Maternal/Parental/Reproductive Health
Focus areas that emerged in this domain include promoting the implementation of risk-appropriate care; expanding universal postpartum home visiting; promoting health care provider assessment of need for contraceptive, preconception, and/or infertility care; improving access to maternal mental health services; expanding economic supports and mobility opportunities for families; increasing fatherhood engagement, and expanding engagement of parents under 26 to improve community health factor related outcomes for families led by young caregivers.
Risk-appropriate care: Access to maternal birth centers is limited in Massachusetts (MA), with only one freestanding birth center. About 23.1% of those who gave birth in MA received inadequate prenatal care (2022). Black non-Hispanic individuals (33.4%) and Hispanic individuals (29.9%) received the least care, while White non-Hispanic individuals (17.9%) received the most. Pregnant women who live in MA's rural areas are more likely to have less-than-adequate prenatal care (22.1%) than pregnant women in urban areas (20.2%). Promoting implementation of risk-appropriate care so that high-risk pregnant women and infants receive appropriate care at a birth facility that is equipped to meet their needs is a key focus area.
Home visiting: MA Maternal, Infant, and Early Childhood Home Visiting Initiative (MA MIECHV) administers a universal postpartum home visiting program known as Welcome Family, in 6 communities, reaching ~ 2,400 families each year with a one-time nurse home visit up to 8 weeks postpartum. Additionally, MA MIECHV provides evidence-based home visiting services to pregnant and parenting families in 18 communities, reaching ~ 2000 families. However, 61% of MA’s home visiting programs do not serve children older than three years old, and 21% do not serve children older than five.
Contraceptive, preconception, and/or infertility care: More awareness of the ACCESS law (enacted in 2017) among pharmacists and health-center-based providers was identified as a need. A 2022 study found that Massachusetts pharmacists had low awareness and no formal training on the ACCESS law and concluded that increased awareness would reduce confusion and hesitancy, allowing more people to receive the full benefit of the law.
Improving access to maternal mental health services The Pregnancy Risk Assessment Monitoring System (PRAMS), 2023 shows that 10.3% of mothers reported experiencing postpartum depression (PPD) symptoms. Those who self-identified as having a disability reported significantly higher PPD symptoms compared to those who reported having no disability (29.4% vs 8.4%). Key barriers include individual shame and fear, restrictive cultural and societal norms, an inadequate workforce to provide essential services and support, and fragmented healthcare systems where mental health services are not integrated into routine prenatal and postnatal check-ups.
Economic support and mobility opportunities: Two years after the implementation of Paid Family Medical Leave (PFML) benefits, data (PRAMS, 2023) shows a shift in utilization of PFML among employed people.
- 72.2% took paid leave only (up from 47.5% in 2020)
- 12.7% took unpaid leave only (down from 33.2% in 2020)
- 2.7% took no leave (down from 6.3% in 2020)
Increasing awareness and education about the PFML was identified as a need that can help families, especially with infants and young children, and families with children with special healthcare needs.
Fatherhood engagement: Fathers and second parents may have varying levels of involvement in pregnancy and delivery decision-making, with some facing barriers to full participation in these discussions. To better understand pregnancy and birth experiences and behaviors among new fathers and second parents, a survey was launched in September 2023, and data were collected through December 2024. Preliminary analysis is planned for summer 2025. Results from this survey can be used to communicate with programs within the MDPH and community partners to work collaboratively, develop, and enhance existing programs to improve the overall health and well-being of children, mothers, and families.
Young parent/caregiver engagement: Data from the MA Community Health Equity Survey (CHES, 2023), indicates that, compared to parents overall, parents under the age of 25 are more likely to report having trouble paying for basic needs (73% vs 44%), more likely to report applying for or receiving food assistance (63% vs. 20%), and less likely to report having a steady place to live (51% vs 87%). Parents under 25 are also less likely to report that there is someone they could count on for support with money, housing, and family problems. Title V will engage young parents to ensure programs meet their needs.
Community Feedback:
Participants highlighted several key areas for improving maternal health: more birthing options beyond hospitals, increased access to doulas, including training of doulas, and better education on patient rights. Participants stressed the importance of community and peer support during and after pregnancy, along with practical resources like home-visiting programs and in-home therapy. Several systemic barriers, such as stigma against postpartum mental health, difficulties with transportation, long waitlists for referral services, and a lack of internet access, were noted. Other areas that need greater attention include stillbirths and bereavement support, a lack of understanding of the paid leave policy (among families and employers), and the need for healthcare providers to be more attuned to the specific needs of parents with disabilities.
