Maryland Title V has three priorities for perinatal health:
- Ensure that all babies are born healthy and prosper in their first year.
- Increase the number of infants that are ever breastfed.
- Reduce the number of sleep-related infant deaths statewide.
The Title V program conducted and supported activities to address national perinatal health performance measures in FY24.
Priority 1: Ensure that all babies are born healthy and prosper in their first year
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 2023, the Maryland infant mortality rate was 5.7 deaths per 1,000 live births, which was 8 percent lower than the rate of 6.2 per 1,000 live births in 2022. The non-Hispanic white infant mortality rate increased by 19 percent from 3.1 in 2022 to 3.7 in 2023 deaths per 1,000 live births. The Hispanic infant mortality rate decreased by 14 percent, from 5.6 in 2022 to 4.8 in 2023 deaths per 1,000 live births. The non-Hispanic Black rate decreased by 13 percent from 10.3 in 2022 to 9.0 in 2023 deaths per 1,000 live births.
The neonatal mortality rate is considered deaths under 28 days of age. This rate was 3.8 deaths per 1,000 live births in 2023 which was nine percent lower than the rate of 4.2 deaths per 1,000 births in 2022. The rate decreased by 23 percent among non-Hispanic Black infants, from 6.9 to 5.3, and remained at 3.5 among Hispanic neonates. The rate increased by 23 percent from 2.2 to 2.7 among non-Hispanic white infants.
Post-neonatal mortality is defined as deaths from 28 days through 11 months of age. The statewide post-neonatal rate stayed the same in 2023 at 1.9 deaths per 1,000 live births. The rate stayed at 1.0 deaths per 1,000 live births in 2023 for non-Hispanic white infants. The postneonatal rate increased among non-Hispanic Black infants from 3.4 deaths per 1,000 live births in 2022 to 3.7 deaths per 1,000 live births in 2023.
The leading causes of infant death in 2023 were:
- Congenital malformations with 67 deaths or 18 percent of deaths.
- Low birth weight with 62 deaths or 16 percent of deaths.
- Sudden unexpected infant death which includes sudden infant death syndrome with 58 deaths or 15 percent of deaths.
- Maternal complications of pregnancy with 25 deaths or seven percent of deaths.
Preliminary data from the Child Fatality Review program show that there were 38 sudden unexpected infant deaths in 2023.
Comparing two five-year periods over the last decade, 2014-2018 and 2019-2023, the overall infant mortality rate in Maryland has declined by eight percent from 6.4 to 5.9 deaths per 1,000 live births. The largest statistically significant declines in infant mortality over the two time periods were seen in the eastern shore area, which had a decrease of 28 percent.
Perinatal Infection Transmission
Between 2018 and 2023, Maryland’s congenital syphilis rate rose from 40.8 per 100,000 live births to 105.2 per 100,000 live births, with an average rate of 56.2 per 100,000 live births during this time period.[1] The highest rates in 2023 were in Baltimore City at 372.9 cases per 100,000 live births with 27 total cases. Wicomico County had the second highest at 142.1 cases per 100,000 live births with 2 cases. Between 2018-2023, there were 8 confirmed perinatal human immunodeficiency virus transmissions in Maryland. In 2023, there was one confirmed perinatal HIV transmission in Maryland.[2]
During FY24, Title V staff continued to partner with the Infectious Disease Prevention and Health Services Bureau to address the rising congenital syphilis and perinatal HIV transmissions in the state. Title V participated in the Maryland Perinatal Action Team meetings, which review these morbidity cases. These reviews indicated that prenatal care was initiated late and there was no initiation of HIV antiretroviral therapy. In Maryland, HIV testing must be offered during the first and third trimesters, and again at labor and delivery if there is no indication of a test before delivery. Title V staff continued to partner with the Morbidity, Mortality, and Quality Review Committee members. This committee informs clinicians across the state of the rising rates and the need to ensure screening for syphilis and HIV. They also inform Title V grantees, which include local health departments, community-based organizations and community health clinics.
Fetal and Infant Mortality Review
Title V funds support Maryland’s Fetal and Infant Mortality Review (FIMR) activities through the required state match. FIMR is an important quality improvement strategy that focuses on maternal and child health. Cases are de-identified and the purpose is to recognize a health disparity in fetal and infant deaths within each jurisdiction. These cases are reviewed to identify preventative measures and action items. Multidisciplinary case review teams 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 outcomes and deaths. The teams develop prevention strategies to address health care delivery systems and identify community resource needs to reduce preventable child deaths. FIMR not only provides important insight into opportunities for systems improvement, but it also serves as a mechanism for local and regional communication, coordination and collaboration on other maternal and child health issues. In FY24, FIMR programs operated in seven of the 24 jurisdictions experiencing the highest number of fetal and infant deaths.
