Introduction

Maryland is a small but diverse state comprising 24 jurisdictions, including 23 counties and the city of Baltimore.  According to the U.S. Census Bureau, Maryland had an  estimated population of nearly 6.2 million in 2020, and ranked as  the nation’s 18th most populous state.  However, Maryland  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 368,767 young adults (ages 20-24) in 2020. According to the National Survey of Children’s Health in 2019-2020, an estimated 273,531 Maryland children and youth (ages 0-17) have special health care needs (NSCH 2019-2020 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 home to Johns Hopkins University consistently ranked as one of the nation’s top hospitals and several of the best diagnostic centers for developmental conditions in children, including  Kennedy Krieger Institute, University of Maryland Division of Behavioral and Developmental Pediatrics, Sheppard Pratt and Mount Washington Pediatric Hospital.

Maryland was one of the initial six 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 (December 2021), there were 1,674,096 Marylanders who were enrolled in Medicaid.  During calendar year 2020, 688,533 children and adolescents (ages 0-22) were enrolled in the Medicaid Program at some point during the year, representing a 4 percent increase from 2020 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 2020, according to the National Vital Statistics System, Medicaid covered hospital delivery costs for 39.2 percent 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. This shortage is expected to be exacerbated by the COVID-19 Pandemic and the loss of health care workers due to fatigue and burnout.  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 2020. 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 2021 Kids Count Data Book (Annie E. Casey Foundation), ranked Maryland 24 in overall child well-being, slipping three spots from its ranking in 2020.  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 9.0% in 2020 according to the American Community Survey. The infant mortality rate in Maryland continues to see stable declines from 7.4 in 2005 to 5.7 in 2020, a 3% decline from 2019. However, in Maryland there remains persistent disparities in infant mortality rates by race/ethnicity.  For example, in 2020 the infant mortality rate for Non-Hispanic Whites was 3.3 compared to 9.9 for Non-Hispanic Blacks.  Additionally, 12.4% of the state’s children (ages zero to five) live in poverty and 14% of children (age 0-18) do not have health insurance based on Census data.  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 reduce health inequities and improve the health and wellbeing of all individuals, families, and communities in Maryland. The vision for the Bureau is that all individuals and families are valued, safe, and informed, with equitable access to resources and services.  The tagline for the bureau is “Healthy pregnancies, healthy children, healthy families, healthier communities.”

 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 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 (OGPSHCN). In addition, Title V funds support the Operations Unit for the Bureau and the Healthcare Systems Coordination and School-Based Health Centers Unit.

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 health outreach specialists, public health 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 2020, the Maryland infant mortality rate was 5.7 deaths per 1,000 live births, a decrease of three percent from the 2019 rate of 5.9 deaths per 1,000 live births. Although infant mortality has declined over the last few years, significant racial disparities still exist. Between 2019 and 2020, the non-Hispanic (NH) White infant mortality rate decreased by 20 percent from 4.1 to 3.3 deaths per 1,000 live births and the Hispanic infant mortality rate decreased by 10 percent, from 5.1 to 4.6 deaths per 1,000 live births. The NH Black rate increased by six percent from 9.3 to 9.9 deaths per 1,000 live births. Additionally, Maryland jurisdictions continue to experience regional disparities in infant mortality rates, including Dorchester County (13.3 per 1,000), Wicomico County (11.2 per 1,000) Baltimore City (10.3 per 1,000), and Allegany County (9.5 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 regional FIMR teams as of FY 2021. 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.

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 care coordination for 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 157 child deaths to local CFR teams during CY2020, of which 156 were reviewed by local CFR teams. The leading manner of child fatalities in 2020 was undetermined, accounting for 30% of child deaths reviewed, followed by accidents at 25% of child deaths reviewed. Approximately 50 cases reviewed were Sudden Unexpected Infant Deaths (SUID). Infant safe sleep promotion continues to be a Title V priority.

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 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:

In previous years, OGPSHCN has focused efforts around 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. These ‘core outcomes’ have been assessed and updated, with the most recent “Version 2.0 of the National Standards for CYSHCN” released in 2017 as a result of a partnership between The Association of Maternal & Child Health Programs (AMCHP) and the National Academy for State Health Policy (NASHP). Version 2.0 organizes the standards into eight core domains and introduces four Foundational Standards for Systems of Care for CYSHCN.[1]

Foundational Standards for Systems of Care for CYSHCN:

• Children and families of CYSHCN are active, core partners in decision making in all levels of care
• All services and supports for CYSHCN are implemented and delivered in a culturally competent, linguistically appropriate, and accessible manner
• Insurance coverage for CYSHCN is accessible, affordable, comprehensive, and continuous
• All care provided to CYSHCN and their families is evidence-based where possible

Core Domains for System Standards

• Identification, Screening, Assessment, and Referral
• Eligibility and Enrollment in Health Coverage
• Access to Care
• Medical Home
  • Pediatric Preventive and Primary Care
  • Medical Home Management
  • Care Coordination
  • Pediatric Specialty Care
• Community-Based Services and Supports
  • Respite Care
  • Palliative and Hospice Care
  • Home-Based Services
• Transition to Adulthood
• Health Information Technology
• Quality Assurance and Improvement

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.

Through the varied programs housed under the office umbrella and through grant funding to LHDs, community-based organizations, and academic and clinical institutions, OGPSHCN endeavors to impact each of the Core Domains for System Standards, with a focus on the national performance measures of medical home and health care transition. Family-Professional Partnership (FPP) was previously categorized as an individual outcome, though OGPSHCN strived to incorporate FPP into all programs as an integral component of the workflow. With Version 2.0, FPP is no longer an individual outcome, but is a Foundational Standards for Systems of Care for CYSHCN. OGPSHCN will explore opportunities to impact each of the core domains while maintaining focus on the foundational standards.

COVID -19 Impact:

The COVID-19 pandemic continued to impact the State significantly in 2021.  The State continued to focus on providing vaccinations, and on January 26, 2021, Governor Hogan announced the opening of mass vaccination sites in the state of Maryland. In addition, Maryland’s COVID-19 Vaccination Support Center, a call-line, was set up to provide support to individuals needing additional assistance.  By May 21, 2021, about 70 percent of adults in Maryland had received their COVID-19 vaccines. In addition to expanding vaccinations, the Maryland Department of Health with local health departments and partners continued to provide contact tracing operations, testing, and information about COVID-19 and vaccinations.

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, and health emergency preparedness teams with the most up to date guidelines
• Established and leads Maryland’s COVID-19 Vaccination Support Center, a call-line,
• 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 asked 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

During 2021, many staff, including Title V staff at both the state and local level, were deployed to provide assistance related to the COVID-19 pandemic through providing testing, serving on outbreak and contact tracing teams, developing guidance for partners, or providing vaccinations. Title V staff developed COVID-19 Vaccine Facts for Pregnant and Breastfeeding Individuals in 2021.

[1] National Standards for Systems of Care for Children and Youth with Special Health Care Needs, Version 2.0 Informational website