Methodology

The Needs Assessment was structured into six stages:

 

Stage 1 was the Planning Stage and included the initial meeting with the Steering Committee and a formal research plan; Stage 2 entailed gathering existing data from a variety of data sources to better understand the population needs, available services and disparities in access or health; Stage 3 consisted of data collection, including 31 key informant interviews and four public forums. Analytic Insight (AI) also held a meeting with the Steering Committee to get their feedback on the data gathered to date;

Stage 4 focused on identifying priorities through strategic planning sessions with key stakeholders across the state and continuing to gather feedback from the public. AI held six strategic planning sessions which covered Children and Youth with Special Health Care Needs (CYSHCN). Due to COVID-19 restrictions planning sessions for Maternal and Child Health were canceled and could not be rescheduled; Stage 5 was reserved for public comment and will include an online survey, accessible through the Internet and optimized for access using any mobile device; and, Stage 6 was for report development.

 

Secondary Data Analysis

Secondary data analysis assessed the data used to measure outcomes for the National Performance Measures (NPMs) and State Performance Measures (SPMs) by other states and evaluate the applicability of those indicators to the activities, policies and populations under study in Maryland. Health outcomes from the previous five-year needs assessment were tracked in order to measure change as a result of actions that were developed as part of those plans, comparisons between Maryland and similar states and, where possible, key differences between regions and subgroups within Maryland. This report uses several national datasets, including:

• National Survey of Children’s Health (NSCH), conducted by the United States Census Bureau, Associate Director for Demographic Programs on behalf of the United States Department of Health and Human Services (HHS), Health Resources and Services Administration’s (HRSA) Maternal and Child Health Bureau (MCHB).
• The Behavioral Risk Factor Surveillance System (BRFSS) is conducted by the Centers for Disease Control and Prevention (CDC). The survey covers health-related risk behaviors, chronic health conditions, and use of preventive services.
• The Youth Risk Behavior Surveillance System (YRBSS) YRBSS is a national school-based survey conducted by CDC and state, territorial, and local education and health agencies and tribal governments. It monitors six categories of health-related behaviors that contribute to the leading causes of death and disability among youth and adults including behaviors that contribute to unintentional injuries and violence, sexual behaviors, alcohol, tobacco and other drug use, dietary behaviors and physical activity, as well as the prevalence of obesity and asthma and other health-related behaviors.
• The National Vital Statistics System (NVSS) provides data on the vital statistics of the population of the United States. It is produced in a coordinated effort of state health departments and the National Center for Health Statistics, a division of the Centers for Disease Control and Prevention. Maryland Vital Statistics Administration are also cited in this report.

 

Selection of National Performance Measures

Ten NPM priority areas were selected among those most prioritized by the greatest number of members. During subsequent investigation and deliberation, NPM 9 on bullying was eliminated to avoid duplication of efforts conducted by Maryland’s Department of Education. NPM 2, Low-Risk Cesarean Delivery was also eliminated because significant progress has been made in this area and hospitals plan to continue with their efforts.

 

The following selection of NPMs were reviewed and approved by the Title V Manager:

NPM 3 Risk Appropriate Perinatal Care

NPM 4 Breastfeeding 

NPM 5 Safe Sleep 

NPM 6 Developmental Screening 

NPM 10 Adolescent Well-Visit 

NPM 11 Medical Home 

NPM 12 Transition 

NPM 13.1 Preventive Dental Visit - Pregnancy 

NPM 14.1 Smoking - Pregnancy 

 

Key Informant Interviews 

The Maryland Department of Health and Maternal and Child Health Bureau identified 75 stakeholders of interest to complete key informant interviews. Interview invitations were distributed by email in mid-December, with follow-ups in mid-January and early February. Follow-ups for those who had not responded to emails began in March, however the COVID-19 emergency may have impeded our ability to interview all stakeholders. Analytic Insight (AI) completed 31 stakeholder interviews with service providers, staff at community organizations, local health departments and other state agencies. Interviews included representatives from each region of the state, as well as representatives who work with each of the Title V populations.

 

Public Forums

Four in-person public forums were held to collect early public feedback regarding the Maryland residents maternal and child-health related needs. The locations for these forums included: Baltimore, Allegany County, Prince George’s County and Salisbury.

 

The public forums were live-streamed to maximize the participation opportunities for those unable to attend in-person. Information about tuning in to the stream was also provided in the advertising materials.

 

Unfortunately, due to COVID-19 concerns and social distancing protocol, four additional public forums scheduled to take place in April 2020 were canceled. Attendees were offered an opportunity to provide input through telephone interviews.

 

Planning Sessions for Children and Youth With Special Health Care Needs

Analytic Insight (AI), MCHB’s vendor for the Title V Needs Assessment, facilitated six strategic planning sessions with service providers to assess the health needs of children and youth with special health care needs and identify and prioritize key findings from the data collection stage, particularly regarding the selected NPMs (Bullying, Medical Home and Transition) with a special emphasis on health equity in underrepresented and underserved populations. Sessions were held from November 18 through 22, 2019.

 

For the larger planning sessions, following an introduction to the assessment and planning process, participants broke into small groups and discussed actions the community and specific organizations can take to address each NPM goal for about 10-15 minutes. Each group completed action cards detailing the ESM they believe would best address each need.

 

Once each small group completed their action cards, we discussed the results as a larger group to determine consensus and feasibility of the selected ESMs. The rationale for the selections, needed resources, timeline and additional details were discussed.

 

The moderator and note taker reviewed and documented each proposed action on a white board or large post-it note paper as they are discussed with the larger group. This exercise was repeated for each identified goal.

 

On each action card, we asked participants to provide the specific actions that need to be taken to address the goal, the rationale behind their selection, resources that will be needed to complete the proposed action, a potential timeline to complete the proposed action and any additional information.

