1. Needs Assessment Activities

Since submitting our Title V five-year needs assessment in 2020, Maine initiated efforts to improve our understanding of current issues impacting our MCH population. Activities ranged from in-depth analyses to better understand our selected performance measures, gathering information from partners, monitoring progress and barriers in meeting our performance objectives. 

Infant and Women’s Health

• Maine CDC’s epidemiology team established a birth outcomes dashboard[1] to monitor demographic data, birth rates and outcomes data statewide and by county. In 2021 and 2022 the number of births increased after several years of declines; in 2022 there were 12,089 births. The dashboard monitors LBW, prematurity, c-section rates, planned home births, VLBW infants born at a level III facility, smoking during pregnancy, prenatal care adequacy, BF, and enrollment in Medicaid and WIC during pregnancy. Maine’s prematurity rate has continued to increase while BF and adequate prenatal care has been declining. Planned home births increased during the pandemic and continue to be higher than prior years. Smoking during pregnancy has been declining since 2014 and continued to decline during the pandemic.
• Maine’s Maternal, Fetal, and Infant Mortality Review (MFIMR) Panel continues to review cases of fetal, infant and maternal deaths to identify system-level changes to reduce these deaths. In February 2020 Maine’s MFIMR statute was amended to allow for review of cases of pregnancy-associated deaths up to one year after birth (previously it specified review of cases up to 42 days after birth). In calendar year 2021 there were 63 fetal deaths (a rate of 5.2 fetal deaths/1,000 live births plus fetal deaths); 62 infant deaths (a rate of 5.2 deaths/1,000 live births); and 10 pregnancy-associated deaths (2 during pregnancy, 2 within the first 42 days after birth, and 6 between 43 and 365 days after birth).[2]
• Maine’s Title V program is taking several approaches to monitoring the impact of COVID-19 on perinatal and maternal mortality. In 2021 we began linking birth certificate data 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. A check box was added to birth certificates and fetal death certificates to indicate the prenatal COVID-19 status of the mother. Of the deaths reported above, COVID-19 is suspected to be a factor in 4 fetal deaths, one infant death, and one pregnancy-associated death.2   Between April 2020 and December 2022 there were 3,602 pregnant people who had confirmed COVID-19 during their pregnancy.
• During 2022 Maine’s Title V staff and epidemiologist collaborated with staff from Maine’s PRAMS to select questions for Maine’s Phase 9 PRAMS survey. Administration of the new survey started in April 2023 and includes questions on social determinants of health (SDOH), discrimination, and family leave.
• The MaineMOM program, Maine’s Medicaid program that provides coordinated care to pregnant and postpartum people with opioid use disorder, conducted a series of listening sessions in Portland and Lewiston in collaboration with Generational Noor, an organization that works to build support for mental health (MH) and substance abuse treatment services among immigrant and BIPOC communities in Maine, to identify barriers to treatment among these communities.
• Analyses of race using birth certificate data were conducted to inform how Maine’s Title V presents data by race and ethnicity. Each race was categorized alone and “in combination.”  In other words, if an individual identified as both “Black” and “American Indian/Alaska Native”, in one categorization scheme they would be classified as “Two or more races”; in the other categorization scheme they would be categorized as “Black, alone and in combination”, as well as “American Indian/Alaska Native, alone and in combination.” Re-categorizing using the second method increased the number of individuals who identified as American Indian/Alaska Native substantially. The re-categorization did not have a large impact on birth outcomes examined. Moving forward Maine’s Title V program will conduct analyses using the “alone and in combination” race categorization method to ensure that all individuals’ races are represented.
• Analyses of perinatal MH were conducted using PRAMS to inform Maine’s Title V priority, as well as highlight Maine DHHS collaboration on the topic of MH. These analyses revealed that depression diagnoses prior to and during pregnancy have been increasing in recent years and factors such as stressful life events (SLEs), unintended pregnancy, food insecurity, and IPV are associated with an increased risk of depression during pregnancy. Those with depression during pregnancy are more likely to smoke during pregnancy, have a preterm birth, and have a LBW infant. They are less likely to BF for at least six weeks and less likely to use safe sleep (SS) practices. We presented these findings to the Maine DHHS Child Health Leadership group along with a discussion of ways to align across department units.
• A survey of WIC participants is conducted annually in May. The 2022 survey addressed the reach of Maine’s SS Initiative as well as SS practices of WIC participants. A report on the 2022 survey results was created and disseminated.

