Michigan’s Title V Maternal and Child Health (MCH) program supports critical MCH programs and services across the state. Its overarching goal is to improve the health and well-being of mothers, infants, children, and adolescents including children with special health care needs (CSHCN). The Michigan Department of Health and Human Services (MDHHS) administers the Title V block grant through the Division of Maternal and Infant Health (DMIH). The Children’s Special Health Care Services (CSHCS) Division serves as the Title V CSHCN program. The Division of Child and Adolescent Health (DCAH) oversees Title V funding to local health departments (LHDs). Collectively the DMIH, DCAH, and CSHCS Division provide leadership on MCH programs and policies, including oversight of program-specific work and statewide multisystem collaboratives, as discussed throughout this application. Since March 2020, Michigan’s MCH programs have responded to the impact of the COVID-19 pandemic on the MCH population. Information related to the COVID-19 pandemic is included in the Overview of the State, the Needs Assessment Update, and state action plans.

Michigan’s Fiscal Year (FY) 2021-2025 state priorities were determined by the five-year needs assessment completed in early 2020, prior to the COVID-19 pandemic. The assessment identified needs for preventive and primary care services for women, mothers, infants, children, and services for CSHCN. Stakeholders and community members representing the Title V population domains were engaged in the process. The goals of the assessment were to:

• Use multiple types of data to understand health outcomes, health behaviors, and health disparities, as well as underlying causes that drive inequity.
• Strengthen partnerships and strategies for achieving health equity.
• Engage diverse populations and system partners in describing and understanding the needs and strengths of the MCH population.
• Identify state priority needs and performance measures for Title V.
• Identify opportunities to address needs beyond the scope of Title V.

Based on the needs assessment, the current Title V state priorities are:

• Develop a proactive and responsive health system that equitably meets the needs of all populations, eliminating barriers related to race, culture, language, sexual orientation, age, and gender identity.
• Improve access to high-quality community health and prevention services in the places where women, children, and families live, learn, work, and play.
• Ensure children with special health care needs have access to continuous health coverage, all benefits they are eligible to receive, and relevant care where they learn and live. 
• Expand access to developmental, behavioral, and mental health services through routine screening, strong referral networks, well-informed providers, and integrated service delivery systems.
• Improve oral health awareness and create an oral health delivery system that provides access through multiple systems.
• Create and enhance support systems that empower families, protect and strengthen family relationships, promote care for self and children, and connect families to their communities.
• Create safe and healthy schools and communities that promote human thriving, including physical and mental health supports that address the needs of the whole person.

As per Title V requirements, National Performance Measures (NPMs) and State Performance Measures (SPMs) were chosen to align with the priority needs and are discussed below by population domain. The needs assessment also identified three key “pillars” across population domains: achieving equitable health outcomes; engaging families and communities; and delivering culturally and linguistically appropriate health education.

Detailed state action plans for NPMs and SPMs (which include information on objectives and strategies, metrics, program planning and improvement, and family and consumer engagement) are included in Section III.E. A brief summary of each NPM and SPM is presented below.

Women/Maternal Health

The first goal in this domain is to decrease the percent of cesarean deliveries among low-risk first births (NPM 2). Michigan’s percentage of low-risk cesarean deliveries has consistently been higher than the US and has been slower to decrease over time. Michigan has also seen no change to slight increases in low-risk cesarean deliveries to Black birthing individuals (from 29.6% in 2012 to 30.9% in 2020) while the percentage of low-risk cesarean deliveries to White birthing individuals has decreased (from 29.5% in 2012 to 27.4% in 2020, MDHHS, Division of Vital Records & Statistics). The Title V plan focuses on reducing the overall rate of low-risk cesarean deliveries while focusing on disparities among women of color. Strategies include working with Regional Perinatal Quality Collaboratives (RPQCs) to implement the Michigan Alliance for Innovation on Maternal Health (MI-AIM) bundle, providing bias and equity training for providers, and increasing the number of birthing hospitals participating in MI-AIM.

The second goal in this domain is to increase the percent of women with a preventive dental visit during pregnancy (NPM 13.1). In 2018, only 49.3% of Michigan women had their teeth cleaned during their most recent pregnancy, a decline from a peak of 53.6% in 2015 (MI PRAMS). Non-Hispanic Black mothers saw a particularly large decrease in preventive dental care during pregnancy, from 47.6% in 2016 to 39.2% in 2018 (MI PRAMS). Strategies to increase dental visits include training for medical and dental providers who treat and refer pregnant people; increasing the number of socioeconomically disadvantaged pregnant people receiving oral health care services; and exploring alternative models of care for service delivery.

