Program Overview

Overview of the State

California is home to one out of every eight US residents, making it the largest population of any state in the nation. California also has one of the most racially and ethnically diverse populations, second only to Hawaii in terms of population diversity.1 Additionally, the state’s economy is the largest in the US, and if California were a country it would rank as the fifth largest economy in the world.  California is a land of contrasts. San Bernardino County covers more than 20,000 square miles and is the largest county in the US by area, while San Francisco County squeezes nearly 900,000 residents into just 47 square miles, making it the most densely populated county in the state.2 Los Angeles-Long Beach-Anaheim is the second largest metropolitan area in the country with more than 10 million residents, while Alpine County has just over 1,200 residents.2

1. Five Census Findings You May Have Missed - The New York Times (nytimes.com)
2. http://www.usa.com/california-state-city-and-city-map.htm

 Title V Program Background

The mission of the California Department of Public Health (CDPH) is to advance the health and well-being of people and communities in California. The Maternal, Child, and Adolescent Health  Division (MCAH) is one of three divisions in the Center for Family Health (CFH) in CDPH. MCAH administers the Title V Maternal and Child Health Services Block Grant Program.

CDPH/MCAH strengthens the capacity of Local Health Jurisdictions (LHJs), communities, and Community-Based Organizations (CBOs) to improve the health and well-being of women, infants, children, and adolescents throughout the state. MCAH programs and initiatives serve California's diverse populations and regions, providing resources, information, and data on physical, emotional, mental, and social health. CDPH/MCAH supports 61 local MCAH programs, based in LHJs in 58 counties and three cities, which differ widely by population, geography, and socioeconomic factors. California’s counties include major metropolitan areas as well as rural and frontier counties; global centers for agriculture, the arts, culture, technology, and innovation; geography ranging from coastal areas and mountains to the desert; nine National Parks; an international border; and countless other unique characteristics. Local MCAH programs play a critical role in the collaborative development of priorities and strategies that drive the MCAH mission.

In addition to local MCAH programs, Title V supports a variety of other programs such as the Black Infant Health Program (BIH), the Comprehensive Perinatal Services Program (CPSP), and the Adolescent Family Life Program (AFLP). CDPH/MCAH funds and supports partnerships with state and local agencies, CBOs, and universities to drive programmatic efforts that improve the health of the MCAH population. CDPH/MCAH also collaborates with partners across the state on topics including oral health, trauma and violence prevention, infectious and genetic diseases, nutrition support, adolescent sexual health, maternal and perinatal quality of care, developmental screening, and others. Families in California have an integral role to play and ongoing efforts to increase engagement of families is an important aspect of our Title V work.

Health Equity: A Core Focus

Achieving health and well-being for all Californians means acknowledging and addressing existing health disparities. CDPH/MCAH recognizes that systemic inequalities based on race/ethnicity, gender, sexual orientation, and disability status, along with poverty, trauma, and other social and environmental factors, have an interconnected and established impact on physical and mental well-being. To capture health disparities and inequities, CDPH/MCAH aims to use a health equity lens throughout our Title V Programs and plans to expand this focus in the future.

Recognition of the role of social determinants in health outcomes is at the heart of our work at CDPH/MCAH.  CDPH/MCAH has the responsibility to apply a health equity focus to all aspects of our work—what we lead, fund, partner, and support—and the capacity to be intentional about addressing the needs of our MCAH populations through our programs. CDPH/MCAH programs connect families to economic, social, and physical supports and services that can help mitigate the impact of discrimination and poverty on their physical and mental/emotional health. CDPH/MCAH recognizes the need to listen to and learn from our population for program development and improvement. CDPH/MCAH encourages engagement of individuals and families that are served by our programs to ensure their needs are addressed.

The MCAH division is committed to exploring and addressing both the causes and the effects of structural injustices on mothers, infants, children, and adolescents within our communities. As one example, between 2017-2019, the pregnancy-related mortality ratio for Black women and birthing people was three to four times greater than the mortality ratios for Asian/Pacific Islander, Hispanic/Latinx, and White persons. CDPH/MCAH has undertaken several efforts, including expansion of the BIH program and establishment of the Perinatal Equity Initiative (PEI), to reduce racial health disparities in birth outcomes among Black women and birthing people. The new State General Funds, distributed in 2020, were expended to increase core BIH staffing; provide childcare for BIH participants; provide door-to-door transportation for participants; and provide participants with the option for one-on-one case management only if they are unable to attend BIH group sessions.

CDPH has an active Office of Health Equity, and our staff participate in the department’s racial equity initiative. A new Health Equity Liaison position has been created for CFH to embed racial and health equity into the department’s policies, programs, and services. The Health and Human Services Agency is a member of the Health in all Policies Task Force whose charge is to address the social, environmental, and policy contributors to inequities in our state. While MCAH has made significant strides in health equity, a great deal of work is still left to do and that is reflected in our planned activities for 2021-2025.

