The Maine Center for Disease Control and Prevention (Maine CDC), Title V Program conducted a comprehensive statewide five-year needs assessment to inform the development of priorities for Maine’s maternal and child health (MCH) population. Maine’s Needs Assessment was designed to gather feedback from a wide variety of stakeholders at both the state and local level. Our approach:

1. Ensured input from numerous stakeholders with diverse perspectives;
2. Solicited geographically representative feedback from across Maine;
3. Incorporated perspectives of leaders of diverse communities;
4. Fostered collaboration and support by including a partnership group in the planning process.

The Title V Program convened a Needs Assessment Team (NAT) to develop a needs assessment process. This team included over 20 state staff who represented programs across the Maine CDC, as well as other State agencies (see table below).

In addition to having a range of stakeholders involved in the planning process, we gathered qualitative and quantitative information from stakeholders, including families, to guide the selection of Maine’s MCH priorities.

Methodology: As part of the qualitative component of the needs assessment, key stakeholders were engaged to solicit meaningful feedback about the priority needs affecting Maine’s MCH population. This included the engagement of leadership and professionals serving the MCH population throughout Maine, as well as families and individual members of the community. Qualitative methods used to gather feedback included: key informant interviews 14 individuals from Maine’s leadership and key stakeholders serving a variety of special populations in Maine; listening sessions with 80 subject matter experts focused on each of the five MCH population domains; and three regional community input forums (18-40 attendees per forum) with individuals and families from three regions of the state.

Quantitative data collection methods included a survey of 1310 MCH stakeholders including families participating in home visiting, public health nursing and Maine’s WIC program; and a youth survey completed by 122 youth. In addition to these primary data collection methods, indicators from administrative datasets and statewide surveys were analyzed and presented to stakeholders in the form of data briefs, which were used to inform priority discussions. (https://www.maine.gov/dhhs/mecdc/population-health/mch/). These briefs described the magnitude of the issue, trends, and disparities based on geographic region, race and ethnicity, and socioeconomic status. Data sources for these products included vital records, US Census data, hospital discharge and emergency department data, and surveys including Maine’s Pregnancy Risk Assessment Monitoring System, Behavioral Risk Factor Surveillance System, Maine Integrated Youth Health Survey, and the National Survey of Children’s Health.

Objective methodologies were used at all stages of the assessment to identify and rank the top issues affecting the MCH population in Maine. Listening session attendees were asked to identify priority needs affecting Maine’s MCH population. They were then asked to rank the top three priority areas they believed were of greatest concern. The number of points awarded to each priority was calculated with the top priority receiving 3 points, the second receiving 2 points and the third 1 point. Community Forum attendees were presented an overview of the priorities identified during the domain listening sessions along with preliminary results from the priorities survey. They then broke into groups by population domain and were asked to discuss if the priorities rang true in their region of the state and share other priorities affecting their region that were not on the list. Groups then selected the top 2 priorities by population domain, discussed existing and potential interventions, necessary resources and potential partners to engage to address the priorities. A web and paper-based survey was developed to solicit feedback from a wide range of professionals and non-professionals invested in MCH across the state. The survey was disseminated through Maine Families Home Visiting, Public Health Nursing, and WIC as well as a number of programs and providers through a variety of networks. To capture the youth perspective, adolescents attending an annual Youth Leadership Conference were asked to participate in a brief survey. A priority-setting meeting was then held to allow stakeholders to review the top priorities identified and associated epidemiological data to help participants understand trends and population level measures. Participants then used a set of objective criteria to rank potential priorities (see Section V. Supporting Documents). Once completed the scores were averaged across the entire group, arriving at the top 2 priorities by population domain. Finally, population domain leads worked with partners to develop action plans to address the priorities for each MCH population health domain for the next five years.

Following is a summary of the health status of Maine’s MCH population. A detailed review is included under Section V. Supporting Documents.

Women/Maternal Health

About 87% of Maine women age 18-44 report that their general health is good or excellent.1.Maine’s rate of maternal morbidity in 2017 was 53.8 per 10,000 delivery hospitalizations, which was lower than the U.S. rate of 70.9 per 10,000.2.Maine’s maternal mortality rate for 2013-2017 was 22.2 per 100,000 live births (U.S. = 21.2 per 100.000). Maine prioritized women’s access to care and mental health for 2020-2025.

Access to care

In 2018, two out of every three (66.3%) Maine women age 18-44 attended a preventive medical visit within the past 12 months.4 Economic, social and environmental barriers may impede women’s access to preventive healthcare. Maine women without health insurance are less likely to have received a preventive visit than women with insurance coverage (45.5% versus 70.1%).4 This finding suggests that more than 1 in 2 uninsured Maine women may be missing important opportunities to receive key health services, such as contraceptive counseling, diabetes and cancer screening, and STI testing, to the detriment of their overall health. In 2016, 81.2% of Maine women age 21-44 reported they received a PAP test within the past three years.4 Higher income women were more likely to have received a screening than lower income women; 91% of women with annual incomes of $75,000 or more received a PAP test within the past three years, compared to 79.4% of women with an annual income of less than $25,000.4

