Maryland’s priority need for the women’s/maternal health domain is “to ensure that birthing people are in optimal health before, during, and after pregnancy.” Maryland Title V provided preventive and primary care through direct, enabling, and public health infrastructure services to a variety of women’s/maternal health needs in FY 2022. 

 

Services and activities focus on the needs of women and birthing people across the Title V pyramid as outlined by the State Action Plan. Within the maternal health priority area, there are three focus areas in maternal health:

• Focus Area 1: Oral Health measured by the national performance measure (NPM 13.1) of percent of women who had a preventive dental visit during pregnancy.
• Focus Area 2: Substance use prevention and linkages to care and measured with two performance measures:
  • 1) NPM 14.1, percent of women who smoke during pregnancy
  • 2) the state performance measure (SPM 1) of Overdose Mortality Rate for women, ages 15-49.
• Focus Area 3: Reduce rates and eliminate disparities in maternal mortality and morbidity with the state performance measure of reducing severe maternal morbidity rates that aligns with the State Priority that is tied to Maryland’ health care financial model called Total Cost of Care.

 

 

Focus Area 1: Oral Health

 

NPM 13.1: Percent of women who had a dental visit during pregnancy. According to Maryland 2021 PRAMS[1] data, 49.3%of mothers had a cleaning during pregnancy, compared with 47% in 2020. The percentage of mothers receiving oral health care during pregnancy in 2021 increased among non-Hispanic Black individuals from 44.3% in 2020 to 46.3%) and among non-Hispanic White individuals (from 53.1% in 2020 to 60.2%). However, the percentage of Hispanic individuals receiving oral health care during pregnancy decreased from 40.0% in 2020  to 31.8% in 2021. Slight increases were seen among mothers (age 20+) with 12 or fewer years of education (37.1% in 2020 to 39.2% in 2021) and among mothers (age 20+) with 13 or more years of education (52.3% in 2020 to 54.5% in 2021). Due to subpopulation response rates not meeting the lower threshold (30 respondents), stratification by age category cannot be reported.

 

Key partners that work toward improving oral health include the Office of Oral Health (OOH) within the Prevention and Health Promotion Administration, local health departments, and local dental clinics. During FY2022, the OOH shared the updated  “Oral Health Care During Pregnancy: Practice Guidance for Maryland’s Prenatal and Dental Providers” with community-based organizations, primary care providers, and local health departments. The practice guidelines emphasize that pregnant individuals should make a dental appointment early in pregnancy. In addition, the guidelines share myths versus facts and emphasize important information such as maternal oral health affects future child health. The guidelines also provide information on the oral conditions during pregnancy such as dental caries, pregnancy gingivitis, periodontitis, pyogenic granuloma, and tooth erosions.

 

 

In FY2022, Title V funds also supported programming to pregnant people at local health departments throughout the state.  A total of 669 pregnant people were referred to dental care by local health departments in FY 2022. The number referred is lower than in FY21 when 1,251 pregnant people were referred and higher than in FY2020 when  only 627 pregnant people were referred. However, it is lower than pre-pandemic levels. Of note, for one of the jurisdictions, referrals to Dental care focus on the undocumented and uninsured population. During COVID, the County Dental program experienced numerous challenges including the lack of dentists, hygienists, and dental assistants.

 

 

Focus Area 2: Substance Use Prevention and Linkages to Care: This focus area has two performance measures: 1) NPM 14.1, percent of women who smoke during pregnancy and 2) the state performance measure (SPM 1) of Overdose Mortality Rate for women, ages 15-49

 

Performance Measure 1: NPM 14.1: Smoking during pregnancy: In 2020, which is the most available data, Maryland was slightly below the national average for women who smoked during pregnancy, with 4.2% of Maryland women who smoked during pregnancy, compared to 5.5% nationally (National Vital Statistics System).[2] Maryland has seen a downward trend in the percentage of women who smoke during pregnancy since 2010 (8.9%), while the national trend reached its peak in 2014 (7.9%) and has started decreasing since 2015. The percentage of Maryland women who smoked during pregnancy in 2019 was highest among non-Hispanic White women (7.4%), followed by non-Hispanic Black women (4.2%), and Hispanic women (0.8%).

