Maryland’s priority needs for Perinatal Health is “to ensure that all babies are born healthy and prosper in their first year of life.” Title V conducted and supported activities to address NPM 5: Percent of infants placed on their back to sleep.
Promoting infant safe sleep continued to be a priority for Maryland in SFY 2020. PRAMS data for 2017 births indicated that 83.2% of new mothers placed their babies on their backs to sleep, up from 77% in 2012. This exceeds the Healthy People 2020 target of 75%. The prevalence was highest among NH white mothers (88%) and mothers over 35 (88%), but lowest among NH Black mothers (76%) and mothers under the age of 20 (68%).
In SFY 2020, infant safe sleep education was provided to 2,433 families through Title V funded local health department home visiting services. In addition, through Title V, 1,292 families received information on second hand/environmental smoke exposure. CFR teams continued to review all sleep-related infant deaths and a detailed analysis and review was provided in the annual CFR legislative report.
As part of SFY 2020 Surveillance and Quality Initiatives (SQI) efforts, local CFR and FIMR teams prioritized dissemination of information and education on sleep-related infant death and Safe Sleep best practices. Teams reported distribution of safe sleep materials, pack-n-plays, and sleep sacks, as well as ongoing community-based safe sleep education training conducted throughout the state. Between Babies Born Healthy (BBH) and SQI grantees a total of 687 portable cribs were distributed across the state during SFY 2020.
Title V continued with an Interagency Agreement (IA) with Morgan State University (a historically black university/college) to better understand why safe sleep practices are not adopted by some new parents, and specifically to use qualitative research methods to identify causes of the persistent racial disparities in sleep related deaths. During SFY 2020, Morgan State University (MSU) conducted a literature review to identify infant safe sleep interventions that are effective among Black Non-Hispanic parents and caregivers. A few studies demonstrated that multiple interventions such as free portable cribs and infant safe sleep education improved infant safe sleep practices. However, given the limited number of published articles focused on infant safe sleep education within Black communities, more research was needed. Morgan State researchers also recognized that environmental barriers resulting from a legacy of disparities in the social determinants of health limited adoption of infant safe sleep practices. These findings led to a publication.[1] Ultimately, the partnership with MSU will lead to a communications strategy and recommendations that includes culturally sensitive and relevant safe sleep messaging.
Home Visiting
During SFY 2020, six local health departments used Title V funds through Core Public Health funding, Child Health Systems Improvement funding, and High Risk Infants funding to support home visiting services to at-risk women and infants. These programs link pregnant and post-partum individuals to needed community resources such as WIC, provide education on safe sleep, breastfeeding, tobacco cessation, and child development, and ensure parents and infants have a medical home. Nearly 2,300 women and infants received home visiting services through a local health department in SFY 2020. The decline in the number served from past years was directly related to COVID-19 closures and restrictions.
Infant Mortality
Infant mortality is a significant indicator of the overall health of a population. Infant mortality reflects the broader community health status, poverty and other social determinants of health, and the availability and quality of health services. In 2019, the Maryland infant mortality rate was 5.9 deaths per 1,000 live births, a decrease of three percent from the 2018 rate of 6.1 deaths per 1,000 live births and reflecting a 10% overall decrease from the average rate of 6.6/1,000 from 2010-2014 . The non-Hispanic (NH) White infant mortality rate stayed constant, at 4.1 deaths per 1,000 live births, while the Hispanic infant mortality rate increased by 34%, from 3.8 to 5.1 deaths per 1,000 births, and the NH Black rate decreased for the second year in a row, from 10.2 to 9.3. for a 9% total decrease. The neonatal mortality rate (deaths under 28 days of age) decreased by 7% from 4.2 in 2018 to 3.9 in 2019, with the rate decreasing by 7% among NH Black infants, from 6.9 to 6.4, and increasing 14% from 2.9 to 3.3. among Hispanic neonates and increasing 4% from 2.6 to 2.7 among NH white infants. The statewide post-neonatal mortality (deaths from 28 days through 11 months of age) rate increased by 5%, from 1.9 in 2018 to 2.0 in 2019. The rate decreased by 12% among NH Black infants (from 3.3. to 2.9) and also decreased among NH white infants, by 7%. However, the postneonatal mortality rate increased 111% from 0.9 to 1.9 from 2018 to 2019 among Hispanic infants. The leading causes of infant death in 2019 were disorders related to short gestation and low birth weight (LBW) account for 23% of losses , congenital abnormalities (18%), sudden unexpected infant death (SUID) including Sudden Infant Death Syndrome (SIDS) (9%), and maternal complications of pregnancy (9%). SUID . There was a total of 44 Sudden Unexpected Infant Deaths in 2019, with an annual rate of SUID of 62.7 per 100,000 live births.