During FY24, FIMR process improvements previously identified 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 several jurisdictions, Babies Born Healthy (BBH) staff participated in FIMR and community action team meetings, and BBH was also involved in the follow-up and outreach process for maternal interviewing. FIMR teams were required to review all cases that were identified as meeting the following criteria: presence of substance use during pregnancy, birth defects or congenital anomalies, racial and ethnic minorities. They were also required to coordinate with local Sexually Transmitted Infections/Human Immunodeficiency Virus Partner Services to identify appropriate congenital syphilis and perinatal HIV cases. Community action teams were required to address Statewide FIMR recommendations and identify a focus area based on their jurisdiction’s data and needs.
Community action teams review the findings of the FIMR Team 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 on the teams consists of those with the political will and fiscal resources to create system level changes. These members can develop a community perspective on how to best create the desired changes within the community. During FY24, 68 fetal cases and infant cases were reviewed by the FIMR Committees; these teams provided recommendations, offered safe sleep resources and personalized messaging to delivering mothers, expanded home visiting program/services, and offered trainings. These trainings topics, such as sharing available health department direct services, high risk pregnancy conditions and severe postpartum warning signs, were selected with a goal of improving their ability to serve their clients. Also in FY24, the Maternal and Child Health Bureau developed a data brief titled Sleep-Related Infant Deaths in Maryland, 2016–2020, to better understand the impact of unsafe sleep practices on infant mortality. The brief analyzed data on sleep-related sudden unexpected infant deaths (SUIDs) from 2016 to 2020, focusing on factors related to how and where the infant was sleeping. In addition, the brief contains information on programmatic and policy Interventions to illustrate Maryland’s current efforts on safe sleep.
During FY24, MCHB provided Surveillance and Quality Initiatives grants to all 24 jurisdictions to support ongoing Child Fatality Review (CFR) activities, in accordance with the Maryland Health General Article §5-702-704. Both FIMR and CFR team goals align, and there is often overlap in coordination at the local health departments. An annual legislative report is mandated and includes annual CFR data and the recommendations of the state CFR team. These recommendations are informed by local CFR team goals and findings.
Multidisciplinary case review teams 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 outcomes and deaths. The teams develop prevention strategies to address health care delivery systems and identify community resource needs to reduce preventable child deaths.
Throughout FY24, both FIMR and CFR teams continued to meet via secure virtual meetings, although some teams began transitioning to in-person or hybrid meeting formats. The majority of teams found that virtual meetings improved attendance and availability of members, and many teams were able to add new members who were previously unable to attend in-person meetings consistently.
For risk-appropriate perinatal care, the number of very low birth weight (< 1,500g) births, Performance Measure (NPM 3), in Maryland hospitals decreased slightly from 2021 to 2022. From 949 VLBW deliveries in 2021 to 882 VLBW births in 2022 across all hospital levels.
A total of 17,497 babies were born at Level I and Level II delivering hospitals in 2022, with 74 of these babies (8.4 percent of all VLBW births) born at weights less than or equal to 1,500g. There were 43,948 births at Maryland Level III/IV delivering hospitals in 2022, of which 808 were VLBW, making up 91.6 percent of all VLBW births.
Maryland Perinatal System Standards
The Maryland Perinatal System Standards were 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 the designation of perinatal referral centers by the Maryland Institute for Emergency Medical Services Systems, 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 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 and the American College of Obstetrics and Gynecology. All Level III and Level IV perinatal referral hospitals were notified of this update, and MIEMSS Regulation Compliance Verification packages were sent to these hospitals to verify compliance with the standards. Of the 32 delivery hospitals in Maryland, six are Level I, eleven are Level II, thirteen are Level III, and two 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 FY24, 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 births should occur at Level III and IV hospitals, which have the necessary subspecialty obstetric care and neonatal intensive care. VLBW infants, who weigh 1,500g 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 (also referred to as a 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 (MMQRC) 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 FY24, the MMQRC conducted virtual site visits at two Level I hospitals and one Level II hospital.
Maryland Perinatal-Neonatal Quality Collaborative
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. The collaborative provides participating birthing hospitals with educational resources, technical assistance, and a platform for communication and sharing best practices.
During FY24, the MDPQC continued sustaining its maternal hypertension bundle, which ended active implementation in June 2023. Through that bundle, the hospitals implemented a bundle of interventions that included best practices for preventing, identifying, and responding to a pregnant woman 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 the 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 pregnant women.
The MDPQC also began implementing its next maternal bundle focused on obstetrical hemorrhage. 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 pregnant woman who has experienced an obstetric hemorrhage and their family after the event.
