- Needs Assessment Activities
Needs assessment is an ongoing component of Maine’s MCH activities. Since submitting our Title V comprehensive five-year needs assessment in September 2020, we initiated several efforts to improve our understanding of current issues impacting Maine’s MCH population. Many of these focused on assessing the impact of COVID-19 on Maine’s MCH population. These activities ranged from in-depth analyses to better understand our selected performance measures, to gathering information from partners, to monitoring progress and barriers to meeting our performance objectives.
Infant and Women’s Health
- In February 2020, Maine’s Maternal, Fetal, and Infant Mortality Review (MFIMR) statute was amended to allow for review of cases of pregnancy-associated deaths up to one year after birth (previously the statute had specified review of cases up to 42 days after birth). An analysis of pregnancy associated deaths in 2020 was conducted and results were presented to the panel in July 2021. Quarterly reports on infant mortality statistics are provided to the MFIMR Panel to keep them apprised of current patterns and trends.
- Maine’s Title V program is taking several approaches to monitoring the impact of COVID-19 on perinatal and maternal mortality. In 2021, we linked birth certificate and fetal death data to COVID-19 case data to ascertain the number of cases of pregnant women diagnosed with COVID-19 during pregnancy and to evaluate the accuracy of pregnancy data collected in the infectious disease case report. In 2020 a check box was added to birth certificates and fetal death certificates to indicate the prenatal COVID-19 status of the mother. In 2020, there were no fetal, infant, or pregnancy-associated deaths attributable to COVID-19. Analyses were also conducted on the relationship between COVID-19 and birth outcomes. A data brief is being prepared to summarize these results and a poster was presented at the annual Council of State and Territorial Epidemiologists Conference in Louisville in June 2022.
- Maine’s MCH epidemiology team provides monthly provisional data on infant deaths and birth outcomes to Title V to inform Maine’s MFIMR Panel and other initiatives. We created a birth outcomes dashboard to monitor birth outcomes monthly during COVID-19 and display demographic characteristics associated with birth outcomes including low birth weight, prematurity, cesarean section, home birth, and breastfeeding. We are working on obtaining approval for this dashboard to post to Maine’s MCH webpage.
- During Summer 2022, Maine is hosting a graduate student through AMCHP’s Graduate Student Epidemiology Program (GSEP). The student is using PRAMS to examine stressful life events and their impact on birth outcomes and mental health.
- In Winter 2021-2022, Maine CDC MCH epidemiologists collaborated with researchers at the University of Southern Maine, the Maine Women’s Lobby, and the Permanent Commission on the Status of Racial, Indigenous, and Tribal Populations to develop a report on racial disparities in prenatal care access in Maine. A legislative report was submitted in January 2022. (https://legislature.maine.gov/doc/7888)
- A survey of safe sleep behaviors among WIC participants was administered in Spring 2022. Results will be available in Fall 2022.
- Medicaid data were linked to birth certificate data and provided to the Title V program in Spring 2022. Analyses will be conducted in Fall 2022.
Child and Adolescent Health
- Analyses were conducted to examine the impact of COVID-19 on youth and young adults. A Tableau dashboard was created and a pdf of this dashboard is currently available on the Maine CDC’s COVID data page: https://www.maine.gov/dhhs/mecdc/infectious-disease/epi/airborne/coronavirus/data.shtml. (This pdf is updated every two weeks.) Based on these analyses, over 60,000 cases of COVID-19 have been diagnosed among youth since the start of the pandemic. The proportion of COVID-19 cases among youth has increased from about 7% in March 2020 to 26% in April 2022. A surveillance report on COVID-19 and youth has also been developed and is currently under review.
- The Maine Integrated Youth Health Survey (MIYHS) is Maine’s biennial survey of students in grades 5-12 that includes data critical to monitoring the health of Maine children and adolescents including substance use, mental health, bullying, discrimination, sexual health, and adverse childhood experiences. Due to COVID-19 the MIYHS was postponed from Spring to Fall 2021. The survey was successfully administered and we anticipate having 2021 MIYHS data in Fall 2022.