 

Due to Covid-19 concerns and social distancing protocol, the remaining Maternal and Infant Health and Children and Adolescent Health strategic planning sessions that were scheduled to take place in March 2020 were canceled.

 

Public Comment Period

The public comment period began June 16 and remained open for 32 days. An online survey was available for public feedback during the public comment period. The online survey was also distributed to key informants. The survey was also distributed to Title V MCH staff at local health departments, and to the newly formed statewide Maternal Health Task Force, a HRSA funded project, of which the Title V Manager chairs.

 

 

Overview of the State

Maryland is comprised of 24 political jurisdictions – 23 counties and the City of Baltimore. With a population of roughly 6 million in 2019, the U.S. Statistical Abstract ranks Maryland as the nation’s 19th most populous and in the bottom 10 of states according to land mass. Although a small state in size and population, Maryland has great geographic diversity. The State is characterized by mountainous rural areas in the western part of the State, densely populated urban and suburban areas in the central and southern regions along the I-95 corridor between Baltimore and Washington DC, and flat rural areas in the eastern region. The “Eastern Shore” borders Delaware, the Atlantic Ocean and the Chesapeake Bay, the largest estuary in the United States. The Bay is a treasured geographic asset, but the fact that it bisects the State presents special challenges (e.g., transportation, access to specialty care services) for Eastern Shore residents.

 

The State’s Maternal and Child Health (MCH) populations include an estimated 1.2 million women of childbearing age (ages 15-44) and 1.5 million children and adolescents (ages 0-19) in 2019, 19.2% of whom have special health care needs.

 

Maryland has been identified as the nation’s seventh most diverse State. Maryland has one of the nation’s lowest poverty rates, with American Community Survey (ACS) estimating that in 2017 9.3% of Marylanders were poor, as compared with 13.4% of Americans nationwide. Maryland’s female residents are 24% more likely to live in poverty than males. African American Maryland residents have a poverty rate of 14.1%, below the national rate for Blacks of 25.2% but significantly higher than that of white Marylanders, 6.6%.

 

Population Trends

The population of the state of Maryland is projected to be 6,125,441 in the year 2021. The state’s population has increased about 10% since 2010 and doubled since 1960. Although the rate of increase has slowed, the state population continues to grow. Maryland is among the ten fastest growing states and the population is projected to reach 6,274,000 in 2025.

 

By county, the largest population increases over the past ten years border Washington DC and include Montgomery, Prince George’s and Frederick Counties. Allegany County had the smallest population increase during this period. None of the Maryland counties decreased in population.

 

Although much of the state is considered large fringe metropolitan, several counties are classified as nonmetro, or rural counties. These include Caroline, Dorchester, Kent, Talbot and Garrett Counties.

 

Birth Rates

The birth rate for Maryland residents has declined since 2008, from 13.7 in 2008 to 11.8 in 2018. This decline was consistent across racial and ethnic groups.

 

Infant mortality has decreased for Maryland residents. Racial and ethnic disparities in infant mortality have decreased somewhat from a difference between Black and White mortality rates of 9.2% in 2009 to a difference of 6.1% in 2018. These disparities remain substantial.

 

There have been several years in which the rate of infant mortality among Maryland residents of Hispanic origin surpassed that of white residents. In 2003, 2015, 2016 and 2017 Hispanic infant mortality rates exceeded the rate of non-Hispanic, White infant mortality.

 

Race and Ethnicity

Maryland includes areas with a great deal of racial and ethnic diversity and others with less diverse populations. In Baltimore City/County and Prince George’s County, over half of residents are African American. In Montgomery County, about one in five residents are Hispanic. In contrast, in Garrett and Carroll Counties, roughly nine out of ten residents are white.

 

Poverty

Statewide, 6.4% of Maryland families live in poverty. In Baltimore city, 16.6% of families live in poverty, and 15.9% of families in Somerset County. The unemployment rate is highest in the city of Baltimore, 16.6%, as compared with 6.4% statewide.

 

Maryland Department of Health (MDH) has four major operational divisions: Public Health Services, Behavioral Health, Developmental Disabilities and Medicaid Administration. MDH also houses a fifth division called Operations. In addition, the department has 26 boards that license and regulate health care professionals; and various commissions that issue grants and research and make recommendations on issues that affect Maryland’s health care delivery system.

Title V resides within the Public Health Services division of the Maryland Department of Health.

 

 

Title V resides within the Prevention and Health Promotion Administration (PHPA) within Public Health Services. The Prevention and Health Promotion Administration is organized into five Bureaus that oversee a diverse array of public health programs targeting all of Maryland citizens and work collaboratively to support the core functions of public health. The bureaus are Infectious Disease Epidemiology and Outbreak Response, Infections Disease Prevention and Health Services, Maternal and Child Health, Cancer and Chronic Diseases, and Environmental Health.

The Office of Family and Community Health Services (OFCHS), the Office of Quality Initiatives, and the Office of Genetics and People with Special Health Care Needs (OGPSHCN) reside in the Maternal and Child Health Bureau (MCHB) at the Maryland Department of Health and are referred to collectively as the MCH Program. These three offices share responsibility for MCH Block Grant development, implementation and evaluation.

 

Maryland’s Maternal and Child Health Bureau (MCHB) includes a highly skilled and diverse team of public health professionals representing a variety of disciplines. This team plans, manages and monitors Title V activities for Maryland and supports a variety of MCH staff in local health departments, including a cadre of community health nurses, physicians, program administrators and clerical personnel, which are also supported by Title V funds. The Maternal and Child Health Bureau has four offices: the Office of the Maryland WIC Program (WIC); the Office of Family and Community Health Services (OFCHS); the Office of Genetics and People with Special Health Care Needs (OHPSCHN); and the Office of Quality Initiatives (OQI). The MCHB also collaborates and coordinates activities with other State agencies on health issues that affect women and children including immunizations, injury prevention, mental health care, medical assistance, oral health care, substance use disorder and smoking cessation.