One participant in the needs assessment said “Postpartum home-visiting program would also be good because women don’t get enough postpartum care.”
Current Efforts and Strengths:
MA is strengthening its health system's capacity to promote mental health and emotional well-being. Programs like Early Intervention Parenting Partnerships (EIPP), the MA MIECHV, and Welcome Family have standardized practices to screen participants for depression. Additionally, MA has made significant strides in preventing tobacco use during pregnancy: the rate fell to 1.7% in 2023 from 4.3% in 2018. The MA Maternal Mortality and Morbidity Review Team (MMMRT) streamlined its review process, improving efficiency and reducing review times. In 2024, they reviewed 87% of cases within two years of a maternal death, far exceeding their goal of 35%.
The Maternal Health Bill, passed in August 2024, will expand coverage for midwifery, birth centers, doulas, and screening and treatment for postpartum depression, among other initiatives. The bill promotes the expansion of licensures for certified professional midwives & lactation consultants, regulations of freestanding birth centers, insurance coverage for perinatal services, and establishes both a legislative Maternal Health Task Force (MHTF) and a Fetal and Infant Mortality Review (FIMR) program and expands the authority of the MA Maternal Mortality and Morbidity Review Committee. Together, these will ensure ongoing monitoring, evaluation, and improvement of maternal health practices.
In addition, a major component of the bill is the implementation of a state-wide, universal postpartum home visiting program. To meet these requirements, the MDPH aims to base the statewide system on the Welcome Family program. Additional initiatives, such as the promotion of PFML benefits and ACCESS law, and perinatal mental health trainings will be continued.
Perinatal/Infant Health
Focus areas that emerged in this domain include improving the system of care for infants whose families are affected by parental substance use; improving healthy infant growth and development through breastfeeding; and reducing infant mortality and expanding access to support for families experiencing loss.
Prenatal substance exposure: MDPH continues to monitor the impact of the opioid epidemic on mothers and babies. The rate of neonatal abstinence syndrome (NAS) in 2022 in MA was 9.8 per 1,000 live births, which is higher than the national estimates of 7.3 per 1,000 births (national data 2010-2017). Among birthing persons, approximately 1 in 10 had an opioid use disorder. A new bill, “Making Substance Use Disorder Treatment and Recovery Support More Affordable and Accessible,” signed by the Governor in December 2024, updated the policy for infants affected by prenatal substance exposure. If an infant is born with prenatal substance exposure, a report to child welfare services is no longer mandated if there are no additional concerns for abuse and neglect.
Breastfeeding: MA has higher breastfeeding rates compared to the national average. About 90% of infants in MA have been fed breast milk at some point, compared to 86.2% nationally. Barriers to breastfeeding include lack of information and education materials in multiple languages, access to affordable and high-quality lactation services, and workplace and school accommodations. Support from programs like WIC, health care providers, families, and partners can significantly help with breastfeeding. In addition, improving coordination across systems and sectors serving parents trying for pregnancy who set an intention to breastfeed is crucial.
Fetal and Infant Mortality Review (FIMR) program: Every year in MA, more than 500 babies die before their 1st birthday. Congenital malformations, short gestation, low birth weight, and sudden infant death syndrome are among the top five causes of infant deaths. The underlying causes of fetal deaths are unknown. While MA has a Child Fatality Review (CFR) program, it does not currently have a FIMR program. In 2022, the CFR program made a recommendation for the creation of a statewide FIMR program to examine the circumstances surrounding individual infant and fetal deaths, understand the system-level factors that contribute to these deaths, and generate recommendations that would prevent future deaths. The Maternal Health Bill requires DPH to establish a FIMR program and provides legal authority to conduct a FIMR; however, promulgation of regulations and resources to design and implement a FIMR are required to support this priority.
Grief services: The critical need for support and resources to help families with compassionate care, managing, and processing such loss was consistently identified in focus group discussions and key informant interviews with partners and families. This aligns with recommendations from a survey of hospitals on grief services and needs, which highlighted the importance of facilitating memory-making for parents, including families in decision-making processes (e.g., autopsy and memorial/funeral arrangements), providing compassionate communication, and offering specialized training on bereavement and self-care for healthcare staff.
Community Feedback:
Many partners emphasized the need for moving towards a more realistic and supportive environment during early pregnancy, the postpartum period for the birthing parent, and supporting new parents around infant needs. Furthermore, addressing shortages in the appropriate workforce is crucial to ensure families receive high-quality care. Improving access to breastfeeding resources and acknowledging the validity of various feeding methods were also identified as vital next steps for enhancing breastfeeding rates in MA. Finally, recognizing the intrinsic connection between mental health needs and community health factors is critically needed to address issues such as substance use disorder.
