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HHS announces equity in postpartum care Phase 1 winners

HHS announces equity in postpartum care Phase 1 winners

More than one-half of pregnancy-related mortality in the United States occurs in the 12-month postpartum period, and about one-third occurs within the first year post-delivery. Pregnancy-related deaths are three to four times more common among Black or African American and American Indian/Alaska Native (AI/AN) women than among Caucasian women.

Black or African American women have the highest risk for progression from gestational diabetes to chronic diabetes, yet have lower rates of getting screened for diabetes postpartum. About 13 percent of postpartum women experience depression, with higher self-reported rates among women of color. Black or African American women ages 20-44 years have more than twice the hypertension prevalence of other racial and ethnic groups.

To address these maternal health disparities, the HHS Office on Women’s Health and the Centers for Medicare and Medicaid Services launched the HHS Racial Equity in Postpartum Care Challenge. This $1.8 million national competition was developed to improve equity in postpartum care for Black or African American and AI/AN women enrolled in Medicaid or the Children’s Health Insurance Program (CHIP). Medicaid covers 42 percent of all births, with two-thirds of births to Black or African American and AI/AN women ensuring quality healthcare for delivery and the postpartum period.

HHS is excited to announce the 25 winners of Phase 1 of the competition.  These organizations demonstrated success in addressing equity during the postpartum period with an emphasis on follow-up care for diabetes, postpartum depression and/or anxiety, hypertension, and substance use disorders.

“Improving postpartum care for Black or African American and American Indian or Alaska Native women is critical to addressing the significant and persistent racial and ethnic disparities in pregnancy-related deaths,” said Dorothy Fink, M.D., Deputy Assistant Secretary for Women’s Health and Director of the Office on Women’s Health. “By partnering with the Centers for Medicare and Medicaid Services to support innovation in postpartum care, we can reach and improve the care of nearly half of all women who give birth in this country.”

Changing the face of postpartum care

From a mobile healing unit on wheels called “Sistas Van” in Brooklyn to doula services in Dallas and American Indian peer support in Wyoming, the 25 challenge winners have found new ways to connect women with the care they need.

The program’s multi-pronged approach includes the use of mobile health units and home visiting as well as telemedicine to bridge obstetrician care with mental health in hard-to-reach communities.

Many of the winners are harnessing technology to improve care. Children's National Medical Center uses Mammha, a HIPAA-compliant mobile and web-based platform that provides in-office/in-hospital and remote maternal mental health screening, psychoeducation, and referral delivery as well as brief care coordination for at-risk patients. In addition, Heart Safe Motherhood, a text-message based platform designed at Penn Medicine, provides patients with automated reminders to check their blood pressure along with tracking blood pressure measurements and alerting patients and medical providers when certain thresholds are exceeded.  

The 25 winners of Phase I of the HHS Racial Equity in Postpartum Care Challenge are listed below:

