In May 2005, the Infant Mortality Task Force at the time issued a report that included 20 recommendations to reduce the number of Delaware babies who die before their first birthday (rate of infant mortality) and to eliminate the racial disparity in the rate at which these babies die.  The infant mortality rate is generally regarded as proxy for the overall health of a community.  The infant mortality rate (IMR) for black babies is 2.7 times that of white babies in Delaware.  Maternal age, chronic illness (asthma, hypertension, diabetes), nutrition, infection (STI, HIV), stress, unwanted pregnancy, smoking, and other drug use and lack of prenatal care are all factors that increase the risk of adverse pregnancy outcomes and maternal complications.  

In 2005-2006, the Division of Public Health (DPH) and key stakeholders developed the infrastructure required to implement the Infant Mortality Task Force recommendations. To this day, DPH partners with Medicaid to develop policy and wraparound services supplementing direct care services for preconception, prenatal, and postnatal care.  The Delaware Healthy Mother and Infant Consortium (DHMIC) was established by Governor appointment to monitor and evaluate implemented programs and services and adopts by-laws necessary for efficient functioning, election officers, appointments of members and meets on quarterly basis. Additionally, the DPH’s Center Family Health and Epidemiology was established to provide scientific expertise and technical support to DPH and the DHMIC. The goal of the DPH staff are to help measure the impact of all programs that provide services in MCH, provide expertise in application for federal and other supplemental funding opportunities, and facilitate evaluation of all MCH-related programs.  In addition, the CDC-assigned State MCH Epidemiologist supervises the research and data projects within the Center, and offers scientific advising for all MCH-related projects.  In 2019, DHMIC and DPH and stakeholders went through a shift in our intervention framework, focused more on addressing the social determinants of health required to achieve desired physical health outcome goals. 

This year, DPH led a comprehensive strategic planning process to develop a five year plan for the DHMIC, which led to another huge paradigm shift, largely related to a change in leadership, whereby the Chair and Vice Chair with more than two decades of experience leading the DHMIC, both stepped down at the same time in the Spring of 2023.  A very special tribute video was created which highlighted many accomplishments, under Dr. David Paul and Susan Noyes’ leadership, which was shared at the 2023 Annual DHMIC Summit.  Over the next year, DPH and the DHMIC will be laser focused on orienting new leadership, new members and addressing themes captured during the DHMIC strategic planning process expressed by members and stakeholders:  a desire for revisiting the committee structure and membership engagement, improved communications and transparency, and accountability strategies such as data dashboards to measure and report on success. 

The DHMIC established the Healthy Women Healthy Babies (HWHBs) program in July 2009.  A significant amount of state funds, approximately $4.2M, is invested in several infant mortality reduction initiatives as well as improved health outcomes for women and babies.  The primary focus of the IMTF/HWHB funding has been to reduce the number of Delaware babies who die before their first birthday.  The strategy has been to identify women at the highest risk of poor birth outcomes and to address any underlying medical conditions that predispose them for poor outcomes before they get pregnant or if they are already pregnant, to work with them to mitigate their risk.  The success of this effort lies in the fact that since its inception, our infant mortality rate had dropped almost 30% over the last decade of intense efforts and evidence-based program interventions.  In the past few years, substantial funding has been directed at addressing the social determinants of health which are the major drivers behind the racial disparity.  In FY 21 and FY22 in state General Funds $1.5 million has been budgeted to this SDOH effort and will remain a priority.  Additional ARPA funds have also been leveraged to support two demonstration projects, one on addressing housing instability and preventing pregnant women from homelessness and a second on a guaranteed basic income pilot, both aimed at improving maternal and infant health outcomes. Over the next year we plan to monitor and share preliminary data and impact of the demonstration projects.  The guaranteed basic income demonstration pilot was launched in April 2022 and the housing instability project will focus on short and long term policy and systems changes.

