Maryland Title V has three priorities for Perinatal Health:

 

1. Ensure that all babies are born healthy and prosper in their first year
2. Increase the number of infants that are ever breastfed
3. 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 2021.

 

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 2021, the Maryland infant mortality rate was 6.1 deaths per 1,000 live births, an increase of seven percent from the 2020 rate of 5.7 deaths per 1,000 live births, and reflecting a 21 percent overall decrease from the average rate of 7.8 deaths per 1,000 live births from 2012-2016.  The non-Hispanic (NH) White infant mortality rate increased by 12 percent from 3.3 (2020) to 3.7 (2021) deaths per 1,000 live births and the Hispanic infant mortality rate increased by 15 percent, from 4.6 (2020) to 5.3 (2021) deaths per 1,000 live births. The NH Black rate decreased by one percent from 9.9 (2020) to 9.8 (2021) deaths per 1,000 live births.

 

The neonatal mortality rate (deaths under 28 days of age) stayed the same from  2020 to 2021 at 4.1 deaths per 1,000 live births.  The rate decreased by one percent among NH Black infants, from 6.8 to 6.7, and increased six percent from 3.5 to 3.7 among Hispanic neonates. The rate  increased by eight percent from 2.4 to 2.6 among NH white infants.  The statewide post-neonatal mortality (deaths from 28 days through 11 months of age) rate increased by 19 percent, from 1.6 in 2020 to 1.9 deaths per 1,000 live births in 2021. The rate increased 22 percent among NH White infants from 0.9 to 1.1 deaths per 1,000 live births and increased 33 percent among Hispanic infants from 1.2 to 1.6 deaths per 1,000 live births. The postneonatal rate remained the same  among non-Hispanic black infants at 3.1 deaths per 1,000 live births. The leading causes of infant death in 2021 were  low birth weight (LBW) accounting for 19 percent of losses, congenital abnormalities (17 percent), sudden unexpected infant death (SUID) including Sudden Infant Death Syndrome (SIDS) (12 percent), maternal complications of pregnancy (six percent) and placenta, cord and membrane complications (4 percent). Preliminary data show that there were 74 Sudden Unexpected Infant Deaths in 2021.

 

Comparing two five-year periods over the last decade (2012-2016 and 2017-2021), the overall infant mortality rate in Maryland has declined by 23 percent. The largest declines in infant mortality over the two time periods were seen in the Eastern Shore area which had a statistically significant decrease of 25.5 percent overall. Cecil and Wicomico counties saw decreases of 15.5 and 22.4 percent, respectively. The National Capital area also saw a significant overall decrease of 24.3 percent in their rate, with Prince George’s and Montgomery counties decreasing by 26.8 and 23.0 percent, respectively. The Baltimore Metro Area saw a statistically significant decrease of 22.8 percent overall, with Baltimore City and Anne Arundel County seeing decreases of 22.6 and 37.7 percent, respectively. Rates of infant mortality increased in the Northwest area, with a 9.0 percent increase in Allegany county. 

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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 that focuses on maternal and child health, where cases are de-identified 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 (CRT’s) 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 preventable child deaths. 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. In FY 2022, FIMR programs operated in seven of the 24 jurisdictions experiencing the highest number of fetal and infant deaths.

 

During FY 2022, 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 (CAT) 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, or coordinate with local Sexually Transmitted Infections/Human Immunodeficiency Virus (STI/HIV) Partner Services to identify appropriate congenital syphilis and perinatal HIV cases. CAT teams were required to address Statewide FIMR recommendations, identify their focus area, and identify three of the following focus areas to align with their recommendations: 1) develop strategies to increase education on safe sleep practices, 2) improving preconception care and early initiation and access to quality clinical care, 3) referral, tracking, and follow-up of high-risk women, and/or 4) systems for treatment and resources related to SUD and substance exposed newborns (SEN).

Community Action Teams (CATs) 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 CATs consists of those with the political will and fiscal resources to create system level changes. These members are able to develop a community perspective on how to best create the desired changes within the community. During  FY 2022, Community Action Teams provided recommendations, offered safe sleep resources and personalized messaging to delivering mothers,  expanded of home visiting program/services, and offered trainings on birth control options, health department direct services, and high risk pregnancy conditions and severe postpartum warning signs with a goal of improving their ability to serve their clients. Also in FY2022, MCHB began work on several SUID and safe sleep data visualization briefs for dissemination to local health departments and other partners.