Child and Adolescent Health

• Maine CDC continues to monitor COVID-19 cases and deaths by age. As of April 2023, those under age 20 represented 23.3% of COVID cases in the state with 12 deaths reported to date in this age group.
• 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, MH, bullying, discrimination, sexual health and ACEs. The 2021 MIYHS findings are discussed below.
• As part of our focus on adolescent MH 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 EDs. A dashboard was created using these data (https://www.maine.gov/dhhs/mecdc/population-health/inj/data.html).  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. The number of ED visits for suicide have been increasing since they hit a low during quarter two of 2020. This was especially true for adolescent females. We conducted analyses of ED visits for MH conditions and found similar patterns.

All MCH Populations:

• Participant satisfaction surveys are administered on an annual basis to parents enrolled in the Maine Families Home Visiting (MFHV) Program. These surveys assess participants’ experiences with the home visiting program. In 2020-22, we included general questions about the challenges facing families during COVID-19. Results from these responses were analyzed and summarized in a report for the Title V and MIECHV programs.
• Maine’s Shared Community Health Needs Assessment (CHNA) is conducted every three years and used to identify public health priorities for the State, county, and hospital systems. Analyses of MCH and other health indicators started in January 2021 and completed in June 2021; virtual community forums were held in all Maine counties during Summer 2021 to review the data and determine priorities. The top health priorities identified through this process were MH, SDOH, access to care, and substance and alcohol use.[3] Shared CHNA data are updated on an annual basis.

• Maine’s 2021 BRFSS includes questions on 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 MH. Data from the 2021 BRFSS were recently made available and analyses will be conducted during the next year.

2. Health Status and Needs Changes

The spread of COVID-19 in Maine has slowed dramatically over the past year. As of April 2023, the number of positive tests, both antigen and molecular, has dropped by at least two-thirds,[4] and 75% of the population is fully vaccinated.[5]

• As of April 17, 2023, 73,327 children and youth under age 20 in Maine have ever been diagnosed with COVID-19; this represents 23.3% of cases.[6]
• In the second half of 2022, nearly 14% of adults lived in households where a child had a health care visit by phone or video, a percentage slightly lower than in the US as a whole.[7]
• The rate of ED visits for suicide ideation and attempts reached a high of 189.8/10,000 ED visits in early 2021; by the first quarter of 2023 it had fallen to 171.7.[8]
• Immunization rates for children and adolescents decreased during the pandemic. Due to Maine’s school vaccine mandate over 95% of kindergarten students received the MMR, DTaP, polio, and varicella vaccines in 2021-22.[9] Rates of HPV vaccination among adolescents are much lower; according to the National Immunization Survey 61.5% of males and females aged 13-17 were up to date on the HPV vaccine in 2021 representing a slight decrease from 2020.[10]
• Enrollment in WIC and other services for pregnant women and children, such as home visiting and public health nursing (PHN) had been declining in recent years. WIC enrollment in Maine reached a low of 15,800 participants in September 2020 however, since that time the number of WIC enrollees has increased. Preliminary data from 2023 suggests that about 17,300 individuals were enrolled in WIC in February. This is not as high as enrollment in 2018, at about 18,000 participants, but is starting to reach pre-pandemic levels. Over half (56.5%) of adults in Maine live in households where a child receives food assistance, one of the highest rates in the nation.[11]

Based on provisional data from 2020-22:

• Maine’s LBW and prematurity rates continue to slowly increase.
• Smoking during pregnancy rates continue to decline but remain higher than the U.S. rate.
• We continue to monitor the impact of substance use during pregnancy. According to AHRQ’s Healthcare Cost and Utilization database the rate of newborns hospitalized with NAS has declined steadily from a high of 36.4/1,000 newborn hospitalizations in 2014 to 20.3/1,000 in 2020.[12]  In 2020 Maine’s rate of NAS was the third highest in the U.S. behind West Virginia and Delaware. In 2020, 903 infants were reported to Maine’s OCFS as being substance exposed. This number decreased to 808 in 2021 and 692 in 2022.

