MCH Population Needs

MDPH conducts a comprehensive statewide needs assessment every five years and in interim years engages in activities to ensure that needs assessment is an ongoing process. Below are examples of efforts to monitor and assess the continuing needs of the MCH population in Massachusetts.

Governor’s Maternal Health Services Report

Massachusetts new administration has identified maternal health and the elimination of racial disparities as top priorities. To inform strategy development and implementation towards these goals, MDPH conducted a review of prenatal, postpartum, and birthing services across the state, through a lens of health equity and health outcomes, with a focus on availability of quality services in rural and other underserved communities. This report synthesized information and data gathered by MDPH and other agencies under the Executive Office of Health and Human Services, including through listening sessions, legislative Commissions and ongoing data analysis.

The report found that Massachusetts has no maternity care deserts, however, the closure of a number of maternity wards and out-of-hospital birth settings has left several communities with limited access to quality perinatal health services. Comparing distances traveled in 2011 to distances traveled in 2021, birthing people in 29 towns have increased their distance traveled by at least 5 miles, and 14 towns have increased their distance traveled by at least 10 miles; only two towns have residents whose average travel distance to birthing facilities decreased in the past decade.

MDPH identified 25 recommendations to address the current state of maternal health services in MA ranging from improving access to birth center care by updating the licensure regulations for birth centers to building capacity for remote blood pressure monitoring programs for postpartum patients. More information on the report can be found here.

Title V Evaluation

The Title V program was evaluated in the fall of 2023 by a group of MPH students from Boston University's School of Public Health. The evaluation focused on organizational structure improvements that could drive further coordination, engagement, and equity across Title V. The evaluation team conducted a site visit, interviews with Title V stakeholder internal and external to MDPH, and a literature review. The Evaluation team found a lack of staff bandwidth due to staff turnover and funding constraints. There is an understanding that these constraints impact participation on and effectiveness of Implementation Teams. The evaluation team developed recommendations and deliverables to utilize institutional knowledge to ensure sustainability, increase staff ownership and responsibility for Implementation Team activities, and improve progress reporting. MDPH is in the process of developing an implementation plan for these recommendations.

PNQIN Family Engagement Survey

PNQIN developed a Hospital Family Engagement Collaborative Practice Survey for NICU/Special Care Nursery and Obstetrics and Gynecology teams to assess hospital and patient family engagement definitions and practices. This effort was led by the Title V Director who serves as the chair for the PNQIN Family and Community Subcommittee.  With support from the Betsy Lehman Center, the Family Voices’ Family Engagement in Systems Assessment Tool (FESAT) was adapted, and survey questions imported into REDCap.  The survey was administered to 26 perinatal units from 41 hospitals. Results from this survey demonstrate that there is considerable variation in family and community engagement across Massachusetts obstetric and neonatal hospital units. Findings from this baseline assessment will inform supports, technical assistance, and resources PNQIN can offer to help hospitals strengthen and deepen their engagement activities. PNQIN will begin this process by convening a patient and family advisory council to co-develop PNQIN projects and initiatives, including supports related to patient, family, and community engagement. PNQIN will support and integrate family members from diverse backgrounds into PNQIN committees and workgroups so that the perspectives of pregnant and postpartum people with lived experiences inform PNQIN’s strategy and projects. Following the creation of this advisory body, and the integration of family members into PNQIN activities, PNQIN will co-develop a new initiative to support hospitals as they strengthen their family engagement efforts.

WIC & Breastfeeding Needs Assessments

An annual needs assessment identifies WIC-eligible populations in all 351 cities and towns and guides the statewide distribution of funds. In 2023, 193,501 adults, infants, and children were eligible for WIC, compared to 197,444 in 2020. Among those eligible in 2023, 48.2% of women, 78.9% of infants, and 62.8% of children participated in WIC.  These coverage rates represent small decreases in coverage for women and infants but significant improvement for the coverage of children.  Local WIC agencies use needs assessment results for outreach plans to engage and enroll eligible families.

The Nutrition Division is also completing a needs assessment in 2024 to strengthen breastfeeding services in the state, including the unique challenges families faced during the COVID-19 pandemic and opportunities to improve or expand services. The needs assessment process has been developed in partnership with the Internal MDPH Breastfeeding Workgroup and has included key informant interviews with internal and external partners, data review, a health care provider survey, and the development of a family-facing survey. The findings will be used to prepare statewide recommendations to better meet the needs of families and improve breastfeeding outcomes in the Commonwealth.

