Maine’s Title V Maternal and Child Health (MCH) Program, in partnership with the US Department of Health and Human Services (DHHS), Health Resources and Services Administration (HRSA), is responsible for promoting the health of all mothers and children, including children with special health needs and their families. The realignment of the Maternal and Child Health Block Grant outlined in HRSAs guidance requires measured accountability and use of evidence-based strategies to address needs. These requirements align well with processes the Maine DHHS implemented to assure use of limited resources in efficiently and effectively assisting the most vulnerable residents receiving DHHS services.

Historically Maine has had positive health outcomes related to MCH such as low rates of premature births, high initiation of prenatal care in the first trimester, high percentage of the population with health insurance and low child and adolescent mortality in comparison to the nation. Factors influencing these outcomes include partnerships with governmental and non-governmental agencies to address issues impacting the MCH population such as; development of a statewide system for the provision of reproductive health services, implementation of comprehensive health education in Maine schools, development of multi-disciplinary clinics for children with special health needs (CSHN) (i.e. cleft lip and palate) and oral health education and dental disease prevention activities.

The Role of Title V in Maine

The Maine Title V program supports a statewide system of services that is comprehensive and family-centered.

The Maine Center for Disease Control and Prevention (Maine CDC) houses the Title V Program along with other MCH programs such as WIC, Maine Families Home Visiting, Tobacco and Substance Use Prevention and Control (TSUPC), Injury Prevention and Public Health Nursing (PHN). These programs work collaboratively to address the needs of the MCH population across the state.

The Title V Program serves as a convener and collaborator as evidenced by its role in collaborating with the TSUPC Program to hold a combined MCH and substance exposed infant conference. The programs worked closely to facilitate a two-day conference addressing issues of substance exposed infants, opioid use by pregnant and postpartum women, along with other MCH topics such as maternal depression. Over 200 community and health providers attended.

Title V utilizes a significant portion of federal funding to support staff in the areas of PHN, CSHN and health education within the Department of Education (DOE) to ensure meeting the needs of the state’s MCH population. The Maintenance of Effort funding supports Public Health District Liaisons. Title V also serves as a systems builder by funding such services as the Maine Maternal, Fetal and Infant Mortality Review Panel, epidemiological surveillance, including the Maine Integrated Youth Health Survey, and program evaluation.

The Maine Title V Program does not operate in isolation. Partnerships with other organizations are central in our ability to expand capacity and reach across the state. The Title V Program collaborates with hospitals, other state agencies, such as the Office of MaineCare Services, Office of Child and Family Services, DOE, Child Development Services, the Developmental Disabilities Council, universities and other stakeholders. Family involvement is encouraged in the areas of needs assessments, program planning and evaluation. To enhance capacity, the Title V Program contracts with several external agencies to ensure needed services are available to the MCH population.

Title V Framework

Maine used the DHHS and Maine CDC strategic plans along with Healthy Maine 2020 and the State Health Assessment, created as part of the Maine CDC’s accreditation preparation, as the framework for developing the Title V priorities.

As part of its 2015 needs assessment process the Maine Title V Program collaborated with multiple stakeholders and partners to develop evidence-based action plans to address each national and state performance measure. These action plans guide the annual work of each population domain.

Maine found that action planning plays a vital role in decision-making and resource allocation for the Title V Program. The development and on-going monitoring of the domain work facilitated the development of realistic goals, strategies and activities to address our priorities. This regular monitoring is also beneficial in determining future year adjustments and identify emerging issues.

Maine’s Title V Program continually emphasizes the importance of data driven decision-making. To achieve this goal, Maine’s lead MCH epidemiologist ensures use of a data-driven approach in developing Maine’s MCH performance measure activities for the State Action Plan and conveys data back to program staff to aid in program planning.

The following graphic outlines the Title V priorities, federal and state PMs by population domain for 2016-2020.

Women/Maternal Health

Reproductive Health

Improving women’s health before, during and between pregnancies is an important public health goal.

