III.E.2.c. State Action Plan Narrative
Perinatal/Infant Health - Annual Report
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 2023.
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 2022, the Maryland infant mortality rate was 6.2 deaths per 1,000 live births, which was similar to the rate of 6.1 per 1,000 live births in 2021. The non-Hispanic white infant mortality rate decreased by 16 percent from 3.7 (in 2021) to 3.1 (in 2022) deaths per 1,000 live births. The Hispanic infant mortality rate increased by six percent, from 5.3 (in 2021) to 5.6 (in 2022) deaths per 1,000 live births and the non-Hispanic Black rate increased by five percent from 9.8 (in 2021) to 10.3 (in 2022) deaths per 1,000 live births.
The neonatal mortality rate (deaths under 28 days of age) was 4.2 deaths per 1,000 live births in 2022 which was about the same as the rate of 4.1 deaths per 1,000 births from 2021. The rate increased by three percent among non-Hispanic Black infants, from 6.7 to 6.9, and decreased five percent from 3.7 to 3.5 among Hispanic neonates. The rate decreased from 2.6 to 2.2 among non-Hispanic 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 non-Hispanic 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 accounting for 19 percent of losses, congenital abnormalities, sudden unexpected infant death (including sudden infant death syndrome) at 12 percent, maternal complications of pregnancy (6%) and placenta, cord and membrane complications (4%). 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.
Congenital Syphilis and Perinatal HIV Transmission
Between 2018 and 2022, Maryland’s congenital syphilis rate rose from 40.4 per 100,000 live births to 68.6 per 100,000 live births, with an average rate of 49.6 per 100,000 live births during this time period.[1] The highest rates are in Baltimore City at 197.7 cases per 100,000 live births with 75 cases total, and Washington County at 168 cases per 100,000 live births with 14 cases total. Between 2016-2020, there were 6 perinatal HIV transmissions in Maryland. In 2022, there were 5 perinatal HIV transmissions in Maryland.[2]
During fiscal year 2023, Title V staff partnered 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 with 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 prior to delivery. Title V staff partnered with the Morbidity, Mortality, and Quality Review Committee members, which comprise clinicians across the state, to inform them of the rising rates and the need to ensure screening for syphilis and HIV as well as Title V grantees that included local health departments, community based organizations and community health clinics. Title V staff also partnered with IDPHSB to develop legislation to change HIV and syphilis testing and reporting for healthcare providers for pregnant people and their newborns.
Fetal and Infant Mortality Review
Title V funds support Maryland’s Fetal and Infant Mortality Review 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 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 maternal child health issues. In FY23, FIMR programs operated in seven of the 24 jurisdictions experiencing the highest number of fetal and infant deaths.
During FY23, 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 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 are able to develop a community perspective on how to best create the desired changes within the community. During FY23, these teams provided recommendations, offered safe sleep resources and personalized messaging to delivering mothers, expanded of home visiting program/services, and offered trainings. These trainings topics (birth control options, 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 FY23, the Maternal Child and Health Bureau developed a safe sleep one-pager and safe sleep social media kit. They updated their website to provide safe sleep resources for caregivers and birthing hospitals. These resources were shared with local health departments and other partners.
During FY23 MCHB provided Surveillance and Quality Initiatives 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 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 FY23, 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 that were previously unable to attend in person meetings consistently.
For the risk appropriate perinatal care, number of very low birth weight (< 1,500g) births performance measure (NPM 3), 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 25,831 babies 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 percent of all VLBW births. This is a slight increase from 2020 with 91.6 percent.
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, 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 in order 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 FY23, 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 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 2023, the MMQRC conducted virtual site visits at two Level I hospitals and one Level II hospital. Additional site visits are planned in FY24 and the Perinatal System Standards will undergo their next revision in Spring 2024.
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 FY23, the MDPQC completed the third and final year of its two projects focused on maternal hypertension and neonatal antibiotic stewardship. The maternal hypertension topic area was implemented in partnership with the Alliance for Innovation on Maternal Health and involved all 32 birthing hospitals. The neonatal antibiotic stewardship initiative involved 26 birthing hospitals. Over the course of the maternal hypertension initiative, the percent of patients receiving appropriate treatment within 1 hour of an elevated blood pressure reading increased from 36.7 percent to 72.6 percent.
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, the Office of Quality Initiatives pre-recorded a neonatal abstinence synndrome 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 were 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.
The University of Maryland led the MPSP from Jul. 1, 2021 through Jun. 30, 2023. During this time, needs assessments conducted by the University of Maryland indicated that birthing hospitals of all levels had established maternal-fetal medicine support through existing academic and clinical partnerships within their health systems and that the MPSP’s support was no longer needed. Attendance at office hours and the number of consultation calls decreased and the MPSP was ended on Jun. 30, 2023.
Babies Born Healthy
For state fiscal years 2024-2028, the MCHB conducted a re-design of BBH, with the goal of aligning with major Statewide Integrated Health Improvement Strategy, or SIHIS, interventions and reducing disparities in infant mortality. Specifically the desire was to address the gap of excess infant mortality between non-Hispanic Black and non-Hispanic white populations. As a result of the re-designed program, BBH will fund new sites/jurisdictions and offer a portfolio of evidence-based initiatives that includes a Doula Training Hub, increasing the number of CenteringPregnancy sites by offering start-up costs and perinatal care coordination.