Mental health

According to the CDC, overall mental health is a core component of health related quality of life.9 In 2018, 35% of Maine women age 25-44 reported they had ever been told they had a depressive disorder by a healthcare provider.4 Lifetime depression was even more common among younger Maine women. Close to 4 in 10 (39.1%) Maine women age 18-24 reported having ever been told they had depression by a healthcare provider.4

Lower income Maine women, and those with less education, are more likely to have experienced depression in their lifetimes. In 2016-2017, 43.9% of women age 18-44 with annual incomes of $15,000-$24,999 reported they had ever been told they have depression, vs. 21.6% of women with incomes of $75,000 or more.4

In 2018, about 1 in 10 Maine women with a recent birth suffered from postpartum depression.6 Postpartum depression was more common among younger and less educated women than older or more educated women. Nearly 18% of new mothers with a high school diploma only reported experiencing postpartum depression, compared to 6.5% of new mothers with at least a college degree.6 Maine women with more limited economic resources also experience postpartum depression at higher rates. Women whose prenatal care and/or birth was covered by MaineCare were more likely to report experiencing postpartum depression than women with private insurance (16.4% vs 6.8%). Similarly, women with a recent birth who participated in WIC were more likely to report postpartum depression (16.5%), than those who did not (8.6%).6

Maine’s MCH Block Grant efforts will focus on increasing standardized screening for mental illness for all women pre-conception, prenatally, and postpartum.

Infant/Perinatal Health

On average, Maine has about 12,500 births per year. The number of births in Maine has been declining steadily since 2006. About 60% of Maine births are to women age 25-34; 23% are to women under age 25 and 16% are 35 years and older. About two-thirds of new mothers in Maine have at least some college education; 61% are married at the time they give birth.7

In 2017, 92% of Maine births were to women who were White, 5% were Black/African American, 1.0% were American Indian/Alaska Native, and 2% were Asian or other Pacific Islander. About 2% of Maine births were to women of Hispanic ethnicity. About 9% of new mothers in Maine were born outside of the United States.7 The percent of births to women who are foreign born increased 80% between 2000 and 2017.7

Maine’s priorities to improve infant and perinatal health for 2020-2025 are to reduce infant mortality and to increase breastfeeding. Both of these priorities will also include a focus on infants affected by maternal substance use during pregnancy.

Infant Mortality

Between 2014 and 2018, an average of 76 Maine infants died annually. Maine’s infant mortality rate in 2018 was 5.4 deaths per 1,000 live births. Maine’s infant mortality rate (IMR) has gradually decreased since 2013, when the State’s IMR was 7.0 deaths per 1,000 births.15 Despite this decline, in 2018 Maine had the second highest IMR in the New England region, and ranked 16th nationally.18

Similar to elsewhere in the US, the majority of infant deaths in Maine occur during the first 7 days of life. In 2018, 62.1% of Maine’s infant deaths were early neonatal deaths (rate: 3.3 per 1,000).15 Maine infants born at very low birth weights and/or very preterm have the worst survival outcomes. In 2013-2017, fewer than half of Maine infants born weighing less than 1000g survived their first year of life.19

About 8.6% of Maine infants are born preterm.7 Maine’s rate is lower than the U.S. rate of 10.0%, but Maine’s prematurity rate has increased since 2012. Similarly, the percentage of low birth weight infants born to Maine women has also increased in recent years and is currently about 7.2%.7 This is lower than the U.S. rate of 8.3% and lower than the Healthy People 2020 target of 7.8%. The increase is mostly among those born “late preterm” (34-36 weeks gestation). Those insured by Medicaid are more likely to have a low birth weight infant (8% vs. 6%). Between 2013-2017, Native American women were more likely to have a preterm birth (<37 weeks gestation) compared to White women (10.2% vs. 8.5%) and both Black women and Native American women were more likely to have a low birthweight infant compared to White women (9.5%, 10.3% vs. 7% respectively).7

Infant sleep position, sleep surface, and sleep location are associated with the risk of SIDS and other sleep-related infant deaths.24 The proportion of Maine infants placed on their backs to sleep is increasing. In 2018, 88.5% of Maine infants were placed on their backs to sleep, up from 77.2% in 2007.6

According to data from the Maine PRAMS survey, many Maine infants sleep in locations that are not firm surfaces, such as a car seat or swing (58.6%), an adult bed (25.6%), or a couch or chair (9%).6 Close to 60% of Maine infants always sleep alone.6

In 2018, 1 in 2 Maine mothers with a recent birth reported their babies do not usually go to sleep with blankets, crib bumpers, toys, pillows or other soft items in their sleep area. Younger Maine mothers were more likely than other mothers to report soft items in their infants’ sleep areas. While 61.8% of mothers age 35 and older reported their babies usually sleep with no soft items, only 26.1% of mothers age 20-24 reported the same.6

Breastfeeding

The AAP recommends exclusive breastfeeding for infants six months and under, and continued complementary breastfeeding for at least one year. In 2018, close to 9 in 10 Maine infants (89.5%) were breastfeeding at discharge following delivery.7