In 2017, almost 1 in 4 low-risk first births in Maine was delivered via cesarean section (C-section). Maine’s low-risk C-section rate is statistically significantly lower than the U.S. rate of 26.0% and has been decreasing over time (8% between 2009 and 2017). This decrease may be due in part to several Maine hospital systems adopting policies around inductions prior to 39 weeks without cause.

Our Perinatal Outreach Consultant worked with Maine Medical Center on an obstetrical clinical transformation project, Safe Prevention of the Primary C-section. The goal of the project was to encourage women in labor to remain at home during early labor and only go to the hospital when in active labor. The hospital developed a patient handout, ‘Ready, Set, Not Yet!’ along with a sample script for nurses. Staff are monitoring to determine if fewer women are presenting during early labor.

Birth Outcomes

Maine’s rate of unintended pregnancies has been decreasing in recent years; in 2012, almost 50% of pregnancies were unintended. Despite our overall success in decreasing unintended pregnancy rates, we remain concerned about the unintended pregnancy rate among young women. About half of Maine women under age 20 and 25% of young women aged 20-24 years who had a recent live birth had not planned to get pregnant at that time or in the future.

Maine Family Planning, in partnership with New Beginnings, works with youth-serving agencies and alternative high schools to deliver “Be Proud, Be Responsible!” to young people across the state. A focus of Maine Families Home Visiting (MFHV) is to counsel around reproductive life plans. Nearly 90% of MFHV enrolled postpartum women received their postpartum exam within 56 days after the birth of their child.

Risk Factors for Chronic Disease

In Maine, about 1 in 8 (13.1%) women smoke during pregnancy.[1] Maine’s smoking rates during pregnancy are among the highest in the U.S. and our quit rates during pregnancy are low. However, we are optimistic; the rate of smoking during pregnancy in Maine has been declining since 2014.

The Non-Clinical Outreach initiative is an effort where tobacco public health partners work with statewide social service programs or service agencies, such as MFHV, WIC or other service providers such as faith-based organizations to increase the number of people, including pregnant women, referred to the Maine Tobacco HelpLine through the QuitLink.

Perinatal/Infant

Birth Outcomes

Maine has had great success in encouraging breastfeeding initiation and promoting breastfeeding duration. Among Maine infants born in 2015, 85% were initially breastfed.[2] Sixty percent were breastfed at least six months and 1 in 3 (34%) were breastfed exclusively for six months. The percent of infants exclusively breastfed for six months in Maine is the 5th highest in the U.S. Maine’s improving breastfeeding rates suggest that efforts around the state to support breastfeeding have been effective.

Safety and well-being for infants

Maine has had increasing success in promoting “Back to Sleep” to new parents. In 2017, 89% of new mothers reported that they most often place their infants on their back to sleep.[3] However, other safe sleep messages, specifically those related to sleep surfaces and soft bedding, have not been embraced by parents at the same level. Only about 1 in 3 Maine infants sleep alone on an approved sleep surface, such as a crib, bassinet or pack and play and not on a couch, bed, car seat, swing, or armchair. Only about half of Maine infants are usually put to sleep without soft bedding. During the first few months of life, four out of five Maine infants are placed to sleep in an unsafe sleep situation.2 Efforts to address unsafe sleep practices are focused in hospital settings, as well as with providers who work directly with families throughout their first year of life.

Child Health

Access to High Quality Health Care

When a developmental delay is not recognized early it can make it difficult for children to learn when they begin school. Based on the 2016-2017 National Survey of Children’s Health (NSCH), only 39% of children aged 9 to 35 months of age received a developmental screening using a parent completed screening tool.[i] Maine ranked 25th highest in the U.S. on this measure.

Maine undertook a quality improvement project focused on a community approach to improving developmental screening referrals and follow up for children ages birth to three. The project aim was to understand the referral process flow and evaluate ways to improve upon referrals and follow up.

Readiness to learn and succeed

In 2011, 69% of third graders in Maine had at least one dental sealant. In 2015, this proportion increased to 72.8%. However, in 2017, there was a decrease to 48.6%; this may have been related to a change in survey methodology. In 2017, the Maine School Oral Health Program contracted with outside dental providers to conduct the screenings. Historically, a trained public health provider conducted the screenings.

