1. Needs Assessment Activities

Since submitting our Title V five-year needs assessment in 2020, Maine has continued its 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, and 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 2023 it declined again, to 11,614 births (based on provisional data). The dashboard monitors low birthweight (LBW), prematurity, c-section rates, planned home births, very low birthweight (VLBW) infants born at a level III facility, smoking during pregnancy, prenatal care adequacy, breastfeeding (BF), and enrollment in Medicaid and WIC during pregnancy. Maine’s preterm delivery rate has continued to increase while BF and adequate prenatal care have 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 CY2022 there were 69 fetal deaths (a rate of 5.7 fetal deaths/1,000 live births plus fetal deaths)[2] and 79 infant deaths (a rate of 6.5 deaths/1,000 live births).[3] Eight deaths occurring in 2022 were identified as pregnancy-associated based on death certificate records (3 occurred during pregnancy, 2 within the first 42 days after birth, and 3 between 43 and 365 days after birth).[4] These deaths will be reviewed by the MFIMR panel in SFY25.
• During 2022 Maine’s Title V staff and epidemiologist collaborated with staff from Maine’s PRAMS to select questions for Maine’s Phase 9 Pregnancy Risk Assessment Monitoring System (PRAMS) survey. Administration of the new survey started in April 2023 and includes questions on social determinants of health (SDOH), discrimination and family leave.
• Analyses of perinatal Mental Health (MH) are conducted using PRAMS to inform Maine’s Title V priority, as well as highlight Maine DHHS collaboration on the topic of mental health. The 2022 PRAMS survey found that one-third of new mothers felt that they needed MH services or supports and 75% received these services. Nearly 80% reported that they usually or always get the social and emotional support they need.
• At the request of the Maine State Breastfeeding Coalition, 2022 PRAMS data were used to assess the prevalence of BF among new mothers and their sources of information about infant feeding. Breastfeeding initiation was reported by 94% of respondents and approximately 80% received information about breastfeeding from medical providers. Nearly 80% reported BF for two months or more, and 94% reported that they ever pumped breast milk.

Child and Adolescent Health

• Maine CDC continues to monitor COVID-19 cases and deaths by age. As of April 2024, those under age 20 represented 22% 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 adverse childhood experiences (ACEs).
• The Maine Department of Education commissioned an environmental scan and assessment of school health services in the state to identify successful models and identify unmet school health needs. The assessment concluded that while Maine has a strong foundation of school health services, more work is needed in the areas of electronic health records, Medicaid financing, and workforce support.[5]
• Maine’s Preschool Development Grant overseen by the Office of Child and Family Services (OCFS) in partnership with the Maine Department of Education, is currently conducting an assessment of the needs and strengths of Maine’s early childhood education system, with a focus on quality and access for vulnerable children.

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.

• 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, most recently conducted in 2022. The top health priorities identified through this process were MH, SDOH, access to care, and substance and alcohol use.[6]
• Maine’s 2021 Behavioral Risk Factor Surveillance System 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 mental health.

2. Health Status and Needs Changes

While the health of children in Maine has largely rebounded from the COVID era, the effects of the pandemic have impacted children’s MH and access to services, and the economic affects continue to be felt within Maine’s families.

• As of April 15, 2024, 76,658 children and youth under age 20 in Maine have ever been diagnosed with COVID-19; this represents 22% of total cases.[7]
• In March of 2024, 56.1% of adults lived in households where a child received food assistance, a rate that is 30% higher than the U.S. as a whole.[8]
• Maine’s Office of the Medical Examiner tracks fatal and nonfatal overdoses that present in emergency departments (ED). Since the beginning of 2017, 4,111 adolescents aged 19 and under were seen for overdoses in EDs.[9]
• Immunization rates for children and adolescents decreased during the pandemic but have fully rebounded. Maine’s school vaccine mandate resulted in over 96% of kindergarten students receiving the MMR, DTaP, polio, and varicella vaccines in 2022-23.[10] Rates of HPV vaccination among adolescents are lower; according to the National Immunization Survey, 66.2% of adolescents aged 13-17 were up to date on the HPV vaccine in 2022 representing a slight increase from 2021.[11]
• 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. Nearly 18,000 individuals were enrolled in WIC in March of 2024, nearing pre-pandemic levels.

