III.E.2.c. State Action Plan Narrative

Women/Maternal Health - Annual Report

Maryland’s priority 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 fiscal year 2023.

Services and activities focus on the needs of women and birthing people across the Title V maternal child health 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 -percent of women who had a preventive dental visit during pregnancy (formerly national performance measure 13.1).
• Focus Area 2: Substance use prevention and linkages to care and measured with two performance measures:

1) Percent of women who smoke during pregnancy (formerly national performance measure 14.1)

2) Overdose Mortality Rate for women, ages 15-49 (formerly the state performance measure 1)

• 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’s health care financial model called the “Total Cost of Care.”

Focus Area 1 - Oral Health

Percent of women who had a dental visit during pregnancy

According to Maryland 2022 PRAMS[1] data, 49 percent of mothers had a cleaning during pregnancy, compared with 49.3 percent in 2021. The percentage of mothers receiving oral health care during pregnancy in 2022 increased among Hispanic individuals from 31.8 percent in 2021 to 36 percent in 2022. The percentage of mothers receiving oral health care during pregnancy decreased among non-Hispanic Black individuals (from 46.3 percent in 2021 to 42.4 percent in 2022) and among non-Hispanic white individuals (from 60.2 percent in 2021 to 59.7 percent in 2022). Slight decreases were seen among mothers (age 20+) with 12 or fewer years of education (39.2 percent in 2021 to 37.4 percent in 2022) while similar rates were seen among mothers (age 20+) with 13 or more years of education (54.5 percent in 2021 to 55.0 percent in 2022). 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 within the Prevention and Health Promotion Administration, local health departments and local dental clinics. During FY23, the Office of Oral Health began producing a series of plain language educational materials in response to House Bill 290, passed in the 2023 Maryland legislative session. Dental services for postpartum patients were also expanded to cover up to 12 months after the end of a pregnancy, due to the expansion of Medicaid coverage up to one year postpartum effective Apr. 1, 2022. 

In FY23, $1,004,104 Title V funds continued to support programming to pregnant people at local health departments throughout the state. Thirteen of the 24 local health departments (Baltimore City, Baltimore County, Calvert, Caroline, Cecil, Frederick, Harford, Kent, Montgomery, St. Mary’s, Talbot, Wicomico and Worcester) used these core public health funds on maternal health enabling services, specifically perinatal care coordination and home visiting. All local health departments receive Title V core public health funds as mandated by House Bill 314, 1995 laws and the local health departments can choose certain services that align with the state action plan and address the local maternal child health needs.

 A total of 1,648 pregnant people were referred to dental care by local health departments in FY23. Two home visiting programs, Healthy Families America and Child Health System Improvement, referred 159 and 28 pregnant people with dental care, respectively. Care coordination services linked an additional 1,461 individuals with dental care. This is more than double the local health department referrals from FY22, when there were a total of 669 referrals. As services were available, more in-person programs saw an increase in participants.

 

Focus Area 2: Substance Use Prevention and Linkages to Care

This focus area has two performance measures:

1. Percent of women who smoke during pregnancy (previously NPM 14.1).
2. State performance measure, Overdose Mortality Rate for women, ages 15-49 (SPM 1).

Performance Measure 1- Smoking during pregnancy

Both Maryland and the U.S. have seen a downward trend in the percentage of women who smoke during pregnancy since 2010. In 2022, which is the most recently available national vital statistics system data, Maryland was slightly below the 3.7 percent national average for women who smoked during pregnancy. The percentage of Maryland mothers who smoked during pregnancy decreased by nearly 36 percent from 2020 to 2022. In 2020, 4.2 percent of Maryland women smoked during pregnancy. The percentage of Maryland women who smoked during pregnancy in 2022 was highest among non-Hispanic multirace individuals (5.3%), followed by non-Hispanic white individuals (4.4%), and non-Hispanic Black individuals (2.3%).

During fiscal year 2023, 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, 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 FY23, the Quitline enrolled 66 pregnant individuals, returning to FY21 enrollment levels. The Quitline also had 45 participants in the pregnancy rewards programs in FY23. 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 during pregnancy through six months postpartum who complete a series of calls with a quit coach. Eligible callers receive $25 gift cards to Target for a max of $100 per participant for completing a total of ten calls.

