The 2020 Title V comprehensive 5-years needs assessment for maternal and child health populations aimed to identify assets, key strengths, resources, and services available to serve MCH populations and identify needs and gaps across the state’s communities to better serve MCH populations. The following table outlines SC’s identified priority needs to focus on for 2021-2026.

The Title V program within SC DHEC’s MCH Bureau values the need for ongoing assessment activities and the continued monitoring of changing MCH population demographics, emerging health trends and shifting program capacity. The bureau is equipped with a team of skilled epidemiologists and evaluators who regularly engage with programmatic partners and leadership to ensure relevant and coordinated data collection and analytic activities are continuous. The primary focus is to facilitate effective monitoring, evaluation, and surveillance efforts, as well as contribute to program policy development and implementation. Working in close collaboration with the Title V Director and Deputy Director, these staff members provide valuable data, analytical insights, and program support for Title V programs and initiatives. Moreover, the success of most programs and initiatives relies on the active participation of local community action teams or advisory councils, consisting of community members who contribute their valuable insights throughout project implementation to address emerging and ongoing needs. To gather comprehensive information from consumers, providers, and partners, programs often employ methods such as focus groups and key informant interviews. The input received from these community groups, focus groups, and other stakeholders is carefully incorporated into the decision-making process.

Changes in the health status of Title V populations are seen below:

Women/Maternal Health

In 2022, the South Carolina Maternal Morbidity and Mortality Review Committee (SCMMMRC) completed the review of 66 deaths from 2019, 22 of these deaths were determined to be pregnancy-related (PR) (30%). Although all deaths are tragic, the focus of the SCMMMRC is PR deaths. In 2019 the SC Pregnancy-Related Mortality Ratio (PRMR) was 38.6 PR deaths per 100,000 live births, a 9.3% increase from 35.3 in 2018. In SC, the non-Hispanic Black population experienced a 67% higher pregnancy-related mortality ratio than their White counterparts in 2018 and 2019. Both were higher than the United States PRMR of 17.3. In 2019, 81.8% of the pregnancy-related deaths investigated by the SCMMMRC were determined to be preventable. This aligns with the national statistic of 80%. Additionally, South Carolina was able to extend post-partum Medicaid coverage to 12 months.

Perinatal/Infant Health

Infant mortality, defined as the death of a live-born baby before its first birthday, reflects the overall state of a population’s health. In the United States (US), the IMR is recognized as a leading health indicator and its reduction is a high-priority Healthy People 2030 objective. While the US IMR has been declining over the past several years, 2 SC’s rate increased 12.3% from 6.5 infant deaths per 1,000 live births in 2020 to 7.3 infant deaths per 1,000 live births in 2021. The IMR was lowest among births to non-Hispanic White women (5.2 infant deaths per 1,000 live births) and Hispanic women (5.1 infant deaths per 1,000 live births) in 2021. Comparatively, the IMR was more than twice as high among live births to non-Hispanic Black women (12.7 infant deaths per 1,000 live births). This racial disparity in infant mortality remains a concern in SC, and as shown in the graph below, the gap has increased from 1.8 to 2.4 in the past five years. While the IMR among births to non-Hispanic White women has remained stable from 2017 to 2021 (5.1 and 5.2, respectively), the IMR among births to non-Hispanic Black mothers has increased 39.6% from 9.1 in 2017 to 12.7 infant deaths per 1,000 live births in 2021.

Child & Adolescent Health

Understanding the leading causes of hospitalization and death in South Carolina is crucial to help inform public health interventions and policies. By examining hospitalization and mortality data, we can identify the key health challenges faced by the population of South Carolina. This understanding enables policymakers, healthcare providers, and public health officials to develop targeted strategies to address the specific needs of the community. The leading cause of hospitalizations in SC varies by age, with those aged 1-4 years being hospitalized due to acute bronchiolitis, those 5-9 and 10-14 years due to encounter for other aftercare, and those 15-17 years due to major depressive disorder. Among individuals aged 1-17 years, accidents were the leading cause of death, constituting 36% of all fatalities, surpassing the combined occurrence of the subsequent three leading causes: homicide (13%), suicide (11%), and cancer (9%).