Another participant in the needs assessment said “Very little information during pregnancy to prepare someone for connecting to baby. Should build in interaction with (a) lactation consultant in prenatal visits.”
Current Efforts and Strengths:
MA fosters a supportive environment and remains dedicated to promoting breastfeeding, with 17 hospitals currently designated "Baby-Friendly" and four more pursuing this status. In 2024, MDPH completed its statewide breastfeeding needs assessment and developed the Statewide Breastfeeding Strategic Plan to improve breastfeeding rates. Existing policies such as PFML and early care and education regulations support breastfeeding initiatives.
Several new bills that impact the well-being of infants and families were passed in 2024. The Maternal Health Bill requires DPH to develop and implement a FIMR program. Another bill addressing SUD treatment and recovery support updated the policy for infants affected by prenatal substance exposure. The bill mandates a collaborative approach to conducting comprehensive assessments of how substance use may affect parental capacity and infant safety, prioritizing family unity and access to appropriate support systems.
Child Health
Focus areas that emerged in this domain include improving the capacity of the pediatric medical home and the community system of supports to provide a high-quality family-centered care; reducing gaps and incidence of children who experience elevated blood lead levels or lead poisoning; expanding awareness and sustainability of the Regional Poison Control Center to assist in the prevention, diagnosis, and management of poisoning; and developing infrastructure to address gaps in children's vision outcomes.
Medial Home and Community System of Support: About half (47.5%) of children ages 0-17 in MA have a medical home, and 63.5% received needed care coordination (2022-2023, NSCH). Community health factors such as food insecurity and unstable housing affect a significant portion of children and families in MA. About 11% of MA children under the age of five live below the Federal Poverty Level (FPL), with a quarter of Black or African American children and a third of Hispanic children living below FPL. Key challenges to integrated care are sustainable financing, technical assistance for practice transformation in pediatrics, and coordination with community health partners and services such as early intervention and home visiting programs.
Childhood lead exposure: Lead paint is the primary source of childhood lead exposure, and MA has the 4th oldest housing stock in the country, making lead exposure a significant health risk for MA children. The lead poisoning prevalence for children between 9 months and 4 years of age was 2.5 per 1,000 children. Children living in rural areas of the state are at greater risk; these children continue to be screened less frequently (51% vs 73% statewide, 2023) and have double the prevalence of elevated venous Blood Lead Level (BLL) ≥5 µg/dL compared to the state overall.
Poisoning (drug and non-drug) among children: In MA, poisoning is one of the leading causes of emergency visits and hospitalization among children. In 2024, the Regional Poison Control Center (PCC) serving MA and RI received 37,682 calls from MA residents. Of those calls, 34,130 were for exposure to poisons and 3,552 were for information. Most exposure calls were for children under 5 years of age. Overall, for exposure calls, more than half involved female children (53%), and most patients were exposed to poisons at their residences (91%).
Vision: Untreated vision disorders have lasting impacts on children's lives, affecting their ability to learn and often causing irreversible damage. Data on comprehensive vision screening is limited in MA; however, 25% of the children screened in preschool and elementary schools in the greater Boston area failed their vision screening. Low-income children, children of color, and children with disabilities are disproportionately affected by untreated vision disorders.
Community Feedback:
Key gaps identified by partners include support during transitions between early intervention (EI) to preschool, and preschool to kindergarten. Gaps in access to services exist particularly for families in certain regions of MA or with specific needs. There was a strong emphasis on supporting parents in speaking up for their children's rights and ensuring that parents/families were aware of the available resources. Integrating mental health services into primary care and the importance of addressing trauma in young children are some of the areas identified for improvement. Improving livable wages and the complicated application processes for assistance (e.g., for housing, PFML) were some system-level changes identified for overall children’s well-being.
Another participant in the needs assessment said “Mental health of the child (is) representative of mental health of the family. Does the family have a strong community around them? Can we integrate the support?”
Current Efforts and Strengths:
Current Title V efforts to improve child health include increasing developmental screenings for young children through WIC and home visiting programs, and using data analysis and parent leadership in quality improvement. Collaborative bodies like the Young Children’s Council continue to advise DPH on optimal service delivery and ways to integrate mental health into pediatric primary care. Strategies to increase food security for families with young children include programs like WIC and SNAP. To address gaps in childhood lead exposure, the Childhood Lead Poisoning Prevention Program is targeting expanded outreach to rural clusters in the state.