 

During Fiscal Year 2022 Title V continued the partnership with MDH’s Center for Tobacco Control and Prevention, which provides enhanced counseling services that motivate pregnant women to quit smoking. Counseling interventions provide motivation to quit and support to increase problem solving skills. Counseling interventions may include motivational interviewing, cognitive behavior therapy (CBT), other psychotherapies, problem-solving and other approaches.  Pregnant people are more likely to quit when cessation counseling is combined with motivational interviewing and is provided by a trained educator.

 

The QuitLine, which is funded by MDH’s Center for Tobacco Control and Prevention is a free service to all Maryland residents age 13 and older.  The program for pregnant people consists of one initial and nine proactive follow-up coaching calls. Participants may call in for additional support at any time. The timing of proactive calls is relapse-sensitive, and the focus of the follow-up coaching calls is relapse prevention. Medication use is monitored to assure use compliance, assess and problem-solve potential side effects. The Quit Coach assesses the participant’s status and progress, builds upon information previously gathered, identifies barriers, and reinforces successes.  Coaches have degrees in counseling or addiction treatment.

 

In FY 2022, the quitlines enrolled 39 pregnant individuals, which is decreased from FY2021 with 67 enrollments. The decrease is most likely due to decreased funding for outreach and communications available. The Center for Tobacco Control and Prevention is looking to resume further outreach and communications in 24.The Quitline also had 23 participants in the Pregnancy Rewards Programs. The Pregnancy Rewards Program encourages and supports pregnant women that use tobacco to engage in support from the Quitline. This incentive program offers rewards to women who are pregnant and up to six months postpartum who complete a series of calls with a Quit Coach. Eligible callers receive $25 gift cards to Target in four installments, based on a total of ten completed calls (maximum of $100 per participant).

 

Title V funds local health departments to routinely screen women for tobacco use and offer referrals to the State’s QuitLine. Staff who screened were from home visiting, home birth certification, early intervention, and family planning clinics.  In FY 2022, 68 individuals were referred to tobacco cessation programs, including the QuitLine. This is a dramatic decrease from FY2020, when a total of 892 prenatal/postpartum people were referred to tobacco cessation programs, including the Quitline above.  This has reflected the overall decreases for referral to services due to COVID.

 

 

Performance Measure 2:  Overdose Mortality Rate for women of reproductive age. (SPM 1)

While overdose mortality rate for women of reproductive age was not a state performance measure during 2016-2020, efforts to prevent overdose deaths are added below to reflect the urgent need to address overdose deaths.

 

The rate of overdose deaths for women ages 15-49 was 29.7 per 100,000 population in 2020 according to the Maryland Vital Statistics Administration.[3] In Maryland, the number of unintentional drug- and alcohol-related intoxication deaths has decreased from 2020 to 2021.

 

Preliminary data showed that unintentional overdose was the leading cause of pregnancy associated deaths in Maryland at 38 percent in 2020 (the most recent year data is available from the Maryland Maternal Mortality Review Program). According to the Maryland Behavioral Health Administration, it is estimated that only 21 percent of pregnant people with opioid use disorder received opioid maintenance treatment in 2019, a substantial decrease from 75 percent reported in 2018. This decrease can be explained by multiple factors: Maryland bases this metric on Administrative Services Organization (ASO)-Optum claims data and starting on January 1, 2020, the question, “Are you currently pregnant?” is no longer a mandatory part of the registration process. Additionally, providers have the option to opt out of asking and providing a response to this question. According to Maryland BHA, preliminary data shows that about 80 percent of providers are opting to not answer additional reporting questions. Finally, due to the MDH Network Security incident, there is a delay in data reporting. It is likely that the 21 percent of pregnant people who received maintenance treatment is an underestimate.

