PRIORITY: Increase Access to Family Planning Services

 

Objective for SPM 1: Increase the percentage of mothers whose pregnancy was intended from 62% in October 1, 2020 to 64% in September 30, 2025.

 

Description: Between 2016 and 2020, 39% of new mothers in Tennessee said that their pregnancy was unintended (i.e., it was mistimed or unwanted), while 18% said they were unsure how they felt about their pregnancy (PRAMS). Unintended pregnancies were most common among Black non-Hispanic mothers (63%), followed by Hispanics (42%) and White non-Hispanics (32%). The prevalence of unintended pregnancies decreased with increasing maternal age. Among teens less than 18 years of age, 93% of pregnancies resulting in a live birth were unintended. This compares to 54% among women aged 18-24 and 32% among those aged 25 and older.

 

To estimate what percentage of the eligible population is being served by the Tennessee Family Planning program, we compared the number of unique female clients seen in 2019 (first full year prior to COVID) who were 19-44 years of age and uninsured, to the estimated number of uninsured females aged 19-44 in the population (family planning program data and American Community Survey). State-wide, the program is serving approximately 18% of the potentially eligible population. Within individual counties this percentage ranged from 5% to 85%. There were 54 counties (out of 95) that served less than 21% of the eligible population [24 nonurban counties (i.e., micropolitan and noncore) and 20 urban counties (i.e., large core, large fringe, medium and small metros)], highlighting geographic disparities in the need for family planning services.

 

Disparity Elimination Focus: While race, age and other disparities will be analyzed, the focus will be on geographic disparities. Out of the 95 counties served by the family planning program, only 54 are serving more than 21% of the eligible population. More than half of these counties are classified as nonurban. The goal is to increase the utilization of family planning services and women’s health services in these areas and reach clients facing place-based disparities through Strategies 2 and 3 below.

 

The following strategies and activities are planned for October 1, 2022, to September 30, 2023:

 

Strategy 1:  Increase knowledge, awareness, and usage of reproductive life plans through PATH across the state of Tennessee

 

Supporting Evidence for Strategy 1:  A reproductive life plan (RLP) is a set of personal goals about having or not having children which is based on each individual’s own values, goals, and resources. Family planning providers play a key role in helping both women and men to reflect on their reproductive intentions, to complete a RLP and to access appropriate services to meet their RLP goals. PATH is a client-centered approach to assess parenthood/pregnancy, attitude, timing and the importance of pregnancy prevention. PATH can be used with any gender, sexual orientation or age. PATH is designed to facilitate listening and efficient client-centered conversations about preconception care, contraception and fertility as appropriate. PATH training is critical to ensuring a skilled family planning workforce that is able to provide client-centered, non-coercive, and culturally competent services.

 

Activity 1a: Facilitate PATH trainings with various internal and external partners including TPCA, TPHA, colleges and universities, rural health clinics, federally qualified health centers etc.

 

Activity 1b: Provide community outreach and education surrounding the importance of a reproductive life plan and birth spacing to faith-based communities and community partners.

 

Activity 1c:  Create pre and post PATH training evaluations to identify gaps in learning.

 

Activity 1d: Increase assessment with PATH with non-family planning clients within TDH.

 

Strategy 2: Increase rural access to family planning services through telehealth

 

Supporting Evidence for Strategy 2:  TDH seeks to ensure that minority communities, individuals residing in underserved rural and urban areas, and individuals with disabilities can reap the benefits of telehealth by overcoming barriers. These barriers can include taking time off work, transportation, childcare and confidentiality among others. Telehealth has the potential to help clients overcome these barriers and improve access to care.

 

Activity 2a: Promote Family Planning Telehealth services through key partners using flyers, posters, social media posts and other identified promotional materials. Efforts to engage partners with direct ties in counties that serve <21% of the eligible population will be prioritized.

 

Activity 2b: Create, disseminate, and evaluate a client satisfaction survey to identify areas for program improvement.

 

Activity 2c: Continue to expand telehealth services in additional rural health regions by providing additional education and training to key staff and researching additional locations where family planning clients can access a safe space for telehealth visits.

 

Activity 2d: Establish partnerships with health clinics at colleges and universities as well as non-traditional partners to refer clients for telehealth family planning services.

