create an oral health delivery system that provides access through multiple systems.” Leadership for Michigan’s MCH oral health programs and initiatives is located within the Oral Health Unit. The Oral Health Unit and Perinatal Oral Health Initiative are housed in the Child and Adolescent Health Division within the Bureau of Health and Wellness in the Population Health Administration, allowing for significant collaboration, particularly on issues related to women’s oral health. The Perinatal Oral Health Initiative partners not only with state programs such as the Maternal Infant Health Program and WIC, but also with Michigan medical and dental schools, nurse practitioner programs, community organizations and local health departments. These partnerships focus on serving populations with the highest level of need and promoting health equity. The Perinatal Oral Health Initiative also continues to partner with Medicaid in the new, enhanced dental benefit for pregnant people, which now includes coverage for services for one year postpartum.
In FY 2023, the Perinatal Oral Health Initiative will continue to maintain educational efforts for the health community and expecting mothers while also exploring additional data to help implement new programs that further address oral health disparities and access to care issues. Current Medicaid data indicate that disparities exist and were further exacerbated by the COVID-19 related dental shutdown in 2020. Currently, less than 1 in 5 pregnant people on Medicaid in Michigan received any dental care during their pregnancy. Less than 5% of pregnant people statewide had any restorative care. In addition, significant racial inequalities persist. African American or Latino pregnant people continue to be less likely to have a dental visit than white pregnant people. Existing strategies that educate providers as well as new strategies that focus on alternative practice models and recent Medicaid enhancements will continue to be harnessed to address disparities. Recent mapping from the University of Michigan that shows racial and ethnic disparities by prosperity region will be shared with stakeholders in local communities and utilized for targeted interventions.
Objective A: Increase the number of medical and dental providers trained to treat, screen, and refer pregnant people and infants to equitable oral health care services.
In FY 2023, the MDHHS Oral Health Program (OHP) will continue to expand efforts to train and educate the medical and dental communities on the importance of perinatal oral health, as well as methodologies and best practices to integrate perinatal oral health into practice. Due to COVID-19, some of these trainings may occur virtually, but the program has adapted to this modality and has systems in place to accommodate virtual trainings. Data collected from a statewide provider survey indicates that many medical providers (82%) acknowledged that perinatal oral health was an important consideration for optimal obstetric management; however, only one-fifth (22%) of providers stated that they routinely examined the patient's oral cavity during pregnancy. Routine oral health assessments by a dentist were also infrequently recommended (28%). These data indicate a need to promote the practices of oral health screening and referral for preventive and restorative dental services among perinatal care providers. Current educational efforts are being evaluated at a 99% approval rating, with professional students indicating that this is the first time they have had comprehensive education surrounding perinatal oral health. In FY 2022, new educational efforts began at a new public health program (Central Michigan University) with a commitment to continue these perinatal oral health lectures into 2023. PRAMS and Medicaid data indicate that continued education efforts must also occur in the dental community surrounding pregnancy, as utilization rates remain low among pregnant women. FY 2023 will see a concerted effort with private practice dentists and Dental Associations to further target these providers. Data driven efforts will focus on health disparities and equity in specific Michigan regions.
The Evidence-based or -informed Strategy Measure (ESM), which is the number of medical and dental professionals who receive perinatal oral health education through MDHHS within a 12-month period, is part of this objective. Departmental trainings and workshops will increase provider knowledge of perinatal oral health as well as provider comfort in discussing the importance of oral health with patients. Trainings include health equity components including but not limited to disparities in access to care and cultural competency. A database of training records continues to be utilized, with the output defined as the number of medical and dental professionals trained by MDHHS. The Perinatal Oral Health Initiative will continue to encourage provider feedback and engagement regarding these trainings with the intention to shift to in-person trainings as allowable based on COVID-19.
Another strategy is dissemination of perinatal promotional and educational materials. Together with a variety of medical and dental professionals and other stakeholders, MDHHS developed Perinatal Oral Health Guidelines to create a unifying voice that emphasizes the importance of perinatal oral health to perinatal care and dental providers. The guidelines provide state-specific resources and tools; provide a summary of the issues surrounding perinatal oral health; and promote the consistent delivery of medical and dental service. In FY 2023, the Perinatal Oral health Initiative will utilize resources in partnership with new perinatal materials such as a Michigan Initiative for Maternal and Infant Oral Health Tool Kit that is under development. This tool kit will be developed in partnership with the Michigan Primary Care Association and a state dental school and will serve as a guide for implementing interprofessional education initiatives within clinical settings. Other materials will focus on health equity, best practices, specific health disparities by region, and proposed recommendations to address health inequities and access to care issues with providers. MDHHS will continue to utilize nationally recognized American Academy of Pediatrics (AAP) materials that are co-branded with both agency logos.