 

Incident characteristics of overdose deaths can be found in the annual Maternal Mortality Review Report, with the latest available report from 2020, which contains data from 2018. In Maryland, from 2010-2018, there were 91 overdose-related pregnancy associated deaths in Maryland, with 75% (n=69) White Non-Hispanic, 20% (n=18) Black non-Hispanic, 3 as other non-HIspanic. On average these overdose deaths occurred 198 days postpartum.  Fourteen percent (n=13) had not initiated prenatal care.

 

The State has developed the Opioid Operational Command Center (OOCC) to coordinate activities to prevent overdose deaths. The OOCC developed an overdose dashboard in 2021 and can be found here: https://experience.arcgis.com/experience/c546d22ec4a946cbb700a282f53c6eb7/

 

 

Strategies to decrease overdose fatalities due to unintentional opioid use

 

Identification and linkages to treatment with the Maryland Medicaid Maternal Opioid Misuse Model

With over 21,000 individuals of childbearing age diagnosed with Opioid Use Disorder in Maryland, substance use is a leading cause of maternal death and has a significant impact on the approximately 1,500 infants born to Medicaid beneficiaries with OUD in Maryland per year.  State Medicaid launched its Maternal Opioid Misuse (MOM) model in January 2020, with funding from the Center for Medicare and Medicaid Innovation (CMMI) and in collaboration with the Centers for Medicare and Medicaid Services (CMS).  The model is a five-year, multi-pronged approach to combating the nation’s opioid crisis by addressing fragmentation in the care of pregnant and postpartum Medicaid beneficiaries with opioid use disorder (OUD).

 

The MOM model focuses on improving clinical resources and enhancing care coordination to Medicaid beneficiaries with OUD during and after their pregnancies through the special needs coordinators in the Managed Care Organization.Under the MOM Model, Healthchoice MCOs received a per member, per month (PMPM) payment to provide enhanced case management services, standardized social determinants of health screenings and care coordination, as well as encourage the utilization of prenatal care and behavioral health counseling. In FY2022, the PMPM payments transitioned to the MCH Population Health Improvement Fund, with federal matching dollars authorized under the §1115 HealthChoice demonstration. The St. Mary’s pilot, started in July 2021, continued for an additional year. The model intends to expand throughout the state, becoming available to all eligible HealthChoice members. 

 

As part of the MOMS Model, the Department, through Maryland Medicaid, partnered with University of Maryland and the Maryland Addiction Consultation Services (MACS) to provide trainings to providers. These trainings encourage the use of buprenorphine for those with opioid use disorder and enrolled 198 practitioners in MACS for MOMs during FY 2021. In addition, there were 44 perinatal calls received through the MACS warmline and they also hosted two webinars with a total of 160 attendees. MACs also launched the MOMS TeleECHO clinic that is held monthly.

 

Title V Program has been partnering with the Medicaid Maternal Opioid Misuse Model team to expand referrals to the Local Health Departments and Managed Care Organizations through the  Maryland Prenatal Risk Assessments (MPRA). Under COMAR 10.09.68.05 the PRA should be completed for Medicaid participants at the first prenatal care visit.  Specifically, the Title V Program has emphasized the importance of the PRA during the local health department technical assistance calls. During FY2022, a pilot to integrate the PRA into an electronic format was conducted in the Baltimore metro region. Five clinics were selected to develop the PRA into an electronic format and integrate it into the Electronic Medical Record System. Integration of the ePRA resulted in a 26% increase in total MPRA submissions.

 

Screening, Brief Intervention, and Referral to Treatment with the Maryland Family Planning Program

The Maryland Family Planning Program (MFPP) values the holistic approach to health service delivery, while noting that family planning service sites often function as the sole source of health care for some populations.  Given this, the MFPP expanded services to include the opportunity to identify those with substance misuse and the ability to facilitate a referral for expanded care.   The MFPP implemented a comprehensive program-wide training to implement SBIRT (Screening, Brief Intervention, Referral, and Treatment) in FY 2021 and developed a means for data collection for initiative evaluation. SBIRT activities are mandated through policies with the MFPP, as the Title X grantee, while service delivery is provided through collaborations with 22 subrecipients who executed SBIRT through 60 service sites across Maryland..  