Division for Surveillance, Research & Promotion of Perinatal Health

The Division for Surveillance, Research & Promotion of Perinatal Health (DSRPPH) formerly known as the Center for Birth Defects Research and Prevention completed a strategic planning process that was steeped in racial equity principles for engaging families and partners in visioning a path forward. The purpose of the Division’s Strategic Planning process was to: 1) refine the Center’s mission and vision; 2) update its goals and objectives; 3) identify opportunities to: a) add new activities, b) enhance/strengthen current activities; and 4) create and/or strengthen Center collaborations. The Division engaged consultants in the fall of 2022 to lead the Strategic Planning process. An application was distributed to Division staff to identify members for a core working team; simultaneously, an application was distributed to family leaders to identify individuals with lived experience to participate in this process. A kick-off meeting was convened in January of 2023, where staff and family leaders were grounded in the process and oriented family leaders to the work of the Division. The core group drafted content for the strategic plan and brought it to the family leaders and staff through an iterative process to get feedback and revise the plan. Part way through the process, the plan was brought to the Bureau’s Senior Leadership Team and internal and external collaborators for additional input. One of the main changes to arise from the process is an update to the Centers name, given the growth of the Center, staff felt it no longer captured the breadth of the work. The name “Division for Surveillance, Research, and Promotion of Perinatal Health” felt more comprehensive and the transition to the new name happened in September of 2023.  The final strategic plan includes an updated mission and vision statement, as well as an implementation evaluation plan.

Division of Children and Youth with Special Health Needs (DCYSHN) Care Coordination Training and Technical Assistance Center

The DCYSHN is creating a care coordination center to provide training and technical assistance to providers regarding comprehensive, enhanced care coordination including training around the social determinants of health, racial equity, family engagement and trauma informed and healing centered care. Throughout this process, family engagement has been at the forefront. The center is being developed based on previous population health work done as part of the MCH population health learning journey with three other states and facilitators from MCH Workforce Development Center at UNC and Population Health Improvement Partners. The DCYSHN had a team of professionals creating a workplan together for this center. The team was comprised of DCYSHN staff and representatives from MassHealth, DPH Office of Health Equity and The Federation for Children with Special Needs and their Family Voices program. As a result of these efforts, the DCYSHN performed need assessments of families of CYSHN and providers, in order to create training that serves the needs of families and is tailored to providers. The DCYSHN held two focus groups in November 2022 with families of different races, ethnicities, and cultures with live translation. Twelve parents participated in total, seven spoke English, four spoke Spanish, one spoke Portuguese and one spoke Vietnamese. Of these parents, five identified as Latina, one as Haitian Creole, one as Vietnamese, and two as African American. The parents were asked about their understanding and experience with care coordination and their wants and needs around improved care coordination. These original focus groups contributed to the strategic planning for the care coordination center and curriculum. In March 2023, the DCYSHN expanded our core team to a full Steering Committee, made up of parents of CYSHN, providers and DCYSHN staff. This committee meets monthly and provides insights and feedback on the vision, plans and goals for the care coordination center. Their input ensures that the DCYSHN is creating comprehensive curriculum for providers to increase their knowledge and skills around serving and working with CYSHN and that the model and structure of the center will be effective in expanding care coordination in Massachusetts. The future will include further needs assessments working with the provider organizations that the center will serve and partnering with families to provide continued insights into the center’s development efforts.

Pediatric Mental Health Access Grant Early Identification and Diagnosis of Autism Project

The Division of Pregnancy, Infancy and Early Childhood received supplemental funding from HRSA for the Pediatric Mental Health Care Access Project to expand pathways to early diagnosis and support for children with ASD. The project conducted a needs assessment to better understand the barriers to getting an ASD diagnosis for children 0-5 that included interviews with over two dozen key stakeholders and three focus groups with parents (n = 33).  Emerging themes included: 1) effective communication, and accurate message transmission are severely hampered when a shared language is absent; 2) the potential presence of bias among assessors in ASD diagnosis is an important and sensitive issue to be addressed; and 3) coming to terms with an autism diagnosis can be incredibly challenging for families, regardless of their cultural background. The focus groups provided valuable insights into the experiences and perspectives of parents navigating the diagnosis process for their children with autism and prioritized culturally sensitive support throughout the diagnosis process, recognizing the influence of cultural beliefs on families' perceptions and approach to autism.