Activity 2e:  Promote family planning through the initiation of a mass media campaign, with additional outreach occurring in the counties that served <21% of the eligible population.

 

Strategy 3: Increase access to women’s health services by addressing and eliminating barriers to care through client navigation.

 

Supporting Evidence for Strategy 3: There are many health inequities surrounding women’s health, obstetrics and gynecology. Client navigation can support efforts to address barriers to care and help to reduce these disparities.

 

Activity 3a: Develop a scope of service for client navigation contracts that at a minimum identify priority populations and expectations               of contracted organization.

 

Activity 3b: Contract with health departments, community clinics, healthcare facilities or federally qualified health centers to secure women’s health client navigators.

 

Activity 3c: Update the navigation tracking tool in REDCap to ensure accurate tracking of clients’ barriers and resolutions.

 

Activity 3d: Provide navigation services according to identified scope while identifying and addressing disparities in care.

 

Planned Partnerships:

• Rural and Metro health departments
• Community Health Services within TDH
• FQHCs/rural health clinic
• Colleges and Universities
• Title X
• National Family Planning and Reproductive Health Association
• Reproductive Health National Training Center
• Faith-based community
• Tennessee Primary Care Association
• Tennessee Public Health Association
• A Step Ahead
• Tennessee Initiative for Perinatal Quality Care
• TennCare
• Association of Maternal and Child Health Programs
• Association of State and Territorial Health Officials
• STD/HIV Program

 

Contextual Factors:

• Ongoing COVID-19 Pandemic
• Access to Technology
• National Program Guidelines and Policies
• Political Environment
• Socioeconomic Factors

 

Assumptions:

• State and Federal funding will be secure throughout the program period
• PATH training will be adopted and used in the way we intended
• Professionals will be motivated to attend trainings and implement what they have learned
• Staff with the necessary skills and abilities can be recruited, hired and retained.
• Continuation of essential health services
• Medical leadership buy-in
• Continued support of increased access to care

 

Percent of Population Served by the Family Planning Program:

PRIORITY:  Decrease Pregnancy-Associated Mortality

 

Objective for SPM 2: Increase the percent of facilities implementing patient safety recommendations from 24% on October 1, 2020 to 33% on September 30, 2025.

 

Objective for SPM 3: Increase the percent of community level recommendations implemented from 10 on October 1, 2020 to 25% on September 30, 2025.

 

Description: Disparities exist among women who die during pregnancy or within a year of pregnancy. Among all deaths, non-Hispanic Black women were 1.5 times as likely to die during or within a year of pregnancy compared to non-Hispanic White women. The disparity is much greater among pregnancy-related causes of death, where non-Hispanic Black women are 3.9 times as likely to die from pregnancy-related causes compared to non-Hispanic White women. The highest risk age group was women forty and older.  This group was nearly four times as likely to die within one year of pregnancy compared to women less than 30. There was also a disparity in place of pregnancy-associated mortality.  The West and Shelby County area had the highest rate (124.1) while Mid-Cumberland had the lowest (57.5).

 

Disparity Elimination Focus: The team will focus on addressing place and race-based disparities. There is a large difference in rate of pregnancy-associated death in Shelby County/West TN, and many of the causes of death in this region of the state have been determined to be preventable. Additionally, non-Hispanic black women are more likely to die overall and even more likely to die from pregnancy-related causes.  The goal is to reduce pregnancy-associated deaths in the Shelby County/West TN area through Strategies 1, 2 and 3 below.

 

The following strategies and activities are planned for October 1, 2022 to September 30, 2023:

 

Strategy 1: Increase surveillance of maternal deaths

 

Supporting Evidence for Strategy 1:  Moderate evidence to suggest maternal mortality review provides comprehensive information on causes of death, preventability, contributing factors, and leads to actions improving maternal deaths.

 

Activity 1a: Identify pregnancy-associated deaths and facilitate state Maternal Mortality Review Committee meetings.  The Committee will identify age, race and place for each death reviewed to identify disparities.

 

Activity 1b: Through the Maternal Mortality Review Committee, determine the relatedness of all deaths to pregnancy, contributing factors, cause(s) of death, and preventability of all deaths. For each pregnancy-related death determine age, race and place of death to identify disparities. For each pregnancy-related death, the MMRC will determine the cause as specified by Pregnancy Mortality Surveillance System.