- Maine’s MIECHV evaluation is focused on home visiting and child maltreatment. Data from birth certificates, home visiting, and Maine’s Office of Child and Family Services’ child welfare reports were linked and analyzed. Results from these analyses were submitted in a report to HRSA in December 2020 and 2021. These analyzes found that about 6% of Maine children born between 2014-2018 had at least one substantiated/indicated child maltreatment report during this time period. Of Maine children with a maltreatment report, 24% ever enrolled in the Maine Families Home Visiting Program. Survival analyses were conducted to examine timing to child maltreatment report and we found that children enrolled in home visiting had increased probability of ever having a child maltreatment report compared to those who were never enrolled.
- As part of our focus on adolescent mental health and suicide prevention, Maine’s Title V program is working in collaboration with Maine’s Syndromic Surveillance Program to monitor suicide attempts and ideation using real-time data from Maine’s emergency departments. A dashboard was created using these data. This information has been especially useful during the COVID-19 pandemic with the increased concern of the pandemic’s impact on mental health. Results indicate that although ED visits decreased during the pandemic, the proportion of visits related to suicide ideation and attempts were higher than previous years. This was especially true for adolescent females. We plan to use the syndromic data to examine ED visits for mental illness within the next year.
All MCH Populations:
- Participant satisfaction surveys are administered on an annual basis to parents enrolled in the Maine Families Home Visiting Program. These surveys, that are translated into several languages, assess participants’ experiences with the home visiting program. In 2020-2022, we also included general questions about the challenges facing families during COVID-19. During Summer 2022, we are working with a graduate student at the University of Southern Maine to conduct qualitative analyses of the data and produce a report on the findings.
- Maine’s 2021 BRFSS includes questions on adverse childhood experiences (ACEs). These questions were last included on Maine’s survey in 2011. Data from these questions will be used to inform analyses on the impact of ACEs on adult physical and mental health.
- A series of maps related to infant, child, and family indicators at the county and sub-county level were created to highlight areas of concern for key MCH issues.
Ongoing performance monitoring and assessment: On a monthly basis, MCH staff provide updates of their progress on activities related to the MCH performance measures. At monthly meetings, Maine’s Title V Director provides an update on progress and one MCH staff person is asked to discuss their current activities related to a performance measure; they discuss progress, as well as challenges. In addition, partners involved with the work on the performance measures are asked to submit quarterly data on their progress. The data are recorded in Smartsheet and are available to the Title V Director.
- Changes in Health Status and Needs
The following summarizes areas of need and health status changes addressed by Maine’s Title V program, which are outside of our selected priorities, yet critical to the health of Maine’s MCH population.
Impact of COVID-19 on the MCH population
- The health of Maine’s women and children in 2020 and 2021 was substantially impacted by the COVID-19 pandemic. Based on a survey of over 300 parents enrolled in Maine’s home visiting program, we know that families in Maine faced challenges related to social isolation, disruptions to childcare, employment loss, financial hardship, and poor mental health.[1] Fear of the virus limited women and children’s social interactions, delayed access to medical and dental care, and made outings, even a trip to the grocery store, stressful. It is not yet clear how the pandemic will impact the health of the MCH population long-term, but it is likely that there will be repercussions for years to come. As of July 18, 2022, 69,041 children and youth under age 20 in Maine have ever been diagnosed with COVID-19; 105 have been hospitalized.[2]
- As of July 2022, a total of 44,836 children age 5-11 and 89,396 children age 12-19 were fully vaccinated. About 70% of 12-19 year olds; 43% of 5-11 year olds, have been fully vaccinated; about 7% of children 0-4 years of age have received their first vaccine dose. Maine’s vaccination rate for 12-17 year olds is the 13th highest in the U.S; our vaccination rate among 5-11 year olds is the eighth highest.
