Introduction

Maryland is a small but diverse state comprising 24 jurisdictions, including 23 counties and the city of Baltimore.  With an estimated population of more than 6 million in 2018, Maryland is the nation’s 19th most populous state, yet ranks as the ninth smallest state according to land area.  Although a small state in size and population, Maryland has great geographic diversity.  The State is characterized by mountainous rural areas in the western part of the State, densely populated urban and suburban areas in the central and southern regions along the I-95 corridor between Baltimore and Washington DC, and flat rural areas on the eastern shore. Maryland is geographically unique with the Allegheny Mountains and Chesapeake Bay separating its western and eastern regions from the population centers of the state.  These geographic “barriers'' often create special challenges in the procurement of health care services due to lack of access (transportation and distance), lack of providers, and lack of specialty care.

The State’s Maternal and Child Health (MCH) population includes an estimated 1.2 million women of childbearing age (ages 15-45), 1.5 million children and adolescents (ages 0-19), and 371,115 young adults (ages 20-24) in 2019. According to the National Survey of Children’s Health in 2019, an estimated 272,432 Maryland children and youth (ages 0-17) have special health care needs (NSCH 2019 Survey).

Maryland’s Health Care Environment

Maryland’s health care system includes 24 local health departments (LHDs), 77 hospitals, 21 federally qualified health centers (FQHCs), the Medicaid Program, private insurers, regulatory agencies, provider groups, advocacy groups and countless health practitioners. MCH specific resources include 32 birthing hospitals, nearly 2,600 pediatricians and/or adolescent practitioners, over 1,200 obstetricians and/or gynecologists, and nearly 1,900 family/general practitioners. Maryland is also home to Johns Hopkins University consistently ranked as one of the nation’s top hospitals and some of the best diagnostic centers for developmental conditions in children, such as Kennedy Krieger Institute, University of Maryland Division of Behavioral and Developmental Pediatrics, Sheppard Pratt, and Mount Washington Pediatric Hospital.

Maryland was one of the six initial states approved to begin a Health Benefit Exchange under the Affordable Care Act (ACA).  The Maryland Health Benefit Exchange, known as Maryland Health Connection (MHC), was launched in 2013 and has implemented ongoing efforts to increase knowledge among individuals and communities about the importance and availability of health insurance coverage.  Within local health departments and through regional consumer assistance organizations, health navigators assist individuals with applying for health insurance options available through MHC.  Maryland also expanded Medicaid eligibility through the ACA to cover income eligible adults ages 19-64 regardless of parental status.

The Maryland Medicaid Program serves as the major source of publicly sponsored health insurance coverage for children, adolescents, and pregnant women.  According to Medicaid data, during calendar year 2018 over 1.4 million Marylanders were eligible for Medicaid coverage.  During calendar year 2020, 665,988 children and adolescents (ages 0-22) were enrolled in the Medicaid Program at some point during the year, representing a 3% decrease from 2019 enrollment.  Maryland has generally been supportive of expanding health insurance coverage for uninsured children and pregnant women.  The Maryland Children's Health Program (MCHP) began operating as a Medicaid expansion program on July 1, 1998. The MCHP program expanded comprehensive health insurance coverage to children up to the age of 19 with family incomes at or below 200% of the federal poverty level (FPL). In 2001, Maryland initiated a separate children's health insurance program expansion, MCHP Premium. MCHP also provides insurance coverage for pregnant women with incomes between 185% and 250% of the federal poverty level.  In 2019, according to VSA data, Medicaid covered hospital delivery costs for 38.8% of Maryland births. 

Health care workforce shortages/distribution affects many Maryland communities. There are federally designated health professional shortage areas and medically underserved areas/populations located throughout the State, particularly in urban and rural areas. Data from the HRSA Data Warehouse indicates that 19 of Maryland's 24 jurisdictions are currently either entirely or partially federally designated as health professional shortage areas for primary care and/or dental services, and 18 are shortage areas for mental health.  Twenty three of the State’s 24 jurisdictions are currently either fully or partially designated as medically underserved areas.  Federally qualified health centers are located in 22 jurisdictions in the State. 