 

Child Fatality Review (CFR):

During FY 2022 MCHB provided Surveillance and Quality Initiatives (SQI) grants to all twenty four 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 (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 preventable child deaths.

 

Throughout FY 2022, both FIMR and CFR teams continued to readjust to the COVID-19 Pandemic.  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 that were previously unable to attend in person meetings consistently.

 

For the NPM 3: Risk Appropriate Perinatal Care, the number of VLBW (very low birth weights, < 1,500g) births at all Maryland hospitals increased slightly from 2020 to 2021, from 932 VLBW deliveries in 2020 to 1,093 VLBW births in 2021 across all hospital levels.

 

A total of 25,831babies were born at Level I and Level II delivering hospitals in 2021, with 73 of these babies (7.7% of all VLBW births) born at weights less than or equal to 1,500g. There were 42,435 births at Maryland Level III/IV delivering hospitals in 2021, of which 878 were VLBW, making up 92.3% of all VLBW births, This is a slight increase from 2020 with 91.6%.

 

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, seven (7) are Level I, twelve (12) are Level II, eleven (11) 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 FY21, 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 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 (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 2021, the MMQRC reviewed the VLBW data from 2018, and conducted virtual site visits at three Level II hospitals (prioritizing those with higher VLBW deliveries than other Level I and II hospitals). Additional site visits are planned in FY 2023.

 

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.

 

The MDPQC Steering Committee was reestablished in August 2020, consisting of physicians, nurses, midwives, and public health experts from hospitals and organizations across the state of Maryland. The Steering Committee, after reviewing relevant data and soliciting hospital input, decided to focus on maternal hypertension and neonatal antibiotic stewardship for our quality improvement topics. The maternal hypertension topic area is being implemented in partnership with the Alliance for Innovation on Maternal Health (AIM). Hospitals were recruited, implementation and data collection plans established, and a kick-off event was held for each topic area (Hypertension on 1/25/21, and Antibiotic Stewardship on 5/7/21). All 32 birthing hospitals were recruited for the maternal hypertension initiative, and 20 hospitals were recruited for the neonatal antibiotic stewardship initiative.

 

The MDPQC also created a baseline assessment of hospital engagement and readiness, and hospitals continue to submit data to the Collaborative on a quarterly or monthly basis. On the administrative side, a Mission Statement was written, a website created, and a listserv including contacts from all birthing hospitals was launched. Learning events hosted included COVID-19 Information for Birthing Hospitals, Maternal Safety Bundle Implementation, and the first two events of a Respectful Care Webinar Series – “Respectful Care for All Families: Introduction to the Unique Families Program and How it Betters Care for All Patient Populations'', and “Respectful Care While Addressing our Implicit Bias”.

 

Neonatal Abstinence Syndrome (NAS):

Due to the network security incident in Maryland in 2022, the latest available data on neonatal abstinence syndrome is from 2021. The rate of neonatal abstinence syndrome (NAS) among Maryland resident newborns born in Maryland hospitals has decreased 30.2%, from 14.2 per 1,000 newborn discharges in 2017, to 9.9 per 1,000 newborn discharges in 2021 (Case-mix data, Health Services Cost Review Commission). From 2016-2020, 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 a 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.

 

The Maryland Department of Health led a work group to establish a Statewide definition of Neonatal Abstinence Syndrome.  The purpose of this effort is to strengthen and standardize NAS reporting and inform program planning. A multidisciplinary team agreed to the following definition and has communicated the definition to all Maryland birthing hospitals:

• Evidence of maternal use of opioids, benzodiazepines or barbiturates; and at least one of the following:
  • Presence of two or more infant withdrawal signs related to NAS
  • Birth hospitalization length of stay >three days

 

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 Fiscal Year 2021, providers from Johns Hopkins Hospital conducted 66 physician and advanced practitioner outreach events and 14 nurse outreach visits. The providers continued to provide technical assistance, education, and case reviews for conditions such as gestational diabetes, antiphospholipid syndrome, and 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. The University of Maryland won a competitive project to take over the Perinatal Support Program beginning in FY 2022.

