Low-risk Cesarean Delivery (FY 2025 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 eliminates barriers. In some situations, and for some medical indications, cesarean deliveries can be a life-saving measure. However, for many low-risk pregnancies, a cesarean delivery can lead to preventable causes of maternal mortality and morbidity outcomes. Such outcomes include mortality due to hemorrhage and morbidities, such as infection, uterine rupture, cardiac arrest, and anesthesia complications. In Michigan from 2016-2020, 7.5% of pregnancy-related deaths were due to hemorrhage and 14.2% were due to infection or sepsis. Overall, 74.5% of pregnancy-related deaths in Michigan from 2016-2020 were deemed preventable1. In 2022, 28.9% of all live births[1] in Michigan were low-risk cesarean deliveries. The 2022 percentage of low-risk cesarean deliveries (28.9%) is above both the Healthy People 2030 goal of 23.6% and the 2022 average for the United States (US) which was 26.3%[2]. While the percentage of low-risk cesarean deliveries has decreased in Michigan from 2021 to 2022, the percentage still remains higher than national and state goals.
As with other birth outcomes, racial disparities are evident in low-risk cesarean births. In 2022, of all live births, 31.5% of black pregnant people had low-risk cesarean deliveries, as did 29.1% of American Indian pregnant people and 35.2% Asian/Pacific Islander pregnant people, compared to 27.9% 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 identified common themes across maternal deaths and drafted recommendations which included increasing access to education for providers and systems related to culturally competent care; reducing stigma, bias, and barriers; and integrating a health equity framework to address systemic inequities. The 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.
The COVID-19 pandemic has had lasting impacts on hospitals across Michigan, including birthing hospitals, as seen through continued staffing turnover rates and low staffing levels. Increasing alignment between the RPQCs, the Michigan chapter of the Alliance for Innovation on Maternal Health (AIM) and the Obstetrics Initiative, encourages birthing hospital participation and accountability with the AIM safety bundles, as well as addresses the disparate outcomes in low-risk cesarean deliveries by bringing awareness of the issue to Collaborative members, and 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%.
The number of low-risk cesarean deliveries will be tracked utilizing data from Michigan’s Vital Records and three strategies will be used to address this objective. The first strategy is to provide information and data related to this NPM to the RPQCs. Increasing the knowledge of RPQC leadership and members related to rates of low-risk cesarean delivery and associated adverse 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 interventions, that can be implemented to reduce the incidence of utilizing cesarean delivery for low-risk births. In addition to the opportunity to garner the voices of families during RPQC quarterly meetings, annual Regional Town Hall meetings, hosted by the RPQCs and MDHHS, provide an additional opportunity for families and birthing people to share their experience with cesarean delivery. The feedback garnered is shared with MDHHS, providers and those leading efforts to reduce Michigan’s number of low-risk cesarean deliveries.
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 are recognized as best practices for safely reducing low-risk, primary cesarean births. RPQC members will continue to become well-versed in these initiatives and will be an asset in providing and technical assistance and education related to data and implementation. In addition to supporting implementation of MI AIM bundle and OBI project components, RPQCs will be encouraged to provide bias training opportunities for providers in their region. Michigan’s disparities in low-risk cesarean delivery rates are attributed to biases and systemic racism. The intent is that as more providers are routinely trained in these topics, they will become increasingly aware of their personal biases, and, therefore, work toward preventing biases from affecting their clinical judgement, especially when faced with decisions related to low-risk cesarean deliveries. As such, it is expected that this strategy will begin to decrease the disparity observed with this measure.