 

An adequately prepared workforce is essential to building capacity to address MCH needs and to provide essential services. Key Title V staff are afforded opportunities to attend both national and state conferences and training that afford opportunities to acquire new skills and strengthen existing ones. Staff annually attend AMCHP, CityMatch and MCH Epidemiology meetings.

 

 

State Agencies

The Governor’s Office for Children (GOC) is the coordinating unit for Maryland Governor’s Children’s Cabinet. The Children’s Cabinet coordinates the child and family-focused service delivery system by emphasizing prevention, early intervention and community-based services for all children and families. The Children’s Cabinet includes the Secretaries from the Departments of Budget and Management; Disabilities; Health; Human Services; and Juvenile Services; as well as the State Superintendent of Schools for the Maryland State Department of Education and the Executive Director of the Governor’s Office of Crime Control and Prevention. The Executive Director of the Governor’s Office for Children chairs the Children’s Cabinet.

 

At the local level, GOC funds Local Management Boards (LMBs) in every jurisdiction. The LMBs are comprised of the local agency counterparts to the Children’s Cabinet agencies, including local child-serving agencies, local child providers, clients of services, families and other community representatives to empower local stakeholders in addressing the needs of and setting priorities for their communities. The Boards serve as the coordinator of collaboration for child and family services. The LMBs conduct periodic needs assessment and this data is shared with Title V. Input from the LMBs is also more broadly sought by Title V on issues and needs impacting children and families in Maryland.

 

MDH shares responsibility for school health with the Maryland Department of Education (MSDE). MCHB coordinates with the MDH Office of School Health on school health issues. MSDE has lead responsibility for early childhood issues in Maryland with much of the work coordinated through an Early Childhood Advisory Council (ECAC). Other key child serving agencies include the Maryland Department of Human Resources (DHR), the Governor’s Office for Crime Control and Prevention and the Department of Juvenile Services.

 

Title V is represented on the Governor’s State Council on Child Abuse and Neglect. MCHB provides consultation and technical assistance on adolescent health and teen pregnancy prevention to the Department of Juvenile Services. The Medical Director for Reproductive Health represents the MDH Secretary on the Governor’s Office of Crime Control and Prevention’s Family Violence Council.

 

The Maryland Community Health Resources Commission (CHRC) was created by the Maryland General Assembly in 2005 to expand access to health care services in underserved communities in Maryland. MCHB collaborated with the Maryland Community Health Resources Commission to establish infant mortality reduction as a priority for Commission grants to safety net providers (primary FQHCs). MCHB provides technical assistance for review of proposals and has joined in site visits to grantees with Commission staff. CHRC and MDH also collaborated on implementation of the 2013 Health Enterprise Zone initiative focused on reducing health disparities in targeted Maryland communities.

MDH Agencies

Maternal and Child Health Bureau (MCHB) is one of five bureaus within the Prevention and Health Promotion Administration (PHPA). MCHB plays a major leadership role for maternal and child health issues across the Administration and its bureaus. Three of the four offices within MCHB: OFCHS, OGPSCHN, and OQI manage Title V Block Grant Funds. The fourth office, the Maryland WIC Program, works closely with the Title V agencies on several issues including preconception health, breastfeeding, nutrition and obesity prevention and family planning outreach.

 

MCHB collaborates with the Environmental Health Bureau (EHB) on several environmentally linked child health issues including birth defects, asthma and childhood lead poisoning. MCHB is represented on the Children’s Environmental Health Advisory Council which is staffed by EHB. EHB also includes the Center for Injury and Sexual Assault Prevention. MCHB coordinates with the Center on childhood injury prevention, intimate partner violence and child abuse and neglect. Title V’s adolescent health coordinator is a member of the Center’s Teen Distracted Driving Task Force and works with staff on violence prevention issues including bullying.

 

Local health departments are unique and key Title V partners who serve as important service delivery arms for many Title V activities. The Office of Population Health Improvement (OPHI), reporting directly to the Deputy Secretary for Public Health Services, oversees the State’s Health Improvement process as well as administering matching funds for core public health services to local health departments. MCHB partners with this Office to deliver vital maternal and child health services to jurisdictions throughout the State using Title V support.

 

The Behavioral Health Administration (BHA) which directs mental health and addiction activities for the State is an important Title V partner. Areas of partnership include early childhood mental health, youth suicide prevention, perinatal depression, perinatal substance abuse and Fetal Alcohol Spectrum Disorders (FASD). MCHB supports a Fetal Alcohol Coalition with assistance from BHA staff. Title V is represented on BHA’s Early Childhood Mental Health Steering Committee and the Governor’s Commission on Suicide Prevention. Maryland Title V is represented on the National Association of FASD State Coordinators.

 

MCHB collaborates with the MDH Office of Minority Health and Health Disparities (OMHDD) on infant mortality reduction as well as other overall reductions in disparate MCH outcomes. MCHB is a frequent presenter at the State’s annual health disparity conference sponsored by this Office.

 

The Vital Statistics Administration (data and surveillance) and the Office of the Chief Medical Examiner (child fatality, maternal mortality) are other major agency partners. MCHB staffs and oversees the State’s Child Fatality Review Team, the Maternal Mortality Review Committee as well as the Morbidity, Mortality, and Quality Review Committee (MMQRC), which includes representatives from Vital Statistics and the Office of the Medical Examiner.

Women’s and Maternal Health Care

 

The needs presented reflect the broader general priority areas which are most important for women and maternal health including: access to women’s and maternal health care, mental health, substance use, intimate partner violence, cesarean deliveries and maternal mortality and morbidity.