Maine promotes oral health disease prevention for children, including education through school nurses and application of sealants. Maine dental providers also promote dental sealants to parents as a good preventive intervention for their children. Maine also has dental hygienists working under public health supervision status who provide sealants on-site at schools. School sealant application facilitates children receiving sealants, especially in more rural and underserved areas where regular access to preventive dental care can be challenging.

Risk factors for chronic disease

Based on the 2016-2017 NSCH, 17% of children in Maine live in a household where someone smokes; 2% live with someone who smokes inside the home.

Maine uses the Smoke-free Homes Pledge to create community recognition around the importance of preventing children’s exposure to second hand smoke. Targeted venues include; housing authorities, schools, employer fairs, local safety days, newsletters, and new mom lunch and learns.

Adolescent Health

Readiness to Learn and Succeed

Despite increased attention to the need for prevention and intervention, bullying and harassment remain common experiences for children and adolescents. According to the 2016-2017 NSCH, 6% of adolescents, aged 12-17 years old bullied others and 27% were bullied.

The Adolescent Health and Injury Prevention (AHIP) Program partnered with the Maine Youth Action Network to support statewide youth engagement programming focused on improving school climate and reducing bullying and harassment. Youth Policy Boards develop youth-led participatory action research projects that identify significant issues in their schools or communities, create recommendations, and implement change.

While efforts targeting adolescents often focus on their physical health, unmet mental health needs among teens has a significant impact on their current well-being, and a lasting effect on their future. According to the 2016-17 NSCH, about 9% of Maine adolescents aged 12-17 years have been diagnosed with depression; this is significantly more than the national average of 5.8%. About 20% have problems with anxiety compared to 10% nationally, and 11% have behavioral or conduct problems vs. 7.2% nationally.

Several Youth Policy Boards and local youth action groups focus on mental health awareness and stigma reduction.

Reducing suicide deaths and serious attempts among youth is a longstanding priority for the Maine CDC. Suicide is the second leading cause of death among Maine youth aged 10-19 years. Maine’s youth suicide rate in 2015-17 was 13.3 deaths per 100,000 youth aged 15-19 years, which was the highest youth suicide rate in New England. The reasons for Maine’s relatively high youth suicide rate are multiple and complex; as in many rural states, Maine’s youth face barriers to receiving mental health care, and few providers in Maine specialize in treating adolescents.

The AHIP Program supports the National Alliance on Mental Illness, Maine Chapter to provide outreach and training to educators, youth service providers and community members on strategies for identifying and supporting adolescents in need of mental health services, including promotion of Youth Mental Health First Aid training throughout the State.

Children with Special Health Needs

Systems of care for CSHN

About half (48%) of Maine CSHN had a medical home in 2016-17; 58% of non-CSHN reported receiving care within a medical home.

The Maine Parent Federation (MPF) is focusing on building stronger relationships with provider offices to provide technical assistance on engagement activities including improving the office environment, the office visit and referrals for supports for families. The MPF’s work can help improve care coordination for parents of CSHN.

In 2016-17, parents of 28% of Maine CSHN ages 12–17 reported that their adolescent received services to assist with transition; this is significantly higher than the national figure of 16.7%.

To support families and youth during this period the MPF developed a Transition Guide (High School and Beyond: A Guide to Transition Services in Maine) and made it available to all parents.

Maine continues to monitor progress and adjust, as appropriate, to improve PM outcomes.

[1] Maine Birth Certificate Data, 2017.

[2] National Immunization Survey, 2016-2017 (breastfeeding data on infants born in 2015).

[3] Maine Pregnancy Risk Assessment Monitoring System (PRAMS)

[i] Child and Adolescent Health Measurement Initiative. Data Resource Center for Child and Adolescent Health. 2016-2017 National Survey of Children’s Health (NSCH) data query. Retrieved [6/7/19] from www.childhealthdata.org. CAHMI: www.cahmi.org.