 

In FY2022, the MFPP provided services to over 53,000 new and continuing care clients.  In that time, there were 113 positive SBIRT evaluations for clients who were referred for further services.  95 were identified as female and 18 identified themselves as male.  Of these individuals served, 23 of those with a positive screening, returned to the service site where a referral follow-up was completed.  The MFPP subrecipients are tasked with developing resources to support the referral process. The MFPP continues to collect data on screening and referral to treatment in FY23 and has established a continuous quality improvement plan through the quality assurance site review process. It is our goal to continue our partnership with the MDH Behavioral Health Administration to explore other opportunities to expand family planning service delivery with those individuals identified as experiencing substance misuse to reduce barriers to care.  Pending the availability of funds, MFPP also intends to provide additional funding to sites to strengthen relationships with substance use disorder treatment centers.

 

 

Babies Born Healthy Initiative

During FY 2022, eight sites across seven local jurisdictions implemented state funded Babies Born Healthy (BBH) programs, which directed resources to engage women and communities in an effort to provide supportive coordinated care and address disparities in infant mortality rates in Maryland. BBH sites provided care coordination services for high-risk pregnant and postpartum people. All program participants are assessed for resource needs and connected to resources and provided resources on a wide variety of topics, including, but not limited to, WIC and food security, prenatal care, health insurance, and infant safe sleep. BBH sites also provided linkages to care for further treatment for those who are experiencing substance use or opioid use disorder. Many BBH sites provide extended care coordination for 6 months to a year, for program participants who are experiencing substance and/or opioid use disorder. One BBH site, Anne Arundel County Health Department, provides home visiting and transportation services through their BBH program to program participants experiencing substance use disorder, to address barriers to receiving care and treatment. 

 

Focus Area 3: Reduce rates and eliminate disparities in maternal mortality and morbidity

 

This focus area is tied to the State Performance Measure (SPM 2) that aims to reduce Black NH to White NH severe maternal morbidity gaps. In addition, this focus area is linked to the national outcome measure (NOM 2)  of Severe Maternal Morbidity and NOM 3 of Maternal Mortality. Title V works to achieve this focus area through a lifecourse approach.

 

As background, this state performance measure is a population health goal tied to Maryland’s health care financial model with the Total Cost of Care. As part of the Total Cost of Care, the State proposed to Maryland to focus on population health goals including having goals related to maternal and child health. In FY 2021, Centers for Medicare and Medicaid Innovation (CMMI) approved the State’s proposal to focus on Severe Maternal Morbidity and asthma. .

 

Based on data through October 2022, the State’s Severe Maternal Morbidity (SMM) rate was 288.5 events per 10,000 delivery hospitalizations (Health Services Cost Review Commission).  This is 18.6 percent higher or 45.4 hospitalizations per 10,000 higher than the 2018 SIHIS baseline. SMM rates were highest among non-Hispanic Black women (405.8  per 10,000) The rate is an increase from the SIHIS baseline of 2018 and 2019.

 

To understand the root cause of the increase in SMM rates and the impact of COVID in maternal health an  analysis was previously conducted by the MCH Epi team on Maryland live births from January 1, 2019 through June 30, 2021.  The Alliance for Innovation on Maternal Health (AIM) ICD-10 codes for SMM were used to determine SMM events and the ICD-10 code U07.1 was used to determine a COVID-19 diagnosis during the birth hospitalizations. It was determined that the results of the analysis indicated that COVDI-19 diagnosis contributed to the rising rates of SMM in Maryland birthing people, especially among the Hispanic population. Overall, there was an increase in SMM rate in Maryland by 30% from 226.0 SMM diagnoses per 10,000 delivery hospitalizations in the Q1 period of 2019, to 292.5 per 10,000 in the Q2 period of 2021. When analyzing the increase in SMM rate by race and ethnicity, the largest increase was seen among Hispanic birthing people, at 52% (from 227.4 per 10,000 in 2019-Q1 to 346.3 per 10,000 in 2021-Q2).While the results were analyzed in FY2021 and 2022, the Title V team used this information in FY2022 to provide further information and work with local health departments on their efforts to increase information on COVID vaccinations. This included developing a printable and electronic version of a brochure of why vaccination for pregnant and breastfeeding people were important. This brochure was translated into several languages including Spanish, French, Tagalog, Chinese, Russian, and Korean.