Comparing two five-year periods over the last decade (2010-2014 and 2015-2019), the overall infant mortality rate in Maryland has declined by six percent. The average rate for NH Black infants decreased significantly by nine percent. The average rate among Hispanic infants increased 13 percent between these two time periods. The post-neonatal mortality rate was stable over the 10-year period among NH Black infants but increased by 17% among NH White and Hispanic infants. The largest declines in infant mortality over the past ten years were seen in the Baltimore metropolitan area, especially in Baltimore City and Anne Arundel, which had statistically significant decreases, with 15.2 percent and 19.2 percent reduction, respectively, as well as in the National Capital Area, with Prince George’s County seeing a 6.7 percent decrease in infant mortality rates. Rates of infant mortality increased in the Northwest, Southern, and Eastern Shore regions, with increases in Somerset (82.8%), Dorchester (48.4%), Washington County (41.6%), and Charles counties (26.1%).
Fetal and Infant Mortality Review (FIMR)
Title V funds support Fetal and Infant Mortality Review (FIMR) activities through the required state match. FIMR is an important quality improvement strategy to improve maternal and child health. FIMR not only provides important insight into opportunities for systems improvement, but they also serve as a mechanism for local and regional communication, coordination, and collaboration on other MCH issues. In SFY 2020, FIMR programs operated in eight of the 24 jurisdictions experiencing the highest number of fetal and infant deaths.
During SFY 2020, FIMR process improvements identified in SFY 2018 and SFY 2019 through the Quality Improvement Council continued. The process improvements included quarterly calls with all local coordinators to allow for cross-jurisdictional collaboration and data sharing. In addition, during SFY 2020, the Annual meeting included an overview of Infant Mortality Profiles created by MCHB Epidemiology program staff, an overview of the Postpartum Infant and Maternal Referral (PIMR) FIMR review of congenital syphilis cases, along with Title V Safe Sleep updates. additional training from the National Center for Fatality Review and Prevention (NCFRP) on case identification, maternal interviews, and translation recommendations into action. Efforts to address ongoing data sharing challenges with the Vital Statistics Administration (VSA) and the Office of the Chief Medical Examiner (OCME) continued.
During SFY 2020 MCHB provided Surveillance and Quality Initiatives (SQI) grants to every jurisdiction to support ongoing Child Fatality Review (CFR) Activities. Multidisciplinary case review teams (CRT) conduct confidential, de-identified reviews of fetal and infant deaths within the jurisdiction to identify non-clinical factors and systems issues contributing to poor pregnancy outcome and deaths. The teams develop prevention strategies to address health care delivery systems and identify community resource needs, in order to reduce fetal and infant mortality and address racial disparities in pregnancy outcomes.
Community Action Teams (CAT) review the findings of the CRT and are charged with advocating for creating large-scale systems change to benefit all pregnant or postpartum women, with particular emphasis on those identified as being most at-risk and vulnerable to poor pregnancy outcomes. Membership of Community Action Teams consists of those with the political will and fiscal resources to create systems changes. These members are able to develop a community perspective on how to best create the desired changes within the community. In 2020, Community Action Teams provided recommendations and developed a distribution plan for Safe Sleep, Kick Count resources, developed patient empowerment campaigns to encourage pregnant people to “Speak Up” about their pregnancy concerns to care providers, addressed care collaboration and continuity of care starting with preconception health, provided public presentations to local government officials on Infant Mortality and racial disparities in their jurisdiction, and continued to participate in local Substance Exposed Newborn (SEN) workgroups with the Department of Social Services (DSS) to implement the START (Sobriety Treatment and Recovery Teams) model within the jurisdiction, among many other activities executed.
Additionally, CFR became an active participant in the Department of Human Services Social Services Administration’s Substance Use Disorder Workgroup to collaborate on interagency efforts to reduce the risk of harm for substance exposed newborns and their families during SFY 2020.
In September 2020, Montgomery County Health Department was featured in a podcast, “What’s Happening MOCO?” to discuss Maternal and Infant Health and SIDS prevention. In the podcast, Angeline Bell, RN discussed the importance of the ABCs (Alone, Back, Crib) of safe sleep and how the local health departments engage in safe sleep.