- Youth aged 18 and under make up 23% of COVID-19 cases in Maine.2
- Enrollment in pre-k and kindergarten in Maine declined in the 2020-21 school year, but largely recovered in 2021-22.[3]
- Although current data on the impact of COVID-19 on CSHCN in Maine are not yet available, national surveys and interviews with family leaders suggest that many children did not receive the support services required by their IEP due to schools moving to virtual learning. Families with children with special health care needs that rely on home health services may not have been able to get these services.[4]
- About 50% of Maine adults delayed getting medical care in the previous month because of the COVID-19 pandemic.[5]
- Immunization rates for children and adolescents decreased during the pandemic. Childhood immunizations have rebounded, but adolescent immunization rates remain lower than previous years. This is especially true for the HPV vaccine, which decreased 9.7% between December 2019 and March 2021.[6]Based on data from the Maine Immunization Program, vaccination coverage among kindergarten students in the 2021-2022 academic year for DTaP, Polio, and MMR was the highest it has ever been. This is likely due to the new immunization law that eliminated religious and philosophical vaccine exemptions for children entering school. In 2021-22, only 1.8% of children in kindergarten in Maine had a vaccine exemption, compared to an average of 5.5% in the previous four years. (https://www.maine.gov/dhhs/mecdc/infectious-disease/immunization/publications/2021/2021-2022%20Maine%20School%20Immunization%20Assessment%20Report.pdf )
- Enrollment in WIC and other services for pregnant women and children, such as home visiting and public health nursing, has been declining in recent years. The proportion of births paid for by Medicaid has also decreased 14% between 2014 and 2022.
Needs related to Infant and Women’s Health
- Rates of both fetal and infant mortality rose between 2019 and 2020; the rate of fetal death in 2020 was 5.7 per thousand live births plus fetal deaths, and the infant mortality rate was 6.2 per thousand live births. The increase in infant mortality from 2019 to 2020 was largely attributable to an increase in deaths in the early neonatal period.[7] Based on provisional 2021 data, Maine’s infant mortality rate declined to 5.2 per 1,000 live births. There were 62 infant deaths in 2021.
- Maine’s low birth weight and prematurity rates continue to slowly increase.
- Smoking during pregnancy rates continue to decline but remain higher than the U.S. rate. In 2021, 10% of pregnant persons in Maine smoked during pregnancy.
- We continue to monitor the impact of substance use during pregnancy. Recent analyses of Maine’s hospital discharge data between 2016 and 2019 showed that Maine’s rate of neonatal abstinence syndrome decreased 11% and our rate of maternal opioid-related diagnoses decreased 2.6%. Similarly, in 2019 the number of infants reported to Maine’s Office of Child and Family Services as substance affected dropped below 900 for the first time since 2012 (n=858). In 2020, the number increased to previous levels (n=903), but decreased to 808 in 2021, which is the lowest we have seen.
We continue to work with our epidemiologists and partners to monitor the MCH population on an ongoing basis to identify emerging needs and develop means to address them.
Maternal morbidity and mortality: Maine’s Title V program is focusing more effort of preventing pregnancy-associated deaths and maternal morbidity. During 2020 there were six pregnancy-associated deaths in Maine; 83% (5 of 6) of these deaths occurred between 43 and 365 days after delivery. Three deaths were injury-related (overdose and motor vehicle crash) and one was due to an obstetric cause. In 2018-2020, half of the pregnancy-associated deaths occurred among decedents with a high school diploma or less education. Nineteen of the 21 pregnancy-associated deaths in 2018-2020 occurred to White decedents; two occurred to Black/African American decedents. Fourteen of the 17 decedents whose deaths occurred after the end of their pregnancy appear to have been covered by MaineCare/Medicaid for their most recent birth. Review of pregnancy-associated deaths is conducted by Maine’s Maternal Mortality and Review Panel. Maine recently became part of the Alliance for Innovation in Maternal Health (AIM) to address maternal morbidity. Our first QI initiative was launched in 2022 and focuses on reducing hypertension.