 

To continue the efforts to address the increase in SMM rates in the state of Maryland, through the internship program PHASE (Public Health Applications for Student Experience) a partnership between MDH and Johns Hopkins Bloomberg School of Public Health. MCH PHASE Intern began a literature review to have a deeper understanding of the root causes of the increase in SMM rates. A meeting with the maternal health team in November 2022 helped focus the analysis to three questions:

 

1) What is the current rate of severe maternal morbidity in the United States?

2) How has the covid-19 pandemic affected maternal health outcomes in the United States?

3) What other initiatives are other states undertaking to address maternal health, specifically severe maternal morbidity?

 

In December of 2022, the search terms were finalized for the first two questions and inclusion and exclusion criteria were developed. The literature review continued into FY23 and it is expected to result in valuable insights and findings that will contribute to ongoing research and inform decision-making processes.

 

 

 

Strategies to reduce rates and eliminate disparities in maternal mortality and morbidity

Overall, there is a Statewide Maternal Health Improvement Program Strategic and Action plan through the Maternal Health Improvement Task Force that focuses on reducing disparities in maternal mortality and morbidity. Please see the Strategic and Action plan here that uses a life course approach. Please see below for further information on Title V contributions to improve maternal health in the state as well as more information on the Maryland Maternal Health Innovation Program.

 

 

Maternal Mortality Review Program

The Maternal Mortality Review Program (MMR Program) reviews all pregnancy-associated deaths (PADs) (deaths during or within one year after the end of a pregnancy from any cause).

 

Due to delays in receiving data because of the COVID-19 pandemic and the Department’s network security incident in December 2021, the analysis of 2020 PADs started later than usual, in Spring 2022. This year was also the first year that the MMR Program utilized the Maternal Mortality Review Information Application (MMRIA) database. MMRIA is built and operated by the Centers for Disease Control and Prevention, to assist MMR efforts and standardize data collected. From a preliminary analysis of 2020 PAD data, behavioral health conditions (which includes substance use disorder and overdose) continue to be the leading causes of death for PADs. We were also able to collect additional information about the impact of the COVID-19 pandemic.

 

Based on the most recent public data, which is the 2020 report that contains data from 2018, there were 38 pregnancy-associated deaths, resulting in a pregnancy-associated mortality rate of 53.5 deaths per 100,000 live births. Of the 38 pregnancy-associated deaths, 18 were determined to be pregnancy-related, for a pregnancy-related mortality rate of 25.3 deaths per 100,000 live births. Among the 18 pregnancy-related deaths in 2018, the leading causes of death were noncardiovascular conditions, cardiovascular conditions, and suicide, each accounting for three deaths. Homicide, amniotic fluid embolism, and thrombotic pulmonary embolism each accounted for two deaths. The remaining pregnancy-related deaths were single cases of substance use with unintentional overdose, infection, and pregnancy-induced hypertension. 

 

Of the 18 pregnancy-related deaths occurring in 2018, six cases (33 percent) involved non-Hispanic White women, ten cases (56 percent) involved non-Hispanic Black women, and two cases (11 percent) involved Asian/Pacific Islander women. Among the 20 non-pregnancy-related deaths, 11 cases (55 percent) involved non-Hispanic White women, seven cases (35 percent) involved non-Hispanic Black women, one case involved a Hispanic woman, and one case involved a non-Hispanic woman whose race was identified as other. The rate of pregnancy-related deaths in non-Hispanic Black women was 2.2 times higher than that of non-Hispanic White women.

Further information of the Maternal Mortality Review Report can be found on the Maternal and Child Health Bureau webpage here: https://health.maryland.gov/phpa/mch/pages/mmr.aspx .