According to data from the National Immunization Survey, the proportion of Maine mothers who exclusively breastfeed until their infant is at least 6 months has increased over the last decade.27 In 2016, close to 1 in 3 Maine mothers reported exclusively breastfeeding until at least 6 months, up from 1 in 5 in 2007.27 Data from 2009-2011 suggest that older Maine mothers, and those with higher educational attainment, are more likely to exclusively breastfeed their infants for their first 6 months.27

State and local policies and programs can contribute to increased breastfeeding.31 Maine’s WIC program provides extensive breastfeeding supports to eligible enrolled mothers, including lactation counseling and provision of breast pumps. Maine state law also requires employers to provide paid or unpaid breaks to express milk and provide a clean space for lactation activities.32

Child Health

Maine’s change in administration in 2019 has led to an increased focus on the health of children. Maine’s Governor re-instated the Maine Children’s Cabinet, which is coordinated by the Governor’s office and focuses on ensuring all Maine children enter kindergarten prepared to succeed.33 Their strategies align with Maine’s MCH Block Grant 2021-2025 priorities to ensure the physical and oral health of Maine children and identify developmental delays in a timely basis.

Developmental Screening

Four of every 10 Maine parents of 9-35 month olds (43.7%) report that they received a parent-completed developmental screening in the past 12 months, which is not statistically significantly different from the 33.5% figure seen nationwide.33 Maine ranks 7th highest among US states in the percentage of children screened. The Maine percentage screened increased from 31.6% in 2016 to 49.3% in 2018, though the change was not statistically significant.33

Physical Activity

Just over a third (37.0%) of Maine 6-11 year olds were physically active for at least 60 minutes every day during the past week, which is significantly higher than the 27.7% seen nationwide. Almost another third (30.1%) of Maine 6-11 year olds were physically active for at least 60 minutes on 0-3 days in the past week. Maine ranks 3rd highest among US states in the percentage of 6-11 year olds who were physically active for at least 60 minutes every day during the previous week.34 The percentage of Maine 6-11 year olds who were physically active for at least 60 minutes every day in the previous week did not change significantly from 2016 to 2018.33 Everyday physical activity did not differ significantly in Maine by sex, presence of special health care needs, household income, or public vs. private health insurance.34

Oral Health

Parents of 82.3% of Maine 1-17 year olds describe the condition of their children’s teeth as excellent or very good, which is not significantly different from the 78.8% figure found nationwide.34 Eight of every 10 Maine children ages 1-17 years (83.8%) has had a preventive dental visit in the previous year, which was not statistically significantly different from the 79.7% seen nationwide.33 Maine ranked 10th highest among US states in the percentage of children who had a preventive dental visit in the past year. Children ages 1-5 years were significantly less likely to have had a preventive dental visit in the past year than were 6-11 or 12-17 year olds (65.3%, 93.1%, and 90.6%, respectively).33

Adolescent Health

Adolescence is a time of significant physical and emotional growth and change. It is also a time during which health behaviors, such as physical activity, substance use, and sexual activity, are established. Fostering supportive environments in homes, schools, and communities, along with promoting coping and problem-solving skills can help adolescents maintain good mental and physical health. In Maine, our 2021-2025 priorities focus on ensuring care for adolescent mental health needs and reducing bullying and its consequences by promoting socio-emotional learning.

Mental Health

In Maine, nearly 1 in 3 high school students felt sad or hopeless almost every day for two weeks or more during the previous 12 months in 2019.35 Depressive symptoms among Maine adolescents have been slowly increasing since 2011; there was a statistically significant increase between 2017 and 2019. Sixteen percent of Maine high school students seriously considered suicide in the past year.35 Compared to high school students who are White, American Indian and multi-racial students are disproportionately more likely to report depressive symptoms and to seriously consider suicide in the past year.35

LGBT youth are also especially vulnerable to symptoms of depression and suicide. More than half (58%) of gay or lesbian high school students, 67% of bisexual students, and 72% of transgender students felt depressed in the past year. More than half (52%) of transgender students considered suicide in the past year, along with 35% of gay or lesbian students and 43% of bisexual students. Among heterosexual students, 12% considered suicide in the past year.35 When asked if they sought help when they felt sad or hopeless, only 1 in 4 Maine adolescents got help from an adult.35

Maine’s efforts in this area focus on ensuring mental health counseling availability at school-based health centers and providing suicide prevention training to school personnel and students that encourages asking for help from a trusted adult. About 51% of Maine students have support from adults other than their parents; 81% strongly agree or agree that at least one teacher really cares and provides help and support when needed.37

Violence and Bullying

In 2019, about 1 in 4 (23%) of Maine high school students were bullied on school property and 20% had been electronically bullied during the previous 12 months; almost half (46%) of middle school students had ever been bullied and 28% had ever been electronically bullied.35 Bullying is especially problematic among Maine’s American Indian students (33% had been bullied in the past year) and Maine’s LGBT students. About 37% of Maine’s gay, lesbian and bisexual students and 44% of Maine’s transgender students had been bullied in the previous year. LGBT students are twice as likely as heterosexual students to feel unsafe at school.35

Almost half (45%) of Maine students who are Black or African American have experienced harassment based on their race at school or on their way to or from school. This is also a common experience for Maine’s Hispanic students (34%), American Indian students (19%), Asian students (28%), and multi-racial students (30%). Half of Maine’s gay or lesbian students have been harassed due to their sexual orientation and 55% of transgender students have ever been harassed due to their perceived gender identity.35

Children with Special Health Care Needs

CSHCN face the same challenges as children without special health care needs, and most of Maine’s infant, child, and adolescent priorities relate in some way to CSHCN. One in five Maine children (22.1%) has a special health care need; approximately 56,062.34

The two priorities specific to CSHCN selected by Maine are to improve care coordination for CSHCN and to facilitate the transition to adult health care among adolescents with special health care needs. Progress on these priorities will be tracked using one state performance measure (percent of CSHCN who receive effective care coordination, among those who need it) and one national performance measure (percent of adolescents with and without special health care needs, ages 12 through 17, who received services necessary to make transitions to adult health care).

