Title V needs assessment activities in FY 2022 have focused on a second COVID-19 MCH Impact Assessment and a review of state action plans to assess family and community engagement. Ongoing or emerging issues that impact the MCH population are also discussed in this section, including infant and maternal mortality, COVID-19 and pregnancy, substance use, fluoridation, and health concerns specific to children and youth with special health care needs (CYSHCN).
COVID-19 MCH Impact Assessment
As the COVID-19 pandemic persisted, Michigan’s MCH and Title V programs continued to focus on identifying and responding to the needs of women, mothers, infants, children, and CYSHCN. The impact assessment used several methods to explore impacts in 2021, including an MCH impact survey, analysis of local MCH (LMCH) workplans, and a literature review. Findings are described below.
COVID-19 MCH Impact Survey
MDHHS MCH program staff completed an 18-item online survey in February 2022. The survey asked respondents to share their experiences and observations about the impact of COVID-19 on the populations served by their programs. Questions focused on provision of services and health information, workforce challenges, and emerging needs. Michigan Public Health Institute (MPHI) analyzed findings from 24 respondents which included, but was not limited to, Title V programs.
Figure 1. MCH Populations Served by Survey Respondents
Seventeen out of 24 respondents indicated their program provided information, technical assistance, or education on COVID-19 and/or COVID-19 vaccines to individuals, families, providers, or local grantees in 2021. In addition to COVID-19 information, programs indicated they provided guidance on telehealth services and resources on mental health and social isolation. Programs shared information via websites, flyers, newsletters, toolkits, and townhalls.
Notably, most state programs that received Title V funding indicated that they did not use funding for COVID-19 related activities in 2021.
Figure 2. Use of Title V Funding
COVID-19 presented challenges for MCH programs in service delivery and staffing capacity. Twenty-three respondents indicated that their program provided services virtually or via telehealth due to limited ability to provide in-person services, as indicated in Figure 3.
Figure 3. Service Provision
Programs such as home visiting, nutrition support, family planning, and mental health services adapted to virtual and telephonic delivery. Exemptions for telehealth reimbursement eased service delivery. Virtual programs made services more accessible for harder to reach populations, and some programs are interested in continuing to offer this option.
Most survey respondents noted workforce challenges and indicated they were most pronounced for local programs, as illustrated in Figure 4.
Figure 4. Workforce Challenges
In addition to staff shortages, turnover, and reassignment due to COVID-19, respondents indicated that other challenges included staff burnout and mental health concerns.
Struggles with social isolation, stress, job security, housing, and food access affected Michiganders across MCH domains centering the need for mental health support. Provider shortages impeded addressing this need. Programs leveraged technology to provide virtual case managers and therapy sessions to address the critical need. Most respondents indicated that COVID-19 impacted groups differently, as indicated in Figure 5.
Figure 5. COVID-19 Impact
These impacts are discussed below.
Findings by Population Domain
Programs that served women and infants identified persistent barriers to in-person activities, such as lactation and breastfeeding support, WIC redemption, and oral health services. Populations with low-income, people living in both rural and urban areas, and people of color had exacerbated experiences from the pandemic’s economic impacts. Job and food security, affordable housing, and childcare were common concerns. However, programs continued to provide concrete supports, such as pack and plays, through no contact means.
Child and adolescent programs reported a heightened need for mental and oral health services, in-person screenings, and academic supports. School closings, academic delays, and social isolation were noted as challenges. School restrictions also limited screenings and services for vision, hearing, blood lead testing, and oral health which particularly impacted low-income, rural, and urban youth. Adaptations extended the reach of school-based programs by connecting with target populations outside of school. For example, technology allowed case managers to meet with clients, deliver mental health services to youth, and use the Michigan Model for Health.
Programs that served CYSHCN reported challenges navigating the telehealth landscape and the stress of exposure at in-person visits, causing some families to delay medical care. Private nurses and respite care for families with CYSHCN were also more difficult to access. However, policies and exemptions reduced burdens for medication and medical equipment access, telehealth reimbursement, and vaccine administration. Collaboration was noted as a strength. For example, grants to local health departments promoted vaccine delivery to CYSHCN.