 

Access to Care

Maryland is a Medicaid Expansion state which has dramatically increased the proportion of insured to uninsured residents. Over the past four years, Maryland residents have enjoyed significantly higher rates of health care coverage, including private health insurance, prepaid plans such as HMOs, and government plans such as Medicare and Indian Health Service.  Women have had slightly higher rates of coverage than men both within Maryland and nationally. Currently, about 95% of Maryland women have some type of healthcare coverage, compared with 91% nationally[1].

Maryland women are more likely to have visited a doctor for a routine checkup within the past year as compared to women nationally, a gap that is increasing as the national rate declines. Additionally, a higher percentage of Maryland women had a mammogram as compared with the national average (80% and 74.7%, respectively).

 

Mental Health

Maryland is ranked number 5 out of 51 (including Washington D.C.) for providing access to mental health services[2]. Approximately 20% of Maryland women have been diagnosed with a depressive disorder, including depression, major depression, dysthymia or minor depression. Nationally, about 23% of women were diagnosed with depressive disorder[3].

 

The mental health of Maryland women was consistent with the national trend in 2018, with more than half reporting zero days of poor mental health over a 30-day period. Both nationally and in Maryland, there has been a slight decrease in mental health since 2016[4].

 

Substance Use

In 2018, Females were dramatically less likely to die of drug- and alcohol-related intoxication death than their male counterparts (640 vs. 1,766, respectively). However, both genders are seeing an increasing trend.  Non-Hispanic White individuals account for the greatest number of drug- and alcohol-related intoxication deaths, followed by Non-Hispanic Black individuals (1,479 vs. 823, respectively). Individuals 25-years and older made up the majority of drug- and alcohol-related intoxication deaths[5].

Since 2015, roughly half of Maryland women reported having an alcoholic drink in the past 30 days. Consistent with the national trend, approximately 5% of Maryland women reported having had more than seven drinks per week[6].

 

In 2018, women in Maryland reported smoking less frequently than the national trend (69.1% and 64.0 respectively). Approximately 30% of Maryland women reported smoking at least some days[7]. Since 2015, Maryland has had a slight decrease in the percentage of females who smoke every day. The percentage of Maryland women who have smoked at least 100 cigarettes in their lifetime remains at approximately 34%, consistent with the national trend[8].

 

In 2017, Fentanyl related deaths spiked and surpassed Heroin as number one, making up approximately 61% of opioid-related deaths. Prescription opioid related-deaths have remained consistent over the last decade and currently represent approximately 12% of opioid-related deaths[9].

 

Intimate Partner Violence

In 2017, 3.3% of Maryland women experienced interpersonal violence during the 12 months before pregnancy by a husband or partner and/or an ex-husband or partner compared with 3% nationally. This is an increase from 2.9% in 2016. Both differences are within the margin of error. 2.9% of Maryland women experienced interpersonal violence during pregnancy by a husband or partner and/or an ex-husband or partner, up from 2.2% in 2016, although this difference is also within the margin of error[10].

 

Low-Risk Cesarean Deliveries

Low-risk cesarean deliveries varied by counties in 2018, with a range from roughly 16% to roughly 33%. Baltimore County and Somerset County represented the highest percentage of low-risk cesarean deliveries, while Kent County and Talbot County represented the lowest.

 

Furthermore, low-risk cesarean deliveries also varied by race and ethnicity. In 2018, Black non-Hispanic women were most likely to receive a low-risk cesarean delivery, whereas Hispanic women were least likely[11].

 

Maternal Mortality and Morbidity

A five-year average is used to assess Maryland’s MMR because there are a small number of maternal deaths and that number may vary widely from year to year, particularly in a small state like Maryland. Although the Maryland MMR has been higher than the national average historically, from 2011 to 2015 the Maryland MMR was slightly lower than the national rate for the first time.

 

The MMR rates for 2012-2017 show that the Maryland MMR is 23.0 deaths per 100,000 live births. This is significantly less than the national rate of 28.4. Between the two 5-year periods, the U.S. MMR increased by 37.2 percent whereas the Maryland rate decreased by 7.6 percent. Both, however, remain above the Healthy People 2020 Objective of 11.4 maternal deaths per 100,000 live births.

 

Nationally, Black women have an MMR that is 2.4 times higher than that of White women, a disparity that has persisted since the 1940s. In Maryland, the MMR for white women decreased by 6.4% in the period since 2007-2011, whereas the MMR for Black women increased by 7.6%, exacerbating the racial disparity. The 2012-2016 Black MMR is 3.7 times the White MMR. Given this racial disparity, it appears that the recent decrease in Maryland’s MMR is attributable solely to the decrease in the White MMR.

 

Findings from Key Informants

 

The most common stated barrier to women’s and maternal health is access. Several key informants stated that access issues include access to OBs for their prenatal care, specifically high-risk OB, which is hindered by the number of providers, transportation and travel, insurance eligibility and immigration status among other things. Some key informants also alluded to a lot of unmet social needs, such as a lack of stable, safe, and affordable housing, food insecurity and a lack of education that include health and financial literacy.

 

Several key informants mentioned that among the immigrant population, there may be low literacy rates and limited English skills. A lack of interpretation presents challenges to receiving adequate prenatal care. Furthermore, one key informant reported that when immigrants come into the country pregnant, they often have no history of prenatal care. In some cases, these women come to the county during the late stages of their pregnancy. Additionally, cultural reasons were also given, such as a lack of trust in the provider and the role of the woman in the culture; some women may not be comfortable traveling to an appointment without their husbands. The lack of trust in the provider can stem from a lack of continuity from prenatal care to delivery as well as being afraid of signing any papers. When asked if these barriers differ for families with low-income and for families of color, many key informants agreed that these barriers are increased for both groups. Many key informants reported that racism affects the healthcare received by women of color and that they are not treated equally due to the systematic biases.