Continued partnership with Michigan AIM (MI AIM) and the Obstetrics Initiative (OBI) is the third strategy toward 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 a reduction in disparities of adverse maternal outcomes. Several staff members from the Michigan Department of Health and Human Services (MDHHS) are working with MI AIM, including the Michigan Title V Director who actively participates on the MI AIM Executive and Steering Teams. In 2022, 63 birthing hospitals in Michigan received a designation status award (e.g., bronze, silver) which corresponds to a certain level of participation in MI AIM. MDHHS will continue to support and encourage all birthing hospitals to participate in MI AIM and OBI through work with MI AIM members and the RPQCs. 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 deliveries 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. Three 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 resources and trainings that hospitals can utilize. Each year Michigan birthing hospitals are assessed for their level of participation and commitment to implementing the AIM safety bundles and subsequently, their commitment to improving maternal birth outcomes. Including bias and equity training in the MI AIM hospital designation 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 Operation 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 advancing maternal outcomes. The goal of this strategy 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, as well as policy and culture change within their respective health care organizations and broadly throughout hospitals participating in MI AIM.
Oral Health – Women (FY 2025 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.” Title V funding provides partial support of an Oral Health Epidemiologist who is responsible for analyzing oral health statistics, community water fluoridation rates, oral health utilization of pregnant people and adults, and Medicaid dental claims.
Leadership for Michigan’s MCH oral health programs and initiatives is located within the Oral Health Section. The Oral Health Section 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, refugee entities, 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 enhanced dental benefit for pregnant people, which now includes coverage for services for one year postpartum. In FY 2025 the enhanced adult dental Medicaid benefit continues to be implemented. The promotion and outreach regarding these changes will continue to play a key role in programmatic activities in FY 2025.
In FY 2025, the Perinatal Oral Health Initiative will continue to maintain educational efforts for the health community and expecting mothers while also continuing to explore 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. As in 2024, 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 be harnessed to address disparities. 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. The data will also continue to be used to bring awareness to the state of Medicaid utilization in Michigan, workforce shortages, and how to create a path forward to address the oral health needs of pregnant people in Michigan. A potential new activity in 2025 is the MI-Mom’s Mouth (MIMM) Project. If the project is awarded funding by HRSA, it would place Community Health Workers (CHWs) into OBGYN departments across Michigan as well as launch a comprehensive educational initiative for providers and patients.
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 2025, 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. The program has adapted to a virtual modality and has systems in place to accommodate virtual trainings, but also completes in person trainings as needed. 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 2025. 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 2025 will see a concerted effort with private practice dentists and Dental Associations to further target these providers, utilizing the new, enhanced Medicaid benefit as a tool to engage the dental community. Data driven efforts will continue to focus on health disparities and equity in specific Michigan regions. If awarded the MIMM HRSA Grant, the OHP will launch a comprehensive, statewide effort to interface with OBGYN providers and other medical professionals and provide targeted oral health education. While this is currently occurring, the award of those funds would dramatically increase populations served.
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 continue hybrid trainings as applicable.
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. 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, the Office of Great Start, home visiting, medical offices (including obstetric providers) and other entities. Material promotion has been a successful strategy and will continue in FY 2025. Efforts may focus on virtual methods of dissemination where applicable. 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 as well as the entire adult Medicaid benefit. MDHHS allotted funds to increase the adult dental Medicaid benefit for pregnant people in FY 2022, and in FY 2023 increased reimbursement and allowable services. This increase in benefits is 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 a second 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 continue to measure the impact of the benefit and guide further educational efforts in FY 2025. 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 2025, the OHP will continue to analyze PRAMS data and new Medicaid data to assess disparities in healthcare access by race and ethnicity. Data will be examined by geographic area which will help to determine targeted interventions and a new data dashboard will be 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 continue to 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 2025, the OHP will continue to take the lessons learned from previous medical dental integrations efforts such as the Michigan Initiative for Maternal Infant Oral Health and will look to promote the best practices discovered surrounding efforts to integrate medical and dental professionals. The MIMM HRSA grant (which the OHP applied for in 2024) uses the MIMIOH model but capitalizes on community health workers to assist pregnant people navigating the dental care system. If awarded, the OHP will develop tools and utilize the CHW community to increase the number of pregnant people within high need areas who receive care. These areas include a clinic in downtown Detroit and two FQHCs (one in southwestern Michigan and one in the Upper Peninsula). New partnerships with refugee entities will continue to be fostered to facilitate models of care to improve oral health service acquisition, with the OHP playing an active role in assisting new arrivals, particularly pregnant people in receiving care.