Family Engagement and Leadership

One of the strategies in the MA Family Engagement Priority State Action Plan is to understand and better coordinate efforts across MDPH bureaus and offices to partner with and engage communities, families, fathers, and youth at the system (i.e., internal/state-level) and program level (i.e., external or direct service delivery level).  The Title V Family Engagement Implementation Team worked with a CDC Public Health Associate to develop a Title V Family engagement survey, administered during spring 2023, to assess progress on this priority. The Title V Family Engagement Survey was a two-part survey comprised of: 1) an adapted version of the Family Engagement in Systems Assessment Tool (FESAT); a self-assessment tool to help programs reflect upon how families are engaged in program-level initiatives (including commitment to family engagement practices, transparency with families, representation of populations served, and impact of family engagement practices), and to share opportunities for improvement; and 2) a questionnaire collecting information on the various family engagement activities (including compensation) in Title V affiliated programs during FY22 for the Annual Report. Results have been analyzed and being used by the Family Engagement Implementation Team to design training, and tools to support programs, highlighting internal best practices and peer learning opportunities.

In addition, BFHN has partnered with the Boston University School of Social Work to conduct an evaluation to understand the impact, reach, and opportunities for improvement and scale of programs such as Family TIES (Together in Enhancing Support) and Early Intervention Parent Leadership Program (EIPLP). The evaluation included key informant interviews with staff and leadership, secondary data analysis of Family TIES program data, and focus groups with parents who have participated in the programs. A final report was provided in July 2023 and included logic models for each program to support planning, implementation and quality improvement activities, a description of the Family TIES participants for Family TIES to better align resources and identify gaps and opportunities, and recommendations for improvement, innovation and future evaluation.

Emerging Issues

MDPH has identified the following emerging public health issues and Title V capacity and resources to address them.

Workforce Challenges

Like many industries across the country, state and local MCH programs and organizations are experiencing tremendous challenges in hiring and retaining staff. At the local level, programs such as WIC and home visiting struggle to appropriately staff client-facing services, limiting their ability to meet the needs of families. The Direct Service Provider Crisis has particularly impacted caregivers of children and youth with special health needs on multiple fronts, including lack of access to desperately needed respite. Workforce challenges is experienced at MDPH as well, where many staff have left the Department or state service over the past few years, leading to a loss of institutional knowledge and necessitating additional staff time and resources to fill vacancies. BFHN is leveraging this as an opportunity to recruit and hire new staff with a racial equity lens and using a healing-centered approach. More information about these hiring efforts can be found in the discussion of the racial equity priority in the Crosscutting domain. In addition, see MCH Workforce Development for information about efforts to strengthen the MCH workforce.

Inflation and Cost of Living

The rising inflation and cost of gas, food, and other goods in Massachusetts and across the country are adversely affecting families served by Title V. As result of the COVID-19 pandemic, many people in Massachusetts were already struggling with important basic needs, like housing, food, medicine, technology, and childcare. Title V programs will support families in accessing concrete supports to meet these needs and assess the impact of public benefits and programs that promote economic stability, including Paid Family and Medical Leave, the Earned Income Tax Credit, and Supplemental Security Income benefits. The WIC program will continue to play a critical role maximizing the number of families with young children who have access to food resources for which they are eligible.  WIC caseload has grown more than 20% since the beginning of the pandemic; this growth combined with significant food cost inflation across most of the WIC food categories raises concerns about the sufficiency of federal WIC funding to serve all families that wish to enroll in the program.

Housing Crisis for Migrant Families

Massachusetts is welcoming many new immigrant families with significant health and social needs.  Significant numbers of families are currently in emergency shelter, and needs are amplified by challenges associated with transportation, health care access, developmentally appropriate play space for children and food storage and preparation facilities.  Programs are working with community partners to ensure that families enroll in and have access to services for which they are eligible.