 

Perinatal and Infant Health

 

The priorities and concerns for this population include prenatal care, preterm birth, low birthweight and very low birthweight, infant mortality, risk-appropriate perinatal care, breastfeeding, smoking in pregnancy and safe sleep.

 

Prenatal Care

Maryland women are more likely to have private insurance for prenatal care as compared with women nationally and less likely to have Medicaid that covers their prenatal care. Maryland women are slightly more likely than the national average to have no insurance[12]. 

 

Preterm Birth

In 2018, 1 of every 10 infants born in the United States was premature. From 2007 to 2014, preterm birth rates decreased, in part due to declines in the number of births to teens and young mothers. However, preterm birth rates rose for the fourth straight year in 2018[13]. Globally, preterm birth complications are the leading cause of death among children under the age of 5 years[14]. 

 

Over the last decade, Maryland has consistently remained at approximately 10% for preterm birth rates. While the national trend is more downward than that of Maryland, it remains higher. In 2018, Maryland reported 1.4% less preterm births than the national average.

 

When looking at preterm birth rates by race and ethnicity, the largest percentage of preterm births is for Black babies (12.9%). Hispanic babies represented the second highest for preterm birth rates (9.3%). Maryland’s racial and ethnic disparity is consistent with what is seen nationwide, where in 2018 Black women had a 50% higher rate of preterm birth than White women[15].

 

Low Birthweight and Very Low Birthweight

The incidence of low birth weight infants was 8.9% in 2018, which represented no change from the 2017 rate. Maryland’s percentage of low birth weight infants has remained consistent over the last decade, with a slightly higher percentage than the national average.

 

When looking at low birth weight and very low birthweight by race and ethnicity, non-Hispanic Black infants represented the largest percentage (12.5% and 2.9%, respectively), while Hispanic infants and non-Hispanic White infants were comparable at 6.9% and 6.8%, respectively for low birth weight, and 1.2% and 1.1% respectively for very low birth weight. Maryland’s racial and ethnic disparity is consistent with the national averages for all three groups[16].

 

Infant Mortality

The leading causes of infant death in 2018 were low birth weight, congenital abnormalities, Sudden Infant Death Syndrome, maternal complications of pregnancy, and cardiovascular disorders. The total number of infant deaths declined between 2017 and 2018, from 462 to 432, along with the number of births. In 2018, Maryland’s infant mortality rate was 6.1% per 1,000 live births, a 6% decline compared with 2017, which represents the lowest rate ever recorded in Maryland. The neonatal mortality rate and post neonatal mortality rates both declined slightly between 2017 and 2018 as well. The neonatal mortality rate was 4.2 per 1,000 live births compared to a rate of 4.4, while the post neonatal mortality rate was 1.9 per 1,000 live births compared to a rate of 2.0.

 

Although the average infant mortality rate has fallen by 4% in Maryland over the last decade, with an 8% decline for Non-Hispanic Black infants and a 2% decline for Non-Hispanic White infants, the Hispanic infant mortality rate has unfortunately increased by 15%. There were 231 (10.2%) deaths among infants born to non-Hispanic Black women, 123 (4.1%) deaths among infants born to non-Hispanic White women, 47 (3.8%) deaths among infants born to Hispanic women, and 25 deaths among infants born to non-Hispanic Asian women. The neonatal mortality rate by race and ethnicity was 2.6 among non-Hispanic Whites, 6.9 among non-Hispanic Blacks and 2.9 among Hispanics. The Hispanic rate decreased by 17.1% from 2017 to 2018. The post neonatal mortality rate was 1.5 among non-Hispanic Whites, 3.3 among non-Hispanic Blacks and 0.9 among Hispanics. The Hispanic rate decreased by 18.2% between 2017 and 2018.

 

Risk-Appropriate Perinatal Care

In 2018, 79.2% of very low birthweight (VLBW) infants were born in a level III or higher NICU, which represents an increase of approximately 1% since 2017. Maryland saw its highest percentage of VLBW infants with level III or higher NICU in 2013 (82.8%) and saw a negative trend until 2018[17].

 

Non-Hispanic Black VLBW infants and Hispanic VLBW infants are seen by level III or higher NICU’s less often (77.2% and 77.7%, respectively) than non-Hispanic White VLBW infants and other non-Hispanic VLBW infants (82.3% and 85.0%, respectively).  This is consistent with the national trend.

 

Breastfeeding

In 2016, the most recent year for which data are available, Maryland was slightly above the national average for infants ever breastfed (84.1% and 83.8%, respectively). Both nationally and in Maryland, there is an upward trend for infants ever breastfed, apart from 2015, where Maryland saw a spike of 91.0% infants breastfed before falling slightly in 2016.

 

Smoking in Pregnancy

In Maryland, 5.2% of pregnant women smoked during pregnancy. White non-Hispanic women were more likely to smoke during pregnancy, followed by Black women. Women who received Medical Assistance were more likely to smoke during pregnancy than those with other kinds of coverage. In the county with the highest rate of smoking during pregnancy, Allegany County, almost one in four pregnant women smoked in 2018[18].

 

Safe Sleep

In 2017, Maryland reported an increase in the percentage of infants placed to sleep on their backs (78.2%) but has a rate which is less than the national average of 79.8%.

 

Maryland reported an increase in the percentage of infants placed to sleep on a separate approved sleep surface (29%), which was approximately 4% lower than the national average. With regard to the percentage of infants placed to sleep without soft objects or loose bedding, Maryland reported an increase of 51.6%, which is higher than the national average[19].