Adolescent Health
Focus areas that emerged in this domain include improving sexual and reproductive health and well-being for adolescents; improving youth mental health and substance use outcomes, and strengthening systems for integrating youth voice and implementing youth-led programming.
Sexual health: About 51.6% MA high school students reported using a condom at last sexual intercourse; 10 % report not using any method to prevent pregnancy at last sexual intercourse (among students who had sex in the past 3 months) and about 19.1% report drinking alcohol or using drugs before last sexual intercourse. Teen birth rate is low in Massachusetts (5.7 births/1000 females aged 15-19); however, the Hispanic teen birth rate remained ten times higher, and the Black Non-Hispanic teen birth rate remained almost five times higher than the White Non-Hispanic teen birth rate.
Mental health: One in five youth report depression or anxiety. Over 80% of youth feel safe with family, but differences by race exist in access to supportive family members. Just over 50% of youth feel they belong at school. Multiracial youth report the highest levels of school bullying. Skipping school due to feeling unsafe is highest among Black (12.5%) and Hispanic youth (10.6%). Cyberbullying affects 17.7% of multiracial youth, the highest among groups. Racial teasing and name-calling affects over 25% of Black and multiracial youth.
Youth-led programming and implementation: Engaging youth in the planning and implementation of programs affecting their well-being is crucial. This approach not only empowers young people in the decision-making process but also increases program utilization and ensures sustainability. By centering youth voices, programs can be more accurately tailored to their needs, leading to increased relevance and effectiveness.
Community Feedback:
Some challenges identified by partners, families, and youth include adolescents experiencing trauma, housing instability, and difficulties transitioning to adult health care services (especially for youth with disabilities), with extended wait times to access services. Youth experiencing trauma and/or housing instability face additional risks in schools and have a higher likelihood of homelessness. Need for comprehensive sexual health education, access to reproductive health services, and support for pregnant youth were also identified. Access to alternatives to talk therapy, housing resources, and life skills, especially for children with Department of Children and Families (DCF) involvement, are some of the opportunities identified.
A different participant in the needs assessment said “Need to ensure any behavioral health -telehealth options would be accessible to all students – [for students] with communication differences or one-to-one care in school support, that [support person] may not be appropriate to attend a confidential mental health appointment”
Current Efforts and Strengths:
Current efforts to improve adolescent health include strengthening mental health and emotional well-being in schools, promoting optimal access to sexual health education and sexual and reproductive health services, and preventing substance use among youth via school-based interventions and community programs. These efforts involve training for educators and healthcare providers, expanding access to behavioral health services (including tele-health), implementing screening and prevention programs, and actively engaging youth voices to ensure services are relevant and effective.
Children and Youth with Special Health Needs (CYSHN)
Focus areas that emerged in this domain include building a comprehensive system for pediatric respite for caregivers and families with children and youth with special health needs (CYSHN) and children with medical complexity; shaping a continuum of care for children with autism spectrum disorder and their families; supporting smooth transition from pediatric to adult health care; improving access to mental health supports and services for CYSHN; and ensuring comprehensive and wrap-around services for CYSHN and their families.
Respite Care: About 23.8% of children in MA have special healthcare needs. Parents of CYSHN report facing financial strain, with 23.9% having not enough money left at the end of the month and 20.4% experiencing unmet health care needs in the past year. Caregivers of CYSHN experience high levels of stress and social isolation, often forego their own healthcare needs, and disproportionately report poor mental health. Families may face substantial long-term financial hardships such as out-of-pocket costs, loss of parental income, and foregone career advancement. Families without support are likely to be unable to prepare for and respond to family emergencies.
Autism spectrum disorder (ASD): There has been an increase in the prevalence of ASD and enrollment in special education for autism. It is estimated that there are 16,000 children with ASD under the age of 18 in MA. Data from the Department of Elementary and Secondary Education (DESE) for 2003-2021 shows that the number of individuals with autism enrolled in special education rose from 4,876 in 2003 to 26,180 in the 2021-2022 school year.
Transition from pediatric to adult health care: About 21% of young adults with special health needs ages 12-17 in MA received services to prepare for the transition to adult health care. Young adults struggle to find providers that are comfortable supporting their health, communication, and technology needs. Managing health insurance and public benefits requirements are overwhelming for young adults and families.
Access to mental health supports and services for CYSHN: About 63.4% (NSCH, 2022-2023) of caregivers of CYSHN reported that it was somewhat or very difficult to get the mental health treatment or counseling they needed (among those who received or needed any mental health treatment.) Several programs within Division for Children and Youth with Special Health Needs (DCYSHN) provide services for both CYSHN and their families, however, gaps still exist.