Based on provisional data from 2020-23:

• Maine’s LBW and prematurity rates increased slightly between 2021-2022 and appear to have leveled off in 2023.
• 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 the Agency for Healthcare Quality and Research (AHRQ) Healthcare Cost and Utilization database the rate of newborns hospitalized with Neonatal abstinence syndrome (NAS) has declined steadily from a high of 36.4/1,000 newborn hospitalizations in 2014 to 20.3/1,000 in 2020, the most recent year for which AHRQ reports data.[12] In 2020 Maine’s rate of NAS was the third highest in the U.S. behind West Virginia and Delaware, but it is declining: in 2020, 903 infants were reported to Maine’s OCFS as being substance exposed. This number decreased to 808 in 2021 and 635 in 2023.[13]
• The rate of severe maternal morbidity in Maine was 65.5/10,000 deliveries in 2021, the most recent year for which data are available. This compares favorably with the national rate of 88.2/10,000.[14]

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. In 2023 and early 2024, the MFIMR panel reviewed the nine pregnancy-associated deaths that occurred in Maine in 2021. Three of these deaths were determined to be pregnancy-related by the MFIMR panel. All nine deaths were determined to have been preventable. Six deaths occurred between 43 days and one year of delivery, two occurred within 42 days of delivery, and one occurred while the decedent was pregnant. Substance use disorder was determined to have contributed to three deaths, and MH conditions were determined to have contributed to two deaths. One death was a suicide. Rates of both fetal and infant mortality increased between 2021 and 2022; the rate of fetal death in 2022 was 5.7/1,000 live births plus fetal deaths compared to 5.2/1,000 in the previous year,2 and the infant mortality rate rose from 5.2/1,000 live births to 6.5/1,000 in 2022.3
• The CDC’s Safe Sleep (SS) Initiative implemented in 2019 comprises 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. Surveys of WIC participants were conducted in 2020, 2022, and 2023 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.[15] The rate of SIDS/SUID mortality declined by 50% between 2019 and 2021 while the overall infant mortality rate increased. In 2022, 17 infant deaths were attributed to SUID, a rate of 1.4/1,000 live births. Based on 2022 PRAMS data, 89.5% of Maine infants are placed to sleep on their backs, 37.5% are placed to sleep alone on an approved surface, and 73.2% are placed to sleep without soft bedding.
• Hospital closures. In September 2023, the obstetrical unit at York Hospital closed, the fourth hospital in Maine to discontinue maternity services in the past three years. While York County is not a rural area, this closure will require some birthing people to deliver in New Hampshire, which may complicate the coordination of services and record-keeping across state lines.
• To address the issue 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.[16] Project staff met with representatives of all 17 birthing hospitals in Maine about their need for telehealth services. The major areas identified were MH support, hypertension management, gestational diabetes management, and treatment for substance use disorder. Hospitals also identified a need for staff training and continuing education and assistance making connections with specialists.
• 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.[17] Births to Maine residents for which the birthing facility is known, 81.9% took place in a Level III or IV hospital.
• 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. For the period 2018-2022, the mortality rate for infants born to Black mothers was 8.7/1,000 live births, and that for infants born to Native mothers was 11.5/1,000 (based on 8 infant deaths); the rate among infants born to white mothers was 5.3/1,000.2 These disparities are driven by racism, structural barriers, SDOH and community norms. The perinatal needs assessment conducted in 2023 identified several key factors driving these disparities, including the need for culturally appropriate care and translation services and distrust of the health care system in many communities. These challenges can be addressed through culturally responsive home visiting services, advocacy, and support for basic needs such as housing and transportation.[18]
• During Summer 2023 a graduate student through AMCHP’s Graduate Student Epidemiology Program analyzed Maine PRAMS data on the prevalence of chronic health conditions at the time of pregnancy. The most prevalent health conditions during pregnancy were depression, high blood pressure, asthma, and gestational diabetes. Depression is associated with younger age and lower levels of income and education, while hypertension rates are consistent across demographic groups. Both high blood pressure and depression are associated with higher rates of C-sections, LBW, and preterm birth.
• Home births. The upward trend of planned home births first reported in 2020 continued in 2023 with a total of 294 births (2.53% of all births) taking place at home (based on provisional data), representing a 30% 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; the Maine CDC is no longer monitoring COVID vaccination levels.[21]

• Developmental Screening and Resources. The Help Me Grow (HMG) program launched in Maine in 2022, offers families developmental screening services through the ASQ online, information on child development, and referrals. In CY2023, the program served 728 children. The most common reasons for contacting HMG were concerns about child development, concerns about a child’s behavioral or MH, and help with basic needs such as food or diapers. One in five families served by HMG speaks a language other than English. The program hired a cultural broker to help the meet the unique needs of New Mainers.