The third goal is to increase the percent of women who have an intended pregnancy (SPM 5). While Michigan has seen a modest increase in the rates of pregnancy intention from 2012 (52.2%) to 2019 (59.8%), White mothers (64.6%) were 2.4 times as likely as Black mothers (26.9%) to report their most recent pregnancy was intended (2019) (MI PRAMS). The state action plan focuses on increasing access to contraception by making most or moderately effective contraceptive methods readily available and by improving the quality of contraceptive care by assessing client-centeredness and offering equity trainings for reproductive health care providers.

Perinatal/Infant Health

The first perinatal/infant health goal is to increase the percent of infants who are ever breastfed and the percent of infants breastfed exclusively through six months (NPM 4). While breastfeeding rates have increased in Michigan, exclusivity rates still fell short of the Healthy People 2020 goal. In Michigan, 82.5% of infants are ever breastfed (2020) and 25.8% are exclusively breastfed through six months (MDHHS, Division of Vital Records & Statistics; National Immunization Survey 2020 Breastfeeding Report Card). According to PRAMS, initiation rates among Black mothers in Michigan continue to be 20% lower than White mothers (2019). To increase breastfeeding rates, MDHHS will implement strategies to support and promote access to breastfeeding professionals and peer counseling and increase the number of Baby-Friendly© hospitals. To address disparities, Michigan will support non-Hispanic Black women who initiate breastfeeding through promotion of culturally responsive messages, racially and culturally diverse breastfeeding professionals, and community-based breastfeeding organizations.

The second goal is to increase the percent of infants placed to sleep in safe sleep environments (infants placed to sleep on their backs, in cribs without objects) (NPM 5). In 2019, 149 sleep-related infant deaths occurred in Michigan (Centers for Disease Control and Prevention Sudden Unexpected Infant Death Case Registry, 2010 to 2019, Michigan Public Health Institute, 2021). Sleep-related infant deaths are a leading type of death for infants aged 1-12 months old (2018-2020 Michigan Resident Infant Death File, Division for Vital Records & Health Statistics, MDHHS). Data between 2016 and 2020 reveal state level improvements in infants reported as sleeping with no soft objects and in a separate approved sleep surface (Michigan PRAMS). MDHHS strategies focus on increasing safe sleep behaviors by all families, while also addressing the disparity for non-Hispanic Black infants. Strategies include supporting local safe sleep activities; working with providers to ensure safe sleep education and resources for families; developing tools for client/patient centered safe sleep conversations; promoting protective factors; and working with hospitals in areas with high rates of sleep-related infant deaths.

Child Health

Michigan continues to focus on increasing the percent of children who have a preventive dental visit (NPM 13.2). The percentage of Michigan children ages 1-17 who receive preventive dental care in the previous year dropped slightly from 77.9% in 2016-to 76.6% in 2019-2020 (National Survey of Children’s Health). A key objective in Michigan’s Title V plan is to increase the number of students who receive preventive dental screenings in a school-based dental sealant program. MDHHS will administer the SEAL! Michigan program and promote the program through school health professionals. To address disparities in access to care, MDHHS will also work with and support Detroit Public Schools Community District to increase dental screenings and sealants.

A second goal is to increase the percent of children less than 72 months of age who receive a venous lead confirmation testing within 30 days of an initial elevated capillary test (SPM 1). Between 1998 and 2021 Michigan made progress reducing lead poisoning, with the percentage of birth to six-year-old children in Michigan with blood lead levels > 5 ug/dL decreasing from 44.1% to 2.3%. Yet some communities still experience higher rates of lead poisoning. Confirming elevated capillary results with a venous test is key to facilitating follow up. Progress has been made, with MDHHS data indicating a rise in venous confirmation testing within 30 days of an initial elevated capillary test from 16.1% in 2013 to 45.3% in 2021. However, due to the COVID-19 pandemic and recalls in blood lead testing kits, Michigan has a seen a significant drop in blood lead testing for children under 6 years old. To continue to make progress, Michigan will screen for lead exposure risk factors in children; conduct provider education; and work to increase blood lead testing for all children, especially those who are Medicaid-enrolled.

