Needs assessment is an ongoing component of Maine’s MCH activities. During FY18 we initiated several efforts to improve our understanding of current issues impacting Maine’s MCH population. These activities ranged from in-depth analyses to better understand our selected performance measures to gathering information from partners, to monitoring progress and barriers to meeting our performance objectives.

Quantitative data analyses

Women’s Health

• There is increased attention nationally on maternal morbidity and mortality. To better understand this issue in Maine, MCH epidemiologists worked collaboratively with epidemiologists in Maine and New Hampshire, along with the Northern New England Perinatal Quality Improvement Network (NNEPQIN) to conduct analyses of hospital discharge data on maternal morbidity using uniform definitions. We presented the results at the fall NNEPQIN conference and the annual meeting of the Maine Chapter of the Association of Women’s Health, Obstetric and Neonatal Nurses and we started working with individual hospitals to understand their data. Results from these analyses indicated that Maine had a higher rate of deliveries with a severe hemorrhage (803 per 10,000) compared to Vermont and New Hampshire, but Maine had the lowest rate of transfusions (50.4 per 10,000) among the three states. Maine’s rate of severe hypertension (216.4 per 10,000) was similar to NH and VT.
• In collaboration with Maine’s Data, Research and Vital Statistics Program (DRVS), we linked data on deaths of women aged 10-55 years with birth certificate data to ascertain the number of pregnancy-associated deaths. This was a pilot linkage to examine whether there was discordance between the linked data and the pregnancy checkbox on the death certificate. We found a high rate of accuracy for the pregnancy checkbox. We will continue to do this linkage on a biannual basis to provide cases for Maine’s Maternal, Fetal, and Infant Mortality Review (MFIMR) Panel and to monitor maternal deaths. Each year in Maine, about eight women die during pregnancy or within one year of giving birth.

Infant Health

• To increase our understanding of infant mortality, MCH epidemiologists developed a partnership with Maine’s DRVS Program to provide MCH epidemiologists provisional birth and death data on a quarterly basis. We use these data to monitor infant mortality, low birthweight, smoking during pregnancy, and other MCH birth outcomes on a timelier basis to help us identify patterns of risk sooner. Every quarter we produce an “Infant Mortality Dashboard” document and provide to Maine’s MFIMR Panel. The document summarizes cumulative information on infant mortality for the current year for panel members to have a “real-time” understanding of infant mortality in the State.
• Maine CDC hosted a MCHB Graduate Student Intern during summer of 2017 who completed a Perinatal Period of Risk (PPOR) analyses. During FY18, we presented the PPOR analysis to the MFIMR and the Perinatal Leadership Coalition. The PPOR methodology is used to understand areas of potential focus for our infant mortality work and Maine’s MFIMR uses it to guide its selection of cases for review.

• To improve our understanding of substance exposed infants (SEI), we created a document highlighting options for surveillance of SEI and started a workgroup to improve data collection of this issue. In addition, we conducted a linkage between birth certificates and reports of drug affected infants from Maine’s Office of Child and Family Services (OCFS). Results from this linkage showed the disparity in poor birth outcomes between drug-affected and non-drug affected infants.
• Participant surveys are administered on an annual basis to parents enrolled in the Maine Families Home Visiting (MFHV) Program. These surveys assess participant satisfaction with the home visiting program. As part of the administration of the 2019 MFHV survey, we included a general survey on MCH issues to gather feedback from participants to inform the MCH needs assessment.