KIDS COUNT profiles the status of children on national and state-by-state bases and ranks states on measures of well-being. KIDS COUNT is supported by the Annie E. Casey Foundation and the 2023 report was the 34th annual report. Within South Carolina, Children's Trust is the leader of KIDS COUNT. Indicators reveal significant deficits for children and families in South Carolina, which sends a strong signal that dedicated strategies are needed to give them more opportunities to succeed. While the US child and teen deaths per 100,000 remained stable from 2010 (26 per 100,000) to 2023 (41 per 100,000), South Carolina saw an increase of about 30% from 32 per 100,000 in 2010 to 41 per 100,000 in 2023. Similarly, South Carolina saw an increase from 33% in 2016 to 40% in 2023 for children and teens overweight and obese, while the US remained stable at 31% during the same time period. South Carolina ranks in the bottom 20% of overall child well-being, which is a composite score of four domains, at 41st. Of these four measures, South Carolina ranks 34th in economic well-being, 40tb in education, 41st in family & community well-being, and 47th in health.

CYSHCN

Within South Carolina, there are many ways that Title V supports Children and Youth with Special Health Care Needs (CYSHCN). The CYSHCN Division recognizes the importance of a medical home that is patient-centered and comprehensive, and this continues to be a primary focus for the program. In South Carolina, the current percentage of children with special health care needs whose care meets medical home criteria is 49.7%. While the program educates 100% of clients served on the need and importance of a medical home, there is still a critical need to move the needle on this indicator to improve health outcomes for this population. The Division plans to utilize results from a point-in-time survey for CYSHCN clients and families to determine any barriers or racial/ethnic disparities in establishing a medical home and develop plans or mechanisms to address those barriers.

Another identified need for the CYSHCN population is preparation for transitioning to adult health care. CYSHCN has several plans in development to address transition to adulthood services, focusing on education and awareness for providers, adolescents, and their families. The CYSHCN Division also strives to ensure families have adequate insurance and the ability to pay for services they need. The program experienced an increase in the number served through CBG, the Hemophilia Program, Children's Rehabilitation, and Care Coordination from 4,688 in 2021 to 5,083 in 2022. Additionally, there was in increase from 45 in 2021 to 57 2022 for infants screened for Sickle Cell who were referred to CYSHCN for care coordination or financial assistance, while a decrease from 358 to 286 in infants referred to CYSHCN for care coordination (not including SCD).

Cross-Cutting/SDoH

Employment and Child Care—The South Carolina Department of Employment and Workforce developed a report on South Carolina Labor Force Participation. A survey was sent to over 150,000 individuals identified as members of the South Carolina workforce population through Survey Monkey. Of the 150,932 links sent, 6,116 (4.1%) individuals responded. One key result they found was how child care could improve the ability of individuals to gain and keep employment. As identified in the report, the lack of child care was the second (23%) leading barrier for those 24 years or younger and the fifth (18%) leading barrier among those 25-54 to get a job. Females reported a lack of child care at the sixth leading barrier to getting a job; however, lack of child care was not in the males top 10. When examining racial differences, the report noted that Black individuals reported a lack of child care as the sixth (16%) leading barrier, while their White counterparts had this as the 10th (14%) leading cause.

Women of Childbearing Age (WOCBA) and Access to Care—Almost 1,000,000 women of child-bearing age live in South Carolina, accounting for over fifty thousand births per year. Medicaid pays for 60% of all deliveries. A recent analysis by USC/IFS indicates that overall, Black women make up nearly a third of all WOCBA (30%) in the state while accounting for 43% of Medicaid deliveries. White women comprise two-thirds of all WOCBA (62%) statewide, accounting for 41% of Medicaid deliveries. Of note, Hispanic/Latina women only comprise around 7% of all WOCBA statewide but 14% of Medicaid deliveries.

Among the deliveries in FFY21, more than half of mothers self-identified as White, non-Hispanic, 31% as Black, non-Hispanic, and 11% as Hispanic, which was a 12% relative increase. One in four delivery patients lived in a rural area. About 28% were below 25 years of age, in which teen deliveries accounted for 6%. Nearly two in five (38%) only had a high school education or less. Medicaid paid for 60% of deliveries accounting for over $700 million in hospital charges in FFY21. About 7% of deliveries were uninsured. Most deliveries were at hospital level II or higher (91%).

Social determinants of health provide an understanding of the impact on health outcomes of where people live and work. A new nationwide index, the Maternal Vulnerability Index (MVI), measures maternal vulnerability at the state and county level and helps to make the connection to social determinants of health at the national and state level. It combines 43 measures that serve as indicators to build 6 themes: Reproductive Health, Physical Health, Mental Health and Substance Abuse, General Healthcare, Socioeconomic Determinants, and Physical Environment. The MVI values were calculated on a national scale, and the state MVI value for SC is 92 out of 100, where a score of 100 indicates the most vulnerable population. Looking at SC counties relative to all the nation’s counties, more than half of the counties in SC (N=28) are in the Very High category of Maternal Vulnerability nationwide, and another twelve counties are in the High category of Maternal Vulnerability nationwide. The two lowest categories (i.e., least vulnerable) of the national MVI are not seen in SC. This is not surprising as South Carolina now ranks 8th in the US for maternal mortality among states without data suppression.