 

Activity 1c: Analyze data for the annual maternal mortality report. Additional data on causes of death by race and place for each death reviewed will be included in order to identify disparities. Data will show the disparity in race, top causes of death by race and region of the states in which the death occurs. Qualitative data will also be included to identify gaps in care among these deaths.

 

Activity 1d: Develop recommendations for preventing subsequent maternal deaths based upon MMRC findings and for inclusion in the Maternal Mortality annual report and dissemination to relevant stakeholders quarterly. These recommendations include reference to specific disparities, contributing factors, and cause(s) of death identified in the reviews.

 

Strategy 2: Increase evidence-based education at hospitals on topics identified by the Maternal Mortality Review Committee (MMRC).

 

Supporting Evidence for Strategy 2:  Moderate. Provider education, such as continued medical educational opportunities appear to be effective.

 

Activity 2a: Contract with Tennessee Hospital Association (THA) and Tennessee Initiative for Perinatal Quality Care (TIPQC) to provide training to birthing and non-birthing hospitals on top causes leading to maternal death as identified by the MMRC.THA will use claims data to identify areas of the state with the top causes of death and then provide simulation training on the top causes at non- birthing hospitals located in those areas. TIPQC will offer birthing hospitals education on pre-eclampsia. Areas of the state with the highest numbers of deaths due to pre-eclampsia will be prioritized. Birthing hospitals in West TN will be given top priority for trainings provided by THA and TIPQC since the highest disparities in maternal deaths overall are observed in this region.

 

Strategy 3: Increase access to services through community agency involvement to improve maternal health outcomes.

 

Supporting Evidence for Strategy 3:  Moderate: There is evidence to suggest that expanded insurance coverage is effective.

 

Activity 3a: Convene a maternal health task force, with a minimum of 25 members, quarterly to highlight innovative and best practices for preventing maternal death. The task force will include membership from the Office of Minority Health and Disparities Elimination to represent vulnerable populations. Analyze membership to determine whether additional participants are needed to represent top causes of maternal death such as homicide and cardiovascular disease. Collaborate with the Office of Health disparities to identify new members that represent/serve individuals who are at the highest risk of dying from the leading causes of maternal death.

 

Activity 3b: Fund a minimum of 3 community agencies to implement MMR recommendations on top causes of maternal death identified by the MMRC. Funded community agencies will be tasked with implementing recommendations to address the leading causes of maternal death (i.e., cardiovascular diseases and violent death) among the most at-risk populations. Applicants will be asked to describe how the proposed project addresses disparities (race and/or place). Proposals will be evaluated on how well they are addressing at-risk populations.

 

Activity 3c: Increase the number of women of childbearing age participating in family planning and well woman visits by expanding and promoting telehealth to better reach those people in areas at risk for pregnancy-associated deaths.

 

Activity 3d: Increase the number of women applying for presumptive eligibility by implementing an outreach plan and collaborating with community partners to reach vulnerable populations.

 

Activity 3e: Disseminate recorded domestic violence trainings to community groups in Shelby County to increase awareness of DV resources. Domestic (intimate partner) violence is a contributing factor to many maternal deaths by homicide. Therefore, this activity addresses the disparity in place of maternal deaths by homicide (almost half of maternal homicide deaths occur in Shelby County).

 

Activity 3f: Contract with agency to provide training on the danger assessment and work with local community agencies to implement the assessment. Community agencies within Shelby County/West TN will be prioritized to address the place-based disparity of maternal death by homicide (almost half of maternal deaths by homicide occur in Shelby County and firearms were the lethal weapon used in 74% of maternal homicides).

 

Planned Partnerships:  TIPQC, THA, Maternal Health Action Team Members, Maternal Mortality Review Committee, Family Planning, Presumptive Eligibility

 

Contextual Factors:

• TIPQC and THA have a long-standing history of statewide education to providers.
• TIPQC only has capacity to assist providing hospitals with implementing one AIM bundle at a time
• Funding of agencies is competitive and dependent upon agencies applications for funding.

 

Assumptions:

• Training healthcare providers will improve maternal outcomes.
• Increasing enrollment in family planning will improve preconception health and prevented unplanned pregnancies, thus decreasing the risk for maternal death.