Care Coordination

The percentage of Maine children who receive effective care coordination, among those who need it, is lower among CSHCN than non-CSHCN (65.7% vs. 77.0%, respectively), but the difference is not statistically significant. Maine’s percentage of CSHCN who get effective care coordination, among those who need it, is similar to the nationwide percentage (59.8%). Maine ranks 11th highest among U.S. states on the percentage of CSHCN who get effective care coordination, among those who need it.34

Transition to adulthood

Only one of every three Maine 12-17 year-old adolescents with special health care needs (ASHCN; 33.8%) receive the services necessary for transition to adult health care, similar to Maine 12-17 year olds who do not have special health care needs (31.5%), but significantly higher than the 18.9% found among ASHCN nationwide. Maine ranks 3rd highest among U.S. states in the percentage of ASHCN ages 12-17 years who receive services needed to transition to adult health care. Every year, on average, about 16,737 Maine ASHCN ages 12-17 years have not received the transition services they need.34

The Maine Title V Agency is located within the Department of Health and Human Services (DHHS). Jeanne Lambrew, PhD, Commissioner of Maine’s DHHS, reports directly to Governor Janet Mills. Nirav D. Shah, M.D., J.D., serves as Director of the Maine Center for Disease Control and Prevention (Maine CDC). Jamie Cotnoir is Associate Director of the Division of Disease Prevention (DDP), which houses direct service programs and population-based prevention and health promotion services. Maryann Harakall, MPPM, is the Title V Director and Director of Children with Special Health Needs (CSHN).

Administrative oversight of the Maternal and Child Health (MCH) Services Block Grant is vested with the DHHS’s Maine CDC. Programs that focus primarily on the MCH population are organizationally located in the DDP. The day-to-day management of the MCH Block Grant (BG) is carried out in the DDP, with Maryann Harakall designated as the manager with ultimate responsibility for administration of the MCHBG.

Programs funded by the Federal/State Title V MCHBG are: Children with Special Health Needs, Adolescent Health and Injury Prevention, Oral Health, Public Health Nursing, MCH Epidemiology, Women’s Health and Maine Families Home Visiting located within the DDP; District Public Health Liaisons in the Division of Public Health Systems and the Department of Education, Health Education Consultants. All programs contribute to the achievement of MCH priorities.

The Title V Director meets monthly with program staff to discuss MCHBG priorities. Agenda items include highlights from program staff related to on-going program activities including those agencies/entities they are partnering with and the outcomes they are observing, updates from the Title V Director on MCH related topics and time for problem solving and brainstorming as program staff network and form collaborations. This meeting allows time for inter-departmental agencies to learn more about each other’s work and seek ways to further their work on priorities. While the focus of conversation is around current MCH priorities and work plan activities, frequently program staff schedule additional time to discuss other ongoing projects.

A listing of programs supported by Title V funds is included in Section V. Supporting Documents.

Our many partnerships and collaborations expand our capacity to ensure good penetration of services in all but the most northern area of our state and a few other remote pockets where we continue to be challenged by difficult access to care. The goal of the Division of Disease Prevention (DDP) is to promote health and prevent disease, injury and disability through a variety of cross programmatic public health interventions ranging across all three levels of prevention through broad-based community health promotion initiatives, early detection, health systems interventions, delivery of health services and the promotion of healthy public policies.

The five-year planning process is an opportunity to reassess the overall direction of Maine’s public health system. In the past 10 to 15 years the Maine CDC Title V program has transitioned from a primary focus on the provision of direct services to Maine residents to a focus on population-based and infrastructure based services to assure there is an ongoing system of care and services for Maine’s MCH population. Each five-year planning cycle is a multi-year process, requiring transitioning of resource allocations from traditional to current and emerging priorities. Continued collaboration with stakeholders and representative advisory groups is critical.

Strong relationships with organizations, in particular the University of Southern Maine (USM); University of New England, and contractors such as Medical Care Development and health care systems such as MaineHealth and Northern Light are critical to our programs’ success. These organizations not only provide human resources, but also make available critical expertise on issues important to the health of Mainers.

Beginning in 2000 the DDP focused on increasing the financial and human resources on developing a strong MCH Epidemiology Team (Epi Team). The Epi Team has 2.5 fulltime equivalent epidemiologists; one doctoral-level epidemiologist, Dr. Erika Lichter and two MPH epidemiologists, Cindy Mervis and Fleur Hopper. Combined with chronic disease funded epidemiologists there are a total of six epidemiologists and three additional support staff positions. The MCH Epi Team is financed through State Systems Development Initiative, State MCHBG match funds and several federal categorical grants.