Maryland was ranked by the Census Bureau as the wealthiest state in the nation as measured by median household income in 2019. Its health care environment is also one of the most robust in the nation as measured by physician to population ratio and the availability of internationally recognized high quality health services. In spite of Maryland's relative affluence and significant health care assets, progress on health measures for the State is often mixed due to the geographic factors that limit access to care. 

The 2020 Kids Count Data Book (Annie E. Casey Foundation), ranked Maryland 21st in overall child well-being, slipping seven spots from its ranking in 2019.  Despite the State’s overall wealth, Maryland still faces many challenges related to maternal and child health outcomes.  Poverty, which is a significant social determinant of health, measured 9% in 2019 according to the Census Bureau. The infant mortality rate in Maryland continues to see stable declines from 7.4 in 2005 to 5.9 in 2019, a 3% decline from 2018. However, in Maryland there remains persistent disparities in infant mortality rates by race/ethnicity.  For example, in 2019 the infant mortality rate for Non-Hispanic Whites was 4.1 compared to 9.3 for Non-Hispanic Blacks.  Additionally, 12.1% of the state’s children live in poverty and 3% of children (age 0-18) do not have health insurance.  For children with special health care needs, successful transition to adult health care is often inconsistent due to the lack of adult specialty care providers for congenital and childhood onset conditions.

Maternal and Child Health Bureau and Title V

Maryland’s lead public health agency is the Maryland Department of Health (MDH), led by Secretary Dennis Schraeder, who was appointed in 2021. Maryland Department of Health houses Title V in the Maternal and Child Health Bureau (MCHB) within the Prevention and Health Promotion Administration (PHPA). The Bureau’s mission is to provide state leadership to improve the health and well-being of Maryland women, infants, children including those with special health care needs, adolescents, and their families.  MCHB focuses on prevention across the lifespan for children and women of childbearing age and serves as MDH's primary prevention unit for unintended and adolescent pregnancy; infant mortality and low birth weight reduction; breastfeeding promotion,  preventive and primary care for children and adolescents; and systems development for children and youth with special health care needs.  MCHB also has the lead responsibility for reducing racial disparities/inequities in perinatal health outcomes for women and children.

Key goals of the Maternal and Child Health Bureau, which intersect with Title V priorities, include improving pregnancy and birth outcomes, improving the health of children and adolescents, including those with special health care needs, assuring access to quality health care services, eliminating health disparities, and strengthening the MCH infrastructure.  Title V programs and services are provided across the three levels of the MCH pyramid to protect and promote the health of all women, children, and families.

Title V funds support programs and activities in four of the five offices of the Maternal Child Health Bureau.  These offices include the Office of Operations; Office of Family and Community Health Services (OFCHS); the Office of Quality Initiatives (OQI); and the Office for Genetics and People with Special Health Care Needs (OGPSHCN). 

Title V and the Bureau collaborate with other MDH units as well as other State agencies to address access to prenatal care, breastfeeding promotion, childhood lead screening, access to family planning, screening and treatment of sexually transmitted infections, immunizations, postpartum depression, school based health, substance use screening and referral, and tobacco use prevention.  A leading strategy is systems building through partnerships with Medicaid and Behavioral Health (also housed within MDH); other State agencies (e.g., Education, Juvenile Services); local health departments; academic institutions; health care systems,  professional organizations (ACOG, AAP); private non-profits; FQHCs; and community based organizations. 

Title V provides $4.4 million in funding to all 24 local health departments each year to drive improvements in the health of women, children, and families at the community level.  Title V works with state and local agencies to ensure coordination of services for all women and children, but particularly those with limited access to care and children and youth with special health care needs (CYSHCN).

In addition to Title V, MCHB manages programs and budgets drawn from several different federal grants, including the Women’s and Infants Program (WIC); Title X Family Planning; Maternal, Infant and Early Childhood Home Visiting Program (MIECHV); Abstinence Education / Title V Sexual Risk Avoidance Education (Section 510); Maryland Optimal Adolescent Health Program; and the Personal Responsibility Education Program (PREP). 