MDHHS will continue to develop and distribute promotional and education materials that promote dental visits during pregnancy and infant oral health to health entities across the state as well as directly to pregnant people. These materials will continue to be developed in partnership with community stakeholders and distributed to local health departments, Federally Qualified Health Centers (FQHCs), WIC clinics, dental offices, medical offices (including obstetric providers) and other entities. Material promotion has been a successful strategy and will continue in FY 2023. Due to COVID-19, efforts may focus on virtual methods of dissemination. Any new materials created will be reviewed with a health equity lens.
The final strategy will include the continuation of communication efforts for dental health providers surrounding changes in Medicaid benefits for pregnant people. MDHHS allotted funds to increase the adult dental Medicaid benefit for pregnant people within the state. This increase in benefit carved dental benefits into Medicaid health plans and increased the availability of dental providers, addressing a critical need in access to care and increasing the number of pregnant people with a dental visit. The number of pregnant people on Medicaid who have at least one dental encounter during the perinatal period is an ESM. Through a data use agreement and IRB with Child Health Evaluation and Research (CHEAR) Center at the University of Michigan) the oral health program will be able to obtain data as needed. CHEAR has access to the data warehouse and the technical ability to analyze the data. Medicaid utilization data that became available in FY 2022 will be crucial to measure the impact of the benefit and guide further educational efforts in FY 2023. This strategy aligns with other statewide efforts by focusing on data-driven solutions, addressing the need for comprehensive care, and reducing poor health outcomes.
Objective B: Increase the number of socioeconomically disadvantaged pregnant people receiving oral health care services.
In FY 2023, the OHP will continue to analyze PRAMS data and new Medicaid data to assess disparities in healthcare access by race and ethnicity. After being delayed by COVID-19, PRAMS data are now available. The data will be examined by geographic area which will help to determine targeted interventions and a new data dashboard will be continually updated to reflect perinatal oral health trends geographically. The targeted interventions will be viewed through a health equity lens and will be adjusted according to the population and groups they address. Efforts will be made to integrate community voice as data efforts move forward and focus on engaging with specific communities across the state through local oral health coalitions. These coalitions are made of local professionals and community members, representing the populations that are being served. This strategy aligns with the statewide focus on data integration and population identification components.
In FY 2023, the Michigan Initiative for Maternal and Infant Oral Health (MIMIOH) will work to maintain participating sites and share results from its comprehensive evaluation. Its continued goal is to improve the oral health of mothers and children in underserved areas and to examine alternative models of care. The MDHHS grant-funded effort began as a one-year project at six sites in partnership with the University of Detroit Mercy School of Dentistry and the Michigan Primary Care Association, with the aim to examine the feasibility and impact of placing a registered dental hygienist in an OBGYN medical clinic. This collaborative model of care also allows for feedback and engagement not only from providers but from the patients served. The feedback obtained from patients via conversations with the dental hygienist will continue to provide an important opportunity to create more culturally and linguistically appropriate educational materials and outreach strategies. FY 2023 will produce a comprehensive evaluation of the program that gives feedback and a community voice to program participants through participant surveys. Efforts will also be made to determine the feasibility of tracking the long-term impacts of the project by determining if dental care during pregnancy resulted in an increase in age 1 dental visits. Also included in the strategy to facilitate models of care to improve oral health service acquisition are new partnerships with refugee entities, with the OHP playing an active role in engaging not only refugee services agencies but also helping to plan alternative models of care for large numbers of Afghan nationals, including pregnant people, in 2023.