During the past ten years, the DDP has significantly expanded its capacity specific to epidemiology. An area for growth is evaluation. Staff within the DDP has the capacity to conduct simple process evaluation. We contract with evaluators for more complex evaluation plans and specific time limited projects.

The capacity of the public and private-sector health care system in Maine to support a comprehensive, coordinated, community-based, family-centered system of care for Children with special health care needs (CSHCN) is improving as the capacity of the Title V agency and its partners expands statewide.

The CSHCN program maintains partnerships with a number of community-based organizations to provide support for families. The Maine Parent Federation provides care coordination services, a Statewide Parent Information Network, and the Family to Family Health Information Network, serving 1,608 families of CSHCN and training 1,821 professionals in 2019. Maine Hands and Voices provides support services for Deaf and hard of hearing children and their families.

The majority of the Maine MCH workforce is located in Augusta, the State capitol. Staff classifications include: administrative/clerical support, comprehensive health planners, program managers, health education consultants, public health nurses and senior administrative managers for a total of 27 positions, representing 25.9 FTEs. Maine uses the MCHBG and state MOE to contract with additional personnel who work on behalf of the MCH/CSHN population and the Title V Program.

The Division of Disease Prevention (DDP) has administrative responsibility for Title V and is led by Maryann Harakall, MPPM. Ms. Harakall has three years of experience in MCH, six years’ with procurement and five years’ with substance abuse prevention and enforcement. She holds a bachelor’s degree in Child Development and Family Relations and a Master’s in Public Policy and Management. Ms. Harakall also serves as the Director of the CSHN Program. Kathyrn Downing, RN is Director of the Public Health Nursing (PHN) Program and has been in this position for 18 months. Ms. Downing has 30 years of nursing experience working primarily in inpatient as a trauma emergency room nurse and in home health. In 2013 she transitioned into management as a clinical supervisor with less direct patient care and a greater focus on day to day operations. In her role as Associate Director of the PHN Division Ms. Downing is responsible for the direct oversight of the PHN Division, development and implementation of strategic goals and initiatives aimed at improving the program’s effectiveness and efficiency and developing and implementing a comprehensive recruitment plan to increase the number of PHNs.

Dr. Erika Lichter, the lead MCH Epidemiologist, has a ScD in Public Health with a major in MCH and minors in Biostatistics and Epidemiology and a master's degree in Developmental Psychology. Cindy Mervis, MPH brings over 20 years of experience as an Epidemiologist. Ms. Mervis began working with the Title V program at the Maine CDC in 2004 and has expertise in injury surveillance, CSHN, quantitative data analyses, and data linkage. Fleur Hopper, MPH conducts analyses on infant mortality, maternal morbidity and other birth outcomes.

Through the State Systems Development Initiative and other categorical funding, we increased our epidemiology capacity. Data, Research and Vital Statistics (DRVS) provide data for this grant application and meet with the Epidemiology Team and DDP managers for specific data needs. Our increased epidemiology capacity is leading to increased cross divisional work between the DDP and DRVS on MCH priorities.

The CSHN Program contracts with several health systems to provide clinical genetic services, cleft lip and/or palate clinics, metabolic clinics and perinatal outreach and education.

Professionals who provide services include: geneticists, pediatricians, plastic surgeons, oral surgeons, pediatric dentists, orthodontists, prosthodontists, speech/language pathologists, audiologists, social worker and master’s level prepared RN. The Maine Parent Federation (Maine’s Family-to-Family) and the Maine Education Center for the Deaf and Hard of Hearing provide assistance to families regarding supports and services for children who are deaf/hard of hearing and who have other special health care needs through family navigators and parent to parent specialists. CSHN contracts with interpreters for both American sign language and computer aided real time translation and medical abstractors for the Birth Defects Surveillance Program.

Parents continue to be an integral part of the CSHN Program. Parents of children with special health needs serve on the Newborn Hearing Advisory Board, the Joint Advisory Board on Newborn Screening and the Birth Defects Advisory Board. The Maine Suicide Prevention Program Advisory Committee membership includes parents and other survivors of suicide.

The Maine MCH workforce maintains license requirements, clinical training and expertise through membership in many professional organizations; Maine Chapter of American Academy of Pediatrics, Association of Maternal and Child Health Programs, American Association of Health and Disability, American Public Health Association, and American Cleft Lip and Palate Association, ensuring an ongoing relationship with primary care providers.

The PHN Program provides services related to communicable disease, medically fragile individuals receiving services through the Maine DHHS and provides technical assistance and guidance to child welfare and child care providers who provide services to DHHS clients to support improved health outcomes.

The Maine CDC Title V has relationships with a number of state and local organizations enabling the program to serve the MCH population statewide. Title V interacts with the medical community through advisory boards and work groups such as the Newborn Screening Joint Advisory Committee, the Newborn Hearing Advisory Board and the Maternal, Fetal and Infant Mortality Review Panel. In addition, CSHN works with cleft lip and/or palate and genetics clinics as well as the parent advocacy organizations, Facing Maine and Maine Parent Federation. Title V also collaborates with the American Academy of Pediatrics, Maine Chapter, Maine Primary Care Association and Developmental Disabilities Council, all who have been invaluable in furthering MCH efforts.

