How Delaware transformed Its healthcare system for women
As we continue to confront the worst public health crisis in our lifetime, health systems are prioritizing emergency care while other essential care hangs in the balance. In many ways, Delaware has been preparing for this moment. During the pandemic, health centers across our state have continued to ensure women have access to birth control, no exceptions. Delaware spent years investing in a new women’s health infrastructure, and now we are seeing those efforts pay off.
Ten years ago, Delaware had the highest rate of unplanned pregnancies in the U.S. - 57 percent of pregnancies were unintended. A decade later, Delaware has transformed its healthcare system and reshaped contraceptive access across the state. By integrating reproductive care into primary care, we’re empowering Delawareans to become pregnant only if and when they want to.
From 2014 to 2017, unplanned births dropped 25 percent in Delaware, according to the Centers for Disease Control and Prevention. At the same time, Delaware saw a 37 percent decline in the abortion rate, the most significant drop of any state in the country and more than four times the national decline.
This remarkable progress is linked to our comprehensive effort to increase access to birth control for all Delawareans. The state of Delaware under governors Jack Markell and John Carney partnered with the nonprofit Upstream USA and our Division of Public Health and the Division of Medicaid and Medical Assistance to work with thousands of providers across the state. Rather than limiting or banning contraceptives or abortions, we ensured access and care for all patients, one health center at a time.
The status quo was not working. Patients were not regularly asked about their pregnancy intentions or reproductive life goals when they went to see a doctor. Doctors were not always providing adequate counseling on the full range of birth control methods. And when women decided they wanted an IUD or implant - considered the most effective forms of birth control - they often had to schedule unnecessary additional appointments. This is a huge burden that could require taking time off work or arranging child care. In fact, one study found that about half of women who requested an IUD did not attend the follow-up appointment to place it.
During my time as cabinet secretary, I’ve heard many stories about how our work with Upstream and providers across our state has changed the lives of women and their families. Brittany’s is one of those stories. During college, she didn’t have a lot of extra money for an IUD and told herself, “I guess I’ll have to get better at taking the pill.” After checking with her healthcare provider, she learned that Delaware had a program to cover the cost of the IUD and she made an appointment. Today as a nurse, she has big career goals. “My IUD lets me plan my life,” she says.
Her story illustrates the importance of integrating reproductive and primary care and making all forms of contraception available in a single visit at low or no cost. And that’s exactly what we did in Delaware. Notably, this did not involve building something new, but instead working within our existing infrastructure to provide training and technical assistance to medical providers both in our hospital systems and in private practices. This may not sound momentous, but training staff at every level at practices of all sizes - from doctors and nurses to receptionists - is crucial and worth the time and investment.
When you put all of these pieces together, it translates to patients receiving best-in-class care in one visit - and that’s a game-changer. Just as important, we implemented a sustainable model, changing the foundation of how health centers operate so that they can continue to provide this patient-centered care going forward. And surveys indicate that over 99 percent of patients either made their own decisions about contraceptive methods or shared decision-making with their provider.
It’s important to note that this work doesn’t happen in isolation, nor is it a singular solution. Delaware’s commitment to improving outcomes for women and families does not start and end with contraceptive access. Delaware, like the rest of the country, must prioritize improving maternal health outcomes, particularly for Black women, people of color, transgender individuals, and those with lower incomes.
As health care providers, we all must address our own biases, particularly when it comes to ensuring patient autonomy. That is why a key component of our training is ensuring that all staff in the healthcare setting can recognize bias and avoid coercive practices.
Over the course of five years, we created systemic change throughout Delaware’s healthcare system. We made sure that family planning and reproductive health are a regular part of conversations between patients and their providers. We made sure that no matter what, women have access to all forms of birth control in a single visit. By investing in more equitable health care, we have laid a foundation of care that has proven resilient and accessible during the COVID-19 crisis.
As I leave my position as cabinet secretary, I know this critical work will be in good hands going forward. Governor Carney nominated DHSS Deputy Secretary Molly Magarik as the new cabinet secretary, and her appointment was confirmed by the Delaware Senate. Our incoming Secretary knows the importance of our partnership with Upstream and health care providers across the state. And she understands the difference it is making in the lives of Delaware women and their families.
During a pandemic, it is clear to me as a family physician that we cannot afford to put off essential health care. In an age of uncertainty for reproductive health care, Delaware’s common-sense solution has made birth control access a reality for tens of thousands of women. We encourage other states and communities to do the same.