Local MCH Workplan Analysis
Year-end LMCH reports from Local Health Departments (LHDs) were analyzed with a focus on understanding the effects of the pandemic on the LMCH program, which is funded by Title V. Expenditures and persons served were quantified and categorized by performance measure, and workplans were analyzed for qualitative themes.
Across the state, LHDs addressed over 120 goals and served 360,850 individuals. Out of 45 LHDs,18 LHDs expended $892,060 (14.6%) in Title V funding to combat COVID-19, serving 187,799 clients. Over half of total individuals served by LMCH were reached with COVID-related services, most commonly vaccinations.
LHDs noted many challenges. For example, the pandemic forced programs to divert both funding and staff to address needs related to contact tracing, case investigation, testing, vaccination, and information hotlines. Limited in-person services were also a barrier to meeting goals. Virtual WIC appointments resulted in fewer immunizations, screenings, and lactation support services. Canceled community events also limited programs’ ability to implement outreach and education activities. While programs adjusted to provide services via telehealth, several programs reported difficulty sustaining virtual programming due to providers’ lack of comfort, poor phone access or internet connections (especially in rural areas), or patient preference. Collecting evaluation data also proved difficult in a virtual format.
LHDs shared successful efforts to serve their community despite limited in-person interaction. Many used alternative communication methods such as print and radio ads, and especially social media, to educate the public on COVID-19 and other health topics. Some programs used virtual events to engage community members. Several LHDs reported partnering with local providers and businesses to reach more people.
Literature Review & Annotated Bibliography
MPHI reviewed recent peer-reviewed and grey literature on the impacts of COVID-19 on MCH populations (see Supporting Documents for the Annotated Bibliography). Search criteria included COVID-19 references and one or more Title V population domains, with a focus on articles about Michigan. Other key terms were service delivery, health equity, pregnancy, breastfeeding, vaccine, insurance, mental health, and substance use.
The review reinforced prior findings on the physical, mental, and social impacts of the pandemic across all population domains and the disparities among demographic groups. In addition, emerging research highlights the direct and indirect long-term impacts on individuals and society.
Scholars continued to assess the phenomenon of ‘long COVID’ and ‘long haulers’ who experience symptoms for months after testing positive for the virus, which can include children (University of California Davis, 2022). A University of Michigan study found 27% of Michiganders who contracted COVID-19 in 2020 reported having a disability following their illness versus 15% before onset (Michigan News, 2022). In turn, specialty clinics have arisen to research and treat higher risk ‘long hauler’ adult and pediatric patients coping with multisystem inflammatory syndrome in children (Michigan Medicine, 2021).
COVID-19 vaccines saved lives in the U.S. and in Michigan (Gupta, 2021; Samson, 2021). Yet inequity and access barriers, mis/disinformation about the vaccine, and mistrust of healthcare systems affected the adoption of this intervention (Clay, 2021). As of March 30, 2022, 67% of Michigan residents had received their first dose—markedly lower than the overall U.S. rate of 82% (MDHHS, 2022; CDC, 2022). Rates vary by race in Michigan, with only 45% of Black residents having their first dose, compared to 56% of White residents (MDHHS, 2022).
Impacts on mental health continued in Michigan, often contributing to substance use issues (Slootmaker, 2022). From April 2020 to April 2021, Michigan opioid-related drug overdoses rose 19% over the prior year. Factors included “isolation, boredom, financial stress, loss of loved ones,” and lack of basic needs. Black, Indigenous, and Hispanic populations, people under age 24, people involved in the criminal justice system, and mothers and infants were especially affected by opioid use and deaths.
To address mental and other health concerns, telehealth options expanded, but access was inequitable. Income and insurance status limited access to telehealth, as did internet access (Darrat, 2020). To reduce inequities, the U.S. Department of Health and Human Services launched the Telehealth Broadband Pilot Program to expand access and improve broadband connectivity in rural areas of many states including Michigan (Augenstein, 2022).