Other relationships within state of Maine departments enhance our capacity and reach. The Maine Department of Education partners with multiple programs to ensure strategies being implemented cross into school environments. Department of Health and Human Services partners include the Office of MaineCare Services, Office of Behavioral Health, Office of Family Independence and the Office of Child and Family Services. The Commissioner’s Office leads a Child Health Leadership Team, which includes representatives from these offices. The team discusses programming and potential projects related to child health and ensures there is coordination and collaboration between offices to maximize resources.

Title V also forms partnerships through a more formal contract process. Maine law requires a competitive procurement process for contracts and successful bidders enter into a contractual agreement to provide services. Some contracted services are for specific deliverables such as qualitative data collection for the MCH needs assessment while others are for ongoing services. These contracts range from public, private or local government. Although there is a contractual agreement, Title V works to develop and enhance relationships.

The State System Development Initiative provides for data collection and analysis of MCH programming. The MCHB directs and funds the CSHN cleft lip and/or palate and birth defects programs. Funding also supports staffing and implementation of the Newborn Screening and Newborn Hearing program activities. Recently the Maine Families Home Visiting (MFHV) Program was relocated to the Maine CDC from the Office of Child and Family Services. The Project Manager for MFHV splits her time between MFHV and other MCH programming.

Maine Title V receives Personal Responsibility Education Program funding through the Administration for Children and Families (ACF). The MCH Manager oversees this program through a contract with the Family Planning Association of Maine, a connection allowing Title V to be more directly connected to ACF.

Title V is housed within the Maine CDC’s Division of Disease Prevention (DDP). Other programs include the Tobacco and Substance Use Prevention and Control Program, Adolescent Health and Injury Prevention, Chronic Disease and WIC. This connection facilitates relationships and collaborations between the programs, as well as to partners working with these programs. The Maine CDC houses both the Data, Research and Vital Statistics (DRVS) and Maine Immunization programs. Title V has a long standing relationship with DRVS; as the provider of data for the Newborn Bloodspot program and the Maternal Fetal and Infant Mortality Review Panel (MFIMR). Title V has also worked closely with the Maine Immunization Program (MIP) by ensuring messaging and educational materials regarding age appropriate vaccinations are disseminated through MCH programs. Recently, during the COVID-19 closure, Maine saw a decrease in vaccine distribution to providers resulting from families not seeking routine preventive services including children not receiving their vaccinations. The Maine CDC began offering a series of free vaccine catch up clinics across the state for families to get their children up to date on their vaccinations. The Public Health Nursing program is working with MIP to staff the clinics.

The Department of Health and Human Services created the Child Health Leadership Team, made up of leaders from each of the offices within the Department (Office of Behavioral Health, Office of MaineCare Services, Office of Family Independence, Office of Child and Family Services, the Maine CDC and the Office of Aging and Disability). The goal of this team is to coordinate services across the Department. The team meets monthly to share current projects and discuss upcoming tasks related to child health.

Title V has a close working relationship with the University of Southern Maine; through a contract for epidemiological services. This partnership provides high quality data collection and analysis. The staff are experienced and knowledgeable in MCH and provide guidance in using data to inform programming decisions.

The Maine CDC, DDP has several methods for establishing working relationships/collaborations with other entities. We engage key stakeholders that provide services and develop policies for our shared populations. We convene planning groups and ask for consensus on group membership and involvement.

Examples of Maine’s Title V collaborative partnerships include: community and family representatives; the MFIMR Panel, the Newborn Hearing Advisory Board and the Newborn Screening Joint Advisory Committee. Each of these groups are comprised of professionals from across the state, as well as family members and consumers of services.

Methodologies used to rank our broad identified needs and Maine’s process for selecting our final ten priorities

Findings from the Five-Year Needs Assessment drove the State’s identification of its priority needs for 2021-2025. Objective methodologies were used at all stages of the assessment to select the final ten priorities. During each input gathering session with key stakeholders (i.e., domain listening sessions and community input forums), the top issues affecting the MCH population in Maine were identified and ranked in order of highest need. Results from the statewide priorities survey and data gathered from Maine adolescents at an annual Youth Leadership Conference were also tabulated and ranked in order of highest identified need. Key findings across all data sources were consolidated and the top five priorities by domain and by data source were identified. Then, looking across all data sources, the overall top five priorities by domain were identified. From there, a priority-setting meeting was convened with key stakeholders and partners to identify the top 1-2 priority issues by domain.

During the priority-setting meeting, attendees broke into groups by domain and assigned a score to each priority area using an objective set of criteria (See Section III.C.2.a Process Description). The scores were then averaged across the entire group, arriving at the top two priorities by domain.