Child and Adolescent Health

• To address emerging issues and identify health disparities, we continue to enhance our data collection systems. This included adding a new item on adverse childhood experiences to the 2017 Maine Integrated Youth Health Survey (MIYHS) for high school students. We also added an item capturing gender identify to the 2017 MIYHS. Infographics highlighting results from these new items were created and are available on the MIYHS website: https://data.mainepublichealth.gov/miyhs/2017Snapshots

General

• Maine’s MCH epidemiologists participated in providing data for Maine’s Shared Community Health Needs Assessment (CHNA) during FY18-19. This involved analyzing and providing data for state, county, and public health district reports, as well as for a tableau data dashboard (see website for report and dashboard: https://www.maine.gov/dhhs/mecdc/phdata/MaineCHNA/). We are currently collaborating with the CHNA coordinator at the Maine CDC to use the information collected from the Shared CHNA to inform the MCH needs assessment.
• Maine’s MCH epidemiologists who are responsible for the quantitative data for Maine’s MCH needs assessment are also responsible for Maine’s MIECHV needs assessment. As a result, data are being collected and analyzed for both processes simultaneously and will be used together to inform the needs of the MCH population in general and those served by Maine’s home visiting program.

Soliciting feedback: As part of our 2020 needs assessment process we are undertaking several efforts to solicit input. We conducted key informant interviews with State leadership including the Commissioner, Deputy Commissioners, the prior MCH Medical Director and other special population directors, such as new Mainers. We are holding listening sessions with key stakeholders in each of the population domains and will be holding community forums later in the summer. During late spring and summer, we administered a survey with MFHV, Public Health Nursing (PHN) and WIC participants. The survey will also be sent to MCH program listservs.

Ongoing performance monitoring and assessment: Monthly, MCH staff provide progress updates on performance measure activities. Maine’s Title V Director convenes monthly meetings for MCH staff and partners to discuss progress and challenges experienced. These meetings also facilitate collaboration across programs and agencies.

Changes in the health status and needs

According to America’s Health Rankings (AHR), the overall health of women and children in Maine is worsening. In their 2016 report, the health of Maine’s women and children was the 11th best in the U.S. However, in their 2018 report, we dropped to 21st. According to AHR, Maine has high rates of health care visits among children (98.7%), adolescents (87.8%), and women (67.1%), as well as prenatal care visits before the third trimester (97.1%). Our teen smoking and drinking rates are declining (50% and 30% decreases since 2009, respectively), and we have the 5th lowest rate of chlamydia in the U.S. However, we also have high rates of tobacco use during pregnancy (18%), alcohol use among women of reproductive age (24.7%), and drug-related deaths among women (9th highest in the U.S; 20.9 per 100,000). Our maternal mortality rates are increasing, along with our adolescent suicide rates. We have high rates of food insecurity (16.4%), childhood poverty (32% of female-headed families), and our childhood immunization rates declined (84% to 71%).

Of these concerning issues, one receiving increased attention is substance use while pregnant and the number of infants born substance exposed. As part of our State Systems Development Initiative, we linked birth certificate data to data on reports of SEIs from Maine’s OCFS. We presented results from these analyses to stakeholders, including the State’s SEI Advisory Group and at the Maine Public Health Association Annual Meeting in October 2018. The analyses indicated that infants reported to OCFS for substance exposure were more likely to have poor birth outcomes, including premature birth and low birth weight. We also found that during a two-year period, 70% of women who had a report for a SEI who went on to have a subsequent birth, had another SEI.

1. Changes in the state’s Title V program capacity or systems of care

The CSHN program experienced staff turnover in several key areas during 2018 and early 2019. In June 2019, Maine hired a manager to oversee women and perinatal initiatives. The manager will also oversee the MFHV Program to allow for consistent alignment between Title V and MFHV.

A rule change adopted in June 2018 now allows for billing to MaineCare for specialty foods (low-protein) for CSHN with PKU. The impact of this policy change meant the CSHN Program no longer had to assist families in paying for these foods. More importantly, the rule change created a long-term solution for CSHN as they no longer have to be concerned about their ability to pay for specialty foods.

Partnerships and collaborations

Maine’s Title V has numerous partnerships and collaborations across the state serving the MCH population. They range from internal partners such as WIC, PHN, MFHV, MaineCare, the OCFS and Substance Abuse and Mental Health Services. External partners include the Department of Education, Maine Quality Counts, Developmental Disabilities Council of Maine, Maine Parent Federation, Maine Education Center for the Deaf and Hard of Hearing, birthing hospitals, the mid-wives’ association and numerous providers.