In addition to these overarching impacts, the review highlighted insights unique to each MCH domain.
A Southeast Michigan study confirmed research that pregnancy elevates the risk of severe illness from COVID-19; suggests pregnant people have a higher risk of early preeclampsia after COVID-19 infection; and indicates that Black pregnant people are twice as likely as White pregnant people to contract early preeclampsia after COVID-19 (Ismailova, 2022). While studies have shown that COVID-19 vaccination of pregnant people is safe and effective (even in protecting the baby), the vaccination rate in this group has remained low.
A national study described the pandemic’s impact on birthing practices, including elevated emotional distress and adverse breastfeeding experiences due to lack of postpartum social support, shifting birthing plans due to hospital policy changes, a disconnect between expectation and reality, and some surprising benefits (such as better bonding with partner and infant) (Shuman, 2022). The pandemic “increased patients’ and policymakers’ interest in alternative care models like birth centers and doula services” over traditional interventions and hospitals (Burroughs, 2021). Expanding access to health insurance and telehealth can facilitate these options, and “expanding and diversifying the maternal health workforce is critical for promoting more culturally and linguistically effective care and addressing inequities” in birth outcomes.
Healthcare disruptions also impacted infants needing neonatal intensive care. Barriers to infants receiving care from NICU nurses included difficulty establishing skin-to-skin contact, problems caused by personal protective equipment, and fear of COVID-19 (Celık, 2021). Mothers faced barriers to providing care to their infants such as lack of family visits, interrupted kangaroo care, and difficulties breastfeeding.
Children also experienced barriers to healthcare during the pandemic. According to a national survey, “26.4% of households reported that ≥1 child or adolescent had missed or delayed a preventive visit because of COVID-19.” This was more likely among respondents who reported material hardships. Common reasons for missing or delaying preventive visits were concern about visiting a health care provider, limited appointment availability, and closed provider locations (Lebrun-Harris, 2022). Missed appointments led to fewer opportunities for lead testing, which decreased during the pandemic nationally and in Michigan (Michigan CLPPP, 2021; Courtney, 2020). Similarly, opportunities were missed to immunize children against vaccine-preventable illnesses. In May 2020 in Michigan, “vaccination coverage declined in all milestone age cohorts [year over year], except for birth-dose hepatitis B coverage…and coverage was lower for Medicaid-enrolled children than their peers” (Bramer, 2020).
As of March 30, 2022, COVID-19 vaccination of Michigan youth aged 5-19 was 41%, with a racial disparity of 40% of White youth compared to 28% of Black youth receiving at least one dose. Asian American and Hispanic/Latinx American youth rates were higher, 66% and 43% respectively, which increased the overall rate. Youth aged 5-11 lagged at 28% compared to 52% for youth aged 12-19 (MDHHS, 2022).
Abrupt school closures in 2020 worsened food insecurity for many students. States struggled to obtain and disburse funds for student meals due to administrative and data sharing barriers (Waxman, 2021). The adverse implications of distance learning on students were also documented (Harvard, 2021). Mental health care infrastructure for children has been overwhelmed by surges in emergency mental health needs and severe labor shortages. This unmet need is especially acute in rural areas of Michigan, such as the Upper Peninsula and northern Lower Peninsula (NIHCM Foundation, 2021; Erb, 2021).
As adult and pediatric COVID-19 cases and hospitalizations peaked due to the Omicron variant, hospitals were short-staffed and had difficulty providing surgeries for serious non-COVID illnesses (Fromson, 2022). Michigan Medicine found many Omicron cases were among younger children and adolescents displaying pneumonia and multisystem inflammatory syndrome.
Adolescents experienced increased mental health issues, with some groups at higher risk due to social and environmental factors (Office of the Surgeon General, 2021). These groups include youth with intellectual and developmental disabilities, racial and ethnic minority youth, youth who have low-income or live in rural areas, youth in immigrant households, foster care or justice system-involved youth, and youth who identify as LGBTQ+. The pandemic elevated stress levels among LGBTQ+ youth with almost half indicating their mental health counseling needs were unmet (The Trevor Project 2021).