Emerging issues or other needs not included in the final list of priorities and why

Substance use disorders (SUD) and substance exposed infants (SEI) were identified among the top MCH priority needs for women/maternal health, perinatal/infant health and adolescent health. While the final list of priority needs does not specify SUDs and SEIs, the selected priorities broadly encompass these issues and were addressed through evidence-based strategies described within each action plan (e.g., increasing breastfeeding support and education for women affected by substance use; smoking prevention and cessation for pregnant women). Furthermore, Maine recently received a $5.3 million Maine Maternal Opioid Model (MOM) grant. This 5-year project led by MaineCare and funded through a cooperative agreement with the Centers for Medicare and Medicaid Innovation will add over $5 million in funding, dedicated staff positions, and stipends for community partners to collaboratively develop a system of care for pregnant women with Opioid Use Disorder. This initiative will help support the strategies planned to address SUD among the MCH population in Maine and will allow Maine CDC to leverage MaineCare’s investment in addressing this critical issue. The Title V Director and the Substance Exposed Infants Coordinator sit on the MOM Steering Committee.

Another issue that was commonly raised, but is not reflected explicitly in Maine’s priorities is the impact of social determinants, such as poverty, unemployment, housing, transportation, and racism, on health. Stakeholders discussed social determinants of health (SDOH) during listening sessions, interviews, and regional forums. Although they are not explicitly listed as priorities, Maine’s Title V program is committed to taking a health equity perspective to each of our priorities that will address SDOH. As a first step, we plan to provide staff training on social SDOH. This training will be designed to better understand the SDOH framework and how to apply it to reduce barriers to better health outcomes for all Mainers.

Emerging issues related to COVID-19 and the response to the pandemic are not addressed in this needs assessment because the assessment was completed before the emergence of COVID-19 in Maine. However, a Council of State and Territorial Epidemiologists (CSTE) fellow started in Maine in August 2020. She is funded by the federal CDC’s Division of Reproductive Health to focus on COVID-19 and its effects on the MCH population. In addition, the Maine Department of Health and Human Services and the Maine CDC are closely monitoring the situation and working to address and mitigate challenges related to COVID-19 and its impact on MCH populations (for example, through declines in the use of preventive physical and oral health services due to lockdown policies, office closures and increases in food insecurity).

An additional state performance measure was added to aid in strengthening Maine’s immunization rates. An immediate strategy is increasing accessibility to families in need of catching their children up on immunizations. This effort will be carried out in partnership with Public Health Nursing through statewide clinics during the fall of 2020. Title V will collaborate with the Immunization Program on future efforts to ensure children receive all age appropriate immunizations.

Changes in Maine’s priority needs since the previous five-year reporting cycle

Changes to the state’s priority needs from the previous five-year reporting cycle reflect the emerging needs of Maine’s MCH population with a narrower focus on the specific needs affecting each population domain. Furthermore, the state’s priority needs reflect new leadership in Maine, increased staffing capacity, and a renewed commitment from all levels of Maine DHHS to serve all aspects of the maternal and child population.

Relationship between the priority need and selected national and state performance measures

The identified priority needs informed the selection of National Performance Measures (NMPs) and State Performance Measures (SPMs), which can be improved through targeted interventions. The following graphic depicts Maine’s 10 priorities and associated NPMs and SPMs followed by a rationale for their selection.

Priority: Improve care for women’s mental health

Women/Maternal: SPM # 1 – Percent of women who report that their health care provider asked them about depression in the 12 months prior to pregnancy.

Reason for Selection: About 1 in every 4 Maine women have ever been diagnosed with depression. In our MCH listening sessions, mental health was ranked among the top two highest priorities for women. On Maine’s Title V Needs Assessment survey, more than half of the participants indicated that mental health should be a women’s health priority. Furthermore, mental health was identified as a priority in all 16 Maine counties in Maine’s Shared Community Health Needs Assessment (CHNA). In order to adequately respond to depression, it is critical for it to be identified as soon as possible. Based on Maine’s PRAMS data, about 94% of new mothers are screened for postpartum depression. This suggests that postpartum depression screening is almost universal in Maine. However, 1 in every 4 new mothers reported that they were not asked about depression at a health care visit prior to their pregnancy. We selected this measure as the State Performance Measure to reflect the goal of universal mental health screening of women.

Priority: Increase women’s access to high quality healthcare

Women/Maternal: NPM # 1- Percent of women, ages 18 – 44 with a preventive medical visit in the past year.

Reason for selection: Access to care is a broad priority that stakeholders noted includes access to primary care, family planning services, prenatal care, oral health care, as well as mental health and child care. It was widely acknowledged in stakeholder meetings that access to care is not universal across the state; women living in rural areas, minority populations, and women without health insurance, have more challenges accessing care. More than 1 in 3 non-professionals that completed the MCH Needs Assessment survey indicated that access to family planning services should be a priority for Maine women. Only about 67% of women age 18-44 had a preventive health visit in the past year. Women who are uninsured are less likely than those who are insured to have had a preventive visit (about 11% of Maine women are uninsured). About 63% of African-American women in Maine received at least 80% of their prenatal care visits compared to 83% of White women. Access to care was identified as a priority in 15 out of 16 counties in Maine’s Shared CHNA. The measure selected is an NPM and it reflects the need for women to have regular preventive health visits. Having these visits can help increase access to family planning and ongoing screening of physical and mental health conditions.

Priority: Reduce infant mortality

Perinatal/Infant: NPM # 5- Percent of infants placed to sleep on their backs; placed to sleep on a separate approved surface; sleep without soft bedding.