- Perinatal and Neonatal Levels of Care. Maine has been facing a rising number of closure of birthing facilities. In 1998, Maine had 32 birthing facilities; currently there are 24. Since 2017, three birthing facilities have closed. In an effort to ensure risk appropriate care for all infants in Maine, the CDC’s LOCATe tool was administered to all hospitals in Maine. Using data from this tool, along with information gathered at individual hospital site visits, in February 2022, the Department of Health and Human Services issued guidelines for the assignment of maternal and neonatal levels of care. These guidelines were based on those of the Washington State Department of Health and follow the recommendations of the American Academy of Pediatrics and American College of Obstetricians and Gynecologists. The guidelines are intended to improve birth outcomes, increase access to appropriate care, and optimize the allocation of resources. Hospitals used these guidelines to apply for designation in one of four levels of care for pregnant women and newborns, and a map and list of facilities and their levels of care was published. In addition, a policy change was issued requesting that facilities inform DHHS if their perinatal services will be changed or terminated.[8]
- Racial Disparities in Maternal Health. LD 1113, passed in 2021, directed the Permanent Commission on the Status of Racial, Indigenous, and Maine Tribal Populations to study and propose solutions to disparities in access to prenatal care in Maine. Maine’s Title V epidemiologists worked with Commission staff to provide data for this study. The Commission report highlighted that the proportion of births in Maine that are to women born outside the U.S. increased 81 percent between 2000 and 2020, and the rate of severe maternal morbidity was 176 percent higher among African American women than white women between 2016 and 2020. African American women were two-thirds as likely to enter prenatal care as early as they wanted as white women. These disparities are driven by racism, structural barriers, social determinants of health, and community norms. The Commission recommended that these disparities be addressed by expanded community-led data-gathering efforts, investment in relationship-centered care, addressing structural inequities, supporting community-led education, and enhancing statewide data collection to better serve communities.[9]
- Home births. An analysis by the National Center for Health Statistics found that Maine saw a significant increase in the number of home births since the beginning of the COVID-19 pandemic, possibly due to limits on the number of people allowed in hospital rooms and fear of contracting COVID in the hospital. Nationally, the percentage of births that took place at home increased 22 percent between 2019 and 2020. In Maine, the percentage of home births increased from 1.88 in 2019 to 2.32 in 2020, a 23 percent increase. Similar increases were not seen between 2018 and 2019.[10] In 2021, there were 100 more home births compared to 2019.
Child and Adolescent Health
- Oral Health. Maine’s School Oral Health program saw the effects of delayed dental care due to COVID in its screenings: in the spring of 2020 and 2021, the percentage of children with early treatment urgency or immediate treatment urgency was at least twice that seen in the spring of 2019, prior to the pandemic.
- Mental health. As has been documented nationally, COVID has taken a serious toll on adolescents’ mental health. One manifestation of this in Maine has been in suicide attempts, particularly among adolescent girls. While the annual number of suicide deaths among youth (age 10-24) has remained stable between 2017 and 2021 (ranging from 24 30, with 27 deaths in 2021), the number of emergency department visits for suicide ideation and attempts among youth under age 19 rose in 2021 after remaining stable from 2017 to 2020. In 2021, there were a total of 2,649 ED visits for suicide ideation or attempt after ranging from 1,931 to 2,145 in previous years. Likewise, 632 of these visits were for suicide attempts, while fewer than 500 attempts were reported in each of the previous years. While the vast majority (85.9%) of youth suicides in the period 2017-2021 were males, the majority of ED visits for suicide attempts were females.
Children with Special Health Care Needs
Quantitative data are not yet available on the impact of COVID on CSHCN, but key informant interviews have provided some insight on ways that the COVID pandemic has been especially difficult for CYSHCN and their families. In general, remote school and social isolation affected children’s mental health and social development. For CYSHCN, these effects were exacerbated by lack of access to physical and mental health services, greater vulnerability to the virus and its effects, and isolation and exclusion from community homeschool “pods.” Family leaders in Maine report that calls to the crisis line have increased, children’s development has been delayed, and, as schools reopened, a growing number of families chose to homeschool their vulnerable children for their safety.