The Title V grant funds local health departments through perinatal care coordination and home visiting services to routinely screen women for tobacco use and offer referrals to the State’s Quitline. Staff who screened respondents were from home visiting, home birth certification, early intervention, and family planning clinics. In FY23, 114 individuals were referred to tobacco cessation programs, including the Quitline. This is still a sustained decrease compared to referrals in FY20, when a total of 892 prenatal/postpartum people were referred to tobacco cessation programs and is consistent with the overall decreases for referral to services due to COVID-19.

 

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

Data from the annual 2022 Maternal Mortality Review Report showed that unintentional overdose was the leading cause of pregnancy associated deaths in Maryland at 38 percent in 2020 (the 2022 report has 2020 data and is the most recent available from the Maryland Maternal Mortality Review Program). According to the Maryland Behavioral Health Administration, it is estimated that only 245 pregnant people with opioid use disorder received opioid maintenance treatment in 2023.

Incident characteristics of overdose deaths can be found in the annual Maternal Mortality Review Report, with the latest available report from 2022, which contains data from 2020. In Maryland, from 2011-2020, there were 114 overdose-related pregnancy associated deaths, with 82 (72%) white non-Hispanic individuals and 24 (21%) Black non-Hispanic individuals. On average, these overdose deaths occurred 192 days postpartum. Fourteen individuals, representing 12 percent, had not initiated prenatal care.

The state has developed the Opioid Operational Command Center to coordinate activities around preventing overdose deaths. The OOCC developed an overdose dashboard in 2021. Data from 2022 to 2024 is preliminary and available here:  https://www.arcgis.com/apps/dashboards/dab44c5d8402443cb359a1db661b5513. The most recent data from FY24 show that western Maryland and the Eastern Shore are seeing an increase in overdose fatalities.

 

Strategies to decrease overdose fatalities due to unintentional opioid use

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. Medicaid launched its Maternal Opioid Misuse program, also referred to as MOM, in January 2020. Funding from the Center for Medicare and Medicaid Innovation and the Centers for Medicare and Medicaid Services were used to support this program as well.

The MOM program focuses on improving clinical resources and enhancing care coordination to Medicaid beneficiaries with opioid use disorder during and after their pregnancies through the special needs coordinators in the managed care organizations. Under the MOM program, HealthChoice MCOs received a per-member per-month payment to provide enhanced case management services, standardized social determinants of health screenings and care coordination. They also encourage the utilization of prenatal care and behavioral health counseling. Starting Jan. 1, 2023, the MOM program became available statewide and open to all eligible HealthChoice members and Maryland ceased its participation in the federal CMMI demonstration. Implementation of the MOM case management services continued seamlessly.

During 2023, the MOM program shared best practices for case management amongst its case managers that included: health-related social needs screening, postpartum depression screening during the postpartum period and providing support for behavioral health visits. Furthermore, a video that emphasized non-judgmental support was developed for potential MOM participants. The video can be seen here: https://youtu.be/HLRRvIQEfkw.​

 

As part of the MOM program, the department, through Maryland Medicaid, partnered with University of Maryland and the Maryland Addiction Consultation Services to provide training to providers. MACS launched the MACS for MOMs program to build provider capacity to better treat the maternal opioid use disorder population. The program includes three components:

• Consultation telephone line that any provider can call for phone consultation.
• Virtual mentorship and learning teleECHO clinics that use the innovative continuous ECHO learning model.
• Training for providers to prescribe buprenorphine (a medication to treat opioid use) and webinars on different topics like cannabis use and pregnancy or treatment of OUD during pregnancy.

To strengthen the MOM program by making it more attractive to communities of color, MDH partnered with Historically Black Colleges and Universities, led by Bowie State, to tailor the program to be more culturally responsive to Maryland’s Black population.

In 2023, the MACS for MOMs enrolled 642 practitioners in their services, consulted on 58 perinatal calls that were received during the warmline, hosted four webinars with a total of 302 attendees and hosted 11 teleECHO clinics with 161 total attendees.

While Title V funds did not fund MACS for MOMs services, Title V local health department staff shared these resources with other clinical providers in the state. Furthermore, Maryland’s Title V program partnered with the Medicaid Maternal Opioid Misuse Model team to expand referrals to the local dealth departments and managed care organizations via Maryland prenatal risk assessment form. The form assesses medical and social needs and connects the pregnant person to special needs coordination with the managed care organization and also perinatal care coordination through local health departments (that are often funded through Title V). Under regulation COMAR 10.09.68.05, the Maryland prenatal risk assessment should be completed for Medicaid participants at the first prenatal care visit. Specifically, Maryland’s Title V program has emphasized the importance of the MPRA during the local health department technical assistance calls. Title V leveraged CDC’s Overdose Data2Action federal grant to fund Calvert, Harford and St. Mary’s county health departments to conduct relationship building activities at local birthing hospitals to educate clinical staff on the MPRA and another postpartum form, the postpartum infant and maternal referral form. The demonstration was successful, with counties seeing an increase in the number of referrals received and an enhanced workflow process to be able to receive more referrals. Calvert County reported a 52 percent increase in referrals throughout the project period, largely due their increased capacity to meet with local and regional birthing hospitals 243 times to obtain and discuss referrals and workflow improvement.