  1. Benten Technologies– Philadelphia, PA
    Program/Focus: MommaConnect mHealth App
    MommaConnect is a digital healthcare platform for Black/African American mothers that facilitates remote psychotherapy. This program offers two evidence-based therapies to reduce PPD symptoms and promote quality of maternal-infant interaction. The app is designed to address potential access challenges for Black/ African American mothers in underserved communities.
  1. Big Horn Valley Health Center, Inc. – Big Horn County, MT
    Program/Focus: Sacred Families Model
    This program provides care and support to postpartum women by utilizing American Indian peer support specialists to connect families to individualized services, including medical care, behavioral health services, and substance use treatment and services. The program was able to triple the number of program participants served from 2019 to 2020.
  1. Black Women's Blueprint, Inc.– Brooklyn, NY
    Program/Focus: Sistas Van, Home Visiting, Telemedicine Mental Health Model
    This program provides care and seeks to extend care throughout the state of New York by using mobile and remote services to address gaps in care for underserved postpartum women. The program uses a combination of approaches, including mobile health vans, home visiting programs, and models that include care, treatment, and referrals to address mental health needs.
  1. Center for Women’s Reproductive Mental Health (Johns Hopkins) – Baltimore, Maryland
    Program/Focus: The Integrated Perinatal Clinic
    This program provides mental health services to postpartum women up to 6 weeks after delivery. The program provided services virtually during the pandemic and strives to expand services to implement an integrative care clinic to provide behavioral health services to African American and low-income prenatal and postpartum patients.
  1. Mammha at Children's National Medical Center – Washington, DC
    Program/Focus: Technology/ Mobile App
    This program offers a mobile app to screen and connect postpartum women to mental health services. The program utilizes peer support specialists and SMS text messages to identify behavioral health needs and connect patients to care. As a result, the program screened 484 women in 9 months. 
  1. Delighted to Doula Birth Services – Dallas, Texas
    Program/Focus: Community Based Postpartum Doula Program
    This program provides comprehensive postpartum support utilizing professional and peer services to educate families on infant feeding and maternal health. The program provides postpartum families hands-on support, including home visiting, assistance with cooking, cleaning, errands, and assistance with attending postpartum appointments. 100% of women served in this program are enrolled in Medicaid or CHIP, and 80% of women are Black or African American.
  1. Diversifying Doulas Initiative – Lancaster, PA
    Program/Focus: The Diversifying Doulas Initiative
    This program focuses on increasing access to certified doula services for Black/African American women in Lancaster County, Pennsylvania. The program has the option for Black/African American women to be trained as doulas and for patients to receive doula services free of charge.
  1. Emagine Solutions Technology, LLC – Tucson, AZ
    Program/Focus: The Journey Pregnancy
    This program focuses on the health of prenatal and postpartum individuals by engaging patients in care and working. The program utilizes a free cell phone application that allows participants to log their symptoms and vitals, such as headaches, nausea, shortness of breath, blood pressure, blood glucose, and mood. This information is then fed directly into the clinic’s interface, where providers can monitor their patients and respond in real-time.
  1. Hamilton Health Center, Inc – Harrisburg, PA
    Program/Focus: Greater Harrisburg Healthy Start, Healthy Start Initiative
    This program utilizes a combination of strategies to improve postpartum care, including patient engagement and incentives, adding qualified healthcare professionals, creating a network between the health center and providers, and evaluation and performance monitoring. Case managers and nurse practitioners educate patients on the postpartum period and work with patients to develop postpartum care plans.
  1. Healthy Hearts Plus II – Chesterfield, VA
    Program/Focus: Mommies Bellies Babies and Daddies Care Coordination, Technologies for Outreach
    This program offers a suite of digital solutions to improve postpartum care and coordination of services for Black/ African American women during the postpartum period. It uses multiple technologies, software and Apps, visualizations, and social media in English and Spanish to engage patients, increase reach, retention, and enrollment in the Mommies Bellies Babies and Daddies program.
  1. Heart Safe Motherhood Institution: Penn Medicine – Philadelphia, PA
    Program/Focus: Heart Safe Motherhood, Way – Text Message Based Platform to Improve Blood Pressure Control
    This program provides patients with automated reminders to check their blood pressure. It tracks blood pressure measurements and alerts patients and medical providers if certain thresholds are exceeded. The program enrolled close to 12,000 patients and received 157,000 blood pressure measurements.  
  1. MedHaul Inc. – Memphis, TN
    Program/Focus: Technology Platform for Providers
    This program provides over 9000 rides for patients who need to get to health-related appointments, including postpartum care visits. This program has provided over 9,000 rides and increased attendance at appointments from 40% to 92%. Providers directly schedule roundtrip patient transportation appointments utilizing a dedicated technology platform.
  1. Northwell Health, Inc. – Westchester County, NY
    Program/Focus: Maternal Health Outcomes and Morbidity Collaborative (MOMS)