In FY 2025, the OHP will also continue to provide education to pregnant people and engage directly with the local communities via partnerships with different agencies and groups in the state. SisterFriends Detroit is a volunteer effort to support healthier women and babies that helps women who are pregnant gain access to services and resources in Detroit. They aim to improve birth outcomes and infant mortality rates in Detroit by connecting mentors to women who are pregnant. The OHP started holding oral health educational sessions in FY 2022 with the intention to continue into 2025. Feedback from pregnant people and their mentors has been extremely positive and this practical presentation helps to not only answer common questions and address concerns, but also provides a chance to hear the consumer voice and engage authentically with Michiganders. For example, feedback from pregnant people has helped to shape the presentation and add more relevant content. In addition, in FY 2025 the OHP intends to continue its collaboration with the Office of Great Start within the Michigan Department of Education to share relevant information with different parent and community advisor groups, as a continuation of previous efforts. This collaboration allows the OHP to receive even more community feedback and develop connections and partnerships that help pregnant people receive the care they need.
NEW: Postpartum Visit (FY 2025 Application)
FY 2025 is the first year of the new universally required Postpartum Visit measure. Postpartum care is critical to helping birthing people stay healthy and should be tailored to each person’s individual needs. In addition to being a time of joy, the time after birth – “the fourth trimester” – can present challenges for individuals including lack of sleep, fatigue, pain, breastfeeding challenges, stress, and new or existing mental health concerns. To support birthing individuals, postpartum care should be ongoing versus a single visit. The American College of Obstetricians and Gynecologists (ACOG) recommends that all individuals have contact with their provider within the first three weeks postpartum followed by a comprehensive postpartum visit within 12 weeks after birth.
Prior to 2018, Michigan had higher rates of postpartum checkups than the US. However, since then, Michigan has seen significant declines in postpartum checkups, from 91.2% in 2017 to 87.6% in 2021 (MI PRAMS). While both non-Hispanic white and non-Hispanic Black mothers have also seen significant declines over the period, non-Hispanic Black mothers (80.3%) were almost a full ten points less likely than non-Hispanic white mothers (90.1%) to report postpartum checkups in 2021, which represents a slight improvement of the disparity between those two groups over the previous year (88.6% vs 75.3% in 2020, MI PRAMS). Given that Black mothers in Michigan were 2.2 as likely to die from pregnancy-associated causes as white mothers, closing the care gap is essential for improving maternal mortality rates in the state (MDHHS, Michigan Maternal Mortality Surveillance Program, 2011-2020).
Additionally, the postpartum checkup serves as an important touchpoint for discussions related to health needs and concerns. Conversations with health care providers include if the birthing person felt down or depressed (91.9%) and postpartum birth control options (87%). Other information frequently covered includes information about prescription medications (71.8%), current emotional or physical abuse (68.7%), cigarette use (62.4%) and other topics. 16.5% of PRAMS respondents reported experiencing significant postpartum depression.
As part of Michigan’s Healthy Moms, Healthy Babies initiative, Michigan expanded Medicaid coverage to 12 months postpartum to support the health and well-being of postpartum people and their babies. Other key components of the Healthy Moms, Healthy Babies Initiative includes Medicaid doula coverage and expanding evidence-based home visiting. Michigan’s initial strategies to address postpartum visit are discussed below.
Objective A: Conduct planning and assessment activities related to Postpartum Visit.
In FY 2025, which is the first year of the new universal Postpartum Visit NPM, Michigan’s team will assess the landscape of data and activities that impact postpartum visits. This assessment will inform the next five-year Title V state action plan for FY 2026 – FY 2030. As an initial strategy, staff within the Division of Maternal and Infant Health (DMIH) and the Division of Lifecourse Epidemiology & Genomics will assess data related to postpartum visit. The data review will include PRAMS; Fetal Infant Mortality Review (FIMR) data with a focus on postpartum visits; and maternal mortality data, specifically on timing among pregnancy-related deaths with a focus on the postpartum period by cause and contributing factors. The team will also determine whether any other hospital or provider data are available for review. Furthermore, the team will review the aligned Michigan Maternal Mortality Surveillance (MMMS) and Fetal Infant Mortality Review (FIMR) recommendations to identify any themes that focus on postpartum visits, care, etc. The results of the data review will be summarized to inform the FY 2026 – FY 2030 state action plan.