The Maine CDC and MaineCare continue to partner on the Medicaid Innovation Accelerator Program for the Maternal and Infant Health Initiative which links MCH to value-based purchasing. Maine’s project is to incentivize providers caring for pregnant women with substance abuse disorders to use the SnuggleME Guidelines (https://www.maine.gov/dhhs/SnuggleME/documents/SnuggleME-2018-GuidelinesFINAL.pdf) to screen and refer them to treatment. The project requires Maine Title V and the State Medicaid provider to work collaboratively.

Operationalizing the Five-Year Needs Assessment

Although a formal needs assessment process occurs every five years, each year in Maine we work towards increasing our understanding of the needs of the MCH population by conducting in-depth analyses of our priorities and gather ongoing feedback from partners.

As part of the 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 are the framework that guides the annual work of each population domain.

Quarterly, we review action plans and report on progress toward meeting outcomes. Regular monitoring of progress allows for minor adjustments to ensure success. Annually, population domain leads convene meetings with stakeholders and partners to review and revise action plans based on prior year progress.

Maine found the action plan plays a vital role in decision-making and resource allocation for the Title V program. The development and on-going monitoring of the plan urged us to be realistic in the goals, strategies, and activities developed to address priorities.

Changes in organizational structure and leadership

The CSHN program released an RFP for cleft lip and palate clinic services; Maine Medical Center and Northern Light/Eastern Maine Medical Center received the award. The two hospitals, in conjunction with the CSHN Program, continue to work to improve services provided to families with a cleft lip and/or palate diagnosis.

Maine CDC added new members to the leadership team. Nirav Shah, M.D. came on board in June as the Director of the Maine CDC. In addition to Dr Shah, Maine’s new Governor, Janet Mills, named Jeanne Lambrew, Ph.D Commissioner. These positions play a critical role in setting Title V priorities.

Table 1 below outlines MCH related programs with a brief description and number of staff.

2. Emerging public health issues

Maine is seeing an increased number of SEI. Maine CDC is addressing this issue through data surveillance, prevention and treatment. Through the State Systems Development Initiative Grant, Maine formed a surveillance workgroup to look at how we collect and report data on prevalence of SEI. The initial focus of the workgroup is to create shared definitions so data can be collected in a standardized manner and analyzed regularly to guide intervention and prevention efforts. The second form of engagement is through the SEI State Steering Committee and Community Level Task Forces. The purpose of these groups is to discuss prevention efforts to reduce substance use during pregnancy and create tools and resources for community providers. This group is comprised of prevention staff from several DHHS offices and outside providers such as prenatal and labor and delivery nurses. The SnuggleMe Guidelines provide prenatal providers tools on how to screen for and treat pregnant women who have substance abuse disorders. The Guidelines include cultural competency skills to assist providers in not judging or shaming women and to encourage them to continue to get prenatal care.

Based on recent national trends, Maine started to focus more on maternal mortality. We are part of a Region I collaboration with the federal CDC to improve our maternal mortality review process, which is part of Maine’s MFIMR. The MFIMR panel reviewed its first maternal death case in April 2018. We are also examining data associated with maternal deaths to ensure that we are accurately counting deaths during pregnancy and within one year of giving birth.

Although not necessarily an emerging public health issue, there is increased understanding within the Maine CDC of the need to address social determinants of health. Social determinants of health emerged as a priority in 15 of Maine’s 16 counties as part of Maine’s Shared CHNA. The Maine CDC is working on a report highlighting data related to social determinants of health in Maine. We anticipate social determinants of health will emerge as key issues during the MCH needs assessment process. We will work collaboratively with local and state-level partners to develop strategies to address these issues.

Another emerging public health issue is the health of recent immigrants in Maine. In summer of 2019, over 200 asylum seekers were re-located to Maine; we anticipate that more will be arriving in the coming months. Maine’s MCH program and partners mobilized to provide safe places to sleep along with safe sleep education; public health nurses are providing on site health assessments, care, and vaccinations. As we conduct our needs assessment to guide future efforts, it will be critical to understand the health needs of these new Mainers.