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.

Infant and Women’s Health

• Maine’s MFIMR Panel continues to review cases of fetal, infant and maternal deaths to identify system-level changes to reduce these deaths. During 2021 there were 10 pregnancy-associated deaths in Maine; 60% (6 of 10) of these deaths occurred between 43 and 365 days after delivery. Five deaths were due to unintentional injury (overdose and motor vehicle crash), one was suicide, one was due to cancer, and three were due to obstetric causes. Rates of both fetal and infant mortality declined between 2020 and 2021; the rate of fetal death in 2020 was 5.2/1,000 live births plus fetal deaths, and the infant mortality rate was 5.2/1,000 live births, a 16% decline from the rate reported in 2020.[13]
• The CDC’s SS Initiative implemented in 2019 comprises a number of interventions including a social marketing campaign, health care quality improvement measures, reimbursement for crib distribution, and home SS assessments. An evaluation of these efforts found that the campaign successfully reached providers and families who reported that their behavior changed as a result of its messages and training programs. A survey of WIC participants was conducted in 2020 and 2022 to assess the reach of the SS Initiative and assess SS behaviors among caregivers enrolled in WIC. Survey results indicated that over 60% of respondents saw or heard media messages about SS. Among those who saw the SS messages 70% spoke with others about SS practices and about half changed where they place their infant to sleep.[14] The rate of SIDS/SUID mortality declined by 50% between 2019 and 2021 while the overall infant mortality rate increased. The rate of SIDS/SUID mortality remained low in 2021.14 Based on 2020 PRAMS data 90% of Maine infants are placed to sleep on their backs, 38% are placed to sleep alone on an approved surface and 67% are placed to sleep without soft bedding. PRAMS data on SS were used to update Maine’s SS Infographic.[15]

• In October 2022 Maine received a $5 million State MCH Innovation grant to work in partnership with the Perinatal Quality Collaborative for Maine to support birthing hospitals in implementing the Alliance for Innovation on Maternal Health Safety Bundles to increase resources for collection and analysis of data on deaths and serious health issues associated with pregnancy and birth and to upgrade collection and submission of data on fetal, maternal and infant deaths.[16] As part of this effort we are developing a maternal health report that will be updated annually.
• In March 2023, the obstetrical unit at Rumford Hospital closed; the third rural hospital in Maine to discontinue maternity services in the past three years. To help address the problem of access to maternity care in rural areas MaineHealth received a $1 million HRSA Rural Maternity and Obstetrics Management Strategies Program grant to establish a statewide telehealth network for rural maternity care developing a network approach to improve the continuum of postpartum care and assuring financial sustainability for these solutions.[17]
• Perinatal and Neonatal Levels of Care. In February 2022, the Maine DHHS issued guidelines for the assignment of maternal and neonatal Levels of Care and began implementing the U.S. CDC’s LOCATe Assessment Tool. 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 Maine DHHS if their perinatal services will be changed or terminated.[18] The state’s goal is for 90% of VLBW infants to be born in Level III or Level IV hospitals, an increase from the baseline rate of 82.5%.

• Racial Disparities in Maternal and Infant Health. Maine continues to experience disparities in maternal health and birth outcomes based on race and other demographic characteristics. The mortality rate for infants born to Black mothers in 2021 was 7.5/1,000 live births, and that for infants born to Native mothers was 13.6/1,000 (based on 8 infant deaths); the rate among infants born to white mothers was 5.4/1,000.2 These disparities are driven by racism, structural barriers, SDOH and community norms. To further investigate and address these disparities the Maine CDC is conducting a perinatal needs assessment focused on the needs of birthing persons in minority and underserved communities overseen by the Office of Population Health Equity (OPHE). This effort will be completed by December 2023 and findings will be incorporated in the 2025 Five-Year Needs Assessment.