The rate of neonatal abstinence syndrome among Maryland resident newborns born in Maryland hospitals has decreased 8.6 percent, from 8.6 per 1,000 newborn discharges in 2022, to 7.9 per 1,000 newborn discharges in 2023.[3] In December 2022, Title V staff pre-recorded a neonatal abstinence syndrome webinar in partnership with the Department of Gynecology and Obstetrics at Johns Hopkins Medicine. The webinar is focused on NAS prevention and surveillance in Maryland and was distributed to providers and local health department partners. To date, 88 individuals have registered to view the webinar. In 2024, Title V staff completed a needs assessment related to NAS and substance use disorder amongst the perinatal population. It was recommended that there was an increased need for continued education for providers and hospital staff, including addressing the issues of stigma and discomfort related to NAS and SUD. Additionally, a series of NAS information sheets was developed for the use of local health department staff, covering 5 topics that were identified as high priority by the local health department partners. These sheets were distributed to key partners, as well as made available on the new “Opioid Use and the Perinatal Period” page on the MCHB website, which includes the webinar, information sheets and additional resources for partners.
Perinatal Support Program
The purpose of the Maryland Perinatal Support Program 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. This program was supported by general state funds and used as a Title V Match.
Babies Born Healthy
For state fiscal years 2024-2028, the Maternal and Child Health Bureau conducted a redesign of Babies Born Healthy to align with the Statewide Integrated Health Improvement Strategy interventions and reduce disparities in infant mortality. Specifically, the desire was to address the gap in excess infant mortality between non-Hispanic Black and non-Hispanic white populations. As a result of the redesigned program, BBH funded new sites/jurisdictions and offered a portfolio of evidence-based initiatives that included increasing the number of CenteringPregnancy sites by offering start-up costs and perinatal care coordination. Planning for doula capacity building grants began in fiscal year 2024 but were not awarded until fiscal year 2025.
In FY24, eight local jurisdictions implemented state-funded Babies Born Healthy perinatal care coordination programs, which directed resources to engage women and communities to provide supportive coordinated care and address differences in infant mortality rates in Maryland. In FY24, a total of 1,139 families were newly enrolled in BBH, and 2,051 families accessed BBH services. Total families who accessed BBH services may include duplication, as clients are enrolled throughout their pregnancy and postpartum period and are likely enrolled over multiple quarters and fiscal years. For those who reported race and ethnicity data, the majority of BBH program participants were reported as being non-Hispanic Black, and the second largest population served was Hispanic. The top referrals made were for safe sleep education, nutrition services or support, dental care, family planning and breastfeeding support. Many jurisdictions reported using BBH as a platform for implementing recommendations from their jurisdiction's Child Fatality Review and Fetal Infant Mortality Review teams to prevent future infant and child deaths. These jurisdictions were selected to receive funding because they have the largest racial differences in infant mortality, particularly in the non-Hispanic Black population, as compared to the non-Hispanic white population.
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, and screening and referrals for mental health and substance use. In FY24, sites continued to utilize prenatal care groups following research pointing towards their effectiveness in promoting prenatal health and birth outcomes.
Priority Area 2: Increase the number of infants who are breastfed
Breastfeeding
The progress of this priority is measured by the percentage of infants who are ever breastfed. This is national performance measure four. In 2023, according to Pregnancy Risk Assessment Management System data,[4] 91.4 percent of Maryland mothers reported having ever breastfed their babies, similar to the proportion in 2022 at 91.3 percent. Rates of breastfeeding in Maryland by race and ethnicity ranged from 83.4 percent among non-Hispanic Black women to 98.3 percent among non-Hispanic Asian women.
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, mostly birthing hospital representatives. Title V does not provide any funding for the Breastfeeding Policy Committee's efforts, but supports through attendance at the committee meeting.
Maryland’s Women, Infants, and Children Program
Maryland’s Special Supplemental Nutrition Program for Women, Infants and Children, often referred to as WIC, ensures that pregnant and postpartum people, infants and children up to age five receive essential nutrients critical to their growth and development. In FY24, Maryland reported WIC monthly participation was 121,185, a 0.7 percent decrease from federal fiscal year 2023.[5] WIC participants received electronic benefits that can be used to purchase specific health-promoting foods, including milk, whole grains, fruits, vegetables and iron-fortified infant formula.
Beyond nutritional support, the program offers health and developmental screenings to monitor and enable early intervention for health issues. Maryland WIC also emphasizes education, providing participants with valuable information on nutrition and healthy eating habits, as well as extensive breastfeeding support that includes counseling and access to supplies like breast pumps when indicated. The WIC program serves as a bridge to other healthcare services, offering referrals to medical providers, immunization programs, and prenatal care programs and services.
The Maryland WIC program is also committed to helping families have positive, successful breastfeeding experiences. WIC provides a variety of lactation services and resources. Education and support are offered in English and Spanish through clinic visits, telephone calls, texting, virtual classes and sharing of written, digital and online information. Language translation is available for all languages for in-person and telephone communications.
