Introduction

Maryland is a small but diverse state comprised of 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 Allegany 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 386,422 young adults in 2015. An estimated 250,000 Maryland children and youth (ages 0-17) have special health care needs.

Maryland’s Health Care Environment

Maryland’s health care system includes 24 local health departments (LHDs), 47 hospitals, 24 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 2018, 685,802 children and adolescents (ages 0-22) were enrolled in the Medicaid Program at some point during the year, a 4% increase over 2016 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 2018, 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 2019 Kids Count Data Book (Annie E. Casey Foundation), ranked Maryland 14th in overall child well-being, consistent with its ranking in 2018.  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 6.1 in 2018, a nearly 6% decline from 2017. However, in Maryland there remains persistent disparities in infant mortality rates by race/ethnicity.  For example, in 2018 the infant mortality rate for Non-Hispanic Whites was 4.1 compared to 10.2 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 Robert Neall, who was appointed in 2018. 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 health outcomes for women and children.

Key goals of the Maternal and Child Health Bureau, which often 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 and children.

Title V funds support programs and activities in three of the four offices of the Maternal Child Health Bureau.  These offices include the 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 (OGPSCHN). 

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 diseases, immunizations, postpartum depression, youth suicide, school based health, substance abuse 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 medical centers; professional organizations (ACOG, AAP); private non-profits; FQHCs; and advocacy groups. 

Title V provides funding to local health departments to drive improvements in the health of women, children, and families at the community level.  The Title V Program 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, the 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); and the Personal Responsibility Education Program (PREP), and one State initiative funded with Title V match dollars, Babies Born Healthy (BBH).  MCHB’s staff is multi-disciplinary 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

In 2018, Maryland's infant mortality rate declined 6% from 6.5 infant deaths per 1,000 live births in 2017 to 6.1. Although infant mortality has declined over the last few years, significant racial disparities still exist.  In 2018, the infant mortality for Non-Hispanic black infants was 10.2, a decline from the 2017 rate of 11.2, yet still remarkably higher than the infant mortality rate for Non-Hispanic White infants. Additionally, Maryland jurisdictions continue to experience regional disparities in infant mortality rates, including Baltimore City (9.2 per 1,000), Prince George’s County (8.0 per 1,000) and the Eastern Shore Region collectively (average 8.6 per 1,000).

Infant mortality reduction remains a MCHB 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 supports Fetal and Infant Mortality Review (FIMR) activities in all 24 jurisdictions since 1998.  FIMR not only provides important insight into opportunities for systems improvement, it also serves as a mechanism for local and regional communication, coordination, and collaboration on broader maternal and child health issues. In all, 264 cases were reviewed by FIMR teams in FY 19.

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 196 child deaths to local CFR teams during FY 19, of which 194 were reviewed by local CFR teams.  Sudden Unexplained Infant Deaths (SUID) were the leading cause of child fatalities in 2018, accounting for 33% of all infant deaths in the state. 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. 

Teen pregnancy prevention has been a focus area for MCHB for several years.  OFCHS oversees the Title X Family Planning Program which includes a Healthy Teen and Young Adult clinical component.  In addition, both Abstinence Education / Sexual Risk Avoidance Education (SRAE) and PREP funds made available under the Affordable Care Act are administered under OFCHS.  Both Abstinence / SRAE and PREP provide support to local community agencies and local health departments to implement evidence based programming to prevent teen pregnancy and promote positive youth development.

Reducing unintended pregnancy by assuring access to family planning services is also viewed as a key strategy for reducing infant mortality.  MCHB administers the Title X Family Planning Program. Title X Staff work closely with Title V to address such issues as unintended pregnancy, adolescent pregnancy prevention, and women’s health.  The Title X Program served a total of 69,029 clients; 59,725 women and 9,304 men in 2018.  Eighty five percent of the clients served were 100% below the poverty threshold and therefore received services without a fee.  As of FY 2018, Title X maintained 64 service sites (23 delegate sites) across the state through local health departments and non-profit organizations which spanned both urban and rural areas and included school based health centers and a college health center.  Title V continues to supplement funding to local health departments for clinical family planning services. 

Promoting healthy mothers, infants and children through home visiting is an integral core component of Maryland’s MIECHV Program.  MCHB administers MIECHV and works in partnership with local health departments, community-based organizations and other state agencies to support and fully integrate systems of care aimed at improving outcomes for families. Maryland MIECHV has received nearly $39.8 million in formula funding since inception in 2010.  From serving and supporting 562 families in six jurisdictions during the first funding period October 2011 to September 2014, MD MIECHV now reaches more than 1300 families annually in 10 of the most at-risk jurisdictions in the state.  Along with direct home visiting services to families, MIECHV funds are also used to support program evaluation, project expansion, workforce development and a statewide home visiting database.  MIECHV collaborates with the Governor’s Office for Children to collect data on twelve standard measures from home visiting programs to develop the biennial “Report on the Implementation and Outcomes of State-Funded Home Visiting Programs in Maryland” which is submitted to the Governor.

OFCHS partners with Medicaid to monitor the percentage of infants 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 CYSHNC 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. 

Surveillance of Zika-exposed women and infants was an ongoing priority for MCHB in FY 2019.  Funds from CDC’s “Surveillance, Intervention, and Referral to Services Activities for Infants with Microcephaly or Other Adverse Outcomes Linked with the Zika

Virus” grant were used to enhance state birth defect surveillance and care coordination to better understand the impact of the Zika virus infection on infant health.  MCHB continued to monitor these activities through coordination by MCHB, OME and the OGPSHCN, and in conjunction with IDEORB (Infectious Disease Epidemiology and Response Bureau). With the emergence of Zika virus, all birthing facilities in Maryland were updated on the appropriate reporting and follow up care for newborns identified via the Zika Pregnancy Registry (ZPR) and the Zika Birth Defects Registry (ZBDR). For FY 19, 1149 babies were identified via birth defects reporting system and linked to resources. The CDC Zika grant ended in July of 2019.

Violence prevention, including intimate partner violence (IPV), is a priority for MDH and MCHB. The Maryland Family Planning Program (MFPP), funded through Title X, continues to screen all clients for IPV and provides resources/facilitates access to appropriate services.  All delegates conduct an annual assessment of the training needs of staff and evaluate the scope and effectiveness of all educational programs offered. Regular training topics include mandated reporting and human trafficking (inclusive of IPV).  Training is required on a biennial schedule.

MFPP recognizes the critical priority of increasing recognition of CDC screening recommendations for chlamydia and other STIs including HIV testing that have the potential for long-term impacts on fertility and pregnancy.  All staff, including administrative and support staff, as well as direct service providers, are trained regarding prevention, transmission and infection control in the health care setting of sexually transmitted infections including HIV.  

The MFPP service sites support resources and referrals for individuals identified with mental health, substance abuse or co-occurring disorders.  By completing health histories with clients, men and women are assessed for need of care.  In an effort to be in alignment with the MFPP key issue of "providing the tools necessary for the inclusion of substance abuse disorder screening into family planning services offered by MFPP applicants,” MFPP provides SBIRT training for delegates.

The integration of Substance Use Disorder (SUD) screening is established throughout the MFPP service sites through the client's medical history assessment and implementation of SBIRT (Screening, Brief Intervention, and Referral to Treatment) tool. As a holistic approach to health care delivery, Maryland requires delegate partners to establish a network of community partners for referrals for treatment and supportive services. In FY 2019, the MFPP Client Visit Record data reported that 212 client referrals for SUD, of which 164 were female, and 48 were male