• During Summer 2022 a graduate student through AMCHP’s Graduate Student Epidemiology Program analyzed Maine PRAMS data on the impact of SLEs during pregnancy. Results indicated that at least 70% of pregnant people in Maine experienced at least one SLE during pregnancy and 1 in 5 experienced four or more SLEs. Experiencing four or more SLEs was associated with having a LBW, small-for-gestational age, and preterm infant. SLEs were also related to smoking during pregnancy and postpartum depression.
• Home births. The upward trend in home births reported in 2020 continued in 2021 with a total of 323 births (2.69% of all births) taking place at home; representing a 38% increase from the pre-pandemic (2019) rate of 1.95%.[19]

Child and Adolescent Health

Children and youth represent 23.2% of total reported COVID-19 cases in Maine (through April 2023), representing a total of 74,788 children and youth under age 20. A total of 210 children and youth under age 25 were hospitalized with COVID.[20] As of April 2023 a total of 43,916 children age 5-11 and 86,851 children age 12-19 were fully vaccinated.[21]

• Oral Health. Maine’s School Oral Health program provides oral health education, fluoride treatment, sealants, and oral health screenings in schools. This program continues to see the effects of delayed dental care due to COVID-19 in its screenings: since the spring of 2021 and through the spring of 2022 at least 20% of children seen had some form of untreated dental decay. In the fall of 2022, 6.3% of students had immediate treatment urgency; the highest rate ever reported and over twice that seen in the spring of 2019, prior to the pandemic.

• Mental health. The 2021 MIYHS provided a concerning picture of the MH of Maine’s adolescents, particularly female and transgender youth. Nearly half (48.1%) of high school girls and over one-third (39.6%) of middle school girls reported depressive symptoms in the previous two weeks, compared to 23.7% of high school boys and 19% of middle school boys; among transgender youth, this percentage was 74% of high schoolers. Approximately one quarter (24.2% of high schoolers and 26.2% of middle schoolers) of female respondents report considering suicide, twice the percentage of males, and 11.1% of high school girls and 9.8% of middle school girls report they had attempted suicide at least once.[22]

• Mattering. Research suggests that adolescents who feel like they matter to others and to their community have lower levels of MH problems and higher academic performance. Analyses from the MIYHS demonstrated that Maine high school students who feel like they matter in their community are less likely to have considered suicide and less likely to have used substances. Gay/lesbian and bisexual students, as well as transgender students, were less likely to report that they felt like they mattered in their community. Results of these analyses contributed to efforts to increase resilience among Maine children and adolescents.

• The importance of sleep: Our current CSTE fellow completed analyses of MIYHS data on the impact of adequate sleep on adolescent health and risk behaviors. In 2021 only 29% of Maine high school students reported reaching the recommended 8-10 hours of sleep on an average school night. When adjusting for confounders the prevalence of adequate sleep was significantly lower for students with any poor MH factors, screen time more than three hours per day, having four or more ACEs, or experiencing discrimination compared to their counterparts. Factors that positively impacted whether the students met the sleep requirement were participating in 60 minutes of PA every day, feeling like they mattered in a community, having people at school who cared about students and encouraged them, having support from adults other than their parents, and family giving the student love and support.

Children with Special Health Care Needs

The increase in referrals to Child Development Services (CDS), the state’s Part C early intervention program, that began during the pandemic continued. In SFY22 a total of 3,551 children were referred to CDS, compared to 2,908 in FY19 and 3,116 in FY21. Referrals increased from all sources including hospitals, physicians, and programs such as MFHV, PHN, and WIC. According to CDS, this increase can be attributed to both the impact of COVID-19 on children’s development and a statewide expansion of outreach efforts. In addition to increased referrals the eligibility rate among referred children again approached 80%. This may be due to fewer children with mild conditions being referred or because of increases in developmental delay due to isolation.

The Maine Parent Federation (MPF), Maine’s support organization for families of CSHN, focuses on care coordination and transition support. Through its Youth Coordinator, MPF provides training and Transition Resource Fairs through local school districts and offers both in-person and virtual Supported Decision-Making (SDM) Training for students and professionals. During the pandemic schools were unable to host Resource Fairs but resumed in the spring of 2023. Virtual SDM trainings proved successful; 58 people participated in three trainings so far in FY23 and evaluation surveys show that 90% of participants found the trainings to be useful and felt more prepared for transition after the workshop.