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

The HWHB program is housed under the Division of Public Health in the Family Health Systems Section and has completed three full years of the new refreshed model to improve preconception, prenatal, and birth outcomes of Delaware women, particularly those at increased risk.  The new model is a value/performance-based approach focused on meeting or exceeding 6 benchmark indicators, with an emphasis on addressing the social determinants of health and incorporates the role of community health workers to further support outcomes.  The Division of Medicaid and Medical Assistance (DMMA) was an essential partner in the transformation of the HWHBs 2.0 model and continues to play a role in the program’s enhanced model and performance-based redesign.  In the next year, we plan to continue to review benchmark data indicators and demographic data as well as explore data linkages of HWHBs 2.0 patient data with Medicaid claims data to monitor benchmarks and outcomes.  We have one year remaining in this 5 year cycle to assess whether the new model is moving the needle on producing evidence on improving health outcomes for women and birth outcomes.  DPH will issue a RFP to solicit bids for HWHBS 3.0 in January 2024.  Two years ago, Medicaid hired a MCH Quality Assurance Administrator or clinical lead who is a Nurse Practitioner, and this position had turnover in November 2022, and was only recently filled in the Spring of 2023. DPH was convening reoccurring monthly meetings with this individual along with the DMMA Medical Director to align quality improvement efforts with Title V MCH priorities to improve health outcomes for women and babies.  However, due to staff turnover, and the DMMA Medical Director being tapped to serve as Interim DPH Director, and balancing two leadership roles, it has been challenging to meet regularly.  As of this writing, DPH was notified that the Interim DPH Director is leaving state employment and her post in interim leadership and her last day is August 4, 2023.  Over the next year, we plan to re engage and hope to meet monthly again to discuss policy, programming and interventions impacting the maternal and child health population. 

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

Over the next year, DPH in collaboration with DHMIC partners plan to further track and analyze benchmark data and the performance based approach to the to the Healthy Women Healthy Babies program, a medical intervention and develop HWHBs 3.0..   DPH will also monitor and support 10 community based interventions in high risk zones implemented across the state that address some of the underlying environmental, economic and social structures that impact resources needed for health, such as poverty, lack of stable housing, access to healthy foods, access to early childhood education, medical legal partnership, financial literacy, etc.  The plan for the coming year, is to discuss the findings with new DHMIC leadership, Committees and  and prepare recommendations that take into account the ROI, costs and sustainability, and explore alternative evidence based models, such as guaranteed basic income models (i.e. Abundance birth project in San Francisco, CA).  In the coming year, Health Management Associates (HMA) will continue working closely with DPH and DHMIC to serve as a backbone agency as part of the maternal and infant mortality reduction work to build state and local capacity, and test the 10 small scale innovative strategies to shift the impact of social determinants of health tied to root causes related to infant mortality.  The primary focus is innovation and to spread evidence-based programs and place-based strategies to improve the social determinants of health and equity in maternal and infant health outcomes.  HMA will work with DPH and DHMIC to staff and facilitate the SDOH Workgroup, staff and facilitate a Doula Adhoc Committee, the Well Woman Committee and provide coaching and technical assistance to the 10 local community based interventions, schedule quarterly learning collaboratives for partners, provide extensive coaching and technical assistance to existing and new mini-grant awardees, and create shared metrics and tools for quality improvement and overall evaluation. 

Implementation of the Delaware Healthy Mother and Infant Consortium (DHMIC) Five Year Strategic Plan will be a priority in the upcoming year.  Plans are underway to onboard the newly Governor appointed DHMIC Chair, Vice Chair, and new members and orient them to the current infrastructure, roles and responsibilities, programs and interventions, and strategic priorities.

The Delaware Perinatal Quality Collaborative (DPQC) was established in February 2011 as an action arm and under the umbrella of the DHMIC and now functions as its own board and is charged to collaborate closely with DHMIC.  The DPQC is composed of representatives from birth hospitals and the Birth Center in Delaware.  The collaborative benefits from the leadership of neonatologists, primatologists, nursing directors, hospital administrators and advocates.  A Medical Director, who serves as a long standing DHMIC member, is a well-respected perinatologist and is also the Chair of the Maternal and Child Death Review Commission.  The Medical Director and the Perinatal Nurse Specialist are tasked with oversight, education and technical assistance on workflow and process issues that will support changes in practice.  The Perinatal Nurse Specialist effectuates changes in practices using academic detailing to explain and implement standards, enhancing access to information and resources, and assessing the program’s impact on a continuous basis. The DPH, Center for Family Health Research and Epidemiology, receives and compiles data for quality improvement purposes and provides the cooperative with access to data and resources.  In 2020, the DPQC was formally established in Delaware Code and signed by the Governor during a virtual press conference.  It was not until June 2023, that formal Governor appointments were solidified, due to staff turnover.  DPH did not have a role in identifying any of the representatives of the hospitals/birthing institutions.  Those selections were coordinated by the Delaware Healthcare Association reaching out to the institutions and asking them for their representative.  The plan is to update and approve bylaws this coming year and set up structures to organize the work of the DPQC.  The Bylaws were discussed at a meeting in March but the group could not vote to approve it because they had not been appointed.

Data collection and analysis is crucial to the DPQC’s efforts to improve the care and outcomes of DE’s women and their babies.  The foundation of the collaborative is to share current data to use for benchmarking and QA/QI, identify best standards of care/protocols, realignment of service providers and service systems, continuing education of professionals and increasing public awareness of the importance of perinatal care.  Establishing the Collaborative in Code gives them the ability to:

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

Over the next year, DPH will revisit the staffing infrastructure and support to the DPQC and will research other state models over the next year.  