Similarly, high school students reported increased “feelings of boredom, anxiety, depression, loneliness, worry, difficulty sleeping, and other negative mental health indicators since the beginning of the pandemic” (NIH, 2021). However, they also reported the largest single-year drop in substance use since the study began in 1975, including alcohol, marijuana, and vaped nicotine. Authors attributed this behavior change to changes in the daily life of adolescents related to “drug availability, family involvement, differences in peer pressure, or other factors.”
Parents of CYSHCN experienced increased stress caused by persistent challenges including “disruption in day care, health care, and employment, and loss of technological and therapeutic supports.” Many of these parents reported substance use including alcohol, cannabis, or other drugs (American, 2021).
Many policies improved CYSHCN access to health care by relaxing Medicare and Medicaid requirements, reducing administrative requirements for specialty services (Silow-Carrol, 2021). Expanded telehealth largely benefited CYSHCN, but low-income and rural families faced barriers such as lack of a device or broadband access. Experts emphasize the need to include CYSHCN and caregivers in emergency preparedness planning to reduce inequities and ensure that diverse needs are met. The U.S. Surgeon General also emphasized the need to address mental health needs, given unique pandemic challenges: “youth with intellectual and developmental disabilities…found it especially difficult to manage disruptions to school and services such as special education, counseling, occupational, and speech therapies” (2021).
Overall, this review emphasized the growing mental health crisis and the need for support. Groups that have been marginalized are disproportionately impacted by the pandemic, and efforts to address the impacts must target upstream social determinants and root causes. The unique needs of each MCH population require attention, including supporting new mothers and their infants, encouraging COVID-19 vaccination and childhood immunizations, and preventing and treating substance use.
Family and Community Engagement Action Plan Review
Michigan’s Title V five-year needs assessment identified three cross-cutting “pillars” that are critical across all MCH population domains. In 2022, Michigan focused on the pillar to “intentionally and routinely find opportunities to seek the knowledge and expertise of communities and families in all levels of decision making to build trust and create policies and programs that align with family and community needs.” To further integrate this pillar, MDHHS partnered with MPHI to review each Title V state action plan using a family and consumer engagement rubric. The aim was to identify strengths and opportunities to improve family and consumer engagement across plans.
MPHI reviewed all state actions plans and provided completed rubrics to Title V program staff. Feedback included examples and resources from the literature, and virtual technical assistance was provided upon request. During the TA sessions, program staff discussed the rubrics and ideas for integrating increased family and consumer engagement into FY 2023 state action plans or future activities.
Ongoing and Emerging Issues that Impact MCH
Infant and maternal mortality remain critical public health issues. Other current issues include COVID-19 and pregnancy, COVID-19 vaccination, substance use, community water fluoridation, and issues that impact CSHCN.
Infant and Maternal Mortality
MDHHS closely monitors infant and maternal mortality and has seen the following trends and emerging concerns. The infant mortality rate in Michigan for 2020 was 6.8 deaths per 1,000 live births, which represents a slight increase from 2019 (6.4 deaths per 1,000 live births). This increase in infant mortality could partially be attributed to a corresponding increase in the infant mortality rate within the City of Detroit. From 2019 to 2020, the infant mortality rate in the City of Detroit increased from 11.0 infant deaths per 1,000 live births in 2019 to 14.6 infant deaths per 1,000 live births in 2020. Although improving, racial and ethnic disparities remain a major contributor to Michigan’s infant mortality rates. The Black infant mortality rate has continued to be nearly three times that of the White infant mortality rate (13.6 versus 5.2 per 1,000 live births in 2020). The pregnancy-related mortality ratio in Michigan for 2018 was 10.9 maternal deaths per 100,000 live births[1]. As with infant mortality, disparities between Black and White mothers exist, with the Black pregnancy-related mortality ratio nearly three times that of the White rate (24.1 versus 8.5 per 100,000 live births based on 2014-2018 data). In addition to maternal deaths caused by pregnancy-related issues, addressing pregnancy-associated mortality[2] remains important: 36.1% of all pregnancy-associated, not related deaths from 2014-2018 were caused by accidental poisoning/drug overdose. Michigan’s maternal mortality committees have focused on developing recommendations to help prevent current and expecting mothers from developing opioid use disorders.