 

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

The Maryland Family Planning Program 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 the Screening, Brief Intervention, Referral, and Treatment initiative in fiscal year 2021 and developed a means for data collection for evaluation. SBIRT activities are mandated through policies with the MFPP, as the HRSA Title X grantee, while service delivery is provided through collaborations with 22 subrecipients who executed SBIRT at 60 service sites across Maryland. MFPP is funded through federal Title X funds and state general funds. The state general funds are matched Maryland Title V funds.

In FY23, the MFPP provided services to over 46,000 new and continuing care clients. In that time, there were 2,265 SBIRT screenings provided and 53 positive SBIRT evaluations for clients who were referred for further services. Of those clients 46 identified as female and 7 identified as male. MFPP subrecipients are tasked with identifying and developing resources to support the referral process. The MFPP continues to collect data on screening and referral to treatment in FY24. The program will partner with the Danya Institute’s Addiction Technology Transfer Center to provide evaluation of previous initiatives and additional training to our subrecipients on referring clients to treatment services. Pending the results of our statewide family planning needs assessment and the availability of funds, the MFPP intends to provide additional funding to sites to strengthen relationships with substance use disorder treatment centers.

 

Babies Born Healthy Initiative

During FY23, seven local jurisdictions implemented state funded Babies Born Healthy  perinatal care coordination, which directed resources to engage women and communities to provide supportive coordinated care and address disparities in infant mortality rates in Maryland. BBH is funded by Title V’s state matched funds.

All program participants are assessed for resource needs, 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 or had perinatal mood and anxiety disorders. All Babies Born Healthy sites provide extended care coordination for 6 months to a year postpartum for program participants who require substance use and/or mental health support. One BBH site, the Anne Arundel County health department, convened a substance exposed newborn multidisciplinary group, who works closely with the local HealthyStart program to make recommendations to support and conduct outreach for families of substance exposed newborns and birthing parents who are experiencing substance use disorder.

 

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 non-Hispanic to white non-Hispanic severe maternal morbidity gaps. In addition, this focus area is linked to the national outcome measure (previously NOM 2) of severe maternal morbidity and maternal mortality (previously NOM 3).

Maryland’s Title V program works to achieve this focus area through a lifecourse approach. Started in 2023 with this report, the department began monitoring self-reported postpartum visit attendance. However, for this annual report and application year, Maryland had selected postpartum visits and smoking during pregnancy (NPM 13.1 and 14.1), as outlined in the state action plan table. According to Maryland 2022 PRAMS[2] data, birthing people reported attending postpartum visits at high rates. Ninety-one percent of parents reported attending a postpartum check up. Of those who did not attend one, 44.8 percent cited that they felt fine and didn’t think a visit was needed , 37.5 percent said they “had too many things going on”, 17.5 percent did not have health insurance to cover visit costs, and 13.8 percent were not able to get an appointment when desired.

Maryland expanded Medicaid

Since the Apr. 1, 2022 expansion of health coverage, Maryland Medicaid-eligible recipients have had a significant increase to essential health care services for pregnant individuals. This policy change ensured that Medicaid-eligible individuals receive comprehensive medical care during their pregnancy and for an extended 12-month postpartum period, without concerns of income or household size fluctuations. As a result, there was an improvement in maternal and child health outcomes, with more individuals attending postpartum visits and receiving essential follow-up care. This expanded coverage is anticipated to continue enhancing the overall well-being of mothers and their children in Maryland.

Additionally, House bill 1080 enacted coverage for non-citizen pregnant Marylanders who would otherwise be eligible for Medicaid but for their immigration status may now be eligible for coverage, which became effective on July 1, 2023.

As background, this state performance measure is a population health goal tied to Maryland’s health care financial model called the total cost of care model. As part of the model, the state proposed the Centers for Medicare and Medicaid for Maryland to focus on population health goals including having goals related to maternal and child health. In FY21, Centers for Medicare and Medicaid Innovation (CMMI) approved the state’s proposal to focus on severe maternal morbidity and asthma.