In FY23, eight local jurisdictions implemented state funded Babies Born Healthy perinatal care coordination 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 FY23, a total of 1,176 families were newly enrolled in BBH, and 2,010 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, WIC or nutrition services, dental care, family planning and breastfeeding support. Many jurisdictions reported using BBH as a platform for implementing recommendations from their jurisidiction’s CFR and FIMR teams to prevent future infant and child deaths. These jurisdictions were selected to receive funding because they have the largest racial disparities in infant mortality, particularly in the non-Hispanic Black population, as compared to the non-Hispanic white population.
Services provided were 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 FY23, 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 percent of infants who are ever breastfed (NPM 4). In 2022, according to PRAMS data,[4] 91.3 percent of Maryland mothers reported having ever breastfed their babies, a 1.5 percent decrease from 92.7 percent in 2021. Rates of breastfeeding in Maryland by race and ethnicity ranged from 87.0 percent among non-Hispanic Black individuals to 99.2 percent 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, mostly birthing hospital representatives. Title V does not provide any funding in the Breastfeeding Policy Committee efforts, but supports through attendance of the committee meeting. However, as the Title V manager position comes on board, Title V hopes to participate and represent on the committee.
Maryland’s Women, Infants, and Children Program
Maryland’s Women, Infants and Children program, often referred to as WIC, ensures that pregnant people, infants and children up to age five receive essential nutrients critical to their growth and development. In federal fiscal year 2023, Maryland reported WIC monthly participation was 122,099, a 2.8 percent increase from federal fiscal year 2022.[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 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 state fiscal year 2023 (July 1, 2022 – June 30, 2023), Maryland WIC staff provided breastfeeding education and support to parents and caregivers of 30,502 (unduplicated) infants as well as prenatal breastfeeding education to 29,838 (unduplicated) participants. This is an increase of 7.2 percent for infants and 3.2 percent for pregnant persons over SFY22.
Home Visiting
In FY23, 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 525 families and facilitated 2,367 home visits. A significant focus of these visits included education on vital health topics. At least 349 families received safe sleep education and 163 families received breastfeeding education and supplemental information. Additionally, 37 families initiated breastfeeding at birth, emphasizing early nutritional support. Moreover, the program facilitated broader community health connections. Seventy families were referred to Maryland’s Women, Infant and Children program, enhancing their access to essential nutritional support. Education on the dangers for secondhand smoke exposure reached 160 families, and a similar number received guidance on family planning. The health department also connected 28 pregnant individuals with dental care services, underscoring the importance of oral health during pregnancy. Furthermore, developmental health was a critical component of the support provided. One hundred fourteen families received education on developmental screenings.
Priority Area 3: Reduce the number of sleep-related infant deaths statewide
Promoting infant safe sleep continued to be a priority for Maryland since FY20. Progress of infant safe sleep is measured by NPM 5. PRAMS data for 2022[6] births indicated that 83.7 percent of new mothers placed their babies on their backs to sleep, an increase of 4.8 percent from 79.9 percent in 2021. This exceeds the Healthy People 2020 target of 75 percent. The prevalence was highest among non-Hispanic white mothers (94.0%) and lowest among non-Hispanic Black mothers (70.5%). Due to subpopulation response rates not meeting the lower threshold (30 respondents), further stratification by age category cannot be reported. In line with the national performance measure 5B definition, 40.1 percent of infants were placed to sleep on a separate approved sleep surface. Over 64 percent of infants were placed to sleep without soft objects or loose bedding (NPM 5C).
In FY22, 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 FY23 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 FY23, Babies Born Healthy grantees distributed 623 portable cribs, and SQI grantees distributed a total of 1,274 portable cribs. During this period, Title V staff developed a safe sleep communications toolkit, including an updated one-pager and posts for social media platforms including Instagram, Facebook and Twitter. Additionally, Title V staff updated the MDH Infant Safe Sleep website to ensure alignment with the most recent AAP Guidelines, and updated guidance for birthing hospitals and caregivers. MDH also provided supplemental funds to Baltimore City via their Babies Born Healthy grant. These funds were used to support a Safe Sleep Summit co-hosted by Baltimore City and Baltimore County, as well as the hiring of a safe sleep consultant who continued to provide technical assistance to birthing hospitals in these jurisdictions to adopt safe sleep policies, and implement safe sleep activities within their hospital.
[3] case-mix data from the Health Services Cost Review Commission
[4] CDC defines the minimum overall response rate threshold as 50% for 2021 and 2022 PRAMS data. In 2021 and 2022, Maryland PRAMS had a weighted response rate of 44.1% and 43%, respectively, and thus did not meet the threshold. Maryland PRAMS 2021 and 2022 data should be interpreted with caution.
[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] CDC defines the minimum overall response rate threshold as 50% for 2021 and 2022 PRAMS data. In 2021 and 2022, Maryland PRAMS had a weighted response rate of 44.1% and 43%, respectively, and thus did not meet the threshold. Maryland PRAMS 2021 and 2022 data should be interpreted with caution.
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