MCHB’s staff is multidisciplinary and includes physicians, nurses, social workers, epidemiologists, educators, community outreach specialists, public health administrators, public administrators, and administrative support staff. At any given time, there are also as many as four public health interns and two preventive medicine residents contributing to the work of MCHB.

Maternal and Child Health Needs

Perinatal Health

In 2019, Maryland's infant mortality rate declined 3% from 6.1 infant deaths per 1,000 live births in 2018 to 5.9. Although infant mortality has declined over the last few years, significant racial disparities still exist.  In 2019, the infant mortality for Non-Hispanic black infants was 9.3, a decline from the 2018 rate of 10.2, yet still remarkably higher than the infant mortality rate for Non-Hispanic White infants, which was 4.1 deaths per 1,000 live births in 2019. Additionally, Maryland jurisdictions continue to experience regional disparities in infant mortality rates, including Allegany County (15.5 per 1,000), Baltimore City (8.8 per 1,000), and Washington County (7.9 per 1,000).

Infant mortality reduction remains a State priority.  While Maryland has made tremendous progress in reducing overall rates of infant deaths, racial/ethnic disparities continue and will thus remain a focus of Title V activities throughout the next budget year.  Title V supported Fetal and Infant Mortality Review (FIMR) activities in all 24 jurisdictions from 1998-2020, and currently supports 8 teams as of FY2021. FIMR not only provides important insight into opportunities for systems improvement, but also serves as a mechanism for local and regional communication, coordination, and collaboration on broader maternal and child health issues. In all, 135 fetal and infant deaths were reviewed by FIMR teams in FY 2020.

Babies Born Healthy, funded with Title V state match funds, was established in 2007 to reduce infant mortality, improve birth outcomes, and reduce racial disparities. Babies Born Healthy provides funds to eight sites located in the seven jurisdictions in Maryland with the highest infant mortality rates and highest racial disparities in infant mortality. Jurisdictions focus their resources on tobacco cessation, substance use prevention and treatment, prenatal care, long acting reversible contraception, and other strategies driven by site-specific data to promote healthy maternal and infant outcomes

Preventing child and adolescent deaths through Child Fatality Review (CFR) is another Title V priority.  CFR was established in Maryland statute in 1999.  Title V supports a 24 member State CFR Team whose purpose is to prevent child deaths by: (1) understanding the causes and incidence of child deaths; (2) implementing changes within the agencies represented on the State CFR Team to prevent child deaths; and (3) advising the State leadership on child death prevention.  The State CFR Team also sponsors an all-day training for local CFR team members on select topics related to child fatality issues. 

The State CFR Team oversees the efforts of local CFR teams operating in each jurisdiction.  Each month the local CFR teams receive notice from the Office of the Chief Medical Examiner (OCME) of unexpected resident child (under age 18) deaths and are required to review each of these deaths.  Local teams meet at least quarterly to review cases and make recommendations for local level systems changes in statute, policy, or practice to prevent future child deaths, and work to implement these recommendations. 

The OCME referred 176 child deaths to local CFR teams during Calendar Year 2019, of which 161 were reviewed by local CFR teams.  The leading manner of child fatalities in 2019 was undetermined, accounting for 27% of all child deaths, and 60% of all infant deaths in the state.  Infant safe sleep promotion continues to be a Title V priority.

In March 2017, Governor Larry Hogan declared a state emergency and committed additional funding in response to Maryland’s current opioid addiction crisis.  The CDC reports that in 2014 Maryland ranked fifth in the number of pregnant women using opioids.   MCHB monitors the number of infants born with Neonatal Abstinence Syndrome (NAS).  According to the Maryland Health Services Cost Review Commission, the number of infants born with NAS increased annually from 2009 with 569 infants to a high of 954 in 2014. Since 2014, amidst the transition from ICD-9 to ICD-10 diagnosis code tracking of NAS, the number of infants born with NAS has decreased and in 2019 there were 800 infants born with NAS. It is unclear if this is a true decrease in NAS or a result of the ICD-9 to ICD-10 code transition and changes in coding practices.  MCHB is committed to addressing substance use among the state’s MCH population, and Title V funds are used to support standardization of care for infants with NAS as well as linkage to substance use treatment for women of childbearing age through funding awarded to local health departments. 