Based on data for April 2023 to March 2024, the state’s severe maternal morbidity rate is 321.9 events per 10,000 delivery hospitalizations according to the Health Services Cost Review Commission. This is 32 percent or 78.8 hospitalizations per 10,000 deliveries higher than the 2018 SIHIS baseline. Severe maternal morbidity rates were highest among non-Hispanic Black women at 455.9 per 10,000 deliveries. The non-Hispanic Black rate is also an increase from the 2018 SIHIS baseline of 334.2 events per 10,000 deliveries.

To understand the root cause of the increase in SMM rates, our Bureau conducted several analyses and reviews in FY23. From November 2022 through May 2023, the bureau worked with an intern to conduct a literature review of the root causes of SMM from 2020 to the present day. The review sought to answer 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 addition to the impacts of COVID-19 on severe maternal morbidity rates, including increased risk of admission to an intensive care unit, the review highlighted the role of blood transfusions, pre-existing comorbidities, hypertensive disorders and mental health conditions as potential drivers of SMM. Over half of the studies reviewed reported two SMM rates (one with blood transfusion and one without transfusion) due to the outsized contribution transfusion alone has on SMM rates. This aligns with guidance we received from HRSA in late 2022 about the removal of transfusion from the list of codes included in the definition of severe maternal morbidity, per the Federally Available Dataset.

The MCHB epidemiology team partnered with Chesapeake Regional Information Systems for our Patients (also referred to as CRISP), a Maryland non-profit that operates the state’s health information exchange, to evaluate the role of blood transfusions in Maryland SMM rates. Approximately 67 percent of SMM cases (as of November 2023, 219.7 cases per 10,000 deliveries) are attributable to blood transfusions alone. In June 2023 CRISP released a modified dashboard that displays the SMM rate overall, by blood transfusions alone and with blood transfusions excluded. The MCHB epidemiology team has continued to work with CRISP to further update the dashboard  for full alignment with MCHB, HSCRC and Statewide Integrated Health Improvement Strategy goals.

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 created by the Maternal Health Improvement Task Force that focuses on reducing disparities in maternal mortality and morbidity. Please see the plan here. The plan 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 reviews all pregnancy-associated deaths, defined as deaths during or within one year after the end of a pregnancy from any cause. The program is fiscally supported mostly through CDC’s Enhancing Reviews and Surveillance to Eliminate Maternal Mortality grant and state Title V match general funds. However, Title V staff, specifically the maternal health manager, oversee the program with support from the bureau’s director, medical director, and office director.

Based on the most recent public data, which is the 2022 report that contains data from 2020, there were 58 pregnancy-associated deaths in 2020, resulting in a pregnancy-associated mortality rate of 84.6 deaths per 100,000 live births. The number was higher than in previous years. Of the 58 pregnancy-associated deaths, 17 were determined to be pregnancy-related, for a pregnancy-related mortality rate of 24.8 deaths per 100,000 live births. Among the 17 pregnancy-related deaths in 2020, the leading causes of death were behavioral health conditions (n=5), cardiovascular conditions (n=3), and infection (n=3). The remaining pregnancy-related deaths were single cases of cancer, pulmonary conditions (excluding acute respiratory distress syndrome), injury, collagen vascular/autoimmune diseases, thrombotic embolism, and metabolic/endocrine conditions.

Of the 17 pregnancy-related deaths occurring in 2020, six cases (35%) involved non-Hispanic white individuals, nine cases (53%) involved non-Hispanic Black individuals, and two cases (12%) involved Hispanic individuals. Among the 41 non-pregnancy-related deaths, 18 cases (44%) involved non-Hispanic white individuals, 18 cases (44%) involved non-Hispanic Black individuals, four cases (10%) involved Hispanic individuals, and one case (2%) involved a non-Hispanic individual whose race was identified as other. The rate of pregnancy-related deaths in non-Hispanic Black individuals was 2.0 times higher than that of non-Hispanic white individuals.

The findings from the MMR team provided recommendations to the state legislature and the Maryland Department of Health at large. These recommendations emphasized the need to partner with community-based organizations and further expand programs such as home visiting and ensure there are warm referrals from transition of the birthing hospital to home. During FY23, the Program also developed an action arm to implement several of these recommendations. The program started the planning process to host the first ever Maternal Mortality Summit in FY24.