 

Findings from Key Informants

 

When key informants were asked about perinatal and infant health, many stated that infant health is based on the level of care of their parents, where there are disparities for families of color and families of low-income. Key informants reported that safe affordable housing, mental health, presence of sickness and illness, access to transportation and childcare largely contribute to perinatal and infant health.

 

Several key informants highlighted a lack of safe, affordable and stable housing. Due to this lack of adequate sleeping space for a crib, this may lead to multiple people sharing a bed, which can then lead to unsafe sleep practices and suffocation.

 

Key informants expressed that racial disparities and income status are heavily present when it comes to gaps and barriers to breastfeeding. One key informant stated that there is a lack of cultural support for breastfeeding. Several referenced the cruel legacy of American slavery, which may have left an association of breastfeeding with the forced breastfeeding of slave owners’ children. Another key informant mentioned that women in lower-paying jobs are often not allowed to take adequate time to pump their milk at work.

 

Child Health

 

The priorities and concerns for this population include immunizations, medical home approach, and injury hospitalizations.

 

Immunizations

Immunization of young children is a positive predictor of avoidance of illness, death, disability, or developmental delays associated with immunization-preventable diseases. Maryland’s immunization rates are higher than the national average for children aged 19 through 35 months. For 2019, Maryland’s immunization rate was 75.2%, well above the national rate of 70.4%[20]. The Healthy People 2020 Goal for Immunizations is 90%. During the COVID-19 pandemic, childhood immunizations have decreased compared to the year before. In April 2020, there was a 46% decrease in immunizations compared to April 2019[21].

 

Medical Home Approach

The Medical Home, also known as Patient or Family Centered Medical Home, is an approach to providing comprehensive primary care that facilitates partnerships between patients, clinicians, medical staff, and families. In 2018, Maryland saw a reduction in the percentage of children with and without special health care needs, ages 0 through 17, who met the criteria for having a medical home. With both populations, Maryland’s percentage was higher than the national average (50.6% vs. 42.7% and 49.7% vs. 49.4%, respectively)[22].

 

Injury Hospitalizations

In Maryland, the rate of injury hospitalizations is measured by the number of hospital admissions among children ages 0 through 9 years with a diagnosis of unintentional or intentional injury. This rate excludes readmissions for the same event. Changes in injury hospitalization coding from ICD-9 to ICD-19 in October 2015 may have influenced the number of child injuries in these years. Furthermore, data reflects Maryland residents in Maryland hospital only.

 

In 2018, the rate of injury hospitalizations for ages 0 through 9 and for ages 10 through 19, non-Hispanic Black children had a higher rate than other racial and ethnic groups (40.8% and 69.8%, respectively). The methodology used to identify race in HSCRC files changed in 2013, so differences in outcomes by race before and after 2013 may be due to data collection.

 

Findings From Key Informants

 

Several key informants discussed challenges associated with developmental screenings. Many highlighted that there is a lack of knowledge of resources out there, a lack of providers and other personnel and a lack of trust. Furthermore, there is a lot of stigma associated with diagnoses that cause fear for the parents.

 

Many key informants felt that a true Medical Home is not available for most due to a lack of funding and reimbursement, a lack of physician and other medical personnel time, a lack of care coordination and an overall lack of understanding.

 

 

 

 

Adolescent Health

 

The priorities and concerns for this population include overweight/obesity and physical activity, mental health, substance use, teen pregnancy and reproductive/sexual health, and medical transition to adult care.

 

Overweight/Obesity and Physical Activity

In 2017, Maryland’s obesity rate for 10-17-year-olds was 14.5%, a decrease from 15.7% in 2016. This was slightly below the national obesity rate of 15.3%[23]. Maryland was below the US average with obesity, overweight and adolescents describing themselves as either slightly or very overweight. Among Maryland high school students, 27.1% described themselves as overweight, as compared with 31.5% nationally and 12.6% had obesity, as compared with 14.8% nationally. A similar percentage were overweight (15.2% vs. 15.6%, respectively.)

 

In 2017, 21.6% of Maryland high school students reported not being physically active (any kind that increased their heart rate and made them breathe hard some of the time) for a total of at least 60 minutes on at least one day during the last seven days, higher than the national average of 15.4%. Similarly, 64.8% reported not being physically active at least 60 minutes on five or more days, higher than the average of 53.5%. 82.1% reported not being physically active at least 60 minutes on all 7 days, higher than the national average of 73.9%. 84.7% of Maryland high school students reported not going to PE classes on all 5 days, almost 15% higher than the national average.

 

Non-Hispanic Black and Hispanic adolescents reported not being physically active for at least 60 minutes at least one day the most (27.4% and 26.6%, respectively).

 

Mental Health

Depression is a leading risk factor for suicide among high school students residing in Maryland. According to the 2017 YRBSS, 29.9% of Maryland high school students felt so sad or hopeless for two or more weeks in a row that they stopped doing usual activities. While slightly lower than the national average, this is an increase since 2007. Females were more likely to report feeling sad or hopeless than their male counterparts (38.7% and 21.0%, respectively). Hispanic adolescents were more likely to report feeling sad or hopeless than other races and ethnicities (37.2%).

 

Almost one in five Maryland high school students (17.3%) seriously considered attempting suicide in the last 12 months, consistent with the national average at 17.2%. The rate was higher for females than their male counterparts (21.8% and 12.4%, respectively).