COVID-19 and Pregnancy
Michigan continues to participate in the CDC COVID-19 Pregnancy and Neonate Surveillance Project. For the project, women who have received a confirmed diagnosis of COVID-19 during pregnancy are identified through the Michigan Disease Surveillance System (MDSS) which is then linked with birth and death certificates to track pregnancy outcomes. After each pregnancy outcome has taken place, medical records for both mother and infant are requested to obtain details regarding the impacts of COVID-19 on the health of mother and infant.
For the 2020 cohort, 1,378 Michigan women were identified with a confirmed COVID-19 diagnosis during pregnancy. A pregnancy outcome was confirmed for 1,288 (93.5%) with the remaining 90 women (6.5%) lost to follow-up. The 1,288 documented pregnancy outcomes resulted in 1,316 live births and less than five fetal deaths. The majority of pregnancy outcomes were to White mothers (65.6%) while 18.9% were to Black mothers. Among the 1,316 live births, 10.4% were classified as preterm births, which is similar to the state average of 10%. The NICU admission percentage among this group was 9.3%, which is higher than Michigan overall at 7.5%. Lastly, the infant COVID-19 positive rate was very low at less than one percent of live births to COVID-19 infected mothers. Michigan recently started working on the 2021 cohort.
In addition to this surveillance project, the Michigan Pregnancy Risk Assessment Monitoring System (MI PRAMS) added COVID-19 questions to the survey. Results from the 2020 MI PRAMS COVID-19 questions indicate that an estimated 2.6% of new Michigan mothers reported that a health care worker told them they had COVID-19 during their most recent pregnancy, and it was confirmed through testing. When including mothers that were told by a health care worker that they had COVID-19 during their most recent pregnancy but they weren’t tested, this number increases to an estimated 3.7% (which represents 3,589 new mothers in 2020). Black, non-Hispanic mothers were nearly twice as likely to report COVID-19 during their most recent pregnancy when compared to white, non-Hispanic mothers.
COVID-19 Vaccination
The chart below provides Michigan COVID-19 vaccine coverage percentages by age group as of March 5, 2022. Initiation is defined as the percentage of Michigan residents who have received 1 or more doses of any vaccine, while completion is defined as the percentage receiving 2 doses of Pfizer or Moderna or 1 dose of Johnson & Johnson. Approximately one quarter of Michigan residents aged 5-11 years have either initiated or completed a COVID-19 vaccination. Initiation and completion rates increase to around 50% for those aged 12-29 years and increase to 60% or above for Michigan residents aged 30 years and above.
Substance Use
Opioid use during pregnancy and, as a result, an increase in the number of infants diagnosed with Neonatal Abstinence Syndrome (NAS) continues to be an issue in Michigan. Figure 1 details the incidence of NAS by region. As illustrated by the map, rural areas of Michigan have been hardest hit by this epidemic.
Figure 1. Map of 2020 NAS Rates by Prosperity Region
Additionally, infants hospitalized and treated for drug withdrawal symptoms has increased[3]. In 2010, 478 infants in Michigan received a diagnosis code of 779.5 (ICD-9-CM) which indicates a drug withdrawal syndrome, not specifically related to opioids. In 2020, 650 infants received a diagnosis code of P96.1 (ICD-10-CM), which indicates neonatal withdrawal symptoms from maternal use of drugs of addiction. This represents a jump from 416.7 per 100,000 live births in 2010 to 624.1 per 100,000 live births in 2020. The opioid epidemic has also impacted maternal deaths. In 2011, 9% of maternal deaths were opioid related compared to 32% of maternal deaths in 2018[4].