During 2020, both FIMR and CFR teams had to adapt to the COVID-19 Pandemic. Local health department staff were deployed to assist with the pandemic efforts. In addition, teams no longer met in-person and adjusted to secure virtual meetings.
Risk Appropriate Perinatal Care
Although NPM 3: Risk Appropriate Perinatal Care was not a selected performance measure for FY 2016- FY 2020, additional information is provided here as perinatal regionalization, breastfeeding, fatality reviews, infant mortality, safe sleep, and home visiting initiatives highlighted progress towards increasing Risk Appropriate Perinatal Care in SFY 2020.
For NPM 3 the number of VLBW (very low birth weights, < 1,500g) births at all Maryland hospitals decreased slightly from 2018 to 2019, from 1,050 VLBW deliveries in 2018 to 954 VLBW births in 2019 across all hospital levels. A total of 17,652 babies were born at Level I and Level II delivering hospitals in 2019, with 63 of these babies (6.6% of all VLBW births) born at weights less than or equal to 1500g. There were 44,801 births at Maryland Level III/IV delivering hospitals in 2019, of which 891 were VLBW, making up 93.4% of all VLBW births, keeping ahead of the Healthy People 2020 goal of 83.7% of VLBW births occurring at Level III or Level IV facilities. This is also an increase from 2017 at 88.1% and 2019 at 90.9%.
Maryland Perinatal System Standards
The Maryland Perinatal System Standards was developed in the mid-1990s by a Maryland Department of Health advisory committee as a set of voluntary standards for Maryland hospitals providing obstetric and neonatal services. Level III and Level IV hospitals are designated perinatal referral centers that have both specialized care for pregnant women, as well as the baby. The Standards have since been incorporated into the regulations for designation of perinatal referral centers by the Maryland Institute for Emergency Medical Services Systems (MIEMSS), as well as the Maryland Health Care Commission’s State Plan regulations for obstetrical units and neonatal intensive care units. MIEMSS regulates Level III and Level IV Hospitals. Level I and Level II are voluntary designations as delivering hospitals but do not have the specialized care as Level III and Level IV hospitals.
The Maternal Child Health Bureau (MCHB) convenes and leads the Perinatal Clinical Advisory Committee that develops, reviews, and updates the Maryland Perinatal System Standards for all levels of obstetric and neonatal care. The Perinatal Standards were updated in April 2019 to be consistent with the most recent edition of the Guidelines for Perinatal Care, a joint manual of the American Academy of Pediatrics (AAP) and the American College of Obstetrics and Gynecology (ACOG). All Level III and Level IV perinatal referral hospitals were notified of this update, and MIEMSS (Maryland Institute for Emergency Medical Services Systems) Regulation Compliance Verification packages were sent to these hospitals in order to verify compliance with the Standards. Of the 32 delivery hospitals in Maryland, six (6) are Level I, 11 are Level II, 13 are Level III, and two (2) are Level IV. The most recent Standards are incorporated in regulations governing the Level III and IV hospitals, and compliance with the Standards is required for designation at these levels. In SFY 20, MCHB continued to work with the Maryland Institute for Emergency Medical Services Systems in the compliance reviews of Level III and IV hospital centers.
The Standards specify that very low birth weight (VLBW) births should occur at Level III and IV hospitals which have the necessary subspecialty obstetric care and neonatal intensive care. VLBW infants, who weigh 1500g or less at birth, are the most fragile newborns. They are more likely to survive and thrive when born in a facility with a Level III or IV neonatal intensive care unit (NICU). MCHB and Vital Statistics monitor the number of VLBW births born in Maryland, and track where these infants were born. Each Maryland delivering hospital receives a report showing VLBW births and neonatal mortality rates by hospital of delivery and level of care.
One role of the MCHB Morbidity, Mortality, and Quality Review Committee is to monitor voluntary compliance of Level I and Level II hospitals with the Standards. During site visits conducted every four to five years, Level I and Level II hospitals are asked to review all VLBW births at their site and to determine if any could have been avoided by transfer of the mother to a higher level of care prior to delivery. During Fiscal Year 2020, the MMQRC reviewed the VLBW data from 2018, and started planning to resume Level I and II site visits. Four sites were identified to prioritize site visits as these sites had higher VLBW than the average Level I and Level II sites. Due to the Covid-19 pandemic, the MMQRC and MDH team updated the self-assessment and case review forms in preparation for the site visits.