A survey of parents conducted early in the pandemic by the Autism Society of Maine, the Maine Parent Federation, and the Developmental Disabilities Council found that families’ primary concerns were homeschooling, developmental regression, and lack of access to in-home supports. The Autism Society of Maine surveyed families of children with ASD in December 2020, finding that families were frustrated by long waitlists for services, and that many adolescents stayed in school until age 21 so as to receive services. Families were also frustrated by the lack of access to respite care.
The effect of COVID on young children is evident in the increase in referrals to Child Development Services (CDS), the state’s Part C early intervention program. In FFY 2020, a total of 3,116 children were referred to CDS, compared to 2,908 in FFY 2019. This trend has continued into FY21 and FY22, with over 2,500 referrals as of March 2022. According to the CDS program, this increase can be attributed to both the impact of COVID on children’s development and a statewide expansion of outreach efforts. However, in addition to increased referrals, the eligibility rate among referred children has risen to 80 percent. This may be because fewer children with mild conditions are being referred or because of increases in developmental delay due to isolation.
- Title V Program Capacity/MCH Systems of Care Changes and Impact on MCH Services Delivery
The Maine CDC was awarded the Early Childhood Comprehensive System (ECCS) grant. This initiative aims to streamline early childhood systems in Maine by providing a central statewide point of coordination, implementing the Help Me Grow model to improve linkages across the early childhood service system, and addressing disparities in access to child development services.
The Maine CDC completed the LOCATe tool with all birthing and non-hospitals in Maine. This standardized assessment tool provided information that facilitated discussions with all birthing hospitals about their levels of neonatal and maternal care. Each birthing hospital completed the tool and the Federal CDC analyzed the results. In collaboration with the Maine DHHS, the Perinatal Outreach Nurse, and neonatologists from Maine’s two hospitals that have NICUs and Maternal Fetal Medicine capabilities met with all birthing hospitals to discuss outcomes of the LOCATe analysis from the Federal CDC and come to consensus on the hospital level of care. A Maine-specific Levels of Care Guidance Document was developed that outlines the criteria required to meet each level of care designation. Future efforts include determining how to align the services provided at each hospital and creating awareness of the resources. The Maine CDC will review the levels of care periodically with the hospitals and use the information in regionalizing perinatal care in Maine.
The Maternal and Child Health Program at the Maine CDC is comprised of the Title V Director, two managers, coordinators for newborn hearing screening, substance exposed infants, newborn bloodspot, care coordination birth defects, and ECCS project manager. We are currently fully staffed.
Title V Partnerships/Collaborations
The Maine CDC Title V has relationships with state and local organizations enabling the program to serve the MCH population statewide. Title V engages the medical community through advisory boards and work groups such as the Newborn Screening Joint Advisory Committee, the Newborn Hearing Advisory Board and the MFIMR Panel. 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 collaborates with the American Academy of Pediatrics, Maine Chapter, Maine Primary Care Association, and Developmental Disabilities Council; all have been invaluable in furthering MCH efforts.
Relationships with State of Maine departments enhance our capacity and reach. The Maine Department of Education partners with programs to ensure implementation of action plan strategies cross into school environments. Maine DHHS partners include the Office of MaineCare Services, Office of Behavioral Health, Office of Family Independence and the Office of Child and Family Services. The DHHS 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 to ensure coordination and collaboration between offices to maximize resources.
The SSDI 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. The Maine Families Home Visiting (MFHV) Manager also oversees MFHV, the ECCS Grant 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.