The Maryland Maternal Mortality Review Program has focused increased attention on disparities in pregnancy-related deaths. In 2018, the Maryland General Assembly enacted legislation to establish a Maternal Mortality Stakeholder Group composed of the Maryland Office of Minority Health and Health Disparities, the Maryland Patient Safety Center, the Maryland Healthy Start Program, women’s health advocacy groups, community organizations, local health departments, health care providers serving minority women, and families that have experienced a maternal death. This Stakeholder Group is tasked with reviewing the findings and recommendations in the annual Maternal Mortality Review Report, examining issues resulting in disparities, and identifying new recommendations with a focus on disparities in maternal deaths.

 

In 2022, the Stakeholder group reviewed the results of the 20190 report, and met again to develop their accompanying recommendations. In 2019, the leading cause of PA deaths was substance use/unintentional overdose. Other leading causes included injuries and non-cardiovascular medical conditions. Overall, there continues to be a trend of racial disparities in PR mortality rates for Black pregnant persons compared to White pregnant persons. The Stakeholder group discussed and recommended the need to engage school-based health centers to support adolescent and young adult health. They also further discussed how to improve access to services at the community level, and what programs have been successful. Expanding policies to support birthing people to attend necessary care was discussed, and the group explored models in other states/jurisdictions that might be applicable to Maryland. They also further noted the need to address transportation as a barrier to receiving care, and strategies they have seen used to support patient access.

 

The Program is also moving towards a multi-disciplinary review team to conduct comprehensive case reviews in line with national best practices for mortality review. In July 2022 the Program released a call for applications to seek additional members to join the Maternal Mortality Review Team (MMRT). We specifically sought members with experience in public health, population health, community birth work, or experiences that would better reflect the experiences of people most impacted by maternal mortality. In Fall 2022 we successfully seated 17 new members, in addition to 16 returning members from the earlier MMR committee. The first MMRT meetings were scheduled for early 2023.

 

Launching the SIHIS Public Health Funding Initiative

 

Through HSCRC funding a competitive procurement was pursued to expand evidence-based and promising practice home visiting as well as to increase CenteringPregnancy, a group-based prenatal care program. Evidence-based home visiting programs offer a proven track record in addressing or at least mitigating disparities in healthcare quality and health outcomes by coordinating care, providing education programs, and continuing findings suggest how home visiting can be a mechanism to improve maternal health and reduce maternal morbidity. CenteringPregnancy is an evidence-based model group for prenatal care that brings patients out of the exam room and into a group setting where they learn from their provider and each other. Below is a description of the sites and home visiting and CenteringPregnancy that were expanded.

 

Montgomery County Health Department expanded the Babies Born Healthy (BBH) program using the March of Dimes Becoming Mom (BAM) curriculum. BAM improves maternal knowledge through a community-based collaborative model of care, prenatal education and quality prenatal care. BBH will serve approximately 40 high-risk pregnant people beginning at any stage in their pregnancy and follow the mother and infant until the child turns six-months of age in the following high-risk. The program places priority and focus on the following zip codes 20903, 20904, 20906 and 20912 and prioritizes ethnic groups.

 

Washington County Health Department  expanded existing home visiting services through the local program affiliate to Healthy Families America. The program will offer services to 50 additional families starting prenatally over the course of three years and continuing through the child’s fifth birthday. Participating families have the option of families to graduate early when the focus child turns three years old and has met the criteria set for graduation by Healthy Families America.

 

Baltimore Healthy Start (BHS)  partnered with Chase Brexton Glen Burnie Health Center to expand home visiting services to postpartum women in Anne Arundel County, particularly in the following zip codes 20724, 21060,21061, 212225, 21226. The program l uses the Great Kids curriculum, designed for home visits beginning in the gestational stage of pregnancy. Families are offered standard BHS case management and care coordination services through the Chase Brexton-based Medication Assisted Treatment for Substance Use Disorder program. The program intends to provide services to 40 additional families annually.

 

The Family Tree expanded home visiting services in Baltimore City through the new implementation of  Parents as Teachers (PAT) model. Home visitors make regular visits from prenatal through kindergarten age. The PAT curriculum focuses on mental health, nutrition, maternal depression, substance use and domestic violence. The program intends to provide home visiting services to 20 additional families annually.