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

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

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

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

Currently, the PPE’s most prominent chapter was re-established this year at the University of Delaware.  PPE at the U of D’s educational outreach has included presentations in high school classrooms, informative kiosks on campus, educational presentations to Greek life organizations, and even occasional abroad experiences in Jamaican villages.  Over the years, this chapter has evolved in many ways, but currently its students as well as the DHMIC are less focused on community and abroad outreach and more focused on the internal organization of each chapter, technical assistance as well as their presence on campus.  The DHMIC Woman, Infant and Families Nurse Specialist provides the support and technical assistance to the PPE chapters, but it is becoming more apparent that more focus needs to be on creating standardized operations and procedures within this chapter to keep the organization afloat when faced with turnover of leadership and participants.  In the coming year, efforts will focus on sustaining the UD PPE Chapter, working with the new faculty advisor.

Over the next year, we will continue incorporating preconception health education into the clinic-based setting, mainly through our family planning sites as well as our Healthy Women Healthy Babies provider sites.  This is an excellent opportunity that will align and enhance Delaware’s efforts to transform the HWHBs 3.0 program.  Delaware will sustain the Preconception CoIIN work through HWHBS 3.0, and bring lessons learned to scale working with 7 health care providers in Delaware.  Milestones include working with providers on implementing small tests of change in asking the Pregnancy Intention Screening Question at the practice site level and gathering data to report on this benchmark indicator, implementing preconception health education in practice based setting, development of education materials and social marketing messaging via DEThrives Facebook, Twitter, and blogs for patients, practice workflow, and prioritizing preconception screening of patients.   

DE CAN Sustainability.  DE CAN has paved the way for improving access to all methods of contraception, including LARCs.  The statewide initiative has improved clinical counseling techniques based on best practices, increased same day access to birth control, increased number of patients screened for pregnancy intention, improved training of staff and clinicians, and increased patient awareness of family planning services.  Several outpatient private providers in addition to our Federally Qualified Health Centers serving our most at risk women, are DE CAN provider sites.  Many of these providers are already receiving funds (state and federal) through the Delaware Division of Public Health, as Title X/family planning providers or Healthy Women Healthy Babies providers.  Essentially, the DE CAN initiative is now sustained building on the fabric of our family planning and reproductive health service provider network. 

DPH is very pleased to share that there continues to be a sustained funding investment, since FY21, through State General Funds in the amount of $1.5M to support the sustainability and ongoing programmatic costs of Delaware Contraceptive Access Now (DE CAN).  DPH in-kind support will continue through DPH and DMMA, a contractual MCH Epidemiologist (.15 FTE) as well as the State Pharmacy as a mechanism to track, store and distribute LARC devices to participating Title X network providers to support the ongoing sustainability, infrastructure and ongoing operational costs.  In addition, DPH gained two (2) new state funded full-time FTEs to sustain limited program operations.  At a minimum, the next phase of DE CAN ensures that health care providers (through the Title X network) who serve low-income uninsured women, are equipped to provide the most effective long acting reversible contraceptive methods.  Furthermore, DPH continues to sustain limited training and technical assistance as designed by Upstream, in consultation with the Delaware DPH, to support the 39 community health centers[1] through attrition and staff turnover who serve the majority of low-income women. 

The DECAN training plan for the upcoming year includes five in-person trainings which include both non-clinical and clinical portions.  Each training session varies in number of attendees and audiences depending on the needs of providers/clinics but the preparation is usually geared towards 10-15 people.  DECAN non-clinical trainings can now be requested for site specific locations or opt for a virtual training.  The Family Planning team is currently working with the TAPP Network to build and develop a virtual training platform for the DECAN non-clinical training which can will allow staff to register and participate in the training fitting into their schedule.  The Family Planning Program will monitor participants and track completion through the new Learning Management System.  

In addition, the Family Planning team drafted regulations to support implementation of a bill passed in 2021 that authorizes and permits pharmacists to dispense and administer hormonal birth control.  The regulations help Delaware comply with the law and help establish a protocol to implement the law into practice.  Over the next year, the Family Planning team will need to develop a training curriculum, expanding current DE CAN training tailored to pharmacists.  This will require research, planning, coordinating with the Board of Pharmacy, other stakeholders as needed and leveraging national technical assistance, and assembling a team to assist with developing a training curriculum.

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

[1] In CY2022, Title X had a total number of 39 provider sites, including SBHCs that provide reproductive health services.