Despite disruptions in accessing medical care due to COVID-19, based on the National Survey of Children’s Health, Maine’s CSHN appear to continue to receive needed care. The percentage of adolescents with a special health care need who had an adolescent well-visit and the percent who received transition services did not decline between 2019 and 2020-21. In 2020-21, 91.5% of adolescents aged 12-17 with a special health care need had a well-child visit; 33.8% received services to transition to adult health care. Maine’s rank on adolescent transition was 3rd highest in the U.S. for CSHCN and 1st in the U.S. for non-CSHCN. The percentage of CSHCN receiving care within a medical home also did not change significantly between 2018-19 and 2020-21. In 2020-21, about half (47.4%) of CSHCN received care within a medical home.

3. Title V Program Capacity/MCH Systems of Care Changes and Impact on MCH Services Delivery

The Maine CDC received an Early Childhood Comprehensive System grant which aims to make early childhood systems in Maine easier for families to navigate by providing a central statewide point of coordination, implementing the Help Me Grow (HMG) model to improve linkages across the early childhood service system and addressing disparities in access to CDS. OCFS launched HMG in November 2022 and as of January 2023 served 72 children, provided 98 referrals and conducted 15 online developmental screens, of which 28% required further evaluation.

Title V Partnerships/Collaborations

Maine CDC Title V relationships include engaging 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. The CSHN works with cleft lip and/or palate and genetics clinics, the parent advocacy organizations, Facing Maine and MPF. Title V also collaborates with the American Academy of Pediatrics, Maine Chapter, Maine Primary Care Association and Developmental Disabilities Council; all are invaluable in furthering MCH efforts.

Relationships with State of Maine departments enhance our capacity and reach. Title V partners with the Maine Department of Education, Office of MaineCare Services, Office of Behavioral Health, Office of Family Independence and OCFS. The Maine DHHS leads a Child Health Leadership Team, which includes representatives from these offices.

Title V is housed in the Maine CDC’s Division of Disease Prevention along with the Tobacco and Substance Use Prevention and Control, Adolescent Health and Injury Prevention, Chronic Disease and WIC programs. This connection facilitates collaborations between programs and their partners. The Maine CDC houses the Data, Research and Vital Statistics (DRVS) and Maine Immunization programs. Title V has a longstanding relationship with DRVS as the provider of data for the Newborn Bloodspot program and the MFIMR. Title V works closely with the Maine Immunization Program to ensure messaging and educational materials regarding age-appropriate vaccinations are disseminated.

Title V 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.

Efforts to Operationalize Five-Year Needs Assessment

Title V staff continue meeting to coordinate implementation of the 2021-2025 action plans. Analyses of data related to Maine’s selected Title V priorities are ongoing to inform activities, action plans, and progress on Title V efforts. Examples of how Maine has operationalized the five-years needs assessment include engaging all hospitals in the LOCATe tool, which is improving the perinatal systems of care, and our efforts to reduce infant mortality by implementing a statewide SS Initiative.

4. Organizational Structure and Leadership Changes

The Maine CDC Director, Dr. Nirav Shah, left in January to take a position with the U.S. CDC. Deputy Director Nancy Beardsley is serving as Acting Director of the Maine CDC while a national search for his replacement is conducted. Holly Richards, the Newborn Screening program manager and domain lead for CSHN left the Maine CDC; efforts are underway to fill the position. Angie Bellefleur left the HMG program and was replaced by Jessica Wood as program manager.

5. Emerging Health Issues

Maternal morbidity and mortality, including perinatal MH and substance use issues that may lead to negative outcomes is an issue of increasing concern. Maine CDC received a Maternal Health Innovation Grant from HRSA to enhance its focus on these issues and received funding from the US CDC ERASE Maternal Mortality program to expand its capacity to review maternal mortality through the MFIMR Committee.

The issue of health equity receives increased attention as Maine’s population becomes more diverse. The Maine CDC established the OPHE in 2021 to identify and address disparities based on race and ethnicity, LGBTQ status, and rural locations throughout Maine. The work began with a $32 million federal grant to address COVID-related health disparities and will go on to explore disparities in chronic disease, access to care, and environmental health and will include a needs assessment focusing on disparities in perinatal care and outcomes in 2023.