 

Further information on 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 2023, the stakeholder group met three times. The first two meetings were to review the results of the 2020 deaths and the last meeting they developed their accompanying recommendations. This data has not yet been published, but there continues to be a trend of racial disparities in pregnancy-related mortality rates for Black pregnant persons compared to white pregnant persons. The stakeholder group also met in June 2023 to review progress towards implementation of program recommendations for the 2016-2018 cases. Recommendations were categorized into four action areas: supporting patients with substance use/opioid use disorder, improving care coordination, clinical care for women and pregnant persons, and social drivers of health and contributing factors of maternal death.

The program also made significant strides 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. They 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, they successfully seated 17 new members in addition to 16 returning members from the earlier MMR committee. All members attended orientation between November 2022 and January 2023 and the MMRT met for its first meeting in February of the same year. As of Sep. 30, 2023, the MMRT has met to review approximately 75% of the 2021 cases.

 

An Update on the Statewide Integrated Health Improvement Strategy (SIHIS) Public Health Funding Initiative

Through additional funding from HSCRC’s Maternal and Child Health Population Health Improvement Fund (or the Fund), MDH pursued a competitive procurement in FY22 to expand evidence-based and promising practice models of home visiting and/or perinatal care coordination. While these grants funds are through specialized funds and are not part of the Title V match, Title V staff coordinate the use of these funds.

Based on feedback from stakeholders, the funds were focused on promising practices of home visiting. Promising practice programs offer innovative solutions and allow for flexibility and adaptation based on data, as they are not bound by the strict protocols of evidence-based programs. Four sites (Montgomery and Washington county health departments, Baltimore Healthy Start and, Baltimore City-based, The Family Tree) were selected and began work in FY23. A summary of their inaugural year activities by site can be found below.

Montgomery County Health Department

The county expanded its prenatal care coordination initiative, also called the Babies Born Healthy program, to connect its participants to its long-term home visiting services. The program offers the March of Dimes’ “Becoming a Mom” curriculum for all BBH participants who wish to participate through group classes or individual sessions. This program enhances maternal understanding through a collaborative community-based model of care. The program focuses on providing services to a number of high-risk zip codes in Montgomery County which include: 20903, 20904, 20906 and 20912. At baseline, the Montgomery County BBH program enrolled approximately 125 families. With HSCRC funding, the program was able to expand to enroll 31 families in their first year of implementation.

Washington County Health Department

The county began the expansion of their existing home visiting services via the local program affiliate, Healthy Families America, which is currently funded by the Maryland MIECHV Program. Healthy Families America has an intensive home visiting program in which families are offered services for a minimum of three years and are visited weekly when families first enter the program.[3] The program enrolled 26 new families from both streams of funding (HSCRC and MIECHV), with four (15%) of those families being attributed to HSCRC fund-supported home visiting expansion. The program successfully organized and conducted three virtual family groups, with an average monthly attendance of 18 families. The virtual family groups have facilitated meaningful connections among families, provided essential parenting insights, and created a platform for the sharing of experiences.  

Baltimore Healthy Start

Baltimore Healthy Start collaborated with Chase Brexton Glen Burnie Health Center and the administrative care coordination unit of the Anne Arundel County Department of Health to expand home visiting services to prenatal and postpartum women in the areas serviced by Chase Brexton Glen Burnie Health Center. This includes zip codes: 20724, 21060, 21061, 212225 and 21226. This initiative utilized the “Great Kids” curriculum, designed for home visits from the prenatal period to when a child reaches 36 months of age. Families are offered standard BHS case management and care coordination services through the Chase Brexton-based Medication Assisted Treatment for Substance Use Disorder program. This program intends to provide services to 40 additional families annually. In the past year they served 24 families. Numbers are lower than the target due to challenges with staffing, which MDH has provided support and assistance around, in partnership with our MIECHV programs.

The Family Tree

The Family Tree facilitated the expansion of home visiting services in Baltimore City through the “Parents as Teachers” model. Home visitors conduct regular visits, supporting families from pregnancy through their child’s kindergarten year.[4] It is designed to build skills, capacities and confidence; the program gives families access to qualified parent-educators who can provide high quality, reliable, home visits and parent engagement activities.[5] The PAT curriculum addresses critical areas including: mental health, nutrition, maternal depression, substance use and domestic violence. In FY23, the program received certification to operate as a PAT-affiliated site from the Parents as Teachers National Center, and successfully recruited and onboarded staff to empower the growth of the PAT home visiting initiative. The program's collaborative efforts extended to partnerships with Health Care Access Mayland, Urban Strategies, and The Parent Helpline. The program successfully enrolled 26 families into the PAT program for home visiting.