MDHHS is working to increase the percentage of children ages 19-35 months who are up-to-date with all recommended vaccines (SPM 2). The estimated percentage of children in this age group who received all age-appropriate recommended vaccines was 69.9% in 2021 (Michigan Care Improvement Registry). The COVID-19 pandemic negatively impacted childhood vaccination rates in Michigan. Strategies to increase vaccination rates include targeted outreach to parents of children who are overdue for a vaccine; vaccine outreach to areas with a high social vulnerability index; working with LHDs to reach under-vaccinated populations; and partnering with the City of Detroit Health Department to increase vaccination rates in Detroit.

Adolescent Health

The first goal in this domain is to decrease the percent of adolescents who are bullied or who bully others (NPM 9). According to the Youth Risk Behavior Survey (YRBS), from 2011 to 2019 just under one-third of Michigan adolescents reported being bullied at school or online. Among CSHCN, the percentage rises to 53.6% (NSCH). In 2019, 36.4% of Michigan adolescents reported feeling sad or hopeless for two or more weeks; 18.7% of Michigan adolescents reported considering suicide (YRBS). Key objectives for MDHHS are to work with secondary schools to implement bullying prevention initiatives; provide schools with guidance on state laws and model policies with protections for LGTBQ+ youth; and support bullying prevention activities for CSHCN.

A second goal is to increase the percent of adolescents who have received a completed HPV vaccine series (SPM 3). As of December 2021, 72.6% of adolescents ages 13 through 17 years were current with immunizations, but that percentage dropped to 42.5% when HPV series completion was included (MCIR). However, Michigan has improved the percentage of adolescents receiving at least one dose of the HPV vaccine, and in 2020 61.3% of Michigan adolescents were up to date with the HPV series (NIS-Teen). The COVID-19 pandemic has had a negative impact on HPV vaccination rates in Michigan. To boost HPV completion rates and increase protection from HPV-related diseases, MDHHS will update HPV materials to ensure an equitable approach to vaccine hesitancy; increase vaccine confidence among parents and adolescents; and work with local health departments, providers, and health systems to implement quality improvement strategies and measures.

Children with Special Health Care Needs

A goal in Michigan is to increase the percent of adolescents with special health care needs who receive services necessary to make transitions to adult health care (NPM 12). In Michigan, 26.7% of CYSHCN reported they received services necessary to transition to adult health care, which is higher than the US at 22.5% (NSCH 2019-2020). To improve transitions to adult care, key efforts will include promoting Health Care Transition (HCT) to students through school-based clinics; piloting an HCT letter for 14-year-old CSHCS enrollees; and increasing the number of health care professionals who have received training on transition to adult health care.

Another goal is to increase the percent of CSHCN enrolled in CSHCS who receive timely medical care and treatment without difficulty (SPM 4). CSHCN often require and use more health care services than other children. Health care costs can pose significant burdens for families, even with private insurance. CSHCS helps to cover the costs of medical care and treatment. During FY 2021, 53,474 individuals were enrolled in CSHCS. Strategies to increase access to high-quality services include covering specialty care and treatment costs for qualifying conditions; expanding access to high quality specialty clinics and the use of telemedicine; improving outreach and advocacy services; and enhancing the CYSHCN system of care.

Cross-Cutting

The needs assessment identified unmet mental health needs in the women/maternal health, adolescent health, and CSHCN domains. A goal across these domains is to support access to developmental, behavioral, and mental health services (SPM 6). In 2020, over 25% of Michigan women ages 18-44 years reported more than two weeks of poor mental health during the prior 30 days (Behavioral Risk Factor Surveillance System). Postpartum depression symptoms were reported by 14.8% of mothers in 2019 (MI PRAMS). In 2019, 36.4% of adolescents reported two or more weeks of sad or hopeless feelings and 18.7% considered suicide (YRBS). Only 68.1% of CSHCN with a mental or behavioral health diagnosis received appropriate treatment in 2019-2020 (NSCH). The Title V program will support the work of local health departments in addressing behavioral health needs; support perinatal screenings among RPQCs; increase collaboration between Title V CSHCS and behavioral health partners; and support the Handle with Care initiative for school-aged children and adolescents.