The reversal of Roe v. Wade raised concerns about a potential increase in demand for abortion services in Maine, where abortion is legal until viability, and where private insurers and MaineCare are required to provide coverage. The number of abortions in Maine rose between 2017 and 2020 (from 1,959 to 2,064) after the coverage requirement went into effect and declined in 2021 to 1,195, of which 60.5% were medication abortions. Currently, approximately 6% of abortion patients in Maine come from other states but the vast majority of these are from elsewhere in New England.[23]

[1] State of Maine Data, Research, and Vital Statistics Maternal and Birth Data Dashboard. https://www.maine.gov/dhhs/mecdc/public-health-systems/data-research/vital-records/births.shtml

[2] Maine Maternal, Fetal, and Infant Mortality Review Panel (MFIMR) Annual Report, July 1,2021-June 30, 2022. Maine Center for Disease Control and Prevention, February 2023.

[3] State of Maine, Maine Shared Community Health Needs Assessment Report, July 2022

[4] Maine CDC COVID-19 Dashboard, https://www.maine.gov/dhhs/mecdc/infectious-disease/epi/airborne/coronavirus/data.shtml

[5] Maine CDC COVID Vaccination Dashboard, https://www.maine.gov/covid19/vaccines/dashboard

[6] Maine Center for Disease Control and Prevention. COVID Dashboard. Accessed 4/22/23 at https://www.maine.gov/dhhs/mecdc/infectious-disease/epi/airborne/coronavirus/index.shtml.

[7] US Census Bureau. Household Pulse Survey Interactive Tool. Accessed 4/22/23 at https://www.census.gov/data-tools/demo/hhp/#/?s_state=00023&measures=HINSEC&periodSelector=48

[8] Maine Center for Disease Control and Prevention, Emergency Department Surveillance of Non-fatal Suicide-related Outcomes (ED-SNSRO). Accessed 4/22/23.

[9] Maine Center for Disease Control and Prevention, Maine Immunization Program, 2021-2022 Maine School Immunization Report.

[10] U.S. Centers for Disease Control and Prevention, National Center for Immunization and Respiratory Diseases, National Immunization Survey, 2021.

[11] US Census Bureau. Household Pulse Survey Interactive Tool. Accessed 4/22/23 at https://www.census.gov/data-tools/demo/hhp/#/?s_state=00023&periodSelector=51&measures=FOODFORCHLD

[12] Agency for Healthcare Quality and Research, Healthcare Cost and Utilization FastStats, https://datatools.ahrq.gov/hcup-fast-stats Accessed 4/23/23

[13] Maine Maternal, Fetal and Infant Mortality Report, July 1, 2021-June 30, 2022.

[14] Maine Department of Health and Human Services, Safe Sleep Initiative Evaluation Report, April 2021.

[15] Maine Department of Health and Human Services. Safe Sleep Among Maine Infants 2020.  December 2021.

[16] Maine CDC Maternal and Child Health Program Awarded Competitive $5 Million Grant to Further Efforts to Improve the System of Care for Pregnant People, New Parents, and Infants, October 7, 2022

[17] HRSA Office of Rural Health Policy, Rural Obstetrics Management Strategies Program 2022 Grantee Directory

[18] Maine Department of Health and Human Services, Maine Perinatal and Neonatal Level of Care 2022 Guidelines, January 2022

[19] State of Maine Data, Research, and Vital Statistics Maternal and Birth Data Dashboard. https://www.maine.gov/dhhs/mecdc/public-health-systems/data-research/vital-records/births.shtml

[20] Maine CDC https://www.maine.gov/dhhs/mecdc/infectious-disease/epi/airborne/documents/COVID-19-Youth-4-18-2023.pdf

[21] Maine CDC COVID Vaccination Dashboard, https://www.maine.gov/covid19/vaccines/dashboard Accessed 4/24/23

[22] Maine CDC, Maine Integrated Youth Health Survey 2021

[23] Maine Department of Health and Human Services, Division of Public Health Systems, Data Index. https://www.maine.gov/dhhs/mecdc/public-health-systems/data-research/data/index.html#induced Accessed 5/2/23