• 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 2023 at least 20% of children seen had some form of untreated dental decay. In the spring of 2023, 5.7% of students had an urgent need for immediate treatment.
• Mental health. The 2023 MIYHS continued to provide a concerning picture of the MH of Maine’s adolescents, particularly female and transgender youth. Just under half (46.0%) of high school girls and nearly as many (44.9%) middle school girls reported depressive symptoms in the previous two weeks, compared to 24.2 % of high school boys and 20.7% of middle school boys; among transgender youth, this percentage was 73.1% of high schoolers. Approximately one-quarter (22.6% of high schoolers and 29.0% of middle schoolers) of female respondents report considering suicide, twice the percentage of males, and 10.1% of high school girls and 12.2% of middle school girls report they had attempted suicide at least once.[22] These statistics are comparable to, and in some cases slightly higher than, those reported in 2021.

• 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.
• Substance Use. The 2023 MIYHS shows declines in the use of substances among both middle and high school students. The percentage of high school students who smoke cigarettes has declined since 2019, from 17.6% to 5.6%, but 15.6% currently use an e-vapor product, 20.5% drink alcohol, and 18.7% use marijuana. Among middle school students, alcohol and marijuana are used by approximately 5% of students, and 5.7% use an e-vapor product.

Children and Youth with Special Health Care Needs

Child Development Services (CDS), the state’s Part C early intervention program, reported 2,968 children, 3 years old and younger, were referred in FY23 compared to 3,551 in FY22, and 3,116 in FY21. Referrals increased from all sources including hospitals, physicians, and programs such as MFHV, PHN, and WIC during FY21 and FY22. 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 MaineCare CAHPS survey used the CYSHCN screener to identify children with chronic conditions enrolled in MaineCare and found that 40% of enrolled children had special health care needs. Of these children, 65% of parents reported that their provider seemed informed and up-to-date about care received from other sources, 55% reported that it was easy to get specialized therapies, and 32% reported that it was easy to get treatment or counseling for their children. However, the vast majority (88-92%) rated their children’s providers highly on the items regarding family-centered care (talking about how the child was doing and understanding how the condition affected the child’s and family’s life).[23]

The Maine Parent Federation (MPF), Maine’s support organization for families of CYSHCN, 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. In 2023, MPF conducted three Transition Resource Fairs, which were attended by 38 parents, 245 students, and 20 providers. In addition, the SDM classes reached 9 family/caregivers and 3 providers, and one Self-Advocacy workshop was attended by 9 students.

Despite disruptions in accessing medical care due to COVID-19, based on the National Survey of Children’s Health, Maine’s CYSHCN appear to continue to receive needed care. The percentage of CYSHCN who had a well-child visit and the percent of youth with special health care needs who received transition services did not decline between 2019 and 2020-21. In 2021-22, 91.1% of children had a well-child visit; 35.3% of adolescents aged 12-17 with special health care needs received services to transition to adult health care. In 2021-22, less than half (44%) of CYSHCN received care within a medical home, a decline from 2019 that was not statistically significant.[24]

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 HMG model to improve linkages across the early childhood service system and addressing disparities in access to CDS. Other systems-building efforts underway include the Preschool Development Grant to build the infrastructure for a more coordinated system of services for children from birth to age 5. The Maine Emergency Medical Services for Children received federal funds to improve readiness for pediatric emergencies throughout the state. In addition, MaineCare eligibility was expanded in October 2023 to cover children up to age 21 with family incomes below 300% of FPL and the Office of MaineCare Services launched an informational campaign about the availability of coverage for children and pregnant people, whether or not they are citizens. Finally, American Rescue Plan grant funds were allocated to expand the number of school-based health centers, which now operate in 20 sites across the state, leading to an 18% increase in the number of students served.