Collectively in FY23, fund-supported home visiting expansion initiatives enrolled over 75 families in priority jurisdictions despite sites describing recruitment challenges. Table 1 indicates the number of those enrolled by race and ethnicity and Table 2 indicates the number of enrolled by insurance provider.

Table 1: Number Enrolled in SIHIS Home Visiting Expansion by Race/Ethnicity in Maryland State Fiscal Year 2023 

 

 

 

Table 2: Number Enrolled in SIHIS Home Visiting Expansion by Insurance Provider in Maryland State Fiscal Year 2023

 

Expanding Group Prenatal Care in Maryland

Another major strategy for Maryland is to expand the “CenteringPregnancy” model. The CenteringPregnancy group prenatal care model follows the traditional recommended schedule of ten prenatal visits, but with the difference that each visit is 90 to 120 minutes long. This model gives pregnant patients ten times the length of interaction with providers when compared with the average amount of interaction time in traditional prenatal visits. Moreover, the model allows for the patient to take their own weight and blood pressure and to record their own health data during the visit.[7] This interactive approach empowers patients and fosters a sense of efficacy in managing their health. After the health assessment is completed, eight to 10 pregnant patients gather with a provider to be a part of interactive activities designed to address important and timely health topics. CenteringPregnancy is shown to be effective in reducing birth outcome disparities among non-Hispanic Black pregnant people, who disproportionately experience adverse maternal health outcomes.[8],[9]

The Maryland Department of Health is currently supporting the expansion of five sites through public health startup funds. In FY23, specialized funds from SIHIS were used to provide these public health startup funds. These funds were approximately $114,000. While SIHIS funds are not part of the Title V match, Title V staff coordinated the expansion of CenteringPregnancy. In FY24, PHPA/MCHB combined additional public health funding from the Babies Born Healthy Program to provide support for three additional sites, for a total of eight new sites supported until the end of FY25. In total, approximately $300,000 (of which approximately $140,000 of state funds) were invested into the start up of CenteringPregnancy. The funding from the BBH Program is used as a Title V match. The expansion of CenteringPregnancy is in collaboration with Maryland Medicaid. As part of the SIHIS initiative, Maryland Medicaid provided an enhanced reimbursement for the CenteringPregnancy sites. Therefore, implementing CenteringPregnancy may be more sustainable.

Mercy Health Foundation received funding in late FY22, launching Centering Pregnancy at one of their OB/GYN practices in downtown Baltimore City. In FY23, the site successfully conducted 15 cohorts and 78 CenteringPregnancy classes benefiting 87 pregnant patients, with a third of the participants completing the CenteringPregnancy classes. Mercy Medical is on track to achieve the “Centering site” accreditation for CenteringPregnancy.

In June 2022, MDH partnered with the Centering Healthcare Institute, resulting in a successful recruitment and provision of startup funds for implementing the CenteringPregnancy model in four prenatal clinics, strategically located in Baltimore, Montgomery, and Prince George’s counties:

• Kaiser Gaithersburg in Montgomery County
• Mary’s Center in Montgomery County
• University of Maryland St. Joseph’s Women’s Health Associates in Baltimore County
• Luminis Health in Prince George’s County

 

All four sites are developing their Centering Implementation Plan, which incorporates processes and tools to help sites identify and address barriers. The CIP aims to position the site to successfully complete the accreditation process. Over 4-6 months, CHI collaborates with each site on the following areas:

1. Creating the steering committee.
2. Engaging leadership.
3. Building a shared vision.
4. Goal setting and evaluation.
5. Creating a centering schedule.
6. Create a centering space in the clinic.
7. Patient enrollment.
8. Provider productivity.
9. Financing and budgeting.
10. Billing and reimbursement.

In 2023, CHI provided training, coaching, technical assistance and tools from CHI expert consultants. During the first three months, a CHI consultant guides the first steering committee meeting and provides guidance through the startup process. Within six months sites typically introduce their first cohort of participants. In twelve to eighteen months, sites obtain their Centering Accreditation. In October 2023, CHI convened a second Centering Consortium of Maryland to increase awareness with health organizations about the opportunities for the three available grants to implement the CenteringPregnancy model group for prenatal care. The Centering Consortium was also attended by both Maryland Medicaid and MCHB, which provided an opportunity for all parties to discuss and strengthen implementation.