As a second strategy, Michigan will explore evidence-based and evidence-informed strategies and best practices related to postpartum visit. It is anticipated that the Strengthen the Evidence for MCH Programs consortium will provide tools and resources (including evidence-based strategies) to assist states in relation to postpartum visit and best practices. Michigan will review the information and identify areas of alignment with work that is either already underway or could be implemented in the future. Michigan will also identify at least one evidence-based or informed Strategy Measure (ESM) which will be required as part of the FY 2026 Title V application. Additionally, a review will be conducted using the Title V Information System (TVIS) website and its search functions to determine whether other states have identified strategies to address postpartum visit. The strategies related to this objective will also be informed by any activities completed through Michigan’s Title V needs assessment which is occurring in 2024.
Objective B: Increase awareness about the importance of postpartum visits among pregnant and postpartum people.
Michigan partners with Philips, the creators of the Pregnancy+ mobile application (app), to tailor the app with Michigan-specific articles and connections to Michigan resources. The Pregnancy+ app is the most downloaded pregnancy app in the world, with one-third of Michigan pregnant people using it. The Pregnancy+ app has daily articles, strategies for staying healthy during pregnancy, and interactive 3D models for tracking development.
App users who are Michigan-based and report receiving Medicaid or not having insurance coverage gain free access to premium Pregnancy+ content, including videos regarding exercise, mental health, and nutrition. Philips also runs quarterly surveys of their Michigan users to assess areas of interest. Philips has developed over a dozen articles related to Michigan-specific resources and services in the app. As a first strategy for Objective A, Philips will develop an article for Michigan users related to the importance of the postpartum appointment and what to expect at the postpartum appointment. The MDHHS team will also work with Philips to develop a survey to assess the understanding and perspective of Michigan users related to the postpartum appointment.
The second strategy within this objective is to recruit up to 25 new and eight existing CenteringPregnancy sites to increase access to the CenteringPregnancy model. CenteringPregnancy has been reported to reduce preterm and low birth rates and NICU admissions, while increasing prenatal and postpartum visit attendance. It has also been shown to improve access to high-quality and patient-centered maternity care for people living in historically marginalized communities. In August of 2023, Governor Whitmer and the Michigan legislature passed HB 4437, which appropriated $5 million to increase access to the CenteringPregnancy model of prenatal care for Michigan families. This effort will contract with the Centering Healthcare Institute (CHI) to recruit, support, and implement and sustain the CenteringPregnancy model in new and existing sites throughout Michigan.
The third strategy is to support development and implementation of a postpartum module in the High Touch, High Tech (HT2) Pregnancy Checkup app. As of Spring 2024, 17 sites across four Regional Perinatal Quality Collaboratives have implemented universal electronic screening for mental and behavioral health. These clinical sites provide obstetric and/or preconception care and currently offer the screening tool to all new OB intake patients utilizing the Pregnancy Checkup application (app). Mental and behavioral health concerns don’t disappear once a pregnant person gives birth; in fact, some mental and behavioral health concerns can become exacerbated in the postpartum period. In Michigan, between 2016 and 2020, most pregnancy-related deaths occurred 1-42 days postpartum (38.7%), followed by 43 days or more postpartum (34%)[4]. In those same years, 11.3% of pregnancy-related deaths were due to substance use disorder and 6.6% were due to mental health conditions1. As the third strategy for this objective, Michigan will provide support in the development and implementation of a postpartum component for the Pregnancy Checkup app. The team at Michigan State University, which oversees the Pregnancy Checkup app, will create a postpartum module that includes evidence-based screening tools for mental and behavioral health, brief interventions specific to common postpartum mental and behavioral health concerns, and some educational modules with related content. The postpartum module will be available to the sites already utilizing the app, as well as any new prenatal and postpartum care sites interested in the intervention.