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 CYSHCN works with cleft lip and/or palate and genetics clinics, and 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), Lead Program 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 meet 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 Safe Sleep Initiative.

4. Organizational Structure and Leadership Changes

The new Maine CDC Director, Dr. Puthiery Va, assumed her role in August 2023. Within the MCH program, Stacey LaFlamme is now overseeing CYSHCN programs and Lynnda Parker oversees Public Health Nursing.

Emerging Health Issues

The closure of labor and delivery units raises concerns about access to timely, high-quality maternity care services, and could potentially contribute to increases in the rate of low-risk cesarean deliveries if women need to schedule their deliveries to ensure access. Maine is hosting a CSTE fellow who is working on an investigation into the impact of recent obstetric unit closures in Maine on the average travel time to birthing facilities for Maine birthing people.

Health equity continues to receive increased attention as Maine’s population becomes more diverse. The Maine CDC established the Office of Population Health Equity (OPHE) in 2021 to identify and address disparities based on race and ethnicity, LGBTQ status, and geography throughout Maine. The MCH program oversaw OPHE’s perinatal needs assessment and met with the Health Equity Advisory Council to explore avenues for future collaboration.

The reversal of Roe v. Wade raised concerns about a potential increase in demand for abortion services in Maine. The state permits elective abortion until fetal viability, and the law was expanded in 2023 to permit abortion at any stage of pregnancy when medically necessary to save the life or health of the pregnant person. In addition, private insurers and MaineCare are required to provide coverage. The number of abortions in Maine rose between 2017 and 2022 (from 1,959 to 2,225), of which 63.3% were medication abortions. Currently, approximately 5.6% of abortion patients in Maine come from other states but the vast majority of these are from elsewhere in New England.[25]

[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 Center for Disease Control and Prevention. Fetal Mortality, 2022

[3] Maine Center for Disease Control and Prevention. Infant Mortality, 2022

[4] Maine CDC Data, Research, and Vital Statistics, 2022 Death Certificates.

[5] Center for School Health Innovation and Quality. Environmental Scan and State Assessment of School Health Services in Maine Schools: A Report Brief to the Maine Department of Education. November 2023.

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

[7] Maine Center for Disease Control and Prevention. COVID Dashboard. Accessed 6/11/24 at https://www.maine.gov/dhhs/mecdc/infectious-disease/epi/airborne/coronavirus/index.shtml

[8] US Census Bureau. Household Pulse Survey Interactive Tool. Accessed 4/22/24 at https://www.census.gov/data-tools

[9] Maine Center for Disease Control and Prevention, Drug Overdose Morbidity and Mortality and Opioid Prescribing Trends in Maine. https://www.maine.gov/dhhs/mecdc/infectious-disease/epi/syndromic/ Accessed April 22, 2024

[10] Maine Center for Disease Control and Prevention, Maine Immunization Program, 2022-2023 Maine School Immunization Report.

[11] U.S. Centers for Disease Control and Prevention, National Center for Immunization and Respiratory Diseases, National Immunization Survey, 2022.

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

[13] Annie E. Casey Foundation, Babies Born Substance-Exposed in Maine. https://datacenter.aecf.org/data/tables/9828-babies-born-substance-exposed#detailed/2/any/false/2545,1095,2048,574,1729,37,871,870,573,869/any/19127,19128 Accessed 4/28/24

[14] Agency for Healthcare Quality and Research, Healthcare Cost and Utilization FastStats, https://datatools.ahrq.gov/hcup-fast-stats Accessed 4/22/24

[15] Maine Department of Health and Human Services, Maine Safe Sleep Survey 2023: Summary of Results, May 2023.

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

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

[18] Market Decisions Research. 2023 Maine Perinatal Disparities Needs Assessment, February 2024.

19  State of Maine Data, Research, and Vital Statistics (DRVS), Birth certificates, final data, 2020-2022; provisional data: 2023.

[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 2023

[23] Catherine Cutler Institute for Health and Social Policy, University of Southern Maine. 2023 Survey of Children Served by MaineCare, November 2023.

[24] Child and Adolescent Health Measurement Initiative, 2021-22 National Survey of Child Health data query, Data Resource Center for Child and Adolescent Health, www.childhealthdata.org. Accessed 4/23/24

[25] 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 Accessed 4/22/24