 

Mercy Health Foundation has received funding for FY 2022 and 2023 to implement the CenteringPregnancy model group prenatal care at their Mead Building location in Baltimore City. The program serves patients from their downtown Metropolitan OB/GYN practice, which serves a high number of individuals that are disproportionately affected by severe maternal morbidity.

 

Centering Healthcare Institute, Inc. (CHI) received funding in October 2022, to recruit (4) four sites in priority jurisdictions and provide administrative support for the implementation of CenteringPregnancy model of group prenatal care, and provide continual technical assistance to sites during their two year implementation phase.

 

Sexual and Reproductive Health through Maryland Family Planning:

The mission of the Maryland Family Planning Program (MFPP) is to reduce unintended pregnancies and to improve pregnancy outcomes by ensuring access to quality, comprehensive family planning services for those individuals with incomes below 250% Federal Poverty Level (FPL). Services include: a broad range of family planning methods, breast and cervical cancer screening, prevention and treatment of sexually transmitted infections, HIV testing and prevention education, infertility and preconception services, and health education/counseling and referrals to community resources. There are 61 family planning sites.  State Match Title V dollars were used to support the Maryland Family Planning program in FY2021. In May 2019, Maryland withdrew from Title X federal funding in the setting of new restrictions. As of 2021, Maryland has rejoined Title X after earlier restrictions were lifted and the Title X 2021 rule went into effect.

 

In Fiscal Year 2022, there were a total of 40347 clients and 58302 visits. Overall there was an 18% decrease in the number of clients, and a 14% decrease in visits compared to FY 2021. Of the unduplicated clients seen this reporting period, 26,459 were new clients and 14,478 were continuing clients.  This was a decrease from FY2021 with 32,559 new clients (↓ 19%) and 16,881 continuing clients ( ↓ 14.2%). The decrease is thought to be due to lingering COVID-related impacts. 

 

In FY22, MFPP served 5,478 people who were less than 20 years old. Over sixty percent of the clients seen at Maryland Family Planning clinics were at 100% or below the poverty line.

 

The racial and ethnic breakdown for clients served by the Maryland Family Planning Program include: 41.6% Black, 33.1% White, 2.4% Asian, 0.1% American Indian, 25.6% Hispanic origin.

 

During FY22, many of the MFPP clinics expanded telehealth services adopted during COVID-19. Twelve MFPP agencies were awarded additional federal funds to continue or implement telehealth services in FY23.  

 

Babies Born Healthy Initiative

During FY 2022, eight sites across seven  local jurisdictions implemented state funded Babies Born Healthy (BBH) programs, which directed resources to engage women and communities in an effort to provide supportive coordinated care and address disparities in infant mortality rates in Maryland. In FY 2022, a total of 1,218 families were enrolled in BBH, and 2,112 families accessed BBH services. There were a total of 516 births among program participants and 10 fetal/neonatal deaths.These jurisdictions were selected to receive funding after the Perinatal Periods of Risk Assessment (PPOR) was conducted, and concluded that these jurisdictions were key to effectively curbing disparities and rates of infant mortality.  Services provided were focused on the promotion of prenatal care, reduction of substance use, tobacco cessation, long acting reversible contraception, accessing health insurance, and other strategies driven by site-specific data to promote healthy maternal and infant outcomes. Specific activities included home visiting strategies, nurse and paraprofessional case management services for high-risk women and infants, family planning services, screening and referrals for mental health and substance use.

 

During FY2022, sites continued to experience challenges due to COVID-19. Many BBH staff are public health nurses in LHDs, and were transitioning back from participating in Maryland’s COVID-19 response, to their pre-COVID-19 duties.Families continued to face numerous challenges including job loss and eviction, difficulty in accessing food, loss of childcare, lack of transportation, intimate partner violence, technology limitations, issues in accessing necessary baby supplies, and others.