As a fourth strategy, the Lifecourse Epidemiology & Genomics Division (LEGD) and Division of Maternal Infant Health (DMIH) will increase awareness about the importance of postpartum visits though the Michigan Hear Her campaign website and media efforts. This campaign mirrors the CDC’s Hear Her campaign and focuses on elevating urgent maternal health warning signs and providing links to statewide maternal health resources. We anticipate there will be increased awareness of urgent maternal health warning signs, resources for birthing persons and their support people, as well as information aligned with the leading causes of maternal morbidity in Michigan. The Michigan Maternal Mortality Surveillance (MMMS) program will promote the campaign through organizations, agencies, and community groups that serve or represent populations disproportionately affected by pregnancy-related mortality in Michigan.
Intended Pregnancy (FY 2025 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.
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 not a 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 2023, 71.6% of female (i.e., assigned at birth) Family Planning clients aged 15 to 44 years old chose a most effective (sterilization, vasectomy, or LARC) or moderately (pills, patch, ring, cervical cap, or diaphragm) effective method, with 21.5% 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 91 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 2025, MDHHS will monitor local agency provision of contraception through semi-annual Family Planning Annual Report (FPAR) submissions.
The second strategy is to facilitate long-acting reversible contraceptive (LARC) training opportunities for Family Planning and other health care providers. This strategy will focus on supporting on-site access to provider-dependent FDA-approved contraceptive methods. Stocking all methods, including LARC, is necessary to ensuring full access to care. In FY 2025, 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). Providers participating in the clinical practicum will receive training on present and historical coercion of marginalized communities and people of color. 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 is to support the integration of telehealth best practices across Family Planning’s provider network. This strategy will focus on continuing to scale up telehealth practices across Michigan’s Family Planning providers, while working to mitigate the unique challenges telehealth presents for ensuring equitable access to care. In FY 2025, MDHHS will focus on incorporating telehealth best practices and promoting project successes from the cohort of eight local Family Planning agencies that received one-time funding to expand and enhance access to telehealth. MDHHS will utilize its program newsletter, annual events, and other standing meetings throughout the year to disseminate best practices and project successes. MDHHS will provide targeted technical assistance to local Family Planning agencies, as requested.
The fourth strategy, to translate regional listening session findings into action for people of reproductive age, who can get pregnant, will focus on creating actionable strategies to meet identified needs and remove barriers that impede access to sexual and reproductive health care across Michigan. Achieving equitable health outcomes for people who can become pregnant begins with incorporating their knowledge and expertise into the programs designed to serve them. In FY 2024, MDHHS will partner with the Michigan Public Health Institute (MPHI) to facilitate and conduct 13 regional listening sessions. MPHI will analyze the data and interpret the results with MDHHS staff, and in collaboration with the Michigan Family Planning Advisory Council, to inform recommendations for clinical service delivery improvements and future program decision-making. Key findings will be disseminated to state/local partners and stakeholders. In FY 2025, MDHHS will develop and disseminate actionable strategies based upon the findings from the listening sessions, focused on client expansion and retention, and service delivery improvement resulting from the listening sessions.
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 disease transmission and unintended pregnancy while enhancing future reproductive health. In 2021, 67% of sexually active high schoolers did not use a most effective reversible method (IUD or implant) or moderately effective method (shot, pills, patch, or ring) and 14% reported not using any methods to prevent pregnancy at last intercourse (Michigan YRBS, 2021). The teen birth rate for 15- to 19-year-old females (i.e., assigned at birth) was 12.2 per 1,000 in 2021, which is a historic low. Despite improvements in Michigan’s teen birth rate, teens and young adults (i.e., 18 to 21) have unmet reproductive and related preventive health needs. During 2023, 14.2% or 6,414 of Family Planning clients were teens (i.e., <15 to 19 years old), with 84.4% of female (i.e., assigned at birth) clients aged 15 to 19 years old choosing a most or moderately effective method and 20.8% choosing LARC. The best contraceptive option is one that will be used consistently and correctly. Approximately 10.2% of female clients (i.e., assigned at birth) aged 15 to 19 years old chose an external condom as their primary method in 2023, the only method that provides dual protection against pregnancy and sexually transmitted infections (STIs).
