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/or 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 an annual combined MCH and Substance Exposed Infant Conference. The programs work closely to facilitate this two-day conference. The 2020 virtual conference titled Building Pathways of Hope and Success will present current research on such topics as social determinants of health, trauma informed care and parental substance exposure.

Title V utilizes a significant portion of federal funding to support staff in the areas of PHN, CSHN and injury prevention 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 essential 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, Department of Education, 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

During fiscal years 2019/20 Maine undertook a comprehensive strengths and needs assessment process that included engagement of multiple stakeholders and partners in selecting our priorities for 2021-2025 (See Section III. C). National and State Performance Measures were selected and evidence-based action plans developed to address the priorities. These action plans will guide the annual work of each population health domain. 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 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 identifying 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.

Women/Maternal Health

Reproductive Health

Improving women’s health before, during and between pregnancies is an important public health goal. In 2018, 1 in every 4 (25%) low-risk first births were born via cesarean section. In 2018, Maine’s rate on this measure was 27th highest among all U.S. states and territories, but was the second lowest in New England. Maine’s rate of C-sections among low-risk first births increased between 2016 and 2018.

The perinatal education and services team provided outreach, support and services to over 2,800 maternal child health providers across the state. This work is showcased at; https://mainehealth.org/barbara-bush-childrens-hospital/services/perinatal-outreach

Birth Outcomes

Based on Maine PRAMS data, in 2017, 65.2% of new mothers reported that their pregnancy was intended; 20.1% reported that they had not wanted to be pregnant at all or wanted to be pregnant later. In the U.S., 59% of new mothers reported that their pregnancy was intended. Between 2016-2018, 43% of Maine women less than age 20 reported that their pregnancy was unintended; 26.5% of those aged 20-24 had an unintended pregnancy. However, the percent of women reporting that their pregnancies were unintended has been decreasing in Maine. In 2014, 27.7% of new mothers reported that their pregnancy was unintended, compared to 19.2% in 2018.

Maine Family Planning (MFP) tracks the prevalence of long acting reversible contraception (LARC) with those they serve and have seen an increase in use. During FY19, MFP providers inserted 2,259 LARCs; this compares to 917 and 809 in the two previous report cycles. MFP attributes this significant increase to adding new clinical partners and targeted training for all partners on the effectiveness of using LARCs.

Risk Factors for Chronic Disease

In 2018, about 12% of Maine women smoked during pregnancy. Maine’s rate is almost double the U.S. rate of 6.5%. Maine’s smoking during pregnancy rates have declined since 2014 when 16.5% of Maine women reported smoking during pregnancy. Starting in 2016, Maine PRAMS included questions on e-cigarette use during the last three months of pregnancy. In 2018, 1.5% of women reported using e-cigarettes or hookah in the last three months of pregnancy. The percent of women using e-cigarettes did not change between 2016 and 2018.

The Non-Clinical Outreach initiative is an effort where tobacco public health partners work with statewide social service programs or service agencies, such as Maine Families Home Visiting (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 infants born in 2016 in Maine, 87.3% were ever breastfed (U.S. = 83.8%) and 32.8% were breastfed exclusively for at least six months (U.S.=25.4%). Maine’s percent of infants breastfed exclusively at six months is the 7th highest in the U.S.

All MFHV sites have certified lactation counselor trained staff available to support breastfeeding mothers, with several sites offering breastfeeding support groups. During FY19, the MFHV program saw participant breastfeeding rates improve from 45.6% to 52.8%.

Maine’s WIC program provides extensive breastfeeding supports to eligible enrolled mothers, including lactation counseling and provision of breast pumps. Maine state law requires employers to provide paid or unpaid breaks to express milk and provide a clean space for lactation activities.32

Safety and well-being for infants

In 2018, 88.5% of Maine infants were placed to sleep on their backs. Maine’s percentage is the second highest among states that participate in the PRAMS survey.

In the summer of 2019, Maine’s DHHS launched the Maine Safe Sleep Initiative, which included a safe sleep media campaign aimed at pregnant women and infant care-givers, the development of new technical assistance resources for health and human services professionals, and support for birthing facilities seeking the Cribs for Kids® National Safe Sleep Hospital Certification.

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. According to the 2017-2018 National Survey of Children’s Health (NSCH), about 44% of Maine parents of children ages 9-35 month’s report that they were asked to complete a developmental screening tool for their child within the previous year. Only six states have higher developmental screening rates.

The Maine WIC program began conducting developmental surveillance using the federal CDC’s Learn the Signs Act Early tool. Beginning in 2019, all children seen at WIC were provided with materials on age appropriate developmental surveillance. WIC documents any developmental concerns found and refers parents to the child’s medical provider for further review.

Readiness to learn and succeed

Maine conducts observations of children’s dental health as part of the Maine Integrated Youth Health Survey. In 2019, 51.6% of third graders in Maine were observed to have dental sealants.

Maine promotes oral health disease prevention for children, including education through school nurses and application of sealants. Maine dental providers 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. In the 2018/19 school year, 1,477 children received dental sealants through the School Oral Health Program.

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, and employer fairs.

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 2018 NSCH, 20% of adolescents, ages 12-17 years old bullied others and 51% were bullied in the previous 12 months. The percent of Maine children who have bullied others is about the same as the U.S. (15.3%).

The Adolescent Health and Injury Prevention Program (AHIP) partners with the Maine Youth Action Network (MYAN) to promote youth leadership and positive youth development. MYAN District Youth Coordinators support Youth Policy Boards (YPBs) and other youth groups across Maine’s nine public health districts.

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 2017-2018 NSCH, about 8% of Maine adolescents ages 12-17 years currently have depression; this is slightly more than the national average of 6.3%. About 18% have problems with anxiety (compared to 11% nationally), and 7.7% have behavioral or conduct problems (vs. 6.4% nationally).

To increase access to care, the AHIP Program supports 15 School Based Health Centers (SBHCs) that offer co-located medical and behavioral health services, including mental health counseling that is accessible to youth during the school day. SBHC providers conduct health risk assessments with young people that include screening for depression and other behavioral health conditions. In FY19, 90% of youth identified as needing mental health services ultimately received that care through the SBHC.

Children with Special Health Needs

Systems of care for CSHN

About half (47.7%) of Maine CSHN had a medical home in 2017-2018; 61% of non-CSHN reported receiving care within a medical home. The Maine Parent Federation (MPF) continues to focus 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 including availability of parent navigators The MPF’s work can help improve care coordination for parents of CSHN.

In 2017-2018, parents of 33.8% 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 18.9%. 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 makes it available to all parents.