Constrained funding for MCH legislative priorities and emerging issues

Maternal and child health covers a wide breadth of programs and services that requires a multi-generational, life course approach to optimize the health and well-being of 860,000 people across Massachusetts.  The challenge is that funds to support nearly 50 Title V programs are siloed and primarily dependent on federal grants, that are time limited, constrained, and restricted. With nearly 70%The Title V MCH Block Grant supporting salaries, funding is significantly constrained by growing salaries and fringe costs. Additional resources are needed to support potential legislatively driven initiatives in Massachusetts like building out a doula workforce, expanding universal home visiting to all pregnant and postpartum people, and eliminating disparities in maternal and infant outcomes. State resources are essential to more effectively promote maternal and child health with initiatives such as strengthening outreach, coordination of care, a statewide breastfeeding strategy that supports all nursing people, ensuring robust data systems, and addressing emerging needs and crisis to name a few.

Agency and Program Capacity

Organizational Structure, Leadership, and Staffing

MDPH is part of the Executive Office of Health and Human Services (EOHHS), where legal, human resources, and information technology are centralized. The EOHHS Secretary reports to the Governor. The Bureau of Family Health and Nutrition (BFHN) within MDPH is the Title V Agency, with overall responsibility for the Title V program and funding. The BFHN Director is also the Title V Director, a senior manager who reports to the Commissioner of MDPH. A sister Bureau, the Bureau of Community Health and Prevention (BCHAP) also includes MCH-related programs. BFHN and BCHAP work closely on many initiatives, including the Needs Assessment and annual Title V reporting. The Childhood Lead Poisoning Prevention Program and Office of Health Equity are also significant components of Title V and reside in the Bureau of Climate and Environmental Health and the Office of Population Health, respectively.

Over the past year, MDPH and BFHN experienced significant leadership changes. In January 2023, Governor Maura Healy took office, appointing Kate Walsh and Dr. Robbie Goldstein as EOHHS Secretary and MDPH Commissioner respectively. Scott Geer joined BFHN as Deputy Director of Finance and Operation to further strengthen BFHN’s infrastructure and play an important leadership role managing Title V’s fiscal processes. After Karin Downes’ retirement, Dr. Ann Peralta was hired as the Director of the Division of Pregnancy, Infancy and Early Childhood and the MCH Director. Finally, Suzanne Gottleib, Director of the Office of Family Initiatives and Title V Parent Representative retired in February 2023 after nearly three decades of service. As BFHN expands parent engagement and leadership in Title V, several options are being considered for backfilling Suzanne’s position, including expanding partnerships with family-led organizations, dedicating a leadership position to family engagement in the Early Intervention System and designing a new role to meet the Bureau’s needs for developing capacity in family engagement as one of our Title V priorities.  Further information about the Title V Partnership senior management team and their qualifications is provided in Attachment 2.

The organizational charts for BFHN and BCHAP are below and show the divisions and programs within each bureau. A MDPH organizational chart is attached, which shows the location of BFHN and BCHAP within the Department.

As of June 2023, approximately 220 full-time equivalent (FTEs) employees throughout MDPH work on Title V Partnership programs, with 136 FTEs paid from Title V Partnership funds. There are approximately 84 FTEs working on MCH programs but paid through other federal grants. In addition, BFHN employs (directly or via a contract) 12 parents of children and youth with special health needs for the EI Parent Leadership Project, Family TIES, and Universal Newborn Hearing Screening Program. Additional details about how parents, families, and youth are involved in Title V programming are provided in the State Action Plan, Family Partnerships, and Attachment 3.

The share of total 220 MDPH staff supported by Title V is slightly lower (48% versus 54% last year) due to successful efforts to cost-share staff with other federal discretionary grants. These totals and percentage distributions may continue to change during FY24 as efforts continue to bring the Title V budget into a more secure long-term equilibrium. The staff support may also be affected by the loss or reduction of federal discretionary grants, including ARPA funding.

Partnerships, Collaboration, and Coordination

MDPH builds, strengthens, and sustains partnerships with other organizations to better serve the MCH population and expand the capacity and reach of the Title V program. MDPH collaborates with families, public and private sector entities, federal, state and local government programs, clinical providers, academia, and public health organizations. The Family Partnerships section and Attachment 3 describe Title V’s partnership with families. Attachment 4 describes partnerships with external organizations and MCH programs within MDPH. These partnerships, collaboration, and coordination give depth and effectiveness to the MA Title V program and are integral to daily operations.