    This program serves over 8 million patients throughout communities in New York. It utilizes comprehensive care coordination and patient-centered approaches throughout the prenatal and postpartum period to identify risk factors and connect patients with medical, behavioral health, and social supports and services.
  1. Nurse-Family Partnership – Denver, Colorado
    Program/Focus: Client-Centered Nurse Home Visitation Program
    This program uses a team of nurses to assess, monitor, educate, and advocate for patients to control pregnancy-induced and postpartum hypertension. Their primary population is low-income women who are pregnant for the first time. More than 85% of participants in this program initiated breastfeeding. This program increased the retention of postpartum participants by adding telehealth services and providing 3,800 smartphones to participants in the program.
  1. Ovia Health – Boston, MA
    Program/Focus: Digital Applications: Ovia Fertility, Ovia Pregnancy, and Ovia Parenting
    This program utilizes free cell phone applications that allow users to log reproductive health information, including their menstrual cycle, pregnancy, and the postpartum period. This information is then used to provide participants with education, reminders, and recommendations to connect with providers.
  1. The University of Texas Southwestern Medical Center – Dallas, TX
    Program/Focus: Maternal Care After Pregnancy (eMCAP)
    This program focuses on extending postpartum care among underserved populations, with 85% of participants enrolled in Medicaid. This program provides postpartum and behavioral health services to participants up to 12 months after birth utilizing community health workers, home visiting, telehealth, and an in-person mobile unit with medical providers, social workers, and pharmacy services.
  1. The Children’s Home Society of New Jersey – Trenton, NJ
    Program/Focus: Maternal Child Health Education and Support Programs
    This program utilized a combination of strategies to provide care to postpartum women: maternal child health education programs, access to doula services, prenatal health education, and pregnancy testing at no cost to participants. The program achieved 383 postpartum doula visits in 2021 and provided education on postpartum care and postpartum medical visits. Through this program’s efforts, 93% of program participants initiate breastfeeding.
  1. The Maternal Health program: CyncHealth, Collective Medical, and Innsena LLC – Omaha, NE
    Program/Focus: The Maternal Health Program Provides Digital Solutions to Care  
    This program serves patients enrolled in Medicaid or CHIP in Nebraska. The program uses technology to identify, track and connect providers to health data, including indicators for diabetes, hypertension, depression and/or anxiety, substance use disorder (SUD), and substance-exposed infants. This information feeds into a system that initiates alerts and sends reports to providers.
  1. The Norton Healthcare Foundation, Inc. – Louisville, Kentucky
    Program/Focus: Doula Program, Institute for Health Equity, Telehealth
    This program developed a doula program, utilizing virtual visits to increase access to care. The program delivers close to 9000 babies every year and provides services to racially and socioeconomically diverse patient populations (50% Black or African American and 73.2% enrolled in Medicaid). 
  1. THE POPPING IN PROGRAM (PIP) – Chicago, Illinois
    Program/Focus: Mental Health Screening and Treatment
    This program uses Graduate Student Volunteers and remote platforms to provide mental health screening and treatment for participants. Mental health screenings and treatment are provided for up to one year after birth.
  1. University of Pittsburgh Physicians – Pittsburgh, PA
    Program/Focus:  Maternity care management (MCM) Baby Steps Program, Payment Models, Outpatient and Remote Services
    This program utilizes a combination of strategies to provide care to postpartum families. It includes The Maternity Care Management (MCM) Baby Steps Program; payment and data collection models to increase access to services and eliminate barriers to payment; increase quality of care; postpartum hypertension remote monitoring; and standardized depression and IPV assessment and support. 
  1. Vital Start Health Inc. – Philadelphia, PA
    Program/Focus: Technology to Improve Postpartum Care, Courage and Perinatal Coaching
    This program focuses on mental health and education. It utilizes digital technologies (virtual and augmented reality) to assess, screen, and treat patients for behavioral health needs. 
    Program/Focus: Postpartum Hypertension Follow Up Program
    This program uses a multidisciplinary approach, including registered nurses, maternal health, and cardiology specialists, to assess and provide follow-up care for postpartum patients with hypertension. As a result of this program’s efforts, there was an increase in follow-up visits with providers from 16% to 37% over three months.
  1. Woman’s Hospital – Baton Rouge, LA
    Program/Focus: Diabetes Navigation System
    This program coordinates and provides care for prenatal and postpartum patients with diabetes. The program is led by a nurse who provides care for prenatal and postpartum patients with care for the patient, including diagnosis, treatment, and follow-up during the postpartum period. 74% of patients attend postpartum appointments in this program. 
  1. Yale School of Medicine Community Health Care Van Mother Infant Program – New Haven, CT
    Program/Focus: Mobile Van (Community Healthcare Van- CHCV), CHCV Mother Infant Program, Curbside Postpartum Care
    This program utilizes mobile support to provide medical services and care to postpartum families. The program’s mobile van provides behavioral health services, substance use disorder screening, and connects patients to treatment and care. In 2021 the program expanded and has served 260 mothers and achieved over 900 visits, with 43% of mothers in the program identifying as Black/ African American.