Several current projects at the agency level that help inform the SC Title V program and the MCH Bureau’s work include the following:

1. SC DHEC’s Office of Diversity, Equity and Inclusion (DEI) has completed a Comprehensive Needs Assessment (CNA) and a Strategic Plan development process to identify Public Health DEI needs and identify strategies to meet those needs. MCH/Title V staff have participated at multiple levels in the CNA and Strategic plan process, from serving on the work group and advisory committee, to providing valuable information on perceptions and beliefs around fairness and equity in the workplace. An external contractor was hired to facilitate the completion of the strategic plan from findings of the DEI CNA. Both qualitative and quantitative data were collected, reviewed by internal and external stakeholders, and incorporated into the strategic plan for agency approval. The DEI Office staff has increased to serve DHEC’s PH DEI better needs. Staff includes a DEI Vaccine Equity Coordinator funded from COVID grant funds, a DEI Head Trainer, funded from COVID grant funds, and an FTE Multicultural Health Specialist. Moreover, the DEI Office coordinates with the four regional DEI specialists for training and resources geared towards the particular needs of each region. The DEI Office continues engagement with SC’s Native American Communities' participation in the Native American Health Board and continuously shares resources, and expertise, and informs the work of PH staff of SC’s indigenous and other unrepresented communities via trainings, resources, and data equity initiatives.

2. SC DHEC is working to finalize the second iteration of the State Health Assessment (SHA) to inform the State Health Improvement Plan (SHIP). The first versions of the SHA and SHIP were released in 2018 and both are required to be updated every five years to maintain Public Health Accreditation and provide a direction for the agency.  The process to develop the new SHA/SHIP began in Spring 2022, and a wide variety of internal and external stakeholders were engaged throughout the development process. Community focus groups were held, public input received, and population health data examined. The primary change from the last iteration was that the SHA is now structured using a life course approach to organize the chapters. This change has allowed for an expansion of the breadth and depth of MCH indicators used. The assessment is now in the final stages of review and will be compiled and visualized through a contracted graphic designer and made publicly available before the end of 2023. The MCH Bureau Epidemiologists and Deputy Director have been heavily involved in these processes and continue to provide insight and ensure alignment between Title V and agency/state-wide initiatives and priorities.  

3. SC DHEC’s Office of Public Health Strategy and Continuous Improvement continues to spearhead the Performance Management/Quality Improvement (PM/QI) Council, which is a group of diverse members from DHEC’s Public Health bureaus and regional offices dedicated to tracking their respective performance in alignment with DHEC Leadership’s vision and prioritizing quality improvement activities. The MCH Bureau’s Deputy Director and Evaluation Manager are members of the council.  Key performance indicators have been developed for MCH and are reported and monitored on a quarterly basis.  This helps drive QI work as the bureau is focused on adjusting practices to support progressive improvement across programs.

Organizational Updates

Since the last reporting period there have been no significant changes in the agency's organizational structure or Title V leadership.  However, several legislative actions were passed in the most recent session that will affect the agency moving forward, listed below, with implementation occurring at varying time intervals. 

1. Bill S. 399—The SC Department of Health and Environmental Control (DHEC) will be split into two separate agencies to be named the Department of Public Health and the Department of Environmental Services, both of which will have directors appointed by the Governor of SC. The two agencies will be divided into a more formalized structure recommended by a study committee and be established by July 1, 2024.
2. Bill S.3978— This bill amends previous language relating to the notification of neonatal testing results. The new law will now require notifications of abnormal time critical newborn screening results be made to the child’s primary care provider and a qualified pediatric specialist simultaneously. This will greatly enhance DHEC's relationship with area specialists and enhance timeliness of follow-up when critical results are received. 
3. Bill H. 3990—This bill granted authority to certain schools the ability to maintain and administer opioid antidotes in cases of emergencies.  This builds on Bill S. 3735 that was introduced in a previous session that granted authority to registered nurses employed by public or private schools the ability to administer Epinephrine auto-injectors to students in an emergency. 
4. A new Proviso has instructed that DHEC’s abstinence education program be transferred to the SC Department of Education before July 1, 2024.