Maryland Title V conducted and supported activities to address national and state perinatal health performance measures in 2019.  Perinatal regionalization, neonatal abstinence syndrome, breastfeeding, fatality reviews, infant mortality, safe sleep, and home visiting initiatives highlighted progress towards performance goals in FY 2019.

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 recently 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 FY19, 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 weight 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.  The number of VLBW births at all Maryland hospitals decreased slightly from 2017 to 2018, from 1,135 VLBW deliveries in 2017 to 1,050 VLBW births in 2018 across all hospital levels. For 2018 births, 90.9 percent of all VLBW babies in Maryland were born at Level III or Level IV hospitals, keeping ahead of the Healthy People 2020 goal of 83.7% of VLBW births occurring at Level III or Level IV facilities. A total of 17,601 babies were born at Level I and Level II delivering hospitals in 2018, with 96 babies (9.14% of all VLBW births) born at weights less than or equal to 1500g. For Maryland in 2018, 954 of 46,100 births in total and 90.9 percent of all VLBW births (1050 total) were born at Level III/IV delivering hospitals.

In FY19, MCHB continued to support the Perinatal Neonatal Quality Collaborative, administered by the Maryland Patient Safety Center (MPSC). This has been a collaborative and confidential effort among the 32 Maryland delivery hospitals to undertake quality improvement initiatives, share best practices, and reduce adverse events in the perinatal period. Only one delivering hospital chose not to participate in the Collaborative for FY19. In FY19, the Collaborative introduced a new obstetric and a neonatal quality improvement initiative and completed the data collection from the first two program initiatives.

The original neonatal initiative was to standardize care of infants with neonatal abstinence syndrome (NAS). In the second quarter of FY 2019, the Collaborative focused on data analysis of this initiative to reduce length of stay and length of pharmacologic treatment, to reduce transfers to a higher level of care, and to reduce 30-day readmissions for NAS. The Collaborative continued to work with the Vermont Oxford Network (VON) and keep their e-learning, evidence-based educational materials and resources available to participants statewide. The use of e-learning modules continued until December 31, 2018. Twenty -seven (27) of the participating hospitals earned the Center of Excellence Award from VON for having 85% of their registered participants complete 100% of the modules.  As a result, Maryland also earned the State of Excellence award for having 85% of the hospitals achieve the Center of Excellence award. Data analysis in FY19 for the NAS standards initiative also focused on the development of a white paper.

The Reducing Primary C-Section Collaborative was also completed at the beginning of FY19. The effort had been focused on reducing low-risk, primary cesarean section rates in women who were nulliparous and at term, with a vertex fetal presentation. The Collaborative had engaged 31 of 32 delivery hospitals in this initiative. Data collection ended in FY18, but sustainability data continued to be collected on outcomes for a one year period in FY19. An article entitled, “Implementation of the Safe Reduction of Primary Cesarean Births Safety Bundle During the First Year of a Statewide Collaborative in Maryland,” which focused on the implementation research for this collaborative was published in ACOG’s Obstetrics and Gynecology Journal in July 2019 (Obstetrics & Gynecology: July 2019 - Volume 134 - Issue 1 - p 109-119). 

In the third quarter of FY19, the Collaborative began the second obstetric initiative, focusing on Obstetric Care of Women with Opioid Use Disorder. Of the 32 Maryland delivering hospitals, 29 participated in the start of the new collaborative. These hospitals joined more than ten other states from across the country, and, worked in conjunction with the Alliance for Innovation on Maternal Health Program’s (AIM) national data-driven maternal safety and quality improvement initiative and AIM’s patient safety bundle focusing on Obstetric Care of Women with Opioid Use Disorder. The collaborative actively participated in coordinated calls with leaders from other states. Data collection began in the 4th quarter of FY2019 and necessary audit tools, resources, and a collaborative schedule were shared between participating hospitals.

The second neonatal-focused initiative, the Safe Infant Sleep Collaborative, was started midyear FY19. Of Maryland’s 32 birthing hospitals, 31 hospitals and the Mt. Washington Pediatric Hospital participated in the kick-off meeting in March 2019. Data was collected through the MPSC portal and audit tools and project resources were shared with participants. There was not sufficient data collected prior to the end of FY19, when the Collaborative concluded.