In FY 2023, the MDHHS Oral Health Program will continue to provide education to pregnant people via the Perinatal Oral Health WIC Module. This module (delivered through wichealth.org) has served as a training mechanism to mothers across Michigan and on a national level. Wichealth.org provides stage-based, client-centered, WIC nutrition education and an anticipatory guidance model in which WIC clients can successfully complete educational lessons in English and Spanish, with pregnant people completing lessons to receive their WIC benefits. Pregnant people receive personalized feedback and educational materials as well as nurse follow up on any questions raised during the training. This model allows for consumer engagement and feedback from participants through comments and conversation upon module completion. By partnering with WIC, the Oral Health Program can target a diverse range of pregnant people who may experience health disparities. This strategy will continue to be evaluated through the number of pregnant people, who complete the perinatal oral health module. Since its inception, tens of thousands of lessons have been completed, nationally. Developing the modules in other languages or being able to provide the interpretative services will continue to help with addressing language barriers of other populations.
Intended Pregnancy (FY 2023 Application)
For most people, who can get pregnant, their first encounter with the health care system is driven by reproductive health needs, with nearly three decades spent avoiding an unintended pregnancy (Sonfield, Hasstedt, & Gold, 2014). Equipping individuals who can get pregnant and their partners, regardless of life circumstances or ability to pay, with knowledge and access to reproductive health services can improve health outcomes and reduce health care costs over the life course when delivered equitably. Title V needs assessment results indicated Michiganders’ health outcomes are negatively affected by systemic racism, poverty, and trauma. Transportation impeded access to health care systems and services (e.g., routine, follow-up) particularly for low-income and rural individuals. Quality of care was found to be influenced by health care providers’ implicit or explicit bias of clients’ race, class, insurance status/type, and sexual orientation. Maternal and child health service systems were found to assume need rather than intentionally seek input from the entire community to inform programs, policies, and practices. Stakeholders also indicated that women’s health policy is oftentimes contentious and routinely restricts or removes access to needed health education and services.
FY 2023 objectives are concentrated on improving 1) contraceptive access and 2) quality of contraceptive care. Strategies seek to address the Title V needs assessment findings noted above and Michigan’s Title V pillars: 1) equitable health outcomes, 2) seeking the knowledge and expertise of communities and families, and 3) delivering culturally, linguistically, and age-appropriate health education. Strategies that can drive improved performance include facilitating regional listening sessions, telehealth as a service delivery tool, supporting minors’ and young adults’ (i.e., 18 to 21 years old) access to publicly funded contraception, measuring the person-centeredness of contraceptive care, provider training on systemic racism and family planning, and applying a reproductive justice framework to program decision-making. Additionally, this state action plan directly supports related key priorities indicated in MDHHS’s Mother Infant Health & Equity Improvement Plan and Maternal Infant Health Strategy Plan, as well as the Governor’s “Healthy Moms Healthy Babies” plan. MDHHS supports contraceptive access at local agencies through a variety of funding sources, including Title X Family Planning. Title V funding helps to support contraceptive access through local clinics with a focus on serving minors and young adults (i.e., 18 to 21 years old) at no or low cost.
Objective A: Increase the percent of females (i.e., assigned at birth) aged 15 to 44 who use a most or moderately effective contraceptive method from 77% to 82% by 2025.
Contraception is a highly effective clinical preventive service that assists people who can get pregnant in achieving their reproductive health goals, such as preventing unintended pregnancy and achieving healthy spacing of births. While there is no single method of contraception that is right for everyone, the type of contraceptive method used by a person who can get pregnant is strongly associated with their risk of unintended pregnancy. Having access to a full range of effective contraceptive methods allows each person the opportunity to choose the method that is right for them to successfully delay or prevent pregnancy. In 2021, 75% 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 (i.e., pills, patch, ring, cervical cap, or diaphragm) effective method, with 17% choosing LARC.
The first strategy—support the provision of contraception to low-income, uninsured, and underinsured people who can get pregnant in the Family Planning Program—will focus on providing client-centered counseling and a broad range of FDA-approved contraceptive methods to reproductive aged people who can get pregnant at no-cost or low-cost. A focus will be working to ensure that Michigan’s Family Planning network of 33 local agencies and 92 clinical sites offer contraceptive services in accordance with Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Populations Affairs. Family Planning providers are required to have a broad range of contraceptives available, including LARCs. In FY 2023, MDHHS will monitor local agency provision of contraception through semi-annual Family Planning Annual Report (FPAR) submissions.