Maryland Perinatal-Neonatal Quality Collaborative (MDPQC)
Perinatal Collaboratives are networks of perinatal care providers and public health professionals working to improve health outcomes for women and newborns through continuous quality improvement (QI). The Collaborative provides participating birthing hospitals with educational resources, technical assistance, and a platform for communication and sharing best practices.
In SFY 2020 the Maryland Perinatal-Neonatal Quality Collaborative (MDPQC) activities focused on transition and re-launching the MDPQC. Following a competitive bid, Health Quality Innovators (HQI) was selected to lead the MDPQC, beginning May 18, 2020. Health Quality Innovators created a website (www.mdpqc.org), designed a logo, and began creating website content. A listserv was initiated, with contacts from every birthing hospital in the state included, and a letter was drafted to MD hospitals announcing the transition of the Collaborative. A Steering Committee was formed, re-engaging many former steering committee members from the previous iteration of the MDPQC. The Steering Committee includes physicians, nurses, and nurse midwives from hospitals across the state, as well as public health stakeholders.
Neonatal Abstinence Syndrome (NAS)
The rate of neonatal abstinence syndrome (NAS) among Maryland resident newborns born in Maryland hospitals has decreased 10.5%, from 14.3 per 1,000 newborn discharges in 2015, to 12.8 per 1,000 newborn discharges in 2019 (Case-mix data, Health Services Cost Review Commission). Initially, Maryland had the State Performance Measure (SPM) on Hospital Policy change to improve quality of care for infants with neonatal Abstinence Syndrome.
The Department of Human Services recently updated their Substance Exposed Newborn Policy to reduce the number of SEN out-of-home placements and to improve the quality and effectiveness of services for SEN and families impacted by substance use disorder. In an effort to address the need for cross-system coordination of services and providers, MCHB program staff participated in statewide training for DHS staff to increase knowledge of community resources for families with a substance exposed newborn. Any newborn displaying effects of withdrawal from a controlled substance exposure as determined by medical personnel will trigger a SEN notification to DHS. MCHB Program staff provided training on the Postpartum Infant and Maternal referral form (PIMR), which allows hospital staff to refer families to their local health department for resources to address the child and family needs. Local DSS staff were encouraged to support delivery hospitals in utilizing the PIMR form for any SEN notification, and information about the PIMR was included in supplemental resources available for those who completed the SEN policy training.
Perinatal Support Program
The purpose of the Maryland Perinatal Support Program (MPSP) is to support and improve the perinatal system of care in Maryland. Specifically, MPSP brings maternal-fetal medicine consultation, education, and technical assistance, as well as obstetric nursing outreach and education, to Level I and II birthing hospitals in the State. Maternal-fetal medicine specialists can provide unique support in the evaluation and management of pregnant and postpartum patients with pre-existing medical conditions, pregnancy complications, or known/suspected fetal anomalies.
During SFY 2020, providers from Johns Hopkins Hospital conducted 68 physician and advanced practitioner outreach events and 11 nurse outreach visits. The providers continued to provide technical assistance, education, and case reviews for conditions such as gestational diabetes, antiphospholipid syndrome, substance use disorders. Due to COVID, many of the outreach visits were limited to remote and telephone meetings. The providers answered questions related to COVID and its effects on pregnant people and their fetuses.
Babies Born Healthy
In SFY 2020, nine sites across eight 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. A total of 1,047 birthing people accessed BBH services, and there was a total of 360 births among program participants and 9 fetal/neonatal deaths. These jurisdictions were selected to receive funding after they had been identified by 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 geared towards the promotion of prenatal care, reduction of substance use, tobacco cessation, infant safe sleep education, 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. Also, in SFY 2020, sites began to utilize prenatal care groups following research pointing towards their effectiveness in promoting prenatal health and birth outcomes.
COVID-19 presented barriers to both families and staff. Many staff are public health nurses in local health departments, and as such they were pulled into Maryland’s COVID-19 response which left BBH sites with very limited capacity. Families faced numerous challenges including job loss and eviction, difficulty in accessing food, loss of childcare, lack of transportation, domestic violence, technology limitations, issues in accessing necessary baby supplies, and others. Many BBH sites responded by doing emergency supply drop-offs to their participants and were a crucial lifeline at the height of the pandemic.
[1] Malliga Jambulingam, Ariel Hunt, Margaret Alston, David Thomas, Yvonne Bronner. Infant Safe Sleep Interventions in African American Communities. American Journal of Public Health Research. Vol. 8, No. 5, 2020, pp 147-153. http://pubs.sciepub.com/ajphr/8/5/3
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