Breastfeeding: The Maryland Department of Health’s Breastfeeding Policy Committee provides technical assistance to birthing hospitals related to the Maryland Breastfeeding Policy Recommendations. The committee consists of 11 members; 6 MDH staff members including the Title V Manager and 5 birthing hospital representatives. MCHB continues to support all delivery hospitals in the state to become “Maryland Best Practices Hospitals,” by either attaining Baby Friendly certification through the Baby Friendly Hospital Initiative (BFHI) or by meeting the ten criteria in the Maryland Hospital Breastfeeding Policy Recommendations. At the implementation of the Maryland Hospital Breastfeeding Policy Recommendations, Maryland had no Baby Friendly designated hospitals. As of FY 19, there were ten that held current designation.  Specific FY 19 included continuation of maternity staff training modules, physician webinars, and technical assistance calls.  The Maryland Hospital Breastfeeding Policies website (https://phpa.health.maryland.gov/mch/Pages/hospital-bf-policy.aspx) provides an overview of the hospital breastfeeding policy background and process, links to the Maryland Hospital Breastfeeding Policy Recommendations, and houses the resources for access by those interested.

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 2018, the Maryland infant mortality rate was 6.1 deaths per 1,000 live births, a decrease of six percent from the 2017 rate or 6.5 deaths per 1,000 live births.  The non-Hispanic (NH) White infant mortality rate increased slightly from 4.0 to 4.1, the Hispanic rate decreased from 4.7 to 3.8, and the NH Black rate decreased from 11.2 to 10.2. The neonatal mortality rate (deaths under 28 days of age) decreased from 4.4 in 2017 to 4.2 in 2018 and the post-neonatal mortality (deaths from 28 days through 11 months of age) rate decreased slightly, from 2.0 in 2017 to 1.9 in 2018. The leading causes of infant death in 2018 were low birth weight (21%), congenital abnormalities (15%), sudden unexpected infant death (SUID) including Sudden Infant Death Syndrome (SIDS) (13%), and maternal complications of pregnancy (12%). Following a substantial decline in infant deaths attributed to SIDS between 2015 (64) and 2016 (43), there was an increase to 55 deaths in 2017, and another increase to 57 in 2018. Of note, the number of infant homicides declined from 15 in 2016 to seven in 2017, and to two in 2018.

Comparing two five-year periods over the last decade (2009-2013 and 2014-2018), the overall infant mortality rate in Maryland has fallen by four percent. The average rate for NH Black infants decreased significantly by eight percent and NH White infants decreased by two percent. The average rate among Hispanic infants increased 13 percent between these two time periods. The overall neonatal mortality rate declined six percent from 2009-2013 to 2014-2018, with a significant decline among NH Black infants. The post-neonatal mortality rate was stable over the 10-year period, with a decrease among NH Black infants but increases 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 Carroll County, which had an 18 percent and 26 percent reduction, respectively, and in the National Capital Area, especially in Prince George’s County with a nine percent drop.

FIMR:  Title V funds support Fetal and Infant Mortality Review (FIMR) activities statewide through the required state match.   FIMR programs operated in all 24 jurisdictions since 1998.  FIMR not only provides important insight into opportunities for systems improvement, they also serve as a mechanism for local and regional communication, coordination and collaboration on other MCH issues.  During FY19 MCHB provided Surveillance and Quality Initiatives (SQI) grants to every jurisdiction to support ongoing Fetal and Infant Mortality Review and Child Fatality Review (CFR) Activities. Multidisciplinary case review teams (CRT) conduct confidential reviews of fetal and infant deaths within the jurisdiction to identify systems issues contributing to these deaths and to develop prevention strategies. Community Action Teams (CAT) review the findings of the CRT and are charged with creating large-scale systems change. Membership consists of those with the political will and fiscal resources to create that systems changes. These members are able to develop community perspective on how to best create the desire changes within the community. In 2019, Community Action Teams provided recommendations and developed a distribution plan for Kick Count resources, provided public presentations to local government officials on Infant Mortality and racial disparities in their jurisdiction, and participated in local Substance Exposed Newborn workgroups with DSS to implement the START model within the jurisdiction, among many other activities executed.