Child and Adolescent Health

OFCHS partners with Medicaid to monitor the percentage of children and adolescents who follow through with well visits.  With lead support from OGPSHCN and in collaboration with the MDH-PHPA, youth transition to adult health care remains an MCHB priority focus area.  Strengthening systems of care for children and youth with special health care needs through the Medical Home model is another priority for OGPSHCN. The Medical Home and Health Care Transition efforts have expanded throughout the State of Maryland to include promotion, implementation, and evaluation of care within most statewide health systems.  Developing “Best Practice Models'' to improve and build strong infrastructures to support providers who serve CYSHCN while focusing on direct access, effective care coordination, and family involvement are all targeted efforts. Continued collaboration with existing programs and community-based organizations will remain a priority as well as developing new collaborations, both internally and externally. 

Children and Youth with Special Health Care Needs

Through the varied programs housed under this umbrella, OGPSHCN focuses efforts on the six core outcomes for CYSHCN: Family-Professional Partnership; Medical Home; Adequate Insurance; Early and Continuous Screening; Easy-to-Use Services and Supports; and Youth Transition to Adult Health Care. Grant funding is provided to LHDs, Community-Based organizations, academic and clinical institutions with a primary concentration on medical home, family professional partnership, early and continuous screening and health care transition, while internal efforts are focused on those core outcomes plus adequate insurance and easy-to-use services and supports.

OGPSHCN reaches  every child born in Maryland with the dual initial birth screenings for hearing and congenital metabolic disorders, as well as critical congenital heart disease and birth defects surveillance. Outreach and intervention continue for some children across the life course, with follow up for any out of range screening results, referral to early intervention services where warranted, continued information dissemination and education for certain diagnosed conditions, and ongoing efforts to effect transition to adult systems of care.

While Family-Professional Partnership (FPP) is categorized as an individual outcome, OGPSHCN will endeavor to incorporate FPP into all programs as an integral component of the workflow.

COVID -19 Impact

The COVID-19 has impacted the State significantly. On March 5, 2020, Governor Hogan declared a state of emergency. The Maryland Department of Health with local health departments and partners worked to expand COVID-19 testing capacity, maintain adequate patient surge capacity, supply personal protective equipment, execute robust contact tracing operations, and deploy and administer COVID-19 vaccinations.

Essential activities that Maryland Department of Health have taken in response to the pandemic include:

• Developing COVID-19 data dashboards that present case rates by county, testing by county and zip code, Intensive Care Units (ICUs) and Acute Hospital beds, testing volume, testing per day, and percent positive rate over 7 days, school outbreak data, nursing home outbreak data, and COVIDLink Contact tracing Data
• Updating public health partners including local health departments, schools, healthcare facilities, college and universities, health emergency preparedness teams with most up to date guidelines
• Launched COVIDConnect, a free platform for individuals who have been affected by COVID to connect with other individuals who are recovering
• Developed public and private partnerships with pharmacies, health care facilities, community based organizations to launch mass testing and vaccination sites throughout Maryland
• Developed frequently answered questions for COVID-19
• Launched the GoVax Campaign, a communication campaign on the importance of COVID vaccinations
• Implemented MD Covid Alert that uses exposure notification technology to notify users who may have been exposed to an infected person

As a result of the Governor’s Executive Order extending eligibility for certain services during the COVID-19 Pandemic State of Emergency, no children were disenrolled from the Children’s Medical Services.  This ensured that services would still be provided for children with special health care needs.

Many staff, including Title V staff at both the state and local level, were deployed to provide assistance to the COVID-19 pandemic though testing, serving on outbreak and contact tracing teams, developing guidance for partners, or providing vaccinations.