 

Substance Use

According to the 2017 YRBSS, 8.2% of Maryland high school students reported currently smoking cigarettes, compared with 8.8% nationally. Males were more likely than their female counterparts to report smoking cigarettes (9.3% and 6.3%, respectively). 13.3% of Maryland high school students reported currently using electronic vapor products, compared with 13.2% nationally. Again, males were more likely than their female counterparts to report smoking electronic vapor products (14.0% and 12.1%, respectively). 6.2% of Maryland high school students reported currently using smokeless tobacco, compared with 5.5% nationally. Males reported using smokeless tobacco at a rate more than double of their female counterparts (8.3% and 3.2%, respectively). 9.0% of Maryland high school students reported currently smoking cigars, compared to 8.0% nationally. Males again reported higher rates of cigar smoking than their female counterparts (10.9% and 6.3%, respectively). 12.9% of Maryland high school students reported currently smoking cigarettes or cigars, compared to 12.3% nationally. Males were more likely than females to smoke cigarettes or cigars (14.9% and 9.9%, respectively).

 

Among Maryland middle school students, 7.9% said they had tried cigarette smoking (even one or two puffs) and 1.3% had smoked cigarettes on at least one day during the 30 days before the survey. Of those students who had smoke in the past 30 days, 12.3% smoked more than 10 cigarettes per day on the days they smoked. Almost one in five Maryland middle school students (18.4%) have used an electronic vapor product (including e-cigarettes, e-cigars, e-pipes, vape pipes, vaping pens, e-hookahs, and hookah pens).

 

According to the 2017 YRBSS, 25.5% of Maryland high school students reported currently drinking alcohol, compared with 29.8% nationally. Females were more likely than their male counterparts to report drinking alcohol (28.6% and 22.2%, respectively). 18.4% of Maryland high school students reported currently using marijuana, compared with 19.8% nationally. Again, females were more likely than their male counterparts to report using marijuana (19.0% and 17.6%, respectively). 23.5% of Maryland high school students reported instances of being offered, sold or given an illegal drug on school property, which is higher than the national percentage at 19.8%. Males reported higher instances than their female counterparts (24.6% and 22.2%, respectively).

 

Teen Pregnancy and Reproductive/Sexual Health

According to the 2017 YRBSS, 22.1% of Maryland high school students reported currently being sexually active, compared with 28.7% nationally. Females were slightly more likely to be sexually active than their male counterparts (22.2% and 21.8%, respectively). 43.1% of Maryland high school students reported not using a condom during their last sexual intercourse, compared with 46.2% nationally. Almost half of females reported not using condoms, while roughly one third of males reported not using a condom (49.3% and 35.8%, respectively).

 

Medical Transition to Adult Care

According to the 2017-2018 National Survey of Children’s Health, 15.3% of children received services necessary to transition to adult health care, compared with 14.2% nationally. 21.6% of children and youth with special health care needs received services necessary for transition to adult health care, compared with 18.9% nationally. 

In looking at Maryland adolescents without special health care needs who received transition services by race and ethnicity, there was a slight difference in rate between non-Hispanic White and non-Hispanic Black, where non-Hispanic Black adolescents received transition services more often.

 

Findings From Key Informants

 

Key informants agreed that well-check visits are low for this population, with many reporting that families focus on bringing their children in for immunizations and start to taper off with their adolescents. Challenges to successful transition included a lack in adult providers and specialty providers, long waitlists, a lack of pediatric training on transition, a lack of family training on transition and a lack of trust with a new provider.

 

Children and Youth With Special Health Care Needs

 

According to the 2017-2018 National Survey of Children’s Health, Maryland reported that 19.2% of children ages 0 through 17 are CYSHCN, compared with 18.5% nationally.

 

Among Maryland children 0-5 years of age, 5.4% have been identified as having special health care needs, as compared to 10.3% nationally, almost double the Maryland percentage. For children 6-11 years of age, 20.8% have been identified as having special health care needs, consistent with the national average of 20.6%. For adolescents ages 12-17 years, 29.8% have been identified as having special health care needs, which is higher than the national average at 24.2%.

 

Racial and Ethnic Disparities In CYSHCN

The social determinants of health, including poverty, racial and ethnic disparities and geographic disparities continues to have an impact on the health care of CYSHCN.

 

About 20% of non-Hispanic White children have been identified as having special health care needs in Maryland and nationally. However, 16.2% of non-Hispanic Black children have been identified as special needs, compared to 24.9% of non-Hispanic Black children nationally. In contrast, Maryland has identified an estimated 23.5% of Hispanic and 20.8% of “other” children as special needs, as compared with national rates of 15.5% and 15.7%, respectively.

 

Among children in Maryland, an estimated 7.6% of those who speak a language other than English have been identified as children with special healthcare needs, as compared with 21.0% of English-speaking children. According to the 2018 National Survey of Children’s Health, 6.5% of non-Hispanic White CYSHCN were reported to currently be receiving services to meet developmental needs, whereas Hispanic and non-Hispanic Black CYSHCN was roughly half of that (3.5% and 3.0%, respectively). “Other” CYSHCN were reported to be currently receiving services the most at 9.3%.

 

The priorities and concerns for Children and Youth With Special Health Care Needs include quality of care, developmental screening for special health care needs, medical home, and services needed to transition to adulthood.

 

Quality of Care

According to the 2018 National Survey of Children’s Health, 4.3% of Maryland CYSHCN ages 0-5 years old are receiving services to meet developmental needs. Similarly, 9.2% of CYSHCN ages 6-11 years old and 2.5% of CYSHCN ages 12-17 years old are receiving services to meet developmental needs.

 

Less than one in ten, 8.3%, of Maryland children with special health care needs were reported to be receiving care in a well-functioning system, significantly below the national percentage of 13.9%[24].

 

Developmental Screening for Special Health Care Needs

In 2018, according to the National Survey of Children’s Health, 39.3% of Maryland children, ages 9-35 months, received a developmental screening using a parent-completed screening tool during the last year, higher than the national percentage of 35.2%. While the national trend is increasing, Maryland saw a peak in 2016 (43.0%), however Maryland’s trend has increased from 2017 at 29.8%.