MDHHS remains committed to supporting substance use disorder (SUD) prevention for pregnant and parenting people and people of childbearing age; increasing screening and identification of SUD; maintaining data collection and reporting; optimizing resource allocation to target resources to those in greatest need; and improving workforce development and training programs.
DMIH has partnered with the MDHHS Office of Recovery Oriented Systems of Care to provide funding to three health systems to implement ‘rooming in’ programs in birthing units. The rooming-in program is a family-centered model that encourages parent-infant bonding and utilizes non-pharmacological care of infants born substance-exposed, ensuring they remain with their birthing parent or caregiver in a private hospital room that is less stimulating for the infant (e.g., room-darkening shades, softer flooring). The rooms are often equipped with murphy beds or sleeper chairs to enable an additional caregiver to stay at the hospital. Hospital staff provide education and support to the birthing parent and family (e.g., breastfeeding, skin-to-skin contact, calming techniques, and referrals to services). The rooming-in program supports bonding between parent and infant, decreases the length of stay for babies born substance exposed, and promotes positive parenting and recovery from substance use disorder.
Fluoridation
In 1945, Community Water Fluoridation (CWF) began in Grand Rapids, Michigan. Over the last 75 years, it has proven to be a safe and effective measure in the prevention of cavities. Over the past few years and during the pandemic, anti-fluoridation groups have attempted to tie faulty science to community water fluoridation. Nationally, municipal water systems that have had an interruption in their supply line for fluoride have come under pressure to stop fluoridating. In Michigan, three cities have seen a push to stop fluoridating. As an overlapping challenge, the once robust School Mouth Rinse Program has ended with the last manufacturer discontinuing production. CWF continues to be the most equitable form of oral public health. The removal of this fluoride delivery system would leave many children at risk of tooth decay and poorer oral health outcomes.
Children with Special Health Care Needs
Efforts to apply a health equity lens have contributed to a greater awareness of disparities in access to health care experienced by individuals with sickle cell disease (SCD) which disproportionately affects African Americans. An estimated 3,500 to 4,000 Michiganders are living with SCD. Of those, 798 are children enrolled in CSHCS and 2,317 are adult Medicaid recipients. Individuals with SCD are prone to higher rates of hospitalization, emergency room utilization, and premature death. In FY 2021, CSHCS partnered with the Lifecourse Epidemiology and Genomics Division to submit a proposal to the Governor’s Office to expand CSHCS eligibility to adults with SCD, expand clinical services, and enhance the system of care serving clients with SCD. The proposal was included in the Governor’s FY 2022 budget recommendation and implemented on October 1, 2021. CSHCS continues to implement outreach strategies to reach adults who can benefit from the CSHCS eligibility expansion. In addition, CSHCS is implementing strategies to expand the CMDS clinic model to include adult clinics caring for patients with SCD and developing toolkits for transition programs to improve transition to adulthood in this population.
Improved access to respite care for families with children with special health care needs was identified as a need in the 2020 Needs Assessment. According to the 2019-2020 National Survey of Children’s Health, parents/caregivers of children with special health care needs in Michigan are five times more likely to have left a job, requested a leave of absence, or reduced their work hours due to the stress of their child’s health or health conditions. In response, CSHCS has convened a workgroup comprised of representatives from Program Review Division, CSHCS, Office of Medical Affairs, and the Managed Care Plan Division to assess the current landscape for respite care in Michigan and explore opportunities to expand the CSHCS respite benefit.
[1] Includes maternal deaths while pregnant or within 1 year of the end of a pregnancy from any cause related to or aggravated by the pregnancy or its management. Data source: Maternal Deaths in Michigan, 2014-2018 Data Update. MDHHS. Michigan Maternal Mortality Surveillance Program.
[2] Includes maternal deaths while pregnant or within 1 year of the end of a pregnancy due to a cause unrelated to pregnancy.
[3] Data from Michigan Inpatient Database Files.
[4] Division for Vital Records and Health Statistics, Michigan Maternal Mortality Surveillance System, MDHHS.
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