During FY19, FIMR process improvements identified in FY17/FY18 through the Quality Improvement Council were implemented. The process improvements included quarterly calls with all local coordinators as well resumption of an annual meeting which was held in August of 2018. The Annual meeting included an overview of FIMR review of congenital syphilis cases, along with additional training from the National Center for Fatality Review and Prevention (NCFRP) on case identification, maternal interviews, and translation recommendations into action. Additional activities implemented in 2019 included the development of a FIMR list-serve to share best practices; serving as liaison with VSA and the OCME to troubleshoot data issues on an ongoing basis; and integration of the FIMR program with other efforts across MCHB to reduce infant mortality, among others. These efforts have continued in FY19 and FY20.

Further analysis was conducted in FY18 and FY19 which included an assessment of the FIMR structure and spending in Maryland compared to other states.  This assessment reviewed performance metrics across Maryland’s FIMR teams, barriers to case review and community action team activities as well as the cost per case reviewed for each team.  Recommendations from this assessment will be used to restructure the Maryland FIMR program. In FY 2019 FIMR teams received 808 fetal and infant cases and reviewed 264 of those cases, nearly 1/3 of all fetal or infant death cases in Maryland were reviewed by the local FIMR team.  

Babies Born Healthy:  In FY 19, eight sites in seven local jurisdictions implemented state funded Babies Born Healthy programs, which directed resources to engage women and communities in the promotion of tobacco cessation, reduction of substance use, prenatal care, long acting reversible contraception, and other strategies driven by site-specific data to promote healthy maternal and infant outcomes. Specific activities included home visiting strategies, paraprofessional case management services for high-risk women and infants, expansion of preconception care and family planning services, screening and referrals for mental health and substance use, and pre-conception and prenatal nutrition support.

Safe Sleep:  Promoting safe sleep continues to be a priority in Maryland. 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 FY 2019, safe sleep education was provided to families through Title V funded local health department home visiting services and Babies Born Healthy programs for high risk families. CFR teams continued to review all sleep-related infant deaths and a detailed analysis and review was provided in the annual CFR legislative report. Also, the Maryland Perinatal Neonatal Quality Collaborative Steering Committee began a statewide hospital-based safe sleep quality improvement initiative. 

In late FY 2019, MCHB entered into an Interagency Agreement (IA) with Morgan State University (a historically black college/university) to conduct a two year mixed methods approach to reducing infant sleep-related deaths in Baltimore City.  The purpose of the project is 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.  Ultimately, the research will lead to a social marketing campaign that includes culturally sensitive and relevant safe sleep messaging.  

Home Visiting: In FY 2019, MCHB’s Maternal, Infant and Early Childhood Home Visiting (MIECHV) program provided funding to ten jurisdictions to implement evidence based home visiting services including 14 Healthy Families America sites and one Nurse Family Partnership site.  Specific FY 2019 activities focused on professional development opportunities for home visiting staff through the development and implementation of a Substance Exposed Newborn training in collaboration with the Department of Human Services, Mental Health First Aid, and continuation of the Home Visitors Training Certificate program.  These trainings provide an opportunity to enhance home visitor skills in appropriately addressing the needs of families and infants affected by substance abuse, mental health, and/or domestic violence issues. 

As part of Maryland’s HealthChoice §1115 Waiver Renewal, the state began offering local governments the opportunity to request up to $2.7 million in matching federal funds for evidence-based home visiting services for high-risk pregnant women and children up to age 2 in FY 2018. The intent of the pilot funding was to expand evidence-based home visiting services to Medicaid eligible high-risk pregnant women and children up to age 2. The HVS Pilot program aligned with two evidence- based models focused on the health of pregnant women; 1) Nurse Family Partnership (NFP), and 2) Healthy Families America (HFA). The Title V Manager collaborated with Maryland Medicaid to establish the protocols for the development of the pilot and to monitor the implementation.  The first pilot was funded in FY 2018 and a second pilot received funding in FY 2019.  Both pilots represented expansions of existing home visiting services provided by two Healthy Families America sites in the state and allowed for the extension of supportive services to more Medicaid-eligible women and infants.  Funding will continue through December 2021. An evaluation component will assess the Medicaid savings across the life of the pilot and will determine the efficacy of future use of Medicaid to reimburse home visiting services in the state.

Additionally, six local health department grantees use Title V funds through Core Public Health funding, Child Health Systems Improvement funding, and High Risk Infants funding to support nurse home visiting services to high-risk women and infants.  These programs link women to needed community resources such as WIC, provide education on safe sleep, tobacco cessation, and child development, and ensure women and infants have a medical home. Nearly 3,300 women and infants received home visiting services through a local health department in FY 2019.