The first strategy to achieve this objective, to support at least 6,500 individuals’ 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. In FY 2025, 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, to translate regional listening session findings into action for youth and young adults, will focus on creating actionable strategies to meet identified needs and remove barriers that impede access to sexual and reproductive health care across Michigan. Achieving equitable health outcomes for young people begins with incorporating their knowledge and expertise into the programs designed to support them. In FY 2024, MDHHS will partner with the Michigan Public Health Institute (MPHI) to facilitate and conduct a virtual statewide listening session with the Michigan Organization on Adolescent Sexual Health’s (MOASH) Sexual Health for Adolescents Rooted in Equity (SHARE) youth advisory council, which is comprised of young people aged 16 to 21 who identify as lesbian, gay, bisexual, and queer (LGBTQ); are part of Black, Indigenous, and other people of color (BIPOC) communities; or reside in rural areas across the state. MPHI will analyze the data and interpret the results with MDHHS staff, and in collaboration with the Michigan Family Planning Advisory Council, to inform recommendations for clinical service delivery improvements and future program decision-making. Key findings will be disseminated to state/local partners and stakeholders. In FY 2025, MDHHS will develop and disseminate adolescent specific recommendations resulting from the listening sessions focused on clinical service delivery improvements and future program decision-making.
The third strategy is to translate youth input into action on the Family Planning website to be more youth-friendly in content and visual appeal. Adolescents deserve to know their rights regarding access to 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 2025, MDHHS will translate this youth input into action to create a more youth-friendly Family Planning website.
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, particularly when historical and contextual barriers to care that 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 promoting a position that prioritizes 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.
The first strategy is to include the person-centered contraceptive counseling (PCCC) measure on Family Planning’s annual statewide consumer survey. This strategy will focus on measuring 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 contraceptive counseling was received, 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. Local Family Planning agencies routinely collect consumer input for continuous quality improvement. In FY 2025, MDHHS’s Family Planning clinics will document the patient-centeredness of contraceptive care with all clients receiving family planning services (adult and teen) using the PCCC on its annual statewide consumer survey. Local Family Planning agencies will aggregate survey results and submit to MDHHS for analysis and dissemination.
The second strategy, analyze the PCCC measure, share key findings with Family Planning network, and promote data-driven decision-making, will focus on evaluating the client-centeredness of contraceptive counseling within MDHHS’s Family Planning network and supporting continuous quality improvement of the client experience, as needed. In FY 2025, MDHHS will analyze the PCCC measure to assess contraceptive counseling strengths and disparities at the program and local agency levels. Key findings and implications for practice will be shared with the Family Planning network and partners via the program’s Advisory Council meeting and other standing meetings. At a minimum, MDHHS will utilize key findings to inform its annual training plan to support client-centered contraceptive counseling across the Family Planning provider network. MDHHS will offer technical assistance to local Family Planning agencies on utilizing quality improvement techniques to address disparities in quality of contraceptive care and improve the client experience, as needed.
The third strategy is to promote MDHHS’s updated Contraceptive Counseling Modules with Family Planning network, other healthcare providers, and related public health programs (i.e., home visitors). This strategy will focus on reaching a broad audience of healthcare providers and public health professionals to encourage the utilization of contraceptive counseling best practices. Client-centered contraceptive counseling techniques assist clients with identifying a method that best fits their needs and preferences, free from coercion. Contraceptive methods that meet client preferences are more likely to be used correctly and consistently. In FY 2025, MDHHS will utilize program (i.e., newsletter) and partner (i.e., listserv) communication mechanisms to promote its updated Contraceptive Counseling Modules with its Family Planning network, other healthcare providers, and staff in related public health programs. Continuing education credits will be offered to incentivize participation. MDHHS will monitor module completion rates and participant satisfaction on a quarterly basis.
[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.
[4] Michigan Department of Health and Human Services, Division for Vital Records and Health Statistics, Resident Death Files, 2016-2020.
To Top
Narrative Search