All Maryland WIC staff have a role in supporting breastfeeding families. Those with more breastfeeding knowledge, skills, and training provide ongoing individual support tailored to the family’s needs. This includes peer counselors and credentialed lactation consultants. In FY24, Maryland WIC staff provided breastfeeding education and support to parents and caregivers of 31,234 infants as well as prenatal breastfeeding education to 30,558 participants. This is an increase of 2.4 percent for infants and 2.4 percent for pregnant women over FY23.
Home Visiting
In FY24, Baltimore City leveraged Title V funds through core public health funding to support home visiting. Throughout the year, Baltimore City successfully assisted a total of 649 families and facilitated 2,762 home visits. A significant focus of these visits included education on vital health topics. At least 584 families received safe sleep education and 438 families received breastfeeding education and supplemental information. Moreover, the program facilitated broader community health connections. Two hundred and ninety-one families were referred to Maryland’s WIC program, enhancing their access to essential nutritional support. Education on the dangers for secondhand smoke exposure reached 232 families, and a similar number received guidance on family planning. The health department also connected 26 pregnant women with dental care services, underscoring the importance of oral health during pregnancy. Furthermore, developmental health was a critical component of the support provided and 114 families received education on developmental screenings.
Priority Area 3: Reduce the number of sleep-related infant deaths statewide
Promoting infant safe-sleep has continued to be a priority for Maryland since FY20 and its progress is measured by national performance measure five. Pregnancy Risk Assessment Monitoring System data for 2023[6] births indicated that 72.3 percent of new mothers had placed their babies on their backs to sleep, which is less than the Healthy People 2030 target of 88.9 percent. The prevalence was highest among non-Hispanic white mothers at 82.2 percent and lowest among non-Hispanic Asian and non-Hispanic Black mothers at 63.3 percent and 63.2 percent, respectively. The prevalence was highest among mothers aged 35 or older at 79.7 percent and those between 30 and 34 years at 71.2 percent. Rates were lower among younger mothers at 66.4 percent among mothers aged 20-24 years and 64.7 percent among mothers aged 25 to 29 years. In line with the national performance measure SS-B definition, 28.8 percent of infants were placed to sleep on a separate approved sleep surface. Over 73 percent of infants were placed to sleep without soft objects or loose bedding, corresponding to national performance measure 5C.
In FY24, infant safe sleep education was provided to 15,206 families, providers and other community members through Title V. Jurisdictions such as Baltimore City have a dedicated provider outreach program to inform providers including pediatricians, obstetrics, gynecologists and the Department of Social Service providers on the importance of focusing on infant safe sleep and the prevention of sleep-related infant deaths. In addition, through Title V, 744 families received information on secondhand and environmental smoke exposure. Child Fatality Review teams continued to review all sleep-related infant deaths and a detailed analysis and review were provided in the annual CFR legislative report.
As part of FY24 Surveillance Quality Initiatives efforts, local CFR and FIMR teams continued to prioritize the dissemination of information and education on sleep-related infant death and safe sleep best practices. Teams continued the distribution of safe sleep materials such as pack-n-plays and sleep sacks, as well as ongoing community-based safe sleep education training conducted throughout the state. In FY24, BBH grantees distributed 448 portable cribs, and SQI grantees distributed a total of 1,346 portable cribs. During this period, Title V staff developed a data brief, Sleep-Related Infant Deaths in Maryland 2016-2020, to understand the burden of unsafe sleep practices on infant deaths in Maryland. Data from 2016-2020 on sleep-related SUIDs infant deaths linked to how or where the baby sleeps or slept were examined. In addition, the brief contains information on programmatic and policy interventions to illustrate Maryland’s current efforts on safe sleep. Additionally, Title V staff updated the MDH Infant Safe Sleep website to ensure alignment with the most recent American Academy of Pediatrics Guidelines and updated guidance for birthing hospitals and caregivers. The department also provided supplemental funds to Baltimore City via its Babies Born Healthy grant. These funds were used to support a Safe Sleep Summit co-hosted by Baltimore City and Baltimore County. The funds were also used to hire a safe sleep consultant to provide technical assistance to birthing hospitals in Baltimore City and Baltimore County.
[3] case-mix data from the Health Services Cost Review Commission
[4] Maryland PRAMS 2021-2023 and 2022 data should be interpreted with caution due to low response rates.
[5] This number reflects the annual state level data for the total participation reported by Maryland to the USDA.https://www.fns.usda.gov/pd/wic-program
[6] Maryland PRAMS data from 2021–2023 should be interpreted with caution due to low response rates. Additionally, the 2023 data used a revised Phase 9 questionnaire with changes to safe sleep questions, making it not directly comparable to prior years.sleep differently than in previous years.
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