The Department of Health and Senior Services (DHSS) utilized several opportunities to seek input on the FFY 2021 Title V MCH Block Grant application and proposed use of funds from the general public and individuals/organizations considered to be “MCH Stakeholders.” This included administrators from the 114 Local Public Health Agencies (LPHAs), healthcare providers, non-profit and other private organizations, and other government agencies. The proposed use of funds (PUF) was posted on the DHSS website/For Public Comment webpage, published in the LPHA weekly newsletter, the Friday Facts, and disseminated via email to a diverse group of stakeholders. Over 250 MCH partners were solicited for comment. The information was also shared with 365 families from the Bureau of Special Health Care Needs Family Partners Listservs.

Responses were received from a total of eight individuals, which are summarized below.

• I look forward to continuing to work with you and these programs in the future. Early Learning Coordinator, Missouri Department of Elementary and Secondary Education
• Thank you for sharing this information and providing the opportunity for comment and feedback. We have reviewed the information and have no comments. Executive Director, Governor’s Council on Disability
• I don’t have any concerns with the proposed use of funds. Thank you for sharing. Clinical Services RN, Missouri Department of Social Services
• We don’t have comments to submit but would like to talk with you about the social determinants of health priority area. We are also interested in learning more about the planned nutrition projects. Manager of Public Policy, Operation Food Search
• Thank you for your great efforts to support the health of Missourians, particularly women and children! President, Board of Directors, Missouri Immunizations Coalition, Inc. and Professor Emeritus, Department of Child Health, University of Missouri School of Medicine
• Thank you for the opportunity to provide feedback on the Title V funding. I noticed that the state priority areas didn’t include any maternal health issues. My thoughts are related to the National Priority Area 1. In my practice, I see barriers with mental health care during pregnancy and postpartum. This is particularly important to keep mom healthy to help with infant/child health and development. Also, I didn’t know if preventative health through vaccinations would be covered with title V or X, but I think promotion of preventative health measures. In particular, HPV-9 is now FDA approved for use up to age 45. Please let me know if you have any questions/comments. I look forward to hearing more from you in the future. Professor of Pharmacy Practice, PGY2 Ambulatory Care Residency Program Director, St. Louis College of Pharmacy and Clinical Pharmacy Specialist, Maternal Fetal Care Center at SSM Health St. Mary’s
• The Madison County Health Department is very disappointed that MCH funds continue to have increase(d) request(s) to support the MO Department of Health personnel costs and this same percentage increase is not requested for distributed funds to Local Public Health Agencies. Local Public Health Agencies continue to struggle to maintain quality personnel and have continued cost increase in benefits and also without program contract increases, are unable to provide increase in personnel compensation. Administrator, Madison County Health Department

A letter was also received from the Director of Policy and Strategic Initiatives, Health Forward Foundation with the following comments.

The Health Forward Foundation submits this public comment in support of state policy areas and services in the FFY 2021 proposed use of funds aimed at further reducing the maternal mortality rate (MMR) and the infant mortality rate (IMR) in Missouri. The State of Missouri continues to lag nationally in our MMR and IMR, leaving significant room for improvement and warranting continued funding and support.

The Missouri State Action Plan included in the application for FFY 2020 included priorities, objectives and strategies focused on reducing MMR and IMR. Specifically, page 76 of the application listed “Improve pre-conception, prenatal and post-partum health care services for women of child bearing age” as a priority need, and listed an objective of reducing maternal mortality by at least 10%, from 24 (baseline: CY 2013 Vital Statistics) to 21.5 per 100,000 live births by June 30, 2020.” Page 111 of the application listed “Ensure risk appropriate care for high risk infants to reduce infant mortality / morbidity” as another priority and included strategies to “continue to collaborate with local infant mortality initiatives in the Kansas City, St. Louis, and Bootheel regions to support efforts to reduce maternal and infant morbidity and mortality.”