 

 

Sexual and Reproductive Health through Maryland Family Planning

The mission of the Maryland Family Planning Program 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 percent of the federal poverty level. 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. General funds support the local health departments within the Maryland Family Planning Programs and are used as state match Title V dollars. Approximately, $5.8 million dollars were used to support the local health department family planning infrastructure. Federal Title X funds are used to support family planning efforts with community clinics such as Planned Parenthood, Mary’s Center, Greater Baden Medical Center and CCI Health Services.

In fiscal year 2023, there were a total of 46,405 clients and 66,131 visits within the Maryland Family Planning Program. Overall there was a 15 percent increase in the number of clients, and a 13 percent increase in visits compared to FY22. Of the unduplicated clients seen this reporting period, 31,827 were new clients and 16,507 were continuing clients. This was an increase from FY22 with 26,594 new clients (20% increase) and 14,588 continuing clients (13% increase).

In FY23, MFPP served 6,588 people who were less than 20 years old. Over 56 percent of the clients seen at Maryland Family Planning clinics were at 100 percent or below the poverty line. The racial and ethnic breakdown for clients served by the Maryland Family Planning Program in FY23 include: 40.7 percent non-Hispanic Black, 23.8 percent non-Hispanic white, 1.7 percent non-Hispanic other race, 0.7 percent non-Hispanic multi-race and 10.9 percent Hispanic. For 22.1 percent of clients, race and ethnicity was unknown.

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 FY23, the MCHB conducted a redesign of BBH for the next 5 years (2024-2028), with the goal of aligning with major SIHIS interventions and reducing disparities in infant mortality, specifically addressing the gap of excess infant mortality between non-Hispanic Black and non-Hispanic white populations. As a result of the redesigned program, BBH funded seven priority sites/jurisdictions for perinatal care coordination and offered a portfolio of evidence-based initiatives to increase the number of community-based doulas in Maryland through a Doula Training Hub and increase the number of CenteringPregnancy sites by offering startup costs.

During FY23, local jurisdictions implemented state funded Babies Born Healthy (BBH) perinatal care coordination programs, which directed resources to provide supportive coordinated care and address disparities in infant mortality rates in Maryland. In FY23, a total of 1,203 families were newly enrolled in BBH and 1,958 families accessed BBH services. The sites (Baltimore City, Baltimore, Prince George’s, Anne Arundel, Charles, Caroline, and Wicomico counties) were selected to receive funding because they have the largest racial disparities in infant mortality, particularly in the non-Hispanic Black population, as compared to the non-Hispanic white population.

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, and screening and referrals for mental health and substance use.

 

Title V Partnerships with the State Maternal Health Innovation Program

Please review the MCH Partnerships and Collaborations document for more information on various partnerships.

Title V partners with the recipient of the HRSA’s State Maternal Health Innovation Program, Johns Hopkins University. The JHU-led initiative, MDMOM, was renewed in FY23 for another five years to continue its work in implementing various maternal health innovations in the state. Title V staff members coordinate the Maternal Health Improvement Task Force as part of the MHIP grant and provide overall guidance to JHU and its partners.

In FY23, the task force and Title V staff began work on two projects:

1. Building a map of providers and resources in Maryland to support maternal health.
2. Preparing an update to the Maternal Health Improvement Strategic Plan (the Strategic Plan), originally completed in 2021.

The Strategic Plan has five main focus areas to improve maternal health, particularly in Black, Indigenous, People of Color populations:

1. Promote equity and mobilize against racism in maternal health
2. Achieve health (preconception, prenatal and birth, postpartum 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.

As part of its update, the task force started to revisit each of the five focus areas and their associated objectives and tactics to ensure they are comprehensive and aligned with maternal health needs in Maryland. Task force members started to divide into working groups, and are utilizing Dr. Monica McLemore’s “Retrofit, Reform, and Reimagine” framework to evaluate the strategic plan components through a reproductive justice lens. We anticipate the revised Strategic Plan will be finalized in Winter 2024.

Furthermore, the task force led efforts to better understand the network of maternal health partners and services across Maryland. The task force initially drafted a survey, as described in the previous year’s report. From that work the task force partnered with JHU and their contracted web developer to build out an interactive map. As of December 2023 this was still in production, and went live in Spring 2024. The interactive map, located here, displays resources and services available to pregnant and postpartum families in Maryland.

The Department continues 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. Title V staff were successfully able to establish a mechanism to pay the co-chair.