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 programs, as well as partners working with these programs. The Maine CDC houses both the Data, Research and Vital Statistics program (DRVS) and Maine Immunization program (MIP). Title V has a long standing relationship with DRVS as the provider of data for the Newborn Bloodspot program and the MFIMR Panel. Title V also works closely with the MIP to ensure messaging and educational materials regarding age-appropriate vaccinations are disseminated through MCH programs. 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 worked with MIP to staff the clinics. PHN also held clinics across the state to administer Covid-19 vaccines.
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 also engages with key stakeholders across the state 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.
- Efforts to Operationalize Five-Year Needs Assessment
Title V staff continued to meet on a regular basis to coordinate implementation of the 2021-2025 action plans. As staff completed their COVID-19 redeployment, they have been able to refocus their efforts on action plan activities. As noted previously, Maine engaged all hospitals in the LOCATe tool. We anticipate the results will inform our efforts to improve the perinatal systems of care.
- Organizational Structure and Leadership Changes
The implementation of the ECCS grant has led to some organizational changes within the MCH program. Angie Bellefleur is now the OCFS Project Director for Help Me Grow, and Ashley Olen serves as ECCS Project Manager. Stacy LaFlamme has replaced Ms. Bellefleur as MCH Program Manager overseeing ECCS and MIECHV.
- Emerging Health Issues
Although not an “emerging” health issue, Maine’s Title V program has been focusing on social determinants of health (SDOH) and specifically how racism impacts health. The Title V program has hosted several trainings followed by discussion about the impact of SDOH and how programs can address SDOH in their work. Title V reached out to Maine’s new Office of Population Health Equity to build relationships and learn how to better incorporate actions that promote health equity into our work. Title V epidemiologists contributed to a recent report on racial disparities related to prenatal care. During Summer 2022, Maine is hosting a GSEP intern who is using Maine’s PRAMS data to examine the impact of stressful life events on pregnancy, birth outcomes, and postpartum mental health.
Monkeypox is emerging as a serious public health concern across the United States and is especially concerning for pregnant persons and children. Monkeypox have been linked to stillbirth, miscarriage, and preterm birth. The first case in Maine was identified on July 22nd. Maine’s Title V program will be collaborating with Infectious Disease staff to disseminate information about Monkeypox vaccination for children and pregnant persons.
[1] Maine Center for Disease Control and Prevention. Maine Families Living and Coping With a Pandemic: Reflections from parents enrolled in Maine Families Home Visiting. February 2021. Augusta, Maine.
[2] Maine Center for Disease Control and Prevention. COVID Dashboard. Accessed 4/18/22 at https://www.maine.gov/dhhs/mecdc/infectious-disease/epi/airborne/coronavirus/index.shtml.
[3] Maine Department of Education. Public Funded Attending Counts by School and Grade. Accessed 4/18/22 at https://www.maine.gov/doe/data-reporting/reporting/warehouse/enrollment
[4] Silow-Carroll S, DuPlessis H, Di Paola S. COVID-19 Policy Flexibilities Affecting Children and Youth with Special Health Care Needs. June 10, 2021. Accessed 7/15/21 at https://www.lpfch.org/publication/covid-19-policy-flexibilities-affecting-children-and-youth-special-health-care-needs.
[5] US Census Bureau. Household Pulse Survey Interactive Tool. Accessed 7/30/21 at https://www.census.gov/data-tools/demo/hhp/#/?s_state=00023&measures=HINSEC&periodSelector=33
[6] Maine Center for Disease Control and Prevention. Maine Immunization Program.
[7] Maine Maternal, Fetal and Infant Mortality Report, July 1, 2020-June 30, 2021.
[8] Maine Department of Health and Human Services, Maine Perinatal and Neonatal Level of Care 2022 Guidelines, January 2022
[9] Permanent Commission on the Status of Racial, Indigenous, and Maine Tribal Populations, Racial Disparities in Prenatal Access in Maine; Report to the Legislature, February 2022
[10] Gregory E, Osterman M, Valenzuela C, Changes in Home Births by Race and Hispanic Origin and State of Residence of Mother: United States, 2018-1019 and 2019-2020. NVSR 2021;70(15).
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