Impact of COVID-19

The COVID-19 pandemic has affected every aspect of life in California and put the state in an extended state of emergency. California’s “Blueprint for a Safer Economy” outlined a framework for a safe progression of opening more businesses and activities in light of the pandemic. Between August 2020 to June 2021, every California county was assigned to a COVID-19 risk-level tier based on weekly updates to local health department data. California’s color-coded county tier system was based on new case rates, positivity rate, adjusted case rate, and a health equity metric. Counties faced varying degrees of activity and capacity restrictions based on their tier level. On June 15, 2021, California fully reopened the economy as significant progress was made in vaccinating individuals and reducing community transmission.

As California emerges from the COVID-19 crisis, CDPH/MCAH strives to redesign and recalibrate programs and initiatives in the context of the pandemic, especially those disproportionately impacted. Within CDPH/MCAH, essential functions were prioritized while coping with the evolving pandemic. The impact on the MCAH population includes, but is not limited to, increased mental health issues; loss of social support and connection; increased risk of preterm births, stillbirth, and other pregnancy complications; increased violence, childhood adversity, and trauma; disrupted access to health care, social services, and education; and increased economic hardships such as food insecurity and employment loss. CDPH/MCAH will continue to monitor other secondary impacts of the pandemic on California families.

Over the past year and a half telehealth was incorporated into our case management and home visiting programs, create population-specific tips sheets and guidance, expand our data collection to track impacts of the pandemic on MCAH populations, pitch in to help each other as staff are redirected to focus on the pandemic response, and respond to other challenges as they arise.  CDPH/MCAH actively tracked changes to local MCAH needs and challenges, adapting MCAH program guidance and data collection to ensure continued services with increased flexibility to address local needs. The impact and stress of the pandemic on MCAH populations and public health professionals has been compounded by layers of additional crises and statewide events, including a devastating wildfire season in 2021, public safety power shutoffs and power outages, resettlement of Afghan refugee families, and civil unrest, among others.

The MCAH workforce has been significantly impacted, with many state and local MCAH staff still redirected and/or are transitioning back from reassignment to the COVID-19 pandemic response. The reduced capacity of local MCAH staff to work on MCAH activities has hindered our ability to utilize existing funding and accept or apply for new funds.  The COVID-19 public health emergency also affected Title V planning and implementation. The five-year needs assessment and action planning process for the new cycle (2021-2025) was largely finalized in early 2020, before the severity of the pandemic was understood. As the pandemic continues, some of the priority needs, strategies, and activities presented in the report may need to be adjusted.

MCAH Priorities

The priorities and focus areas below were identified through a synthesis of local MCAH needs assessments, a review of population data and key literature, engagement of MCAH programs and stakeholders through surveys, interviews, and stakeholder meetings, and an assessment of program capacity and key partnerships at the state level.  The following Priority Needs outline the overarching goals in the five Title V population health domains. Focus area within each priority further delineate and communicate the most pressing needs for our populations.

WOMEN/MATERNAL Priority Need 1: Ensure women in California are healthy before, during, and after pregnancy.

Focus areas:

• Reduce the impact of chronic conditions related to maternal mortality.
• Reduce the impact of chronic conditions related to maternal morbidity.
• Improve mental health for all mothers in California.
• Ensure optimal health before pregnancy and improve pregnancy planning and birth spacing.
• Reduce maternal substance use.

PERINATAL/INFANT Priority Need 1: Ensure all infants are born healthy and thrive in their first year of life.

Focus area:

• Improve healthy infant development through breastfeeding.
• Improve healthy infant development through caregiver/infant bonding.

PERINATAL/INFANT Priority Need 2: Reduce infant mortality with a focus on eliminating disparities.

CDPH/MCAH recognizes that infant mortality in California hit a record low at 3.9 infant deaths per 1,000 live births, a decrease of 7.1 percent from 4.2 infant deaths per 1,000 live births in 2019. However, the Black infant mortality rate increased to 10.2 deaths per 1,000 live births in 2020, 3.8 times higher than the White infant mortality rate (10.2 vs. 2.7) in 2020. CDPH/MCAH recognizes the need to be intentional in addressing this disparity and adapt our ongoing activities to address the underlying causes.

Focus areas:

• Reduce Black infant mortality.
• Reduce preterm births.

CHILD Priority Need 1: Optimize the healthy development of all children so they can flourish and reach their full potential.

Focus areas:

• Expand and support developmental screening.
• Raise awareness of adverse childhood experiences (ACEs) and prevent toxic stress through building resilience.
• Support and build partnerships to improve the physical health of all children.

CHILDREN AND YOUTH WITH SPECIAL HEALTH CARE NEEDS (CYSHCN) Priority Need 1: Make systems of care easier to navigate for CYSHCN and their families.

Focus areas:

• Build capacity at the state and local levels to improve systems that serve CYSHCN and their families.
• Increase access to coordinated primary and specialty care for CYSHCN.

CHILDREN AND YOUTH WITH SPECIAL HEALTH CARE NEEDS Priority Need 2: Increase engagement and build resilience among CYSHCN and their families.

Focus area:

• Empower and support CYSHCN, families, and family-serving organizations to participate in health program planning and implementation.

ADOLESCENT Priority Need 1: Enhance strengths, skills, and supports to promote positive development and ensure youth are healthy and thrive.

Focus areas:

• Improve sexual and reproductive health and well-being for adolescents.
• Improve awareness of and access to youth-friendly services for adolescents.
• Improve social, emotional, and mental health and build resilience among adolescents.