 

Babies Born Healthy:  In FFY 2022, 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. In FFY 2022, a total of 1,218 families were enrolled in BBH, and 2,112 families accessed BBH services.There were a total of 516 births among program participants and 10 fetal/neonatal deaths. These jurisdictions were selected to receive funding after 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. In FFY 2022, sites continued to utilize prenatal care groups following research pointing towards their effectiveness in promoting prenatal health and birth outcomes.

 

 

During FFY 2022, sites continued to experience challenges due to COVID-19. Many BBH staff are public health nurses in LHDs, and were transitioning back from participating in Maryland’s COVID-19 response, to their pre-COVID-19 duties. Families continued to face numerous challenges including job loss and eviction, difficulty in accessing food, loss of childcare, lack of transportation, intimate partner violence, technology limitations, issues in accessing necessary baby supplies, and others.

 

Priority Area 2: Increase the number of infants who are breastfed

 

Breastfeeding:

The progress of Priority Area 2 is measured by NPM 4: Percent of infants who are ever breastfed. In 2021, according to PRAMS data,[1] 92.7 percent of Maryland mothers reported having ever breastfed their babies, a 3.1% increase from 89.9% in 2020. Rates of breastfeeding in Maryland were high across all races and ethnicities ranging from 89.4 for Non-Hispanic Black individuals to 98.7% among non-Hispanic Asian individuals.

 

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. For  FY 2021, there were ten that held current designation. Due to the COVID-19 Pandemic, many of the activities of the Breastfeeding Policy Committee were halted including regular committee meetings, redesignation of Baby Friendly Hospitals, updating of training modules, and technical assistance site visits. 

 

Maryland WIC Program:

The Maryland WIC Program is committed to helping families have positive, successful breastfeeding experiences. WIC provides resources, such as a FAQ sheet, handouts and a breastfeeding checklist available in both English and Spanish, as well as videos that provide information on various breastfeeding-related topics.  Maryland WIC employs 31 breastfeeding peer counselors who provide ongoing one on one support to pregnant and breastfeeding participants. Maryland WIC staff provided breastfeeding education and support to parents and caregivers of 28,464 (unduplicated) infants during SFY2022 (July 2021-June 2022.)  Additionally Maryland WIC staff provided prenatal breastfeeding education to 28,918 unduplicated participants during the same reporting period.

 

WIC Breastfeeding coordinators started training for their staff on diversity, equity, and inclusion to provide an inclusive environment. In October 2021, WIC Breastfeeding coordinators received a presentation entitled “Equity in Breastfeeding: Voices of Black Mothers.” In December 2021, Nekisha Killings, an IBCLC, provided a presentation on breastfeeding and normalizing brown breasts.

 

Home Visiting: During FY 2021, 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 women to needed community resources such as WIC and breastfeeding. In FY 2021, nearly 3,800 pregnant women enrolled in home visiting services and infants received home visiting services through a local health department.   Local health departments reported challenges due to COVID-19 that ranged from local health departments temporarily closing and then adapting to changes after reopening to an overflow of patients in other local health departments that remained open during COVID-19 and the decline in the number served from past years was directly related to COVID-19 closures and restrictions.

 

 

Priority Area 3: Reduce the number of sleep-related infant deaths statewide

 

Promoting infant safe sleep continued to be a priority for Maryland in FY 2020. Progress of infant safe sleep is measured by NPM 5. PRAMS data for 2021[2]0 births indicated that 79.9% of new mothers placed their babies on their backs to sleep (NPM-5A), a slight increase of 1.8% from 78.5% in 2020. This exceeds the Healthy People 2020 target of 75%. The prevalence was highest among NH white mothers (89.6%) and lowest among NH Black mothers (63.5%). Due to subpopulation response rates not meeting the lower threshold (30 respondents), further stratification by age category cannot be reported. In line with the NPM-5B definition, 33.6% of infants were placed to sleep on a separate approved sleep surface. 58.4% of infants were placed to sleep without soft objects or loose bedding (NPM-5C).

 

 

In FY 2022, infant safe sleep education was provided to 7,562  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, 5,952 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 FY 2022 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.  In FY 2022, Babies Born Healthy (BBH) grantees distributed 623 portable cribs, and SQI grantees distributed a total of 1,274 portable cribs.

 

 

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

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