However, the state of Missouri has not been successful at reducing MMR in the past few years. According to the Center for Economics and Policy at Washington University, in 2019, MMR for all of Missouri was 40.7 compared to the national average of 29.6 deaths per 100,000 live births, ranking Missouri 44th in the United States. This same study found that from 2016-2019, MMR increased by 42.8%, up from 28.5 deaths per 100,000 live births. Between the years of 2013-2017, MMR for African American women was nearly three times the maternal mortality of white women - 91.9 and 32.9 deaths per 100,000 live births, respectively – compared to 63.8 and 26.1 deaths per 100,000 live births nationally. The numbers illustrate that there is far more work to be done to reduce MMR and increase the likelihood of life beyond childbirth for new mothers.

In contrast to the alarming rise in MMR, IMR has been on a slow decline, however, Missouri should remain diligent in continuing the downward trajectory, as we remain higher than the national average of 5.7 deaths per 1,000 live births. In 2015, IMR for all of Missouri was 6.5 deaths per 1,000 live births, and only dropped to 6.4 deaths per 1,000 live births in 2019. According to the Center for Disease Control, in 2018 Missouri ranked 34th among states, placing us in the bottom half for IMR in the United States. In the Kansas City area, and specifically in Lafayette and Jackson counties, IMR remains higher than or near the state average, at 8.2 and 6.3, respectively. IMR for African American infants in Kansas City was 9.1 in 2018 compared to that of White infants at 2.8 per 1,000 live births. In St. Louis County, the IMR for African American infants was 7.1 in 2018, over twice that of white infants from 2014-2018 (11.4 per 1,000 live births; 5.1 per 1,000 live births). These figures support continued attention and resources on reducing IMR in Missouri.

State priority areas and services directed at reducing MMR and IMR will also complement the FFY 2021 state priority area No. 3 related to “addressing social determinants of health inequities.” Further efforts to address health injustices in MMR and IMR will not only reduce those rates, they will also lessen the negative health outcomes that both result from and lend themselves to health inequities.

For the aforementioned reasons, the Health Forward Foundation supports the inclusion of state priority areas and services focused on reducing MMR and IMR in the FFY 2021 proposed use of funds. I can be reached at mbryantmacklin@healthforward.org for on-going correspondence. Thank you for your consideration.

Responses were sent by the Title V MCH Director to each person who commented on the PUF. Each comment will be taken into consideration when making final revisions to the FFY 2021 application and in future Title V program discussion and planning.
 

Opportunities for public comment regarding the Title V grant are also available throughout the year. Quarterly Statewide Public Health System meetings involve DHSS senior management and LPHA administrators and allow discussion regarding issues that impact the MCH population. Discussions focus on a variety of public health topics including Maternal Child Health issues. Over the past year there have been multiple discussions regarding the opioid epidemic and other emerging health risks and priority health issues impacting maternal mortality and severe maternal morbidity.

Examples of other meetings in which the DHSS seeks input from those considered “Stakeholders” for the MCH community are the Genetics Advisory Committee, Council for Adolescent and School Health (CASH), Missouri Injury and Violence Prevention Advisory Committee (MIVPAC), Pregnancy Associated Mortality Review (PAMR) committee, Advisory Committee on Women’s Health, Neonatal Abstinence Syndrome (NAS) stakeholder work group, and local infant mortality coalitions (Kansas City, St. Louis, Bootheel). In addition, a quarterly call with Healthy Start grantees allows an opportunity to share resources and discuss program updates and methods for collaboration.

In summary, DHSS recognizes the critical role of Title V funds in addressing the ongoing needs of Missouri’s MCH population. Input from the MCH stakeholders and public served an important role in the development of this application and most importantly in the selection of the state priorities and development of the State Action Plan. DHSS collaborates with existing partners and continually seeks opportunities to obtain input from other sources, and stakeholder engagement will be an ongoing prioirity.

The DHSS Maternal Child Health Block Grant (MCHBG) webpage lists Missouri’s National and State Priority Areas and has a link to email any questions regarding the MCHBG. The FFY 2021 Application and FFY 2019 Annual Report will be added to this webpage once the final document is available. This link will remain available throughout the duration of the grant. A link is also currently on the webpage to direct the reader to the Title V Information System (TVIS) website, which includes access to the State Application/Annual Report(s) for Missouri.