 

Medical Home

See the Medical Home section in Child Health for more information on Maryland residents’ access to the medical home approach.

 

According to the National Survey of Children, 44.9% of CYSHCN in Maryland received coordinated, ongoing, comprehensive care within a medical home, compared to 42.1% nationally. The national trend has remained relatively consistent since 2016, whereas Maryland has seen a decrease since both 2016 and 2017 (57.8% and 54.9%, respectively).

 

In 2018, 83.0% of Maryland children with more complex special health care needs reported having at least one personal doctor or nurse, while 79.5% of Maryland children with less complex special health care needs reported having at least one personal doctor or nurse. Both percentages reflect a rate higher than for children with no complex special health care needs at 71.9%.

 

Services Needed to Transition to Adulthood

In 2018, according to the National Survey of Children’s Health, 21.6% of adolescents with special health care needs received services to transition to adult health care. This percentage is higher than the national average of 18.9% and reflects an increase from 2017 (16.2%).

 

 

Findings From Key Informants

 

Children and youth with special health care needs experience the same challenges as their neurotypical counterparts, with the added stress of more appointments and specialty care. A few key informants reported that families may have to travel far distances, such as to Johns Hopkins, because providers in the area may not have the expertise. Some key informants reported a shortage of respite services in Maryland. Without respite services, day to day activities are difficult for families and can lead to family structures breaking down, which can directly hinder health outcomes.

 

Many key informants reported that it can be challenging to identify adult providers who are comfortable with individuals who have complex health care needs. Families of children and youth with special health care needs are often reluctant to seek adult health care because they may not trust that the adult physician is knowledgeable enough. A few key informants said that physicians are not listening to families of children and youth with special health care needs.

 

Cross-Cutting or Life Course

 

The priorities and concerns across the life course include COVID-19, adequate insurance, oral health care, and smoking in households.

 

COVID-19

On March 30, 2020, Maryland’s Governor Larry Hogan, issued a stay-at-home order. Since then, Maryland has experienced 92,426 confirmed cases and 3,402 deaths as of August 5, 2020. Many stakeholders have commented that COVID-19 has affected families and communities. Since April 2020, according to the Department of Labor Claims, 660,142 Maryland residents have applied for unemployment insurance. [25]

 

Adequate Insurance

According to the National Survey of Children’s Health, 73.2% of parents reported that children, ages 0 through 17 years, were adequately insured in 2017-2018, which is consistent with 2016-2017. Maryland remains higher than the national average at 67.5%. There was virtually no racial disparity in access. Non-Hispanic Black children were reported to be adequately insured the most at 75.1%, compared with non-Hispanic White children who were reported as the least adequately insured at 71.9%.

 

Oral Health Care

According to the Pregnancy Risk Assessment Monitoring System (PRAMS), 52.6% of pregnant women received a preventive dental visit during pregnancy in 2017, higher than the national average of 46.3%. The rate of pregnant women receiving preventive dental visits has remained somewhat consistent, despite the peak rate in 2014, and has increased slightly since 2015.

 

Likewise, during the 2017-2018 year, 81.5% of children ages 1 through 17 were reported to have had a preventive dental visit in the last year, compared with 79.7% nationally. This percentage represents a slight drop since 2016-2017, where Maryland reported 83.1%[26].

 

Smoking in Households

According to the National Survey of Children’s Health, in 2017-2018, 12.1% of children were reported to live in households where a member smokes, compared with 14.9% nationally. Maryland has remained almost consistent since 2016-2017, where the percentage was slightly more at 12.9%.

 

 

Findings from Key Informants

 

Key informants reported that adequate insurance is hindered mostly due to financial burden and immigration status. Key informants stated that many people and families are underinsured due to the cost of health insurance, which means that their insurance does not cover the level of care needed. One key informant mentioned a middle-income level gap, where a family may not qualify for Medicaid, but the cost is too high to get adequate coverage. Undocumented residents do not qualify for Medicaid or subsidies through the Health Exchange, leading to health care being prohibitively expensive for many among this population.

 

A few key informants said that vaping is a problem. One key informant reported that low-income individuals may have a hard time with the affordability of smoking cessation options, while another key informant stated that when it comes to smoking cessation it is a “lack of desire, not a resource issue.”

 

 

[1] BRFSS, 2018

[2] https://www.mhanational.org/issues/ranking-states

[3] BRFSS 2018

[4] BRFSS, 2016-2018

[5] Unintentional Drug- and Alcohol-Related Intoxication Deaths in Maryland, 2018, Maryland Department of Health https://bha.health.maryland.gov/Documents/Annual_2018_Drug_Intox_Report.pdf

[6] BRFSS, 2015-2018

[7] BRFSS, 2015-2018

[8] IBID.

[9] Maryland Vital Statistics Administration

[10] Prevalence of Selected Maternal and Child Health Indicators for Maryland, Pregnancy Risk Assessment Monitoring System (PRAMS), 2016-2017

[11] Maryland Vital Statistics Administration

[12] Pregnancy Risk Assessment Monitoring System, PRAMS, 2018

[13] https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pretermbirth.htm

[14] https://www.who.int/news-room/fact-sheets/detail/preterm-birth

[15] https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pretermbirth.htm

[16] https://www.marchofdimes.org/complications/low-birthweight.aspx

[17] Maryland Vital Statistics Administration

[18] Maryland Vital Statistics Administration

[19] Pregnancy Risk Assessment Monitoring System (PRAMS)

[20] National Immunization Survey

[21] Maryland Immunet

[22] National Survey of Children’s Health

[23] 2017 Youth Risk Behavior Surveillance System (YRBSS)

[24] Child and Adolescent Health Measurement, 2017-2018

[25] Department of Labor Claims https://oui.doleta.gov/unemploy/claims.asp

[26] National Survey of Children’s Health