Reason for selection: In Maine, our goal is to decrease the infant mortality rate to 4.0 per 1,000. SIDS/SUID is the third leading cause of infant mortality; these deaths can often be prevented through safe sleep practices. Starting in 2019, the state engaged in multiple efforts to decrease sleep-related deaths, including a statewide media campaign. The safe sleep measure was Maine’s NPM for 2015-2020 and by continuing to focus on infant safety through promoting safe sleep practices, we will build on our existing efforts.

Priority: Increase breastfeeding initiation and duration

Perinatal/Infant: NPM # 4- Percent of infants who are ever breastfed and percent of infants breastfed exclusively.

Reason for selection: Breastfeeding has many known benefits for children including boosted immune system, healthier early childhood, and lower risk of obesity in later years. About 1 in 3 participants on Maine’s MCH Needs Assessment survey identified breastfeeding as an important infant health priority. It was also prioritized by stakeholders in regional listening sessions and in listening sessions with experts on infant health. Maine CDC is currently working with community partners to promote breastfeeding in Maine. Based on this solid foundation, additional work will help to increase the numbers of mothers that breastfeed and those that sustain breastfeeding for more than six months.

Priority: Optimize children’s physical and oral health

This broad priority emerged from discussions with stakeholders that focused on the importance of children’s physical, oral, and mental health on readiness for school, ability to learn, and long-term health. Stakeholders cited the need to reduce childhood obesity, increase physical activity, reduce screen time, improve children’s oral health, increase vaccination rates, and decrease lead poisoning. Based on this range of potential health concerns, we selected to focus on physical activity and access to oral health care.

Child: NPM # 8.1- Percent of children, ages 6 – 11, who are physically active at least 60 minutes per day.

Reason for selection: In Maine, 1 in 3 middle school students are overweight or obese and only about half are physically active for at least 60 minutes during an average week. Schools are a key setting as the promotion of physical activity has long been a fundamental component of the American educational experience. Over 95% of youth are enrolled in schools. The school day, typically 8-9 hours long, traditionally provides a sedentary setting away from home. Adding physical activity during the school day can reduce the sedentary nature of classrooms and enhance academic performance.

Child: NPM # 13.2 – Percent of children, ages 1 through 17, who had a preventive dental visit in the past year.

Reason for selection: About 1 in 10 Maine parents report that their child had cavities or tooth decay in the past year. About 16% of children did not have a preventive dental visit in the past year. Maine’s School Oral Health Program is designed to identify and help children with oral health needs.

Priority: Ensure early detection and intervention for developmental delay

Child: NPM # 6- Percent of children, ages 9 - 35 months, receiving a developmental screening using a parent-completed screening tool.

Reason for selection: One of the overarching goals of the Maine Governor’s Children’s Cabinet is to ensure that all Maine children enter kindergarten prepared to succeed. In Spring 2019, Maine established the Children’s Cabinet Early Childhood Advisory Council to focus on implementing effective services and education to children from birth to third grade. Developmental screening is a key component of a comprehensive early childhood system of care. Only about 1 in 3 Maine parents report that they received a developmental screening using a parent-completed screening tool. Maine’s Title V program is working closely with the Maine DHHS Commissioner’s Office on this initiative.

Priority: Address adolescent unmet mental health needs

Adolescent: SPM # 2- Percent of Maine high school students who report feeling so sad or hopeless (for 2 or more weeks) that they stopped doing regular activities (past 12 months).

Reason for selection: Unmet mental health needs represent a significant burden on the wellbeing of adolescents in Maine. In 2019, 32.1% of Maine high school students reported feeling sad or hopeless for two or more weeks at least one time in the past 12 months, a significant increase from 2017. To address these concerning trends, Maine CDC is proposing an approach that combines increased access to high-quality behavioral health services for youth with prevention initiatives that emphasize resiliency and connectedness.

Priority: Prevent bullying and its consequences

Adolescent: NPM # 9- Percent of adolescents, ages 12-17 who are bullied or who bully others.

Reason for selection: About 1 in 5 Maine high school students have been bullied on school property or electronically bullied. People are more aware of childhood bullying and its negative health effects. Maine CDC will work with existing partners at the Maine Department of Education to train more adults and youth on how to prevent the behaviors and intervene when it occurs.

Priority: Improve care coordination for children and families with special health care needs

CSHCN: SPM # 3 - Percent of children with special health care needs who receive effective care coordination, among those who need it.

Reason for selection: The need for better coordination of care for children with special health needs was raised as an issue by experts in the field in all MCH needs assessment meetings. Stakeholders noted that coordination needs to be improved between State agencies; between providers; and between families and providers. On the National Survey of Children’s Health, about 1 in 4 parents report that they did not receive effective care coordination when they needed it.

Priority: Support adolescents with special health care needs transition to adult care

CSHCN: NPM # 12- Percent of adolescents with and without special health care needs who have received the services necessary to make transitions to adult health care.

Reason for selection: Transitioning to adult care is an important component of child health for all children, but especially so for children and youth with special health care needs. This measure was selected to enhance the current work in the Maine CDC with children with special health care needs. Two out of three CSHN do not receive necessary services for transition to adult health care.