 

Maryland Perinatal Quality Collaborative

Maryland’s Perinatal Quality Collaborative 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 FY23, the MDPQC closed out implementing its hypertension bundle. All 32 Maryland birthing hospitals participated in an initiative focused on maternal hypertension from January 2021 through June 2023. The hospitals implemented a bundle of interventions that included best practices for preventing, identifying and responding to a birthing person experiencing high blood pressure. The combined efforts led to a 59.1 percent improvement across all hospitals in the timely treatment of elevated blood pressures. This was defined as administration of the appropriate treatment within 60 minutes of identification of the elevated blood pressure. This included a 79.3 percent improvement in the timely treatment of elevated blood pressures for non-Hispanic Black birthing people.

The majority of birthing hospitals identified that they were prepared to advance to the next initiative while transitioning their work focused on maternal hypertension to sustaining the improvements in care that were made. The MDPQC steering committee, which consists of perinatal care providers and public health professionals, worked with birthing hospitals to select obstetric hemorrhage as the next area of focus beginning Jul. 1, 2023. Obstetric hemorrhage is one of the leading causes of maternal mortality and severe maternal morbidity in Maryland. This initiative capitalizes on another AIM Patient Safety Bundle with a focus on prevention, early identification, and rapid response to obstetric hemorrhage. Bundle components also focus on how hospitals can support a birthing person who has experienced an obstetric hemorrhage and their family after the event.

MDH was also awarded a supplemental grant from HRSA to support implementation of AIM bundles in birthing hospitals. From FY24 through FY28 MDH will partner with a non-profit organization, The Bloom Collective, to provide technical assistance and training to birthing hospitals. The Bloom Collective will conduct regional training sessions to introduce the subjects of reproductive justice, holistic care, implicit bias and what it means to center Black birthing people in quality improvement work. They will then organize and conduct in-person half-day workshops at birthing hospitals across Maryland to provide specific support through focused training, capacity building, and technical assistance for specific projects or interventions identified by the birthing hospital.

[1] CDC defines the minimum overall response rate threshold as 50% for 2021 and 2022 PRAMS data. In 2021 and 2022, Maryland PRAMS had a weighted response rate of 44.1% and 43%, respectively, and thus did not meet the threshold. Maryland PRAMS 2021 and 2022 data should be interpreted with caution.

[2] The CDC defines the minimum overall response rate threshold as 50% for 2021 and 2022 Pregnancy Risk Assessment Monitoring System data. In 2021 and 2022, Maryland PRAMS had a weighted response rate of 44.1% and 43%, respectively, and thus did not meet the threshold. Maryland PRAMS 2021 and 2022 data should be interpreted with caution. Note: 2022 PRAMS data was collected using Phase 8 PRAMS questionnaires. The next iteration of the PRAMS questionnaire (Phase 9, starting with 2023 births) frames questions relating to postpartum visits slightly differently. Thus postpartum visit data from 2023 onwards may not be directly comparable to data from 2022 and prior.

[3] Healthy Families America. https://www.healthyfamiliesamerica.org/our-approach/#:~:text=Home%20Visiting,-Should%20home%20visiting&text=Most%20families%20are%20offered%20services,trusting%20relationships%20with%20participating%20families.

[4] Most home visitors (72%) have a bachelor’s degree or higher. The PAT mode requires a high school diploma or GED plus 2 years of experience working with young children and/or parents for home visitors. https://nhvrc.org/model_profile/parents-as-teachers/#:~:text=PAT%20was%20implemented%20by%204%2C127,or%20parents%20for%20home%20visitors.

[5]  The Family Tree. https://www.familytreemd.org/parentsasteachers/

[6] Total number who have enrolled in the SIHIS Home Visiting Program

[7] Centering Healthcare Institute. https://centeringhealthcare.org/what-we-do/centering-pregnancy. Accessed 8 December, 2023

[8] Crockett, A. H., Chen, L., Heberlein, E. C., Britt, J. L., Covington-Kolb, M. S., Witrick, M. B., Doherty, M. E., Zhang, L., Borders, A., Keenan-Devlin, L., Smart, M. B., & Heo, M. (2022). Group versus traditional prenatal care for improving racial equity in preterm birth and low birthweight: the Cradle randomizedclinical trial study. American Journal of Obstetrics and Gynecology.

[9] CHI. CenteringPregnancy and CenteringParenting Annotated Bibliography. December 2022.   https://www.centeringhealthcare.org/uploads/files/Centering-Healthcare-Institute-Annotated-Bibliography.docx-16.pdf