 

State Maternal Health Innovation Program

In September 2019, the Health Resources Service Administration awarded Johns Hopkins University (JHU) to participate in the State Maternal Health Innovation Program. The JHU-led initiative, MDMOM, is a 5-year project to assist in addressing disparities in maternal health and improving maternal health outcomes, with a particular emphasis on preventing and reducing maternal mortality and severe maternal morbidity (SMM). For the program areas, JHU has partnered with several other organizations, and specifically to coordinate the Maternal Health Improvement Task Force, JHU has partnered with the Department. Title V staff members support the Task Force and their activities.

 

In FY 2022 the Task Force and Title V staff completed the Maternal Health Improvement Strategic Plan (the Strategic Plan), and identified activities to implement the Strategic Plan.  The Strategic Plan process was described in the 2021 report.The Strategic Plan, which was submitted to HRSA in September 2021, has five main focus areas to improve maternal health, particularly in BIPOC populations:

 1. Promote Equity and Mobilize Against Racism in Maternal Health

2. Achieve Health (Preconception, Prenatal and Birth, Post Partum, and Interconception Periods) Using the Life Course Model to Support Maryland Birthing People Through Advocacy and Implementation of Effective Policies.

3. Develop Strategies that Acknowledge the Influence of the Social Determinants of Health and Historical Racism to Improve Resiliency for Birthing People, Families, and Communities and to Promote an Optimal Quality of Life.

4. Improve Access and Utilization of Data and Improve Surveillance of Data on Structural Racism and its Impact to Make Informed Decisions.

5. Develop a Maternal Health Provider Workforce that will be Available, Accessible, and that Offers Services Based on the Principles of Cultural Humility, Equity, and Racial Justice.

 

The Strategic Plan was finalized in November 2021, and published on the MDMOM website. The final version was also shared with the Task Force at the January 2022 quarterly meeting.

 

In Summer 2022, the Task Force began meeting again in person, starting with a session in June 2022. Members gathered to further discuss implementation of the Strategic Plan, and how to ensure the Task Force membership represents birthing people across the State. This was further explored at the July quarterly meeting and a September in-person meeting. The Task Force decided to draft a survey, to be distributed through Task Force members to their networks, to better understand who provides services to birthing people. As of September 30, 2022 this survey was in development by the Department in collaboration with the Task Force members and Co-Chairs.

 

Additionally, the Department was successfully able to establish a mechanism to pay the Co-Chairs for their time related to Task Force activities. This was at the suggestion of the Equity Advisor and members to ensure that community representatives are compensated equitably as other staff members would for serving in this role.

 

 

Maryland Perinatal Quality Collaborative

Maryland’s Perinatal Quality Collaborative (MDPQC) is a network of perinatal care providers and public health professionals working to improve health outcomes for women and newborns through continuous quality improvement. The Collaborative provides participating birthing hospitals with educational resources, technical assistance and a platform for communication and sharing of best practices.

 

During 2022, the Collaborative completed two initiatives and transitioned them both to sustainability while planning the next three-year-long projects. The first initiative focuses on improving management of maternal hypertension through implementation of the Alliance for Innovation on Maternal Health (AIM) Patient Safety Bundle. All 32 delivery hospitals in Maryland participated in this collaborative and their work led to a 64.5% relative improvement in the proportion of patients with acute onset of severe hypertension who received treatment within one hour of onset.. The second quality initiative focuses on antibiotic stewardship in the Neonatal Intensive Care Unit (NICU). 26 delivery hospitals in Maryland participated in this collaborative and their work led to 91% of participating hospitals using the Neonatal Early-Onset Sepsis Calculator and significant increases in the proportion of physicians and nursing staff trained in its use.

 

 

 

 

[1] CDC defines the minimum overall response rate threshold as 50% for 2021 PRAMS data. In 2021, Maryland PRAMS had a weighted response rate of 44.1% and thus did not meet the threshold. Maryland PRAMS 2021 data should be interpreted with caution.

[2] Please note that access to 2021 data was not available at the time of the submission due to the Network Security Event

[3] Final Data from the Vital Statistics Administration for 2021 are still pending.