Comprehensive and wrap-around services for CYSHN and their families: Over 60% of caregivers of CYSHN report having to change or leave their employment due to the needs of their loved ones, while 80% report that caregiving needs negatively impact their productivity at work. Additional barriers that exacerbate these challenges include caregiving workforce shortages and the high financial burden on families to access care. Wrap-around services aim to integrate and coordinate care across services, agencies, and providers for comprehensive care.
Community Feedback:
Participants consistently highlighted the challenges faced by families raising CYSHN, including lack of respite care. In addition, involvement from the DCF adds considerable burden and stress to the families. Financial strain is another major issue, as parents often struggle to maintain employment due to their child's health care needs and may not qualify for financial support. Gaps in support and services available after age 22 lead to anxiety and instability for families. Families encounter provider assumptions and a lack of understanding of disabilities. They also face significant physical and service accessibility concerns, including inaccessible medical offices, extended wait times for crucial services, and difficulties navigating multiple complex service systems.
One parent who was interviewed in the needs assessment said ‘[I’m] working a part time job, but I need to leave work a lot because my kid has a seizure disorder. It’s really hard for me to keep a full-time job”
Current Efforts and Strengths:
DCYSHN collaborated with various state initiatives and organizations, including MassHealth and Pappas Rehabilitation Hospital, to increase facility-based respite beds and support caregiver well-being. Key programs/strategies currently being implemented include developing a Health Transition Toolkit, establishing a Young Adult Advisory Council, enhancing care coordination practices, expanding public benefits training, and collaborating with numerous state agencies and community partners. Additionally, Title V programs aim to increase access to mental health services and improve social-emotional skills in early intervention, utilizing data-driven approaches across all initiatives to ensure optimal family-centered support for CYSHN and their families.
Cross-cutting
The two priority needs that emerged in this domain include strengthening the maternal and child health workforce to ensure families and communities are supported by high-quality providers and integrating MCH needs into state emergency preparedness and response efforts, and embedding a preparedness perspective within MCH programs.
Maternal and Child Health Workforce: The MCH workforce needs that emerged include community birth, childcare, behavioral health, primary care, home visiting, CYSHN, and caregiver workforce, and capacity building of the local public health clinical workforce. The recurring theme of insufficient access to and availability of various MCH workforce members was consistently identified in both quantitative data and qualitative feedback from focus groups and key informant interviews. Despite significant investments by MassHealth in primary care, sustainable financing continues to be identified as a challenge for health systems to hire and retain community health workers and personal experience professionals.
Emergency preparedness and response for MCH needs: Effective emergency preparedness and response efforts must consider the unique and functional needs of pregnant, postpartum, and lactating women, as well as infants, children, and children with special healthcare needs. In addition, the housing crisis in MA particularly impacts children and families. Approximately 4,500 families are currently within the state's emergency shelter system. In addition to housing, these families require critical support in areas such as transportation, health care access, developmentally appropriate play space for children, and food storage and preparation facilities.
Community Feedback:
Partners highlighted the need for a skilled workforce across all domains and that workforce shortages remain a huge barrier to providing high-quality, timely, and integrated MCH services for families. Care coordination remains a challenge, and families find the process of filling out various applications for different services (e.g., housing, transportation) burdensome.
One participant in the needs assessment named that there was a “Need for workforce development and support – need staff to understand developmental frameworks and provide reflective consultation.”
Partners strongly recommended for the integration of MCH needs into emergency preparedness and response efforts. This includes planning for how the unique needs of families with infants and children, such as the availability of feeding formula and childcare, will be met in emergency shelters. Participants in the focus groups and interviews also highlighted the need for cross-sector collaboration on emergency preparedness.
For example, one recommended that MDPH “Map out the resources that each department has that families could access”.
Current Efforts and Strengths:
The Maternal Health Access and Birthing Patient Safety Task Force, established in April 2025 is actively studying the adequacy of the maternal healthcare workforce as part of its broader mission to improve maternal health access and safety. MDPH is developing a pathway for doula certification acknowledging their vital role in improving birth outcomes and providing essential support. Additionally, MDPH is also focused on building a workforce to include community health workers and professionals with personal experience through comprehensive training and improved integration into healthcare systems
MCH programs are collaborating with community partners to ensure families enroll in and access eligible housing services. The Massachusetts Emergency Management Agency's (MEMA) Access and Functional Needs (AFN) Advisory Committee’s overarching goal is to promote optimal accessibility into all products, programs, and services developed by MEMA and its supporting partners to serve everyone in the Commonwealth. BFHN leadership is represented on this Committee to help ensure pediatric and family representation.
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