The second strategy— facilitate long-acting reversible contraceptive (LARC) training opportunities for Family Planning and other health care providers—will focus on supporting on-site access to provider-dependent FDA-approved contraceptive methods. Stocking all methods, such as LARC, is necessary to ensuring full access to care. Clients who receive their method of choice are more likely to use it consistently and correctly, be more satisfied, and continue with it. In FY 2023, MDHHS’s Family Planning Program will offer at least one clinical practicum, promoting it with local Family Planning providers and other safety-net providers (e.g., Medicaid Health Plan, Federally Qualified Health Centers). Additionally, MDHHS’s Family Planning Program can assist local providers by connecting them with pharmaceutical company representatives for individual clinic and/or regional trainings.
The third strategy— support the continued integration of telehealth as a service delivery tool across Family Planning’s network—will focus on continuing to scale up telehealth among Michigan’s Family Planning providers, while working to mitigate the unique challenges telehealth presents for ensuring equitable access to care. In FY 2023, MDHHS will focus on working with a cohort of eight local Family Planning agencies to build upon their lessons learned from providing telehealth services during the pandemic by expanding and enhancing telehealth infrastructure and removing significant technology barriers clients experience to accessing reproductive health services via telehealth. MDHHS will utilize its annual conference to disseminate project successes, innovative service delivery strategies, equity advancements, and lessons learned with its provider network.
The fourth strategy—facilitate regional listening sessions with people of reproductive age who can get pregnant—will focus on gathering the lived experiences of adults who can get pregnant navigating their sexual and reproductive health needs to inform health education, clinical, and case management services. Achieving equitable health outcomes begins with incorporating the knowledge and expertise of individuals who can become pregnant into the programs designed to serve them. In FY 2023, MDHHS will develop the listening session protocol, coordinate session logistics, and summarize session findings. MDHHS will disseminate key findings to state and local partners and stakeholders.
Objective B: Increase the percent of females (i.e., assigned at birth) aged 15 to 19 who use a most or moderately effective contraceptive method from 84% to 89% by 2025.
In Michigan, sexually active adolescents encounter multiple barriers to accessing affordable contraception. Contraception is critical because it protects against unintended pregnancy, disease transmission, and enhances future reproductive health. An estimated 171,780 sexually active females (i.e., assigned at birth) <20 years old need publicly supported contraception (Guttmacher Institute, 2014). In 2019, 65% of sexually active high schoolers did not use a most effective reversible method (i.e., IUD or implant) or moderately effective method (i.e., shot, pills, patch, or ring) and 14% reported not using any methods to prevent pregnancy at last intercourse (Michigan YRBS, 2019). The teen birth rate for 15- to 19-year-old females (i.e., assigned at birth) was 15.1 per 1,000 in 2019, which is a historic low. However, premature birth and low-birthweight babies to 15- to 19-year-old birthing persons worsened the past five years (MDHHS Division of Vital Records & Health Statistics, 2017). Despite improvements in Michigan’s teen birth rate, minors and young adults (i.e., 18 to 21) have unmet reproductive and related preventive health needs. During 2020, 34% or 7,206 of Family Planning clients were teens (i.e., <15 to 19 years old), with 77% of female (i.e., assigned at birth) clients aged 15 to 19 years old choosing a most or moderately effective method and 18% choosing LARC. The best contraceptive option is one that will be used consistently and correctly. Approximately 20% of female clients aged 15 to 19 years old chose an external condom as their primary method in 2020, the only method that provides dual protection against pregnancy and STIs.
The first strategy to achieve this objective—support at least 10,000 minors’ and young adults’ access to publicly funded contraception—will focus on providing client-centered counseling and a broad range of FDA-approved contraceptive methods to sexually active adolescents (i.e., ≤15 to 21 years old) at no-cost or low-cost. Removing financial barriers to contraception assists young people in deciding if, when, and under what circumstances to get pregnant. In FY 2023, MDHHS will monitor local Family Planning providers’ provision of contraception semi-annual clinical service delivery data submissions. Service delivery is routinely informed by youth voice for continuous quality improvement.
The second strategy—facilitate regional listening sessions with minors and young adults—will focus on gathering adolescents’ lived experiences navigating their sexual and reproductive health needs to inform health education, clinical, and case management services. Achieving equitable health outcomes for young people begins with incorporating their knowledge and expertise into the programs designed to support them. In FY 2023, MDHHS will develop the listening session protocol, coordinate session logistics, and summarize session findings. MDHHS will disseminate key findings to state and local partners and stakeholders.
The third strategy—obtain youth input on Family Planning’s website content—will focus on updating Family Planning’s website to be more youth-friendly in content and visual appeal. Adolescents deserve to know their rights regarding accessing sexual and reproductive health services in Michigan, medically accurate information about contraceptive and barrier methods, and what to expect at a Family Planning clinic visit. In FY 2023, MDHHS will work with the Michigan Organization on Adolescent Sexual Health (MOASH) youth advisory councils to review current website content, suggest website enhancements for content and visual appeal, and review revised content and graphics.
Objective C: By 2025, increase by 10% percent the number of Family Planning clients who rate their experience of care with a score of 4 or 5.
Research in family planning has demonstrated that contraceptive counseling has an influence on a client’s family planning outcomes. The clinical encounter provides an opportunity to equip Family Planning clients with quality contraceptive services and counseling for informed decision making. It also has the potential to improve the experiences of clients seeking Family Planning services, when historical and contextual barriers to care which impact disparities are considered. Provision or access to contraception is only one aspect of quality. Given the historical and present-day context of reproductive coercion and oppression experienced by Black, Indigenous, and People of Color, low-income, and incarcerated persons in the United States, there is risk of incentivizing inappropriate pressure to provide certain methods to clients when the sole focus of contraceptive quality is on access to most or moderately effective contraceptive methods. Person-centered contraceptive counseling is an important mechanism for contraceptive access and evaluates the domains of interpersonal connection, adequate information, and decision support between the provider and client. Intentionally assessing clients’ contraceptive counseling experience affords the Family Planning Program the opportunity to measure client-centeredness and implement quality improvement strategies to improve the client experience, as needed.
The first strategy—include the person-centered contraceptive counseling (PCCC) measure on Family Planning’s annual statewide consumer survey—will focus on better understanding the quality of contraceptive care Family Planning clients receive from their provider such as interpersonal connection, adequate information, and decision support. Following a visit at which they received contraceptive counseling, clients will be asked to complete the survey before leaving the clinic. MDHHS collects Family Planning client input annually through a statewide consumer survey administered at each clinic site. The results of the statewide survey will be presented at the program’s Advisory Council meeting and shared with partners. Local Family Planning agencies routinely collect consumer input for continuous quality improvement. In FY 2023, MDHHS will monitor local agency performance on the PCCC measure to observe patient experience, inform quality improvement efforts, and measure changes in patient experience over time.
The second strategy—convene at least one training for 50 health care professionals on systemic racism and reproductive health—will focus on how historical and present-day systemic racism has shaped access, provider interactions, and quality of reproductive health care for Black, Indigenous, and People of Color within the United States. To achieve equitable reproductive health outcomes, providers must understand the role systemic racism plays in creating and sustaining inequities in clinical settings and systems. In FY2023, MDHHS will coordinate training, event marketing, logistics, and evaluation.
The third strategy—apply a reproductive justice framework within Family Planning and related maternal and infant health projects—will focus on continuing to identify program and project opportunities where policies, practices, and performance metrics can be adapted to better align with the reproductive justice framework, which is rooted in maintaining bodily autonomy, the right to have or not to have children, and the right to parent a child or children in a safe and healthy environment. Applying a reproductive justice framework centers the voices and concerns of women of color, which have been historically ignored within the reproductive health and rights frameworks. In FY 2023, MDHHS will use listening session findings, guidance from leading experts in the field (e.g., Sonya Borrero), and lessons learned from other state health departments to identify internal opportunities. MDHHS will vet identified opportunities with leadership and community partners prior to implementation.
[1] Michigan Resident Live Birth Files; MDHHS Division of Vital Records and Health Statistics. Maternal and Infant Health program staff use Michigan Vital Records data more regularly than NVSS data, as the Michigan data are accessible on a more immediate and regular basis.
[3] Michigan is increasingly adopting a health equity framework for MCH outcomes. Utilizing only 1-2 years of race-stratified data from NVSS reduced opportunities to regularly review how these rates were changing for Women of Color and White mothers in Michigan; therefore